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A  TEXT-BOOK 


OF  THE 


Practice  of  Medicine 


BY 

JAMES  M.  ANDERS,  M,D.,  Ph.D.,  LL.D. 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Medico-Chirurgical  College, 

Philadelphia;   Attending  Physician  to  the  Medico-Chirurgical  and 

Samaritan  Hospitals,  Philadelphia,  Etc. 


ILLUSTRATED 


FOURTH  EDITION.  THOROUGHLY  REVISED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS    &    COMPANY 
J900 


Copyright,  1900, 
By  W.  B.  SAUNDERS   &  COMPANY. 


PRESS  OF 

ELECTHOTYPED  BY  ^     3     SAUNOEBS  &  COMPANY 

WESTCOTT  II  THOMSON.    PHILAOA. 


PREFACE  TO  THE  FOURTH  EDITION. 


The  third  edition  of  this  work  appeared  in  September,  1899,  and 
■was  so  quickly  exhausted  as  to  render  it  unnecessary  to  make  extensive 
alterations  in  the  present  issue.  Numerous  changes  in  the  text,  how- 
ever, have  been  made  in  all  parts,  and  considerable  new  matter  has 
been  added,  with  a  view  to  enhancing  the  general  usefulness  of  the 
work.  The  section  on  Diseases  of  the  Digestive  System  has  received 
numerous  additions  and,  I  trust,  improvements.  A  number  of  subjects 
have  been  written  anew,  among  which  some  of  the  more  important  are 
Sprue,  Ileo-colitis  in  Children,  and  Acute  Cholecystitis. 

Special  effort  has  been  made,  by  means  of  careful  condensation,  to 
make  room  for  the  new  material,  and  so  avoid  a  repagination  of  the 
entire  work. 

I  have  again  availed  myself  of  the  opportunity  offered  to  improve  the 
arrangement  of  the  subject-matter  for  the  greater  convenience  of  both 
student  and  practitioner.  The  modern  methods  of  diagnosis,  as  well  as 
the  most  recent  advances  in  therapeutics,  have  been  introduced.  The 
desire  to  maintain  the  practical  character  of  the  book  and  to  furnish  in 
the  present,  as  in  previous  issues,  a  full  presentation  of  the  important 
and  confessedly  difficult  subject  of  differential  diagnosis,  especially  be- 
tween affections  that  show  a  close  correspondence  in  their  symptoms, 
forbade  a  lengthy  discussion  of  numerous  controverted  questions  in 
internal  medicine. 

Should  my  earnest  endeavor  to  render  the  work  worthy  of  a  contin- 
uance of  the  commendation  and  favorable  reception  it  has  previously 
enjoyed  prove  successful,  I  will  be  much  gratified.  Dr.  Joseph  Sailer 
carefully  revised  the  section  on  Diseases  of  the  Nervous  System.  I  am 
indebted  to  Dr.  Howard  S.  Anders  for  aid  in  scrutinizing  and  revising 
the  Animal  Parasitic  Diseases  and  the  Intoxications.  My  thanks  are 
also  due  to  Dr.  Warren  Z.  Anders  for  much  assistance  rendered  while 
the  book  was  passing  through  the  press. 

JAMES  M.  ANDERS. 

1605  Walnut  Street, 
September,  1900. 


PREFACE  TO  THE  THIRD  EDITION. 


In  the  second  edition  of  this  work,  issued  less  than  a  year  ago,  it 
was  found  unnecessary  to  make  any  important  alterations.  The  present 
issue,  however,  is  the  result  of  careful  and  thorough  revision.  Espe- 
cially was  this  deemed  necessary  as  relating  to  the  section  on  Infectious 
Diseases — a  department  in  which  the  advance  in  our  knowledge  since 
the  publication  of  the  first  edition  has  been  considerable. 

A  few  new  subjects  have  been  introduced — Glandular  Fever,  Ether- 
pneumonia,  Splenic  Anemia,  Meralgia  Paraesthetica,  and  Periodic  Paral- 
ysis. The  affections  that  have  been  substantially  rewritten  are :  The 
Plague,  Malta  Fever,  Diseases  of  the  Thymus  Gland,  the  Liver  Cir- 
rhoses,  and  Progressive  Spinal  Muscular  Atrophy.  The  following 
articles  have  been  extensively  revised :  Typhoid  Fever,  Yellow  Fever, 
Lobar  Pneumonia,  Dengue,  Tuberculosis,  Diabetes  Mellitus,  Gout, 
Arthritis  Deformans,  Autumnal  Catarrh,  the  Diseases  of  the  Circula- 
tory System,  more  particularly  Hypertrophy  and  Dilatation  of  the 
Heart,  Arterio-sclerosis,  and  Thoracic  Aneurysm,  Pancreatic  Hemor- 
rhage, Jaundice,  Acute  Peritonitis,  Acute  YelloAV  Atrophy,  Hematoma 
of  the  Dura  Mater,  and  Scleroses  of  the  Brain. 

These  extensive  changes  have  given  the  author  an  opportunity,  of 
which  h^  gladly  availed  himself,  to  accomplish  in  many  places  an  im- 
proved classification  of  the  practical  portion  of  the  matter  under  appro- 
priate headings.  Scarcely  subsidiary  to  clearness  and  accuracy  of 
delineation  in  clinical  medicine,  to  meet  the  needs  of  the  medical 
student  and  busy  practitioner,  is  a  systematic  and  convenient  arrange- 
ment of  the  diagnostic  and  therapeutic  data.  The  proper  classification 
of  knowledge  facilitates  its  acquisition  by  the  student,  and  conveys  to 
his  mind  a  clearer  and  more  lasting  image.  The  leading  symptoms 
have  been  more  uniformly  italicized — a  modification  that  cannot  fail  to 
prove  helpful  to  the  medical  student. 

The  preliminary  chapter  in  the  section  on  Nervous  Diseases  is  new, 
and  deals  with  the  subject  of  localization  and  the  various  methods  of 
investigating  nervous  affections  ;  it  has  thus  been  brought  into  closer 
harmony  with  the  practical  character  of  similar  chapters  introductory 
to  other  divisions  of  the  book.  Dr.  Joseph  Sailer  rendered  efficient  aid 
in  the  revision  of  Part  VIII. ,  Diseases  of  the  Nervous  System. 

1 


2  PREFACE  TO   THE   THIRD  EDITION. 

There  has  been  no  appreciable  increase  in  the  size  of  the  volume, 
the  numerous  additions  having  been  compensated  by  patient  and  care- 
ful condensation  of  the  text.  A  repagination  and  an  enlarged  index 
were  found  to  be  necessary. 

Six  new  illustrations  have  been  added.  They  are  microscopic  prepa- 
rations, and  Avere  derived  directly  from  patients  while  under  observation. 
They  have  been  introduced  to  emphasize  the  fact  that  the  microscope, 
along  with  the  use  of  the  senses  and  laboratory  investigation,  is  some- 
times essential  for  an  absolute  diagnosis. 

I  desire  to  thank  numerous  correspondents  who  have  kindly  volun- 
teered warm  expressions  of  approval,  mingled  sometimes  with  timely 
suggestions.  My  thanks  are  also  due  Mr.  Thomas  F.  Dagney,  of  the 
Editorial  Department  of  W.  B.  Saunders,  Publisher,  for  his  aid  in 
supervising  and  expediting  the  work  while  passing  through  the  press. 

I  venture  to  hope  that  by  the  changes  and  additions  which  have 
been  made  in  carrying  out  my  purpose  the  practical  value  of  the  work 
has  been  enhanced,  and  that  the  third  edition  will  enjoy  the  same 
measure  of  popularity  so  generously  accorded  the  previous  issues. 

JA3IES  M.  ANDERS. 

1605  Walnut  Street, 
Philadelphia. 


PREFACE. 


This  work  is  meant  to  introduce  the  student  to  the  present  state  of 
our  knowledge  of  the  practice  of  medicine  in  general  and  of  the  diagno- 
'sis,  dijfferential  diagnosis,  and  treatment  of  disease  in  particular.  The 
historic  development  of  the  subjects  treated  has  been  either  briefly  given 
or  intendedly  omitted,  since  this  scarcely  falls  within  the  scope  of  a  prac- 
tical treatise  on  medicine.  Although  the  book  as  a  whole  is  submitted 
to  the  critical  judgment  of  a  learned  profession,  it  may  be  pardonable  to 
emphasize,  provisionally,  a  few  features  pertaining  to  the  mode  of  treat- 
ing the  separate  subjects,  or  the  arrangement  of  the  material  under  the 
latter — to  indicate  some  of  the  more  salient  lineaments,  so  to  speak,  in 
the  general  design.  Since  in  medical  schools  it  is  taught  from  a  separate 
chair,  the  pathology  (special)  of  the  individual  affections  has  almost  in- 
variably been  taken  up  before  the  etiology ;  from  this  point  the  student 
will  find  the  story  of  each  affection  a  continuous  one.  The  practitioner, 
however,  must  ever  aim  to  associate  the  clinical  symptoms  with  the 
morbid  lesions. 

Under  special  etiology  the  bacteriology  has  been  prominently  men- 
tioned, since  we  owe  to  it  the  rapid  progress  that  is  being  made  in  the 
study  of  the  causation  of  disease. 

The  differential  diagnosis  has  in  naany  instances  been  tabulated — an 
ear-mark  that  I  confidently  believe  will  be  found  especially  helpful.  It 
may  be  stated  that  not  less  than  fifty-six  diagnostic  tables  are  scattered 
throughout  the  work,  and  that  by  far  the  greater  number  of  these  are 
my  own. 

Such  formulae  have  been  introduced  into  the  text,  and  only  such,  as  a 
more  or  less  extended  experience  has  shown  to  be  possessed  of  real  thera- 
peutic importance.  Whilst  these,  and  all  additional  points  relating  to 
the  treatment  of  the  single  aff"ections,  may  serve  as  guides,  particularly 
to  the  beginner,  I  fully  appreciate  how  often  the  practising  physician  is 


4  PREFACE. 

placed  in  a  position  in  which  he  is  compelled  to  form  a  therapeutic 
judgment  for  himself.  Whenever  the  dosage  is  stated,  the  metric  equiv- 
alent is  placed  in  parentheses,  the  number  of  grams  being  stated  in  round 
numbers  (3J — 4.0  ;  |j— 32.0)  in  order  to  render  it  of  greater  practical 
value.  In  all  instances,  however,  in  which  this  would  involve  an  im- 
portant difference  in  quantity  the  exact  decimal  figures  are  given.  A 
considerable  variation  from  the  usual  classification  of  diseases  may  be 
observed,  but   this  is  accounted  for  in  the  text  wherever  it  occurs. 

Preference  has  been  given  to  the  modern  orthography  and  termi- 
nology, not  only  because  it  is  more  euphonious,  but  also  because  of  its 
adoption  by  the  standard  lexicographers. 

I  have  gleaned  without  stint  from  medical  literature  with  a  view  to 
bringing  the  book  up  to  date,  and  if  I  have  failed  to  give  full  credit  in 
every  instance,  my  grateful  acknowledgments  are  here  due  and  are 
cheerfully  made.  The  chief  results  of  my  personal  experience  and  obser- 
vation, extending  over  a  period  of  two  decades,  and  derived  from  both 
hospital  and  private  practice,  will  also  be  found  upon  these  pages. 

I  wish  to  thank  Prof.  W.  C.  Hollopeter,  who  has  written  some  of  the 
articles  upon  the  diseases  of  children,  as  measles,  chicken-pox,  mumps, 
whooping-cough,  and  the  acute  diarrheas,  and  who  has  kindly  aided  in 
the  preparation  of  those  upon  diphtheria  and  scarlatina. 

My  cordial  thanks  are  due  also  to  Dr.  C.  L.  Furbush  for  kind  aid 
in  preparing  some  of  the  illustrations,  to  Doctors  Robert  N.  "Willson, 
Howard  S.  Anders,  and  Geo.  W.  Pfromm  for  valuable  assistance  while 
the  work  was  passing  through  the  press,  and  to  Dr.  A.  M.  Davis  for 
preparing  the  index. 

JAMES  M.  ANDERS. 


CONTENTS. 


PART  I.— INFECTIOUS  DISEASES. 

PAGE 

Typhoid  Fever 17 

^Mountain  Fever 67 

Typhus  Fever 67 

Relapsing  Fever 73 

Malarial  Fever 79 

Dysentery 97 

Catarrhal  Dysentery 99 

Amebic  Dysentery  (Tropical  Dysentery) 100 

Diphtheritic  Dysentery 103 

Chronic  Dysentery 106 

Cholera  (Epidemic) 109 

Yellow  Fever 11' 

Cerebro-spinal  Meningitis 124 

Lobar  Pneumonia 132 

Ether  Pneumonia 149 

Secondary  Pneumonia        157 

Influenza 158 

Dengue 167 

The  Plague 169 

Erysipelas 172 

Diphtheria 179 

Septicemia 195 

Pyemia 199 

Acute  Articular  Eheumatism 202 

Subacute  Articular  Rheumatism 213 

Gonorrheal  Arthritis 213 

Variola 215 

Vaccination 229 

Varicella 231 

Scarlet  Fever 234 

Measles 245 

Rubella 248 

Whooping-cough 251 

Parotitis 258 

Tuberculosis 260 

Tuberculosis  of  the  Lymph-glands 271 

Acute  Tuberculosis 274 

General  Miliary  Tuberculosis 275 

Typhoid  Form 275 

Pulmonary  Form 277 

Cerebral  or  Meningeal  Form 278 

Acute  Pneumonic  Phthisis 282 

Chronic  Tuberculosis 285 

Fibroid  Phthisis 302 

Tuberculosis  of  the  Alimentary  Tract 304 

Tuberculosis  of  the  Serous  Membranes 307 

Tuberculosis  of  the  Pericardium 308 

Tuberculosis  of  the  Peritoneum • 309 

Tuberculosis  of  the  Liver 311 

Tuberculosis  of  the  Genito-urinary  System 312 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus 314 

Tuberculosis  of  the  Mammary  Glands 315 

Tuberculosis  of  the  Brain 315 

Tuberculosis  of  the  Spinal  Cord • 315 

Tuberculosis  of  the  Heart 315 

5 


6  CONTENTS. 

PAGE 

Tuberculosis  of  the  Arteries  and  Veins 316 

Treatment  of  Tuberculosis 317 

Syphilis .        .  326 

Visceral  Syphilis 333 

Syphilis  of  the  Liver 334 

Syphilis  of  the  Alimentary  Tract 336 

Syphilis  of  the  Lungs 337 

Syphilis  of  the  Spleen 338 

Syphilis  of  the  Circulatory  System 338 

Syphilis  of  the  Arteries 339 

Syphilis  of  the  Kidneys 339 

Syphilis  of  the  Joints' 339 

Syphilis  of  the  Testicles 340 

Leprosv 345 

Glanders • 348 

Actinomycosis 350 

Anthrax 352 

Hydrophobia 355 

Tetanus 358 

Infectious  Diseases  of  Unknown  Etiology 362 

Muscular  Rheumatism 362 

Chronic  Articular  Rheumatism 365 

Weir  s  Disease 367 

Schlammtieber 368 

Malta  Fever  .        • 368 

Febricula 369 

3Iilk-^•ickness 370 

Miliary  Fever 371 

Foot-and-mouth  Disease 372 

Glandular  Fever      372 

PART  11.— CONSTITUTIONAL  DISEASES. 

Diabetes 374 

Diabetes  Insipidus •  385 

Arthritis  Deformans 387 

Gout 392 

Lithemia ■ 4G0 

Rachitis 402 

Scorbutus 407 

Infantile  Scorbutus 411 

Purpura 412 

Hemopliilia 415 

Hemorrhagic  Diseases  of  the  New-born 418 

PART  III.— DI5EASE5  OF  THE  BLOOD  AND  THE  DUCTLESS 

GLANDS. 

Anemia 419 

The  Primary  or  Essential  Anemias 420 

Si  HI  pie  or  Benign  Anemia 420 

Chlorosis 421 

Progressive  Pernicious  Anemia 426 

The  Secondary  Anemias 433 

Leukocytosis 436 

Leukocytliemia 437 

Pseudo-leukemia 444 

Anaemia  Infantum  Pseudo-leukfemica 449 

Splenic  Anemia .    .  450 

Chloroma      451 

Disea.ses  of  the  Ductless  Glands 451 

Diseases  of  the  Suprarenal  Capsules 451 

Addison's  Disease 451 

Diseases  of  the  Thyroid  Gland      455 

Thyroiditis 455 

Goiter 456 

Exophthalmic  Goiter 458 

Myxedema 462 


CONTENTS.  7 

PART  IV.— DISEASES  OF  THE  RESPIRATORY  SYSTEM. 
1.    DISEASES  OF  THE  NOSE. 

PAGE 

Acute  Rhinitis 467 

Chronic  Rhinitis 468 

Autumnal  Catarrh 471 

Epistasis 472 

II.  DISEASES  OF  THE  LARYNX. 

Acute  Catarrhal  Laryngitis '. 473 

Chronic  Laryngitis 475 

Spasmodic  Laryngitis ._  477 

Edematous  Laryngitis 479 

Tumors  of  the  Larynx 480 

III.  DISEASES  OF  THE  BRONCHI. 

Catarrhal  Bronchitis 480 

Acute  Bronchitis 481 

Chronic  Bronchitis 485 

Brochiectasis 489 

Bronchial  Stenosis ; 492 

Asthma 493 

Fibrinous  Bronchitis , 498 

IV.  DISEASES  OF  THE  LUNGS. 

Circulatory  Disturbances  in  the  Lungs 500 

Congestion  of  the  Lungs 500 

Active  Hyperemia 500 

Passive  Hyperemia 501 

Pulmonary  Edema 502 

Hemoptysis 504 

Pneumorrhagia 510 

Pulmonary  Embolism 510 

Chronic  Interstitial  Pneumonia 512 

Broncho-pneumonia 514 

Pulmonary  Atelectasis 521 

Emphysema 524 

Interlobular  Emphysema 524 

Vesicular  Emphysema 524 

Compensating  Emphysema 525 

Hypertrophic  Emphysema 525 

Senile  Emphysema 531 

Gangrene  of  the  Lungs 531 

Abscess  of  the  Lungs 534 

Pneumonokoniosis 535 

New  Growths  of  the  Lungs 538 

Carcinoma  of  the  Lung .  538 

Sarcoma  of  the  Lung 539 

Hydatid  Cyst  of  the  Lung 540 

V.  DISEASES  OF  THE  PLEURA. 

Pleurisy 541 

Acute  Plastic  Pleurisy 541 

Sero-fiibrinous  Pleurisy 544 

Empyema 558 

Chronic  Pleurisy 562 

Pneumothorax 564 

Hydrothorax 569 

New  Growths  of  the  Pleura 570 

Diseases  of  the  Mediastinum 571 

Inflammation  of  the  Mediastinum 571 

Tumors  of  the  Mediastinum 572 

Diseases  of  the  Thymus  Gland 574 

Mediastinal  Hemorrhage 574 


8  CONTENTS. 

PART  v.— DISEASES  OF  THE  CIRCULATORY  SYSTEM. 
I.  DISEASES  OF  THE  PERICARDIUM. 

PAGE 

Pericarditis 575 

Acute  Plastic  or  Fibrinous  Pericarditis 575 

Sero-fibrinous  Pericarditis 578 

Purulent  Pericarditis 583 

Hemorrhagic  Pericarditis 584 

Adhesive  Pericarditis 584 

Hydropericardiuni 586 

Hemopericardinm 587 

Pneumopericardium 587 

II.  DISEASES  OF  THE  HEART. 

Endocarditis 588 

Simple  Acute  Endocarditis 588 

Ulcerative  Endocarditis .    •  592 

Chronic  Endocarditis 596 

Aortic  Incompetency 599 

Aortic  Stenosis ,    .    .  605 

Mitral  Incompetency 607 

Mitral  Stenosis 613 

Tricuspid  Incompetency 617 

Tricuspid  Stenosis 620 

Pulmonary  Incompetency 621 

Pulmonary  Stenosis 622 

Combined  Forms  of  Cardiac  Diseases 622 

Cardiac  Thrombosis 636 

Hypertrophy  of  the  Heart 638 

Dilatation  of  the  Heart 645 

Myocarditis 650 

Acute  Mj'ocarditis 650 

Chronic  Myocarditis 651 

Disease  of  the  Coronary  Arteries 655 

Degenerations  of  the  Heart 656 

Fatty  Degeneration 656 

Fatty  Overgrowth 658 

Brown  Atrophy 659 

Calcareous  Degeneration 659 

Amyloid  Degeneration 659 

Hyaline  Degeneration 659 

Cardiac  Aneurysm 660 

Rupture  of  the  Heart 661 

Minor  Aflections  of  the  Heart 662 

New  Growths 662 

Parasites 662 

Misplacement 663 

Floating  Heart 663 

III.  NEUROSES  OF  THE  HEART. 

Palpitation 663 

Tachycardia 665 

Brachycardia 667 

Arrhythmia 669 

Angina  Pectoris 671 

IV.   CONGENITAL  AFFECTIONS  OF  THE  HEART. 

Arrested  Development 674 

Fetal  Endocarditis 675 

V.  DISEASES  OF  THE  ARTERIES 

Acute  Aortitis 677 

Arterial  Sclerosis 678 

Aneurysm 682 

Aneurysm  of  the  Thoracic  Aorta 683 


CONTENTS.  9 

PAGE 

Aneurysm  of  the  Abdominal  Aorta 692 

Aneurysm  of  the  Pulmonary  Artery 693 

Aneurysm  of  the  Coronary  Arteries 693 

Aneurysm  of  the  Celiac  Axis 693 

Aneurysm  of  the  Splenic  Art«ry 693 

Aneurysm  of  the  Hepatic  Artery 693 

Aneurysm  of  the  Superior  Mesenteric  Artery 69-1 

Aneurysm  of  the  Inferior  Mesenteric  Artery 694 

Aneurysm  of  the  Eenal  Arteries 694 

Arterio-venous  Aneurysm 694 

Congenital  Aneurysm 694 

PART  VI.— DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

I.  DISEASES  OF  THE  MOUTH. 

Stomatitis 695 

Catarrhal  Stomatitis 695 

Aphthous  Stomatitis 696 

Aphtha  Cachectica  (Riga's  Disease) 697 

Membranous  Stomatitis 698 

Ulcerative  or  Fetid  Stomatitis 699 

Neurotic  Ulceration 700 

Parasitic  Stomatitis 701 

La  Perleche -    -  703 

Gangrenous  Stomatitis 703 

Mercurial  Stomatitis 705 

II.  DISEASES  OF  THE  TONGUE. 

Glossitis 706 

Acute  Glossitis 706 

Chronic  Superficial  Glossitis 707 

Glossitis  Desiccans 708 

Lingual  Glossitis 70S 

Leukoplakia  Oris 708 

Angina  Ludovici 709 

III.  DISEASES  OF  THE  SALIVARY  GLANDS. 

Hypersecretion 709 

Xerostoma 710 

Glassblowers'  Mouth 710 

Symptomatic  Parotitis 710 

Chronic  Parotitis .  711 

IV.   DISEASES  OF  THE  TONSILS. 

Acute  Tonsillitis 711 

Chronic  Tonsillitis 717 

V.  DISEASES  OF  THE  PHARYNX. 

Pharyngitis 720 

Acute  Pharyngitis 720 

Membranous  Pharyngitis 721 

Chronic  Pharyngitis 722 

Acute  Infectious  Phlegmon  of  the  Throat      723 

Retropharyngeal  Abscess 724 

VI.  DISEASES  OF  THE  ESOPHAGUS. 

Esophagitis 724 

Acute  Esophagitis 724 

Chronic  Esophagitis 726 

Ulcer  of  the  Esophagus 726 

Carcinoma  of  the  Esophagus 726 

Rupture  of  the  Esophagus 728 

Keuroses  of  the  Esophagus : 729 

Muscular  Spasm 729 

Paralysis  of  the  Esophagus 729 


10  CONTENTS. 

PAGE 

Dilatation  of  the  Esophagus 730 

Esophageal  Diverticulum 731 

Stricture  of  the  Esophagus 732 

VII.  DISEASES  OF  THE  STOMACH. 

Methods  of  Diagnosis 735 

Examination  of  the  Gastric  Functions 735 

Physical  or  External  Examination 740 

Malposition  of  the  Stomach 743 

Gastroptosis 743 

Dilatation  of  the  Stomach 744 

Inflammatory  Diseases  of  the  Stomach 749 

Acute  Catarrlial  Gastritis 749 

Toxic  Gastritis 752 

Diphtheritic  Gastritis 753 

Acute  Suppurative  Gastritis 753 

Chronic  Catarrhal  Gastritis 754 

Gastric  Ulcer 763 

Carcinoma  of  the  Stomach 771 

Hematemesis 778 

Hypertrophic  Stenosis  of  the  Pylorus 778 

Neuroses  of  the  Stomach 779 

Nervous  Dyspepsia      779 

Neuroses  of  Secretion      782 

Hyperchlorhydria .  782 

Neuroses  of  Motility 784 

Increased  Peristalsis  of  the  Stomach 784 

Diminished  Peristalsis  of  the  Stomach 784 

Neuroses  of  Sensation 785 

Cardialgia 785 

Hyperesthesia  of  the  Stomach 787 

Anorexia 787 

Hyperorexia 788 

VIII.  DISEASES  OF  THE  INTESTINES. 

Methods  of  Diagnosis 788 

Enteroptosis ■ 791 

Intestinal  Catarrh 792 

Diarrheas  of  Children 800 

Acute  Gastro-intestinal  Catarrh 800 

Celiac  Disease 805 

Phlegmonous  Enteritis 805 

Croupous  or  Diphtheritic  Enteritis      805 

Sjirue  (Psilosis) 806 

Cholera  Morbus 807 

Intestinal  Infarction 808 

Intestinal  Ulcers 809 

Duodenal  Ulcer 809 

Follicular  Ulcers 811 

Stercoral  Ulcers 811 

Simple  Ulcerative  Colitis 811 

Solitary  Ulcers 812 

Diffuse  Catarrhal  Ulcer      812 

Cancerous  Ulcer 812 

Appendicitis 812 

Chronic  Appendicitis 824 

Recurrent  Appendicitis 825 

Intestinal  Obstruction •   .  828 

Carcinoma  of  the  Intestine 835 

Habitual  Constipation 838 

Dilatation  of  the  Colon 842 

Neuroses  of  the  Intestine 842 

Secretory  Disturbances 842 

Membranous  Enteritis 842 

Sensory  Disturbances 843 

Enteralgia 843 

Diminished  Intestinal  Sensibility 844 


CONTENTS.  11 

PAGE 

Disturbances  of  Motility 845 

Nervous  Diarrhea 845 

Enterospasm 845 

Constipation 846 

IX.  DISEASES  OF  THE  LIVER. 

Anomalies  in  Shape  and  Position 847 

Jaundice 848 

Catarrhal  Jaundice 849 

Other  Forms  of  Jaundice 852 

Acute  Infectious  Cholecystitis 853 

Biliar}'  Calculi 854 

Chronic  Obstruction  of  the  Duct  by  Gall-stones 856 

Obstruction  of  the  Common  Duct 856 

Obstruction  of  the  Cystic  Duct 858 

More  Remote  Effects  of  Gall-stones 858 

Carcinoma  of  the  Bile-ducts 862 

Stenosis  of  the  Bile-ducts 863 

Icterus  Neonatorum 865 

Vascular  (Circulatory)  Affections  of  the  Liver 866 

Anemia 866 

Hyperemia 866 

Acute  Hyperemia 866 

Passive  Hyperemia 866 

Diseases  of  the  Portal  Vein 867 

Thrombosis  and  Embolism 867 

Suppurative  Pylephlebitis 868 

Stenosis 870 

Affections  of  the  Hepatic  Blood-vessels  ■    •  <,; 870 

Atrophy  and  Hypertrophy  of  the  Liver 870 

Hepatic  Infiltrations  and  Degenerations 871 

Amyloid  Infiltration 871 

Fatty  Infiltration 873 

Fatty  Degeneration 874 

Perihepatitis 875 

Acute  Perihepatitis 875 

Chronic  Perihepatitis 877 

Abscess  of  the  Liver '. 878 

Acute  Yellow  Atrophy 883 

The  Liver  in  Phosphorus-poisoning 885 

Cirrhosis  of  the  Liver ' 887 

Carcinoma  of  the  Liver 895 

Other  New  Growths  in  the  Liver 900 

X.  DISEASES  OF  THE  SPLEEN. 

Dislocation  of  the  Spleen 901 

Splenic  Hyperemia 901 

Splenitis 902 

Amyloid  Degeneration  of  the  Spleen 904 

Morbid  Growths  of  the  Spleen 904 

Rupture  of  the  Spleen 905 

XI.   DISEASES  OF  THE  PANCREAS. 

Acute  Pancreatitis 905 

Hemorrhagic  Pancreatitis 905 

Suppurative  Pancreatitis 907 

Gangrenous  Pancreatitis 907 

Chronic  Pancreatitis 908 

Pancreatic  Hemorrhage 909 

Carcinoma  of  the  Pancreas 910 

Other  Tumors  of  the  Pancreas 912 

Pancreatic  Cyst 912 

Pancreatic  Calculi 913 


12  CONTENTS. 

XII.  DISEASES  OF  THE  PERITONEUM. 

PAGE 

Acute  Peritonitis , 914 

Peritonitis  in  Children , 918 

Localized  or  Partial  Peritonitis 918 

Chronic  Peritonitis      923 

Ascites 926 

New  Growths  in  the  Peritoneum 930 

Carcinoma  of  the  Peritoneum 930 

Other  Tumors  of  the  Peritoneum 932 

Fibromata  and  Lipomata 932 

PART  VII DISEASES   OF   THE   URINARY    SYSTEM. 

I.  DISEASES  OF  THE   KIDNEY. 

Mobility  of  the  Kidney     .    .    _. 933 

Circulatory  Disorders  of  the  Kidneys 937 

Active  Hyperemia 937 

Passive  Hyperemia 937 

Special  Pathologic  States  of  the  Urine 938 

Hematuria •    ■•    •  938 

Hemoglobinuria 940 

Albuminuria 942 

Pejttonuria  and  Albumosuria 945 

Indicanuria 945 

Pyuria 946 

Chvluria 947 

Choluria 948 

Urobilinuria 949 

Glycosuria 949 

Acetonuria,  Diacetonuria,  and  Oxybutyria 952 

Lithuria 953 

Oxaluria 954 

Phosphaturia _.   • 955 

Leucinuria  and  Tyrosinuria 956 

Cystinuria > 956 

Various  other  Conditions 957 

The  Nephritides 959 

Morphologic  Constituents  of  the  Urine  in  Kenal  Disease 959 

Dropsy  of  Renal  Disease 961 

Uremia 962 

Amyloid  Kidney 966 

Nephrolithiasis 968 

Acute  Nephritis      974 

Chronic  Nephritis  (Exudative) 981 

Chronic  Nephritis  (Non-exudative) 985 

Pyelitis 993 

Hydronephrosis 997 

Perinephric  Abscess 1000 

Cystic  Kidney •    ■    •  1002 

New  Growths  of  the  Kidney 1003 

II.  DISEASES  OF  THE  BLADDER. 

Cystitis 1006 

Acute  Cystitis 1006 

Chronic  Cystitis 1009 

Neoplasms  of  the  Bladder 1011 

Vesical  Hemorrhage 101 1 

Neuroses  of  the  Bladder 1012 

Irritability  of  the  Bladder 1012 

Neuroses  of  Micturition 1014 

PART  VIII.— DISEASES  OF  THE  NERVOUS  SYSTEM. 

Introduction 1017 


CONTENTS.  13 

I.    DISEASES  OF  THE  PERIPHERAL  NERVES. 

PAGE 

Neuritis 1028 

Beri-beri 1031 

Neuromata 1032 

Neuralgia      ,    .    . 1033 

Tic  Douloureux 1034 

Neuralgia  of  the  Neck  and  Trunk 1035 

Neuralgia  of  the  Extremities 1036 

Diseases  of  the  Cranial  Nerves 1038 

Diseases  of  the  Olfactory  Nerve 1038 

Diseases  of  the  Retina,  Optic  Nerve,  and  Tract 1039 

Diseases  of  the  Motor  Nerves  of  the  Eyeball 1043 

Diseases  of  the  Fifth  Nerve 1047 

Diseases  of  the  Seventh  or  Facial  Nerve 1048 

Diseases  of  the  Auditory  Nerve .      1051 

Meniere's  Disease 1053 

Diseases  of  the  Glosso-pharyngeal  Nerve 1054 

Diseases  of  the  Pneumogastric  Nerve 1054 

Diseases  of  the  Spinal  Accessory  Nerve 1058 

Torticollis 1058 

Paralysis  of  the  Spinal  Accessory  Nerve 1060 

Diseases  of  the  Hypoglossal  Nerve 1060 

Diseases  of  the  Spinal  Nerves 1062 

Diseases  of  the  Cervical  Plexus 1062 

Diseases  of  the  Brachial  Plexus 1062 

Diseases  of  the  Lumbar  and  Sacral  Plexuses 1064 

Acute  Ascending  Paralysis 1065 


II.    DISEASES  OF  THE   SPINAL  CORD  AND  ITS  MENINGES. 

Diseases  of  the  Meninges 1067 

Pachymeningitis 1067 

Leptomeningitis 1068 

Acute  Leptomeningitis 1068 

Chronic  Leptomeningitis 1069 

Hemorrhage  into  the  Spinal  Meninges 1069 

Disturbances  of  Circulation  in  the  Cord 1070 

Hemorrhage  into  the  Spinal  Cord 1071 

Acute  Myelitis - 1072 

Clironic  Myelitis      1074 

Anterior  Poliomyelitis 1076 

Essential  Paralysis  of  Children 1076 

Acute,  Subacute,  and  Chronic  Poliomyelitis  in  Adults 1078 

Abscess  of  the  Spinal  Cord 1078 

Unilatei-al  Lesion  of  the  Spinal  Cord 1079 

Locomotor  Ataxia 1081 

Hereditary  Ataxia 1086 

Spastic  Paraplegia 1087 

Primary  Lateral  Sclerosis 1088 

Secondary  Spastic  Paralysis 1089 

Congenital  Spastic  Paraplegia 1089 

Ataxic  Paraplegia 1089 

Combined  System  Sclerosis 1090 

Eeflex  Paraplegia 1091 

Intermittent  Paraplegia •   .    .  1091 

Multiple  Sclerosis 1091 

Pseudosclerosis 1094 

Bulbar  Paralysis      1094 

Amyotrophic  Lateral  Sclerosis 1095 

Syringomyelia 1097 

Compression  of  the  Spinal  Cord 1098 

Tumors  of  the  Spinal  Cord  and  its  Membranes 1100 

Lesions  of  the  Conus  Terminalis  and  the  Cauda  Equina 1103 


14  CONTENTS. 

III.    DISEASES  OF  THE   BRAIN   AND   ITS   MENINGES. 

PAGE 

Diseases  of  the  Dura  Mater 1104 

Diseases  of  the  Pia 1105 

Disturbances  of  Circulation  of  the  Brain 1107 

Hyperemia 1107 

Anemia 1108 

Edema  of  the  Brain ■         1108 

Embolism  and  Thrombosis 1109 

Vascular  Degeneration 1112 

Inflammation  of  the  Brain 1113 

Focal  Encephalitis 1113 

Diffuse  Encephalitis 1114 

Cerebral  Hemorrhage 1115 

Aphasia 1120 

Intracranial  Growths 1124 

Chronic  Hydrocephalus 1128 

External  Hydrocephalus 1128 

Internal  Hydrocephalus 1128 

Sclerosis  of  the  Brain 1 1 30 

General  Paralysis  of  the  Insane 1131 

Cerebral  Palsies  of  Childhood 1133 

Acute  Delirium 1135 

IV.    DISEASES  OF   UNKNOWN   PATHOLOGY. 

Epilepsy 1137 

Migraine 1142 

Acute  Chorea 1144 

Huntingdon's  Chorea      1147 

Rhythmic  Chorea 1148 

Choreiform  Disorders 1148 

Paramyoclonus  Multiplex 1148 

Chorea  Electrica 1148 

Fibrillary  Chorea 1150 

Athetosis 1150 

Habit-spasm 1152 

General  Tic 1152 

Saltatoric  Spasm 1154 

Chorea  Major 1154 

Paralysis  Agitans 1154 

Other  Forms  of  Tremor 1156 

Tetany 1156 

Infantile  Convulsions 1159 

Occupation-Neuroses 1161 

Periodic  Paralysis 1163 

Hysteria    .    .  " 1164 

Neurasthenia 1174 

Acromegaly 1179 

Astasia-abasia 1181 

Caisson  Disease 1182 


V.  VASOMOTOR  AND  TROPHIC  DISORDERS. 

Angioneurotic  Edema 1184 

Hydrops  Articulorum  Intermittens 1185 

Raynaud's  Disease ^'^^ 

Progressive  Hemiatrophy  of  the  Face 1187 

Scleroderma  Diffusum 1189 

Morphea 1190 

Ainhum 1190 

Erythromelalgia 1191 

Acroparesthesia ....  1192 

Meralgia  Panesthetica 1193 


CONTENTS.  15 

PART   IX.— DISEASES   OF  THE   MUSCLES. 

PAGE 

Myositis 1195 

Infectious  Myositis 1195 

Progressive  Ossifying  Myositis 1196 

Progressive  Spinal  Muscular  Atrophy ■ 1196 

Progressive  Neural  Muscular  Atrophy 1197 

Pseudo-hypertrophic  Muscular  Paralysis 1199 

Dystrophia  Musculorum  Progressiva  {Erh) 1200 

Dystrophia  Musculorum  Progressiva  (Dejerine-Landouzy) 1202 

Hereditary  Muscular  Paralysis 1203 

Arthritic  Muscular  Atrophy 1203 

Muscular  Atrophies 1204 

Muscular  Hypertrophy ; 1204 

Thomsen's  Disease 1204 

PART  X.— THE   INTOXICATIONS;    0BE5ITY ;    HEAT=STROKE. 

The  Intoxications 1207 

Alcoholism 1207 

Ginger  and  Cologne- water  Inebriety 1214 

Morphinism 1214 

Plumbism 1216 

Arsenicism 1219 

Mercurialism 1220 

Food-infection  and  Ptomain-poisoning 1222 

Grain-  and  Vegetable-poisoning 1224 

Obesity 1226 

Heat-stroke • •    • 1280 

PART  XL— ANIMAL  PARASITIC  DISEASES. 

Psorospermiasis 1236 

Distomiasis 1237 

Nematodes 1288 

Ascariasis 1238 

Ankylostomiasis , 1242 

Trichiniasis 1243 

Filariasis • 1247 

Dracontiasis 1249 

Other  Filariffi • 1250 

Other  and  Uncommon  Nematodes 1250 

Cestodes 1251 

Tsenise  or  Tape-worms 1256 

Tsenia  Nana 1260 

Taenia  Cucumerina 1260 

Taenia  Flavopunctata     .    .    ■ 1260 

Parasitic  Arachnida 1260 

Other  Parasitic  Insects 1261 

Pediculosis 1261 

Cimex  Lectularius 1262 

Pulex  Irritans 1262 

Pulex  Penetrans 1262 

Ixodes    1263 

Dermanyssus  Avium  et  Gallinae 1263 

Culicidse 1263 

Hirudo 1263 

Estridse 1263 

Muscidffi '. o    .    .  1263 


PART   I. 

INFECTIOUS    DISEASES. 


TYPHOID   FEVER. 

{Enteric  Fever:  Abdominal  Typhus;  lleo-typlwid :  Kerven  Fieber.) 

Definition. — An  acute  infectious  disease  of  which  the  definitive 
cause  is  the  specific  bacillus  of  Eberth,  It  is  characterized,  patholog- 
ically, by  hyperplasia  and  sloughing  of  Peyer's  patches ;  and  clinically 
by  its  slow,  insidious  onset,  peculiar  temperature-curve,  swelling  of  the 
spleen,  rose-colored  spots,  diarrhea,  tympanites,  and  a  liability  to  cer- 
tain complications  (intestinal  hemorrhage,  peritonitis,  etc.).  The  disease 
has  an  average  duration  of  from  three  to  four  weeks. 

History. — Although  known  beyond  the  reach  of  tradition,  typhoid 
fever  was  clearly  distinguished  from  typhus  at  a  comparatively  recent 
date.  Louis  of  Paris -in  1829  proposed  the  term  typhoide^  but  it  re- 
mained for  Gerhard  of  Philadelphia  to  discriminate  typhoid  from 
typhus  fever  as  the  result  of  his  own  precise  clinical  observations. 
His  account  of  the  disease  was  ably  corroborated  by  the  writings  of 
E.  Hale  and  James  Jackson,  Sr.  (1838,  1839).  Later,  Shattuck  of 
Boston  and  Jenner  of  London  made  important  contributions  to  the 
subject.  Shattuck's  experiments  on  typhus  and  typhoid  fevers  at  the 
London  Fever  Hospital  in  England,  and  Alfred  Stille's  studies  of  the 
former  afi"ection  in  Dublin  and  Naples,  and  of  the  latter  in  Paris,  in- 
creased greatly  our  knowledge  of  these  diseases.  As  a  result  of  the 
labors  of  the  above-mentioned  American  authors  the  ti'ue  nature  and 
identity  of  typhoid  fever  were  appreciated  in  America  at  an  earlier  day 
than  in  either  France  or  England. 

Briefly,  the  decade  from  1840  to  1850  witnessed,  on  the  one  hand, 
the  overthrow  of  erroneous  notions  concerning  the  similarity  of  typhoid 
and  typhus  fevers,  and,  on  the  other,  the  establishment  of  their  points 
of  dissimilarity. 

Pathology. — The  lesions  produced  by  typhoid  fever  may  conve- 
niently be  divided  into  two  groups :  (1)  Primary  lesions,  due  to  the 
direct  efi"ect  of  the  special  bacillus  upon  the  lymph-follicles  of  the 
intestines,  the  mesenteric  and  other  lymph-glands,  and  the  spleen. 
(2)  Secondary  lesions,  due  chiefly  to  the  long-continued  fever  and  to 
secondary  infection,  for  the  occurrence  of  which  the  essential  lesions 
of  typhoid  fever  furnish  the  golden  opportunity. 

(1)  The  primary  morbid  changes  in  the  Peyer's  patches  and  solitary 
glands  of  the  intestines  are  divided,  usually,  into  four  stages : 

(a)  The  Stage  of  Infiltration. — The  lymph-follicles  become  engorged 

2  17 


18  INFECTIOUS  DISEASES. 

(hyperplasia),  particularly  Peyer's  glands  in  the  ileum  and  near  to  the 
valve,  and,  to  a  lesser  extent,  in  the  lower  part  of  the  jejunum.  Fre- 
quently, the  solitary  glands  in  the  small  intestines,  the  colon,  and  rarely 
the  rectum,  become  similarly  infiltrated.  In  about  33  per  cent,  of  the 
cases  the  chief  morbid  lesions  are  confined  to  the  large  intestines.  In 
mild  cases  a  few  Peyer's  patches  in  the  lower  part  of  the  ileum  are  alone 
the  seat  of  infiltratioE  and  subsequent  changes.  The  follicles  are  grayish- 
white  in  color,  and  may  project — particularly  the  patches  of  Peyer — 
from  3  to  5  mm.  or  more.  Rarely,  the  solitary  glands,  which  vary  in 
size  from  a  mustard-seed  to  a  large  pea,  become  very  prominent  and 
show  a  bold  attempt  at  pedunculation. 

The  histologic  changes  at  first  consist  in  a  marked  dilatation  of  the 
capillary  blood-vessels,  which  later  are  more  or  less  compressed  (as  a 
consequence  of  cell-infiltration),  giving  to  the  follicles  their  whitish, 
anemic  appearance.  The  cellular  elements  partake  of  the  nature  of 
lymph-corpuscles.  Some  of  these  cells  are  larger  and  are  epithelioid 
in  character,  with  ten  or  more  nuclei.  The  mucosa  and  muscularis  ad- 
jacent to  the  glandular  structures  may  be  similarly  infiltrated. 

From  the  eighth  to  the  tenth  day  the  stage  of  infiltration  terminates 
either  in  resolution  or  in  necrosis  and  sloughing.  The  infiltrated  cells 
may  undergo  granular  or  fatty  degeneration,  followed  by  absorption. 
This  process — resolution — during  its  progress  produces  pitting  of  the 
swollen  follicles.  In  consequence  of  these  minute  points  of  necrosis 
the  plaques  now  present  a  characteristic  reticulated  appearance  (plaques 
a  surface  reticulee).  AVhen  resolution  occurs,  accomj»anied  by  destruc- 
tion of  the  follicles,  small  hemorrhages  may  take  place  into  the  glandu- 
lar structure.  These  hemorrhages  may  occasion  pigmentary  deposits  in 
the  follicular  depressions,  giving  rise  to  the  so-called  "shaven-beard" 
appearance.  Resolution,  however,  terminates  the  stage  of  medullary 
infiltration  with  comparative  infrequency.  Far  more  frequently  the 
hyperplasia  of  the  lymph-follicles  ends  in 

{h)  Necrosis  or  Sloughing. — In  all  save  the  milder  grades  of  cell- 
infiltration  the  hyperplasia  of  the  lymphatic  tissue  cannot  subside 
before  necrosis  occurs.  The  latter  process  results  partly  from  com- 
pression and  choking  of  the  blood-vessels  by  the  cell-infiltration,  and 
partly  from  the  direct  action  of  the  typhoid  bacillus,  leading  to  so-called 
anemic  necrosis.  Thus,  necrotic  crusts  (sloughs)  are  formed.  Avhich  are 
gradually  separated  and  cast  off".  While  not  all  of  the  glands  of  Peyer 
which  are  the  seat  of  cellular  infiltration  undergo  subsequent  necrosis, 
as  a  rule  those  situated  in  the  lower  portion  of  the  ileum  do,  and  show 
the  process  in  its  completest  development.  The  depth  to  which  the 
necrosis  extends  is  quite  variable.  It  may  involve  only  the  most  super- 
ficial layers  of  the  mucosa,  or  it  may  extend  in  depth  till  it  reaches,  or 
even  perforates,  the  outer  or  serous  coat ;  but  usually  this  work  of 
destruction  does  not  dip  below  the  submucosa  or  muscularis.  The 
necrosed  portions  become  detached — a  process  that  proceeds-  from  the 
periphery  toward  the  center — leaving  behind  the  typhoid  ulcer.  The 
stage  of  necrosis  and  sloughing  begins  between  the  eighth  and  tenth 
days,  and  ends  on  or  about  the  twenty-first  day. 

{c)  Stage  of  Ulceration. — The  size  and  shape  of  the  ulcers  corre- 
spond exactly  to  the  necrosed  areas  in  these  respects.     A  single  gland 


TYPHOID  FEVER.  19 

of  Peyer  generally  presents  several  ulcers  of  irregular  outline  separated 
by  strips  of  mucous  membrane.  Rarely,  the  entire  plaque  is  implicated, 
in  which  case  a  large  oval  ulcer  is  the  result,  and  at  the  lower  end  of  the 
ileum  the  ulcers  often  coalesce  until  they  almost  encircle  the  bowel.  The 
ulcers  of  the  solitary  glands  assume  a  rounded  form.  The  character 
of  the  floor  of  the  ulcer  will  vary  with  the  character  of  the  intestinal 
coat  which  forms  its  base,  though  usually  it  is  clean  and  smooth.  The 
edges  are  usually  irregular,  engorged,  soft,  and  frequently  overhanging. 
In  the  lower  segment  of  the  ileum  ulcers  may  be  numerous,  Avhilst  in 
other  portions  of  the  gut  Peyer's  plaques  may  be  merely  hyperemic. 
In  about  25  per  cent,  of  the  cases  the  typhoid  ulcers  are  found  in  the 
large  intestines — i.  e.  in  the  cecum  and  colon.  Perforation  of  the 
large  bowel  is  exceedingly  rare.  Exceptionally,  the  appendix  is  the 
seat  of  ulcer,  and  in  a  recent  case  of  my  own  that  came  to  autopsy  per- 
foration had  occurred  during  the  fourth  week  of  the  disease.  Localized 
abscesses  have  been  found  under  these  circumstances. 

Hemori'hage  usually  results  from  erosion  of  a  vessel — an  accident 
which  is  occasioned  by  the  separation  of  the  sloughs — but  small  bleed- 
ings may  take  place  from  the  swollen,  hyperemic  edges  of  an  ulcer. 
Perforation  of  the  bowel  occurs  in  a  small  percentage  of  cases  (about 
6  per  cent.).  In  the  inajority  of  instances  it  is  attributed  to  a  perfora- 
tive necrosis ;  hence  it  is  that  the  sloughs  are  usually  found  attached 
to  the  orifice.  Perforation  may  also  occur  after  the  separation  of  the 
necrosed  portions  during  the  stage  of  ulceration.  The  perforations  may 
be  multiple,  though  they  are  usually  single  and  rarely  exceeding  two  in 
number.  The  small,  deep  ulcers  are  more  apt  to  lead  to  complete  per- 
foration than  larger  ones,  and  the  site  of  the  orifice  is  usually  some- 
where in  the  course  of  the  lower  third  of  the  ileum.  The  lesions  of 
peritonitis  are  invariably  present,  and  during  the  stages  of  necrosis 
and  ulceration  a  catarrhal  state  of  the  mucosa  of  the  small  and  large 
intestines  exists.  The  diarrhea  which  usually  accompanies  this 
aifection  is  to  be  ascribed  chiefly  to  the  catarrhal  state  of  the  large 
bowel. 

{d)  Healing  follows  promptly  upon  the  formation  of  the  ulcer.  At 
first  a  granular  tissue  covers  its  floor.  The  mucous  membrane  is 
replaced,  including  the  glandular  elements  and  epithelial  layer,  and,  as 
in  the  stage  of  necrosis  and  sloughing,  so  the  healing  process  advances 
inward  from  the  border  of  the  ulcer.  Indeed,  it  is  this  process  that  dis- 
lodges the  necrotic  crust.  Occasionally,  ulcers  are  seen  extending  in 
one  direction  while  healing  in  another.  The  cicatrix  formed  by  the 
healing  of  an  ulcer  presents  a  smooth  and  often  pigmented  surface. 

The  stages  thus  far  described  do  not,  strictly  speaking,  follow  one 
another,  since  two  or  more  may  be  illustrated  at  once  by  a  group  of 
ulcers  occupying  the  same  section  of  the  intestine.  Again,  when  death 
occurs  during  a  relapse  fresh  ulcers  are  observed  by  the  side  of  others 
that  are  partially  healed. 

The  Mesenteric  Grlands. — Changes  in  the  mesenteric  glands  occur 
simultaneously  with  those  in  the  intestines,  and  those  situated  opposite 
to  the  lower  third  of  the  ileum,  the  portion  of  the  bowel  showing  the 
most  extensive  ulceration,  are  most  profoundly  involved.  Hyperemia, 
and    later    swelling    due   to    cell-infiltration,    are    among     the    earliest 


20  INFECTIOUS  DISEASES. 

changes,  and  correspond  with  the  lesions  noted  in  the  intestines  {vide 
supra).  The  mesenteric  glands  exhibit  great  variations  in  size,  rang- 
ing, as  they  do,  from  that  of  a  pea  to  a  hen's  egg.  Their  color-appear- 
ance is  a  grayish-red.  Resolution  occurs  quite  commonly,  but,  if  it 
does  not  take  place,  then  necrosis  of  the  central  portion  (due,  most 
probably,  to  the  same  causes  that  produce  necrosis  of  the  intestinal 
lymph-follicles)  occurs,  and  suppuration  has  been  observed  in  some 
cases.  Still  other  glands  become  hyperemic  and  swollen  (retroperi- 
toneal,  bronchial) ;   but  these  usually  tend  toward  resolution. 

Tlie  Spleen. — With  rare  exceptions  the  spleen  becomes  enlarged  in 
typhoid  fever.  At  first  hyperemic,  the  tissue  then  grows  soft  and  gran- 
ular, and  at  times  is  almost  diffluent  on  section.  Infarction  is  not  a  rare 
occurrence  and  may  lead  to  suppuration.  Keen  has  searched  the  litera- 
ture and  found  only  9  cases  of  abscess.  In  rare  instances,  either  spon- 
taneously or  as  the  result  of  injury,  a  rupture  of  the  organ  may  occur, 
and  the  records  of  2000  post-mortems  at  the  Munich  Pathologic  Insti- 
tute furnish  5  cases. 

(2)  Secondary  Lesions  due  chiefly  to  the  Continued  Fever  and  to  Sec- 
ondary Infections. — The  lesions  in  other  organs  are  of  subsidiary  import- 
ance, and  are,  for  the  most  part,  secondary  in  nature,  though  we  can- 
not, in  the  present  state  of  our  knowledge,  draw  a  sharp  line  of  dis- 
tinction between  these  lesions  and  those  that  are  primary.  While  the 
pathologic  changes  above  described  are  chiefly  due  to  the  direct  action 
of  the  specific  bacillus  of  typhoid,  yet  a  few  of  them  are  ascribed  to 
secondary  infection,  and,  at  all  events,  they  do  not  belong  peculiarly  to 
this  disease — e.  g.  suppurative  processes,  etc.  Further,  in  connection 
with  the  clinical  history  of  the  affection  I  shall  point  out  that  in  a 
small  percentage  of  cases  the  initial  specific  lesions  may  be  localized, 
either  in  the  throat  or  in  the  lungs  or  kidneys.  It  is  to  be  emphasized, 
therefore,  that  whilst  the  essential  pathologic  processes  of  the  disease 
have  been  described  above,  a  classification  of  the  lesions  into  primary 
and  secondary,  based  upon  the  involvement  of  particular  organs,  can 
only  be  approximately  correct. 

The  liver  early  becomes  hyperemic,  and  later  is  softer  and  paler  than 
is  natural.  Handford  has  described  necrotic  areas,  and  Wagner  minute 
lymphomata.  Infarction  and  abscess  occur  in  rare  instances.  The 
gall-bladder  may  show  catarrhal  inflammation,  and  rarely  a  croupous, 
diphtheritic,  or  ulcerative  inflammation  leading  to  perforation.  West- 
cott  has  tabulated  30  cases  of  typhoid  infection  of  the  gall-bladder  that 
resulted  in  perforation.     The  bile  is  thin  and  j)ale. 

The  microscope  reveals  parenchymatous  and  granular  degeneration. 
The  cells  contain  an  abundance  of  fat,  whilst  their  nuclei  have  lost,  in 
great  part,  their  outline. 

The  kidnegs,  like  the  liver,  exhibit  parenchymatous  degeneration. 
They  are  somewhat  pale-looking,  are  cloudy  on  section,  and  slightly 
swollen,  and  under  the  microscope  granular  and  fatty  degeneration  of 
the  epithelial  cells  of  the  convoluted  tubules  is  observed.  More  rarely 
the  lesions  are  those  of  aciite  hemorrhagic  nephritis.  Small  areas  of 
round-cell  infiltration  may  develop  late  in  the  course  of  typhoid,  and 
these  may  present  an  appearance  similar  to  lymphomata  or  may  undergo 
softening  and  suppuration,  giving  rise  to  miliary  abscesses.     The  mu- 


TYPHOID  FEVER.  21 

cous  membrane  of  the  pelvis  of  the  kidney  is  not  infrequently  the  seat 
of  a  mild  grade  of  catarrh,  and,  rarely,  of  diphtheritic  iniiammation. 
Vesical  catarrh  is  still  more  common,  and  the  bladder  may  also  be  the 
seat  of  diphtheritic  inflammation.  Earely  orchitis  is  encountered.  On 
making  cultures  from  sections  of  the  kidneys  not  a  few  observers  have 
been  able  to  demonstrate  the  specific  bacillus  of  typhoid,  particularly  in 
the  softened  areas. 

In  the  lungs  are  found  morbid  lesions  in  nearly  all  cases  of  typhoid 
fever,  and  belonging  to  the  essential  pathologic  processes  is  bronchitis, 
due  to  a  congested  and  catarrhal  state  of  the  bronchial  mucous  mem- 
brane.  The  lesions  of  lobular  pneumonia  present  a  complicating  con- 
dition in  many  instances  ;  those  of  lobar  pneumonia  also  may  be  present, 
though  less  commonly.  The  so-called  hypostatic  congestion  is  often 
found,  but  is,  I  think,  less  frequent  than  is  supposed  by  many  authors. 
Embolic  infarctions,  having  their  origin  in  thrombi  occupying  the  right 
side  of  the  heart,"  are  sometimes  present.      Gangrene  may  also  occur. 

Pleurisy  is  sometimes,  though  rarely,  met  Avith.  It  is  most  fre- 
quently of  the  plastic  variety,  although  empyema  occurred  in  nearly  2 
per  cent,  of  the  Munich  cases. 

The  larynx  and  the  pharynx  may  manifest  changes.  Ulcers  have 
been  observed  on  the  epiglottis  and  posterior  wall  of  the  larynx,  and  I 
have  more  than  once  seen  them  on  the  pharynx.  When  situated  in  the 
larynx  they  may  extend  in  depth  till  they  reach  the  perichondrium, 
causing  perichondritis,  with  or  without  edema  of  the  larynx  as  an 
associated  lesion.  Typhoid  bacilli  have  been  found  in  the  ulcers  (Eich- 
horst).  Catarrhal,  or  even  croupous,  pharyngitis  may  occur,  and  a 
swelling  of  the  follicles  of  the  pharynx  and  base  of  the  tongue  is  to  be 
noticed  in  many  cases.  True  aphthous  changes,  affecting  the  mouth 
and  pharynx,  may  be  present  as  a  secondary  event.  The  mucosa  of  the 
stomach  is  sometimes  congested,  and  may  even  ulcerate,  although  this  is 
very  rarely  seen. 

Peritonitis  is  always  found  in  fatal  cases  in  which  the  bowel  has  been 
perforated.  The  condition  is  a  general  one,  save  in  the  rare  instances 
mentioned  below,  and  there  is  usually  much  fibrino-purulent  effusion 
present.  Diffuse  peritonitis  may  be  present  without  perforation,  and 
results  sometimes  from  a  localization  of  the  typhoid  poison  in  the  peri- 
toneum, from  rupture  of  suppurating  mesenteric  glands,  but  more  fre- 
quently, I  think,  from  direct  extension  of  intestinal  inflammation  to  the 
peritoneum. 

The  hea7't  may  be  the  seat  of  morbid  changes.  Acute  endocarditis 
may  be  a  very  rare  complication,  while  pericarditis  occurs  relatively 
more  often — viz.  in  14  of  the  Munich  post-mortems  before  mentioned. 
Myocarditis  is  a  not  uncommon  event,  the  cardiac  muscle  exhibiting 
parenchymatous  and,  less  commonly,  hyaline,  degeneration,  and  the  lat- 
ter change  sometimes  leads  to  sudden  rupture  of  the  muscular  fibers, 
with  a  fatal  result  (myocardite  segmentaire).  It  is,  however,  a  signif- 
icant fact  that  in  the  majority  of  instances,  even  of  the  severest  type, 
the  cell-fibers  may  show  slight,  if  any,  noticeable  change.  Out  of  48 
cases,  16  showed  granular  or  fatty  degeneration,  and  3  a  proliferative 
endarteritis  in  the  small  vessels  (Dewevre). 

The  arteries  have,  in  a  number  of  instances,  been  found  to  be  the 


22  INFECTIOUS  DISEASES. 

seat  of  tvro  forms  of  arteritis  (Barie) :  (a)  Acute  obliterating  arteritis, 
and  (b)  Partial  arteritis.  These  conditions  may  affect  the  smaller  ves- 
sels, particularly  those  of  the  heart,  but  they  occur  most  commonly  in 
the  arteries  of  the  lower  extremities.  Thrombi  are  found  in  the  right 
chambers  of  the  heart  and  in  the  veins — most  frequently  in  the  femoral, 
and  less  often  in  the  cerebral  sinuses. 

The  voluntary/  muscles  undergo  parenchymatous  and,  occasionally,  a 
hyaline,  change,  though  this  is  not  a  feature  peculiar  to  typhoid  fever. 
The  latter  form  of  degeneration  does  not  affect  the  whole  muscle,  only 
certain  fibers  being  involved,  and  as  a  rule  the  recti  abdominis,  the  dia- 
phragm.  the  adductors  of  the  thigh,  and  the  pectorals  are  the  seats  of 
the  lesion.  The  parts  affected  are  pale  and  possess  a  grayish,  waxy 
luster.  Histologically,  the  process  implies  the  transformation  of  the 
muscular  fibers,  and  especially  the  cement  substance,  into  a  homogeneous, 
pliable  mass.  Regeneration  of  the  fibers  thus  destroyed  occurs  during 
convalescence. 

The  nervous  system  presents  no  gross  lesions,  if  we  except  menin- 
gitis, the  latter  occurring  as  a  complication  ;  but  it  is  exceedingly  rare, 
having  been  present  in  only  11  of  the  2000  Munich  cases.  In  a  few 
instances  large  cerebral  hemorrhages  have  been  met  with,  but  these  are 
apparently  coincidental,  while  capillary  hemorrhages  into  the  cortex 
may  be  numerous.  Meningeal  hemorrhages  may  also  occur.  Slight 
edema  of  the  cerebral  cortex  has  been  noted.  The  peripheral  nerves 
are,  not  infrequently,  the  seat  of  parenchymatous  change,  with  or  with- 
out local  neuritis,  and  the  ganglia  of  the  trunks  of  the  vagi  exhibit  an 
inflammatory  change,  which  Levin  feels  is  the  cause  of  certain  symp- 
toms and  conditions,  such  as  laryngitis,  pharyngitis,  pharyngolysis, 
arrhythmia,  etc. 

The  blood  shows  few  important  alterations.  The  red  blood-corpuscles 
are  relatively  increased  during  the  febrile  period  and  markedly  dimin- 
ished durinw  convalescence,  but  the  orreat  loss  of  water  durincr  the 
former  period  and  a  reabsorption  during  the  latter  will  explain  these 
interesting  facts  (Henry).  Leukocytosis  is  absent,  and  there  is  often  an 
actual  decrease  in  the  number  of  leukocytes.  The  mononuclear  forms 
are  more  numerous  than  in  health. 

Btiologfy. — Bacteriology. — The  bacterium  which  is  the  specific  cause 
of  typhoid  fever  was  discovered  by  Eberth.  whose  researches  were  later 
confirmed  by  the  careful  investigation  of  Gaffky. 

General  Characters. — It  is  a  short,  thick  bacillus,  about  three  times  as 
long  as  it  is  broad,  with  rounded  ends  (Fig.  1).  It  is  motile,  due  to  the 
presence  of  cilia  on  both  sides,  and  when  stained  exhibits  vacuolations 
that  have  been  mistaken  for  spores.  It  is  easily  stained  with  all  the 
anilin  dyes. 

Characteristic  Growth. — L^pon  gelatin  plates  it  develops  in  grayish 
translucent  colonies  with  irregular  borders  and  ridged  surfaces.  Upon 
agar  the  growth  is  not  characteristic ;  upon  the  potato,  especially  if  it 
has  been  rendered  slightly  acid,  it  forms  a  perfectly  transparent  growth 
that  is  only  evident  as  a  slight  apparent  increase  of  moisture  upon  the 
surface,  and  as  offering  a  greater  resistance  to  the  point  of  the  needle 
when  scraped  across  it.  It  neither  coagulates  milk,  li(juefies  gelatin, 
nor  produces  indol.      The  organism  never  forms  spores.     Moreover,  the 


TYPHOID  FEVER.  23 

bacillus  has  no  greater  powers  of  resistance  than  the  ordinary  bac- 
teria. 

Experimental  Typhoid. — Inoculated  into  lower  animals,  the  bacillus 
frequently  causes  fatal  results  without  producing  the  lesions  characteris- 
tic of  typhoid  in  human  beings,  although  occasionally  typical  typhoid 
ulcers  have  been  found.    The  suscep-  ^ 

tibility  of  lower  animals,  though  nor- 
mally slight,  can  be  increased  by  pre- 
liminary   injections    of    saprophytic       ^^^^^^^^H  \ 

bacteria,  this  result  having  been  ob- 

served   by  Alessi  when   he   exposed    J^  {  \ 

animals  to  the  gases  produced  by 
putrefying   matters.       It  "  has    been 

found  that  the  ulcerative  intestinal  1 

lesions  produced  by  the  inoculation      ,•  .  «  / 

of  the  bacilli  or  their  toxins  in  large  ,    j.        ^  j  *         L 

quantities  into  the  blood  of  rabbits  r^''^       J  9,' 

may  also  be  caused  by  other  bacteria,  j      ^j 

including  the  bacillus  coli  commune.  .  ^ 

Usually  inmaking  a  bacteriologic  f^,.  i._Typhoid  bacmi  with  flageiia ;  x  looo. 
diagnosis  the  typhoid  bacillus  is  to  be 

diiferentiated  from  those  organisms  that  morphologically  resemble  it  and 
present  almost  identical  characteristics  upon  various  culture-media.  Par- 
ticularly is  this  true  of  the  bacterium  coli  commune,  which  can  noAv  be 
separated  from  the  bacillus  of  Eberth,  bacteriologists  having  pointed 
out  the  fundamental  difference  between  these  related  forms.  Smith  and 
Tennant,  in  a  study  of  the  1898  epidemic  of  typhoid  fever  in  Belfast, 
failed  to  find  typhoid  bacilli  in  the  water-supply,  but  were  able  to  isolate 
a  large  number  of  varieties  of  the  bacilli  coli  communis.  Occasional 
races  were  isolated,  which,  when  tested  with  the  serum  of  typhoid  pa- 
tients, showed  by  their  reactions  that  they  possessed  special  relation  to 
the  typhoid  disease. 

The  real  poison  of  typhoid  fever  is  most  probably  a  ferment  (?) 
secreted  by  the  bacillus — typJio-toxin ;  and  Brieger  has  extracted  the 
latter  agent,  finding  that  it  produces  the  fever,  nervous  symptoms,  and 
the  other  manifestations  characteristic  of  the  affection. 

Distribution  in  the  Body. — The  bacillus  has  been  found  in  the  intes- 
tinal tract,  the  lymph-glands,  the  contents  of  the  intestine,  the  spleen, 
the  liver,  and  the  blood.  The  bacillus  typhosus  is  demonstrable  in  the 
stools  (in  about  50  per  cent,  of  the  cases),  the  urine  (Wright  and  Semple), 
the  sputa,  the  vomita,  and  the  sweat.  Less  frequently  they  have  been 
found  in  foci  of  suppuration  and  in  exudations  (pleural,  endocardial, 
meningeal). 

The  Bacilli  Outside  the  Body. — The  bacilli  cannot  maintain  a  perma- 
nent existence  outside  the  human  body.  From  time  to  time,  however, 
the  conditions  indispensable  to  the  growth  and  development  of  the  ty- 
phoid germs  prevail,  and  corresponding  with  such  periods  of  time  more 
or  less  extensive  epidemic  outbreaks  of  the  disease  may  occur.  It  is 
known  that  the  typhoid  bacilli  may  retain  their  vitality  for  from  seven 
to  fourteen  days  in  water,  disappearing  from  the  same  on  account  of  the 


24  INFECTIOUS  DISEASES. 

presence  of  saprophytes  ;  but  an  epidemic  or  an  endemic  of  typhoid  fever 
implies  persistent  contamination  of  the  drinking-water.  Multiplication 
of  the  bacilli  may  take  place  in  water,  in  milk  (very  rapidly),  and  in  the 
soil  (where  they  preserve  their  vitality  under  favorable  conditions  for 
months).  Freezing  does  not  kill  them,  as  they  may  live  in  ice  for  sev- 
eral months  (Prudden).  They  have  been  discovered  in  infected  water, 
but  they  are  thoroughly  destroyed  by  boiling. 

Predisposing  Causes! — («)  Geographic  Location. — In  temperate  zones 
typhoid  fever  prevails  constantly  to  a  greater  or  less  extent,  and  is  the 
most  important  infection.  But,  though  the  disease  occurs  most  fre- 
quently in  temperate  climates,  it  cannot  safely  be  inferred  that  climate 
per  se  exerts  any  marked  influence  over  its  appearance.  Thus  it  has 
been  shown  in  recent  times  to  be  comparatively  common  in  the  tropics 
as  well  as  in  many  cold  latitudes  (Iceland,  Norway). 

(h)  Seasons  exert  a  decided  influence  upon  the  frequency  of  the 
occurrence  of  typhoid.  According  to  the  statistics  of  Murchison,  Bart- 
lett.  Osier,  Hirsh,  and  others,  the  time  of  greatest  liability  to  typhoid 
fever  is  during  the  late  summer  and  the  early  autumn  (August,  Septem- 
ber, and  October).  The  remaining  summer  and  autumn  months  yield  a 
relatively  larger  number  of  cases  than  the  winter  and  spring :  again,  in 
Avinter  more  cases  are  met  with  than  in  the  spring,  Avhich  furnishes  few- 
est number  of  cases.  After  hot  and  dry  summers  typhoid  fever  is  espe- 
cially apt  to  be  prevalent,  and,  according  to  Baumgarten,  a  relatively 
large  amount  of  dust  in  the  atmosphere  may  disseminate  the  typhoid 
germs. 

{c)  Condition  of  the  "  Ground  Soil." — I*cttenkofer  and  his  disciples 
contend  that  Avhen  the  standing  water  in  the  soil  reaches  a  high  level 
fewer  cases  occur,  and  when  it  fiills  to  a  low  level  or  below  the  mean 
height  the  cases  become  more  numerous.  This  dictum,  however,  has 
not  as  yet  been  conclusively  proven  with  reference  to  many  localities. 
Whilst  the  condition  of  the  soil  as  to  moisture,  etc.  cannot  explain  all 
of  the  peculiarities  noticeable  in  the  behavior  and  distribution  of  the 
disease,  certain  characteristics  of  the  soil  may  furnish  the  conditions 
essential  to  the  growth,  development,  and  multiplication  of  the  typhoid 
bacillus,  or  the  poisoned  foci  may  be  more  eifectively  drained  by  the 
springs  -and  streams  when  the  ground-water  is  low,  when  an  increased 
prevalence  of  the  disease  is  the  result.  It  is  certain  that  epidemics  of 
typhoid  fever  occur  repeatedly  without  regard  to  the  condition  of  the 
ground-water. 

(d)  Age. — Typhoid  fever  may  occur  at  any  age.  It  is,  however, 
especially  frequent  among  young,  robust  individuals  between  the  ages 
of  fifteen  and  thirty  years.  Later  in  life  it  becomes  progressively  less 
frequent,  though  cases  have  occurred  at  or  beyond  the  seventieth  year. 
Younc  children  are  not  exempt,  and  cases  among  them  are  of  rather 
frequent  occurrence,  if  we  except  those  under  one  year  of  age.  When 
contracted  late  in  pregnancy,  typhoid  fever  may  be  congenital  (Freund 
and  Levy). 

{e)  Sex  probably  does  not  aff"ect  the  degree  of  liability  in  typhoid. 
(/)  Individual  Predisposition. — This  may  be  acquired  or  inherited. 
An  instance  of  acquired  predisposition  is  to  be  noted  in  the  great  sus- 


TYPHOID  FEVER.  25 

ceptibilitY  -wliicli  exists  among  persons  who  have  recently  moved  from 
rural  districts  to  cities.  Thus,  Louis  found  '"that  of  129  cases,  73  had 
not  resided  in  Paris  over  ten  months,  and  102  not  over  twenty  months." 
To  account  for  this  fact  we  have  the  influence  of  a  change  both  of  sani- 
tary surroundings  and  of  the  habits  of  life.  There  is  considerable  evi- 
dence to  show  that  the  disease  is  on  the  increase  in  rural  sections.  That 
the  predisposition  to  this  affection  may  also  be  inherited  I  have  no  doubt. 
We  must  assume  in  these  cases  the  existence  of  certain  peculiarities  of 
the  family  soil  to  account  for  the  heightened  receptivity  that  is  observed 
throughout  successive  generations.  Most  persons,  however,  enjoy  natural 
immunity  from  the  affection. 

{g)  Intestinal  Catarrli. — It  is  quite  probable  that  a  catarrhal  state 
of  the  intestinal  mucosa  produces  local  predisposition  to  infection  with 
the  typhoid  poison.  I  have  observed  cases  of  influenza,  with  marked 
catarrh  of  the  gastro-intestinal  tract,  to  be  followed  promptly  by  the 
symptoms  of  typhoid  fever  [vide  Influenza). 

(/;)  Nervous  Influences. — Great  mental  excitement  and  overwork  are 
among  the  predisposing  nervous  causes. 

Immunity. — The  occurrence  of  typhoid  fever  confers  an  approximate, 
though  not  an  absolute,  immunity  against  subsequent  attacks. 

In  this  connection  two  questions  present  themselves  for  consideration  : 

(1)  What  are  the  methods  of  conveyance  of  the  poison  into  the  human 
body? 

In  the  first  place,  isolated  cases  and  epidemics  of  typhoid  fever  are 
alike  to  be  attributed  to  antecedent  cases  of  the  disease,  and  this  fact 
presupposes  that  the  bacillus  of  typhoid  leaves  the  body  of  the  sufferer 
during  the  attack.  This  it  does  in  the  stools,  which  are  practically  the 
only  primary  source  of  infection  and  contain  the  bacillus  of  Eberth 
in  great  numbers.  From  the  dejecta  the  bacilli  may  be  conveyed  to 
well  persons  by — 

(a)  Infected  Drinking-water. — In  the  vast  majority  of  instances  the 
poison  is  transmitted  from  those  affected  with  the  disease  to  those  in 
good  health  through  the  drinking-water  supply.  This  has  been  especi- 
ally true  in  most  extensive  epidemic  outbreaks  in  which  the  mode  of 
origin  has  been  traced.  Wells,  storage  reservoirs,  springs,  and  rivers 
may  alike  become  contaminated  and  cause  epidemic  prevalence  of  the 
disease. 

In  the  spring  of  1885  a  most  instructive,  though  deplorable,  epi- 
demic occurred  in  Plymouth,  Penna.,  a  town  of  8000  inhabitants.  At 
first  the  nature  of  the  affection  was  not  recognized,  and  before  it  ceased 
to  appear  1200  persons  were  affected,  with  130  resulting  deaths.  This 
epidemic  was  investigated  by  Shakespeare  and  L.  H.  Taylor,  and  was 
found  to  have  arisen  from  a  single  case  of  typhoid  occurring  in  a  house 
on  a  hill  which  sloped  toward  the  water-supply  of  the  town.  This 
patient  was  ill  during  January,  February,  and  March,  while  the  ground 
was  frozen  and  covered  with  snow,  upon  which  .the  dejecta  were  thrown 
by  the  attendant.  On  March  2oth  there  was  a  considerable  rainfall, 
followed  by  a  sudden  thaw,  and  the  water,  unable  to  sink  in  the  frozen 
earth,  ran  at  once  through  the  various  surface  channels  into  a  brook, 
"which  in  turn  emptied  into  the  reservoir.  Coincidently  with  the  thaw 
the  patient  had  frequent  and  copious  stools,  and,  strangely  enough,  for 


26  INFECTIOUS    DISEASES. 

certain  reasons  the  infected  water-supply  was  at  the  same  time  more 
largely  drawn  upon  than  usual.  On  April  10th  other  cases  of  the  dis- 
ease appeared,  and  careful  investigation  showed  that  those  citizens  who 
obtained  their  Avater  from  other  sources  than  the  infected  reservoir 
escaped  the  disease. 

(6)  Infected  milk  frequently  conveys  the  poison.  It  may  become  pol- 
luted by  water  which  has  been  used  either  to  wash  the  cans  or  for  diluting 
purposes,  or  the  bacilli  may  be  transferred  to  milk  by  the  unclean  hands 
of  the  milker.  Numerous  instructive  epidemics,  originating  in  infected 
milk,  have  been  reported.  The  occurrence  of  numerous  cases  among 
children  suggests  contaminated  milk. 

Solid  forms  of  food  (salads,  celery,  fruits)  may  be  contaminated  by 
infected  water  or  dust  or  by  the  fingers  of  the  nurse  or  the  patient. 
During  the  late  Spanish-American  war  the  typhoid  bacilli  may  have 
been  conveyed  from  the  latrines  directly  to  the  victims  or  to  the  kitchens 
and  mess-tables  by  swarms  of  flies.  H.  W.  Conn  has  shown  that  oysters 
while  being  fattened  or  freshened  may  become  infected,  and  Foote  has 
shown  that  the  typhoid  bacillus  will  not  only  retain  its  vitality  in  the 
salt  water  in  which  the  oysters  are  fed,  but  that  it  will  live  even  longer 
in  the  oyster  itself.  Oysters  caused  typhoid  in  14  persons  in  6  families 
(Chantemesse). 

((.')  Contagion  or  Direct  Transmission. — This  necessitates  direct  con- 
tact with  the  typhoid  stools,  and  its  possibility  cannot  be  denied.  It 
affords  a  ready  explanation  for  contraction  of  the  disease  by  nurses  who 
attend  to  the  stools,  the  bed,  and  the  body-linen  of  the  patient,  and  by 
laundresses  who  are  also  obliged  to  handle  the  soiled  clothing,  and  who 
are  affected  with  great  relative  frequency.  During  the  prevalence  of  an 
epidemic  in  1897  in  Montgomery  Co.,  Penna.,  house  epidemics  occurred 
in  which  contamination  of  water  or  food  could  be  excluded  with  reason- 
able certainty. 

(d)  "  Ground-soil." — According  to  Pettenkofer's  view,  the  typhoid 
poison  Avhich  leaves  the  body  of  an  infected  person  must  undergo  modi- 
fication or  development  in  the  ground-soil  before  it  is  potent  to  cause  the 
disease  in  question.  The  former  great  prevalence  of  typhoid  fever  in 
Munich  was  due  to  the  great  pollution  of  the  soil  (including  specific 
pollution)  modified  by  certain  unknown  conditions  in  the  soil  which 
correlated  with  the  movements  of  the  subsoil-water  (Childs). 

(e)  Sewer-gas. — The  typhoid  stools,  if  they  have  not  been  thoroughly 
disinfected,  may  meet  in  sewers  all  the  conditions  favorable  to  the  growth 
and  propagation  of  the  bacilli.  Moreover,  if  under  these  circumstances 
the  house-drain  be  defective,  typhoid  bacilli  may  escape  into  the  atmos- 
phere of  homes.  But  the  recent  researches  of  Bergey  and  of  Abbott 
show  that  sewer  gas  is  not  decidedly  deleterious,  and  it  certainly  cannot 
of  itself  cause  typhoid  fever. 

('2)  Through  what  channel  or  channels  does  the  bacillus  enter  ? 

(a)  In  the  vast  majority  of  the  cases  the  bacilli  are  swallowed.  It 
must  not  be  forgotten  that  bacilli  when  inhaled  may  find  lodgement 
in  the  mouth,  pharynx,  etc..  and  then  be  carried  along  into  the 
stomach  with  the  next  food  or  drink  that  is  ingested.  In  the  stomach 
they  meet  with  the  acid  gastric  secretions,  which  often  destroy  them. 
They  may,  however,  pass  into  the  intestinal   canal,  where  the  alkaline 


TYPHOID    FEVER.  27 

juices  of  the  small  intestine  furnish  every  condition  necessary  for  their 
further  growth  and  development.  They  penetrate  the  mucosa  and 
attack  primarily  the  solitary  follicles  and  Peyer's  plaques.  Next  they 
invade  the  mesenteric  glands,  reaching  the  circulation,  spleen,  liver,  and 
other  organs  a  little  later. 

{b)  The  possibility  that  the  bacilli  may  reach  the  blood-stream  through 
the  respiratory  organs  must  be  conceded ;  and  hence  the  added  possi- 
bility that  they  may  set  up  initiatory  lesions  either  in  the  tonsils,  lungs, 
or  pleura,  passing  thence  into  the  circulation,  must  also  be  granted. 
Primary  localizations  may  also  occur  in  the  kidneys  and  cerebro-spinal 
meninges.  Special  clinical  varieties  arise  from  these  localizations  {vide 
infra),  and  they  may  or  may  not  show  the  more  usual  intestinal  lesions. 

(c)  Typhoid  Septicsemia. — By  this  is  meant  a  general  infection  with 
the  bacilli  without  localized  lesions.  The  special  mode  of  infection  is 
not  clear. 

(d)  Typhoid  infection  predisposes  the  system  to  secondary  infections 
with  various  bacilli  (streptococcus,  staphylococcus,  bacillus  coli  commune, 
pneumococcus).  The  portals  of  entrance  for  these  micro-organisms  are 
various  (<?.  g.,  respiratory  tract,  lymphatics). 

Clinical  History. — I.  Incubation. — The  average  duration  of  the 
period  of  incubation,  or  the  time  between  the  introduction  of  the  poison 
into  the  system  and  the  appearance  of  the  first  active  symptoms,  ranges 
from  ten  days  to  three  weeks,  though  it  sometimes  lasts  for  a  longer, 
and  oftener,  I  think,  for  a  shorter,  time.  During  this  period  the  patient 
may  experience  no  deviation  from  health,  but  in  most  cases  there  are 
prodromal  symptoms,  such  as  languor,  loss  of  appetite,  nausea,  headache, 
neuro-muscular  pains  in  the  back  and  limbs,  a  disinclination  to  exercise, 
etc.     These  symptoms  last  usually  from  a  few  days  to  a  week  or  more. 

II.  General  Symptomatology  and  Course. — On  account  of  the  peculiar 
temperature-curve  in  typhoid  fever  its  course  falls  naturally  into  three 
periods — the  stage  of  development ;  the  acme  or  fastigium  (correspond- 
ing to  the  height  of  the  disease) ;  and  the  stage  of  decline  or  deferves- 
cence. It  is  convenient  to  speak  of  the  various  weeks  of  the  affection 
when  referring  to  these  stages.  Thus,  the  first  week  represents  the 
stage  of  development  (stadium  incrementi),  the  second  and  third  weeks 
(in  cases  of  average  severity)  the  fastigium,  Avhile  the  fourth  week  in  the 
typical  form  (the  third  week  in  mild  cases)  corresponds  to  the  third  stage 
(stadium  decrementi)  of  the  disease. 

(a)  Stage  of  Development. — The  invasion,  as  a  rule,  is  gradual,  the 
symptoms  being  chilliness  and  feverishness,  with  increase  in  the  severity 
of  the  prodromal  symptoms.  Typhoid  fever  rarely  starts  in  with  a  dis- 
tinct rigor.  At  or  about  this  time  nose-bleed  may  betray  the  nature  of 
the  disease.  The  symptoms  just  described  are  c[uickly  followed  by  a 
prostration  sufficiently  well  marked  to  compel  most  patients  to  take  to 
their  beds.  From  this  latter  event  is  usually  dated  the  onset  of  the  affec- 
tion. It  is  safer,  however,  to  regard  the  time  of  occurrence  of  the  above- 
mentioned  symptoms  (elevation  of  temperature,  with  its  attendant 
discomforts)  as  the  time  of  onset,  since  many  patients  continue  in  their 
avocations  for  days  after  the  first  symptoms  appear.  The  onset  may  be 
marked  by  symptoms  resembling  influenza  (Bunce). 

With  the  progress  of  the  initial  period  the  symptoms  usually  increase 


28  INFECTIOUS  DISEASES. 

in  severity  with  considerable  rapidity ;  the  fever  rises  day  by  day,  ter- 
race-like, till,  at  the  end  of  four  or  five  days,  the  second  stage,  or  fas- 
tio-ium,  is  reached.  Anorexia  is  complete,  thirst  is  great,  headache 
rather  intense,  the  skin  hot  and  dry  to  the  feel,  the  tongue  coated,  the 
sleep  disturbed,  and  constipation  is  present.  The  patient  may  complain 
of  fits  of  chilliness,  alternating  with  flushings  of  heat,  and  there  is  a 
slight  cough  with  some  thoracic  oppression.  The  pulse  is  quickened 
(from  90  to  110  per  minute)  and  is  full,  though  rarely,  thus  early,  is  it 
dici'otic. 

The  physical  sif/ns  are  not  prominent.  The  abdomen  is  often  slightly 
distended  and  tender;  the  spleen,  on  palpation,  is  found  to  be  somewhat 
swollen. 

(6)  Fastigium,  or  the  second  stage,  commences  usually  on  the  fourth 
or  fifth  day  of  the  disease,  and  lasts,  in  typical  cases,  about  two  weeks. 
During  the  first  week  of  the  fastigium  (the  second  of  the  disease)  the 
general  .symptoms  become  more  marked.  The  fever  remains  high  (the 
evening  temperature  usually  reaching  103°  or  104°  F.  (40.°  C.),  and 
exhibits  the  continued  type.  The  pulse  is  accelerated  but  not  dicrotic. 
The  headache  disappears,  and  mental  dulness  and  slowness  are  conspicu- 
ous, but  there  may  be  mild  delirium,  particularly  at  night.  There  is  a 
dry  cough  and  the  physical  signs  indicate  more  or  less  extensive  bron- 
chitis. The  tongue  is  coated  and  may  become  dry,  the  belly  is  some- 
what swollen  and  tender,  and  diarrhea  replaces  constipation.  The 
spleen  is  decidedly  enlarged,  and  about  the  eighth  day  of  the  disease  a 
number  of  roseate  spots,  which  are  pathognomonic,  appear  on  the  trunk. 
During  the  latter  part  of  this  week  a  grave  or  even  fatal  condition  may 
be  developed  as  a  result  of  intense  nervous  or  pulmonary  symptoms,  in- 
testinal hemorrhage,  or  perforation. 

During  the  second  week  of  the  fastigium  (the  third  week  of  the  dis- 
ease) the  marked  general  symptoms  already  noted  persist  in  severe  types 
of  the  affection.  The  pulse  varies  from  110  to  130,  and  the  tempera- 
ture may  approach  the  remittent  type.  In  addition,  this  period  fur- 
nishes the  most  numerous  as  well  as  the  most  untoward  comj)Ucations 
(lobular  pneumonia,  hypostatic  congestion  of  the  lungs,  intestinal  hem- 
orrhage, perforation,  peritonitis),  and  in  the  absence  of  serious  local 
complications  grave  general  conditions  may  be  presented.  The  duration 
of  this  stage  varies  with  the  severity  of  the  type. 

(c)  Stage  of  Decline  or  Defervescence. — At  the  end  of  the  second 
stao-e,  and  about  the  twenty-first  day  of  the  disease,  in  favorable  cases 
the  fever  begins  to  decline,  and  with  it  the  other  general  and  local 
symptoms  gradually  disappear.  This  is  followed  by  true  convalescence. 
In  protracted  cases,  however,  the  fourth  week  of  the  disease  may  present 
much  the  same  clinical  indications  as  the  third,  and  these  may  even  be 
intensified.  Frequently  an  aggravated  type  of  the  typlioid  state  is  now 
superadded,  the  symptoms  being  stupor,  muttering  delirium,  subsultus 
tendinum,  a  rapid,  feeble  pulse,  a  dry,  brown  tongue,  marked  diarrhea, 
greatly  swollen  belly,  and  an  involuntary  discharge  of  feces  and  urine. 
Inflammatory  complications  may  add  to  the  perils  of  the  condition. 

In  not  a  few  cases  the  febrile  period  is  prolonged  into  the  fifth,  and 
rarely  into  the  sixth  or  even  the  seventh  week,  and  the  fever  observed 
Avhen  defervescence  is  retarded  presents  an  irregular  type.     I  have  else- 


TYPHOID  FEVER.  29 

where  reported  a  case  in  -which  it  lasted  not  less  than  seven  -w"eeks.^ 
About  this  time  recrudescences  and  relapses  mav  occur  in  typical  cases. 
DiiFerent  epidemics  of  typhoid  fever,  however,  vary  so  greatly  in  their 
clinical  characteristics  as  to  make  it  impossible  to  include  all  cases  in 
any  outline  of  the  course  of  the  disease  that  might  be  attempted. 

III.  CMef  Clinical  Features  lq  Detail. — {a)  Course  of  the  Fever. — 
During  the  stage  of  development  (the  first  four  or  five  days)  the  temper- 
ature usually  rises  in  "  step-ladder  "  fashion.  The  evening  exacerbation 
is  on  each  day  from  a  degree  and  a  half  to  two  degrees  higher  than  on 
the  preceding,  and  the  same  is  true  of  the  morning  remissions.  A 
glance  at  the  temperature-charts  (Figs.  2  and  3)  will  show  that  the 
mornino;  remissions  touch  a  level  from  one-half  to  one  deocree  lower  than 
the  precedincr  evening  registers.     This  stage  is  rarelv  met. 

When  the  fastigium  is  reached,  the  evening  temperature  mav  be 
103°,  104°,  or  105°  F.  (39.4°-40.5°  C),  and  is  usually  thus  main- 
tained, with  the  slight  morning  remissions.  The  tide-like  character  of 
fever-curve  seen  in  the  initial  period  is  absent.  Often,  during  the 
latter  half  of  the  fastigium  (the  third  or  fourth  week  of  the  disease) 
the  morning  fall  of  temperature  becomes  decidedly  greater.  According 
to  my  own  observation,  the  height  of  the  fastigium  is  reached  a  day  or 
two  after  its  onset  or  at  the  end  of  the  first  week  of  the  affection.  Marked 
morning  remissions  are  afavorable  indication.  On  the  other  hand,  and 
contrary  to  the  general  rule,  the  morning  temperature  may  be  higher 
than  the  evening,  forming  a  somewhat  unfavorable  symptom.  Morning 
temperatures  of  104°  F.  (40°  C.)  or  over  are  indicative  of  a  serious 
type.  In  manv  instances  of  mild  grade  the  evening  temperature  at  no 
time  exceeds  103°  (39.4°  C),  but  oscillates  between  lOOf °  and  102f° 
F.  (38.1°-39.2°  C).  In  cases  of  average  intensity  the  morning  remis- 
sions touch  102°-102|-°  F.  (39.2°  C),  and  the  evening  exacerbations 
reach  104-1 04f°  F.  (40.3°  C).  When  the  temperature  rises  above  105° 
F.  (40.5°  C)  hyperpyrexia  exists.  Ampugnani  made  studies  of  hourly 
charts  from  200  cases  of  typhoid  fever,  and  found  the  maximum  tem- 
perature to  occur  between  three  and  six  o'clock  in  the  afternoon,  and 
the  minimum  between  four  and  eight  o'clock  in  the  mornino-.  The 
duration  of  the  fastigium  exhibits  a  wide  range  and  is  dependent  upon 
a  variety  of  conditions — e.  g.  the  degree  of  mildness  or  severity  of  the 
type,  the  presence  or  absence  of  complications,  etc.  In  cases  of  a  mild 
character  it  lasts  from  a  few  days  to  one  week ;  in  cases  of  average 
severity,  from  ten  days  to  two  weeks ;  in  the  severest  forms,  from  two 
to  four  weeks. 

In  typical  cases  the  end  of  the  fastigium  marks  the  beginning  of  the 
last  stage  (that  of  defervescence),  and  during  this  period  the  tempera- 
ture falls  by  lysis.  Measured  by  days,  it  declines  by  degrees,  both 
the  morning  and  evening  temperatures  being  often  one  or  two  degrees 
lower  than  on  the  preceding  day.  Thus  is  formed  a  more  or  less  regu- 
lar step-like  line  of  descent.  To  this  general  rule  there  are  two  nota- 
ble exceptions  :  From  the  beginning  of  the  period  of  defervescence  the 
morning  remissions  may  strike  the  normal  point,  while  the  evening  ex- 

^  "A  Case  of  Typhoid  Fever ;  numerous  Intestinal  Hemorrhages,  the  Amount  of 
Blood  Lost  being  Seventy-eight  and  one-half  Ounces  ;  and  Obstinate  Vomiting,  with 
Eecovery,"  International  Clinics,  vol.  i.  5th  series,  April,  1895,  p.  29. 


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TYPHOID  FEVER.  31 

acerbations  become  less  and  less  marked,  until  thev  also  touch  the 
normal.  Under  these  circumstances  the  temperature-curve  resembles 
somewhat  that  of  the  quotidian  intermittents,  and  rarely  the  tertian 
type  of  curve  obtains.  In  comparatively  rare  instances  the  morning 
temperature  shows  a  deeper  remission  on  each  successive  day,  while  the 
evening  temperature  remains  high  for  several  days,  when  it  also  declines. 
This  period  lasts  from  one  week  to  ten  days — a  longer  time  than  the 
initial  stage  with  its  ascending  type  of  fever. 

In  the  severe  and  protracted  forms  of  typhoid  fever  there  occurs 
between  the  second  stage  (fastigium)  and  the  third  stage  (defervescence) 
another,  to  which  Wunderlich  has  given  the  name  of  the  "  ambiguous 
period."  This  lasts  from  a  few  days  to  a  week  or  more,  and  is  charac- 
terized by  a  striking  diurnal  range  of  temperature,  with  marked  irreg- 
ularities. It  is  probable  that  it  is  sometimes  produced  by  an  auto- 
intoxication. 

Abnormal  Course  of  the  Fever. — The  pyrexial  peculiarities  yet  to 
be  pointed  out  are  less  usual  than  the  foregoing,  though  of  sufficient 
frequency  of  occurrence  to  demand  a  brief  description. 

The  first  stage  varies  but  little  from  the  regular  course  described 
above.  A  sudden  elevation  of  temperature,  however,  is  seen  in  those 
cases  that  begin  with  a  severe  rigor,  accompanied  by  pneumonic,  catar- 
rhal, and  gastro-intestinal  symptoms.  Pepper  and  Stengel  have  reported 
seven  cases  with  acute  onset,  and  Moore,  of  Dublin,  states  that  the 
whole  course  (since  1889)  has  become  more  typhus-like  than  formerly. 

In  the  lightest  forms  the  fastigium  may  be  practically  absent, 
defervescence  setting  in  upon  the  first  day  of  the  fastigium.  There  is 
also  a  class  of  cases  in  which,  throughout  the  greater  part  of  their 
course,  the  fever  is  distinctly  intermittent  or  remittent,  and  in  which 
careful  blood-examination  fails  to  disclose  the  plasmoclium  malarice.  The 
same  characteristic  marks  the  temperature-curve  in  those  rare  instances 
of  typhoid  fever  Avhich  occur  in  subjects  previously  infected  with  malaria. 
These  two  classes  of  cases  run  a  favorable  course  as  a  rule. 

Sudden  deep  temporary  drops  in  the  temperature  may  occur  during 
the  fastigium.  (1)  This  may  take  place  during  the  early  part  of  the 
fastigium  without  obvious  cause.  (2)  Intestinal  hemorrhage  almost 
invariably  produces  a  sudden,  and  sometimes  a  great,  fall  of  tempera- 
ture. Osier  has  reported  a  case  in  which  a  drop  of  10°  F.  (5.5°  C.) 
followed  melena.  The  blood  does  not  appear  in  the  evacuations  of  the 
patient  for  six  to  twelve  hours  or  more  after  the  temperature  has  begun 
to  fall ;  and  hence  a  critical  decline  of  temperature  during  the  latter 
part  of  the  second  and  the  third  week  of  the  disease  suggests  that  hemor- 
rhage has  probably  taken  place.  (3)  The  occurrence  of  peritonitis  is 
marked  by  a  sudden  and  considerable  fall  of  temperature..  (4)  In  the 
female,  abortion  or  premature  delivery  occurring  in  the  course  of 
typhoid  fever  produces  a  decided  lowering  of  the  temperature.  (5) 
Collapse  of  the  circulation  sometimes  occurs  with  a  notable  remission 
of  temperature — an  ominous  association  of  events,  and  one  which  I 
observed  in  two  cases  occurrincr  in  females  in  the  Medico-Chirurgical 
Hospital.  In  one  of  these  cases  two  such  periods  of  collapse  occurred, 
and  in  the  other  three,  though  both  finally  recovered  under  prompt  and 
continuous  stimulation.    Occasionally  hyperpyrexia  is  observed  in  typhoid 


32  INFECTIOUS  DISEASES. 

fever,  and  most  frequently  just  before  dissolution,  Avhen  the  tliermometer 
may  register  108°  or  even  109°  F.  (42.7°  C).  A  fresh  rise  Avith  marked 
irregularity  of  temperature  may  occur  during  the  latter  part  of  the  fas- 
tigium  or  the  period  of  decline,  and  is  often  dependent  upon  some  local 
complication  (late  pneumonia,  parotitis,  etc.). 

The  stage  of  defervescence  is  sometimes  much  prolonged,  though 
most  frequently  there  is  simply  a  slight  evening  elevation  (99°  to  100°  F. — 
37.7°  C),  the  morning  temperature  being  normal.  The  causes  of  retarded 
decline  are,  for  the  most  part,  obscure.  I  believe  that  many  of  them  are 
ascribable  to  a  mild  grade  of  auto-intoxication,  and  in  my  hands  a  mild 
saline  laxative  has  been  the  means  of  cutting  them  short  in  a  number 
of  instances.  An  examination  should,  however,  be  made  for  some 
localized  inflammatory  complication,  though  this  is  not  always  dis- 
cernible, as  in  the  case  of  suppuration  in  the  mesenteric  glands,  etc. 
Sluggish  typhoid  ulcers,  which  refuse  to  heal  promptly  and  are  due  to 
the  now  well-known  post-typhoid  anemia,  may  act  as  a  cause  of  the 
slow  decline. 

Post-typhoid  Elevations  of  Temperature. — After  both  the  evening 
and  morning  temperatures  have  become  normal,  fresh  temporary  eleva- 
tions (102°  or  103°  F.— 38.8°  or  39.4°  C.)  frequently  appear.  They 
are,  as  a  rule,  unassociated  with  any  other  symptoms,  and  at  the  end  of  a 
few  days  the  temperature  falls  rapidly  to  the  normal.  These  are  termed 
recrudescences.,  and  are  to  be  distinguished  from  true  typhoid  relapses. 
They  are  probably  produced  in  various  ways — by  errors  in  diet,  consti- 
pation, mental  emotion,  excitement,  etc. — and  there  are  cases  in  which 
the  presence  of  the  fever  seems  to  be  really  a  nervous  phenomenon 
(Osier).  It  is  most  common  in  children  and  in  persons  of  a  decidedly 
nervous  temperament.  Certain  local  sequel<«  may  cause  post-typhoid 
fever,  such  as  abscess,  periostitis,  etc.  Rarely  during  convalescence  a 
sudden  and  marked  elevation  of  temperature,  accompanied  or  not  by 
rigor,  occurs,  but  it  is  usually  of  short  duration  and  seldom  is  of  serious 
import.  I  recently  saw,  with  the  attending  physician.  Dr.  Modell,  a 
case  in  Avhich  the  temperature  had  been  normal  for  six  days,  when 
rigors,  followed  by  steep  elevations  of  temperatui*e,  occurred  several 
times  and  at  intervals  of  thirty-six  or  forty-eight  hours.  These  high 
temperatures  wei'e  followed  by  a  rapid  decline  to  the  normal,  and  by 
sweating,  leaving  the  patient  profoundly  exhausted.  Subsequently  the 
convalescence  was  sIoav,  but  uninterrupted. 

Afebrile  Typhoid. — As  the  term  indicates,  typhoid  fever  may  run 
a  course  attended  with  all  of  the  characteristic  symptoms  save  the  fever. 
Cases  of  this  kind  are  of  great  rarity. 

{h)  Skin. — The  eruption  is  highly  characteristic,  and  usually  decides 
the  diagnosis.  It  makes  its  appearance  on  or  about  the  eighth  day,  and 
sometimes  a  little  later.  Occasionally  it  does  not  appear  until  the  tenth 
or  twelfth  day  of  the  disease.  It  consists  of  distinct,  rose-colored,  and 
slightly  elevated  papules,  having  a  rounded  or  lenticular  form  and  a 
diameter  varying  from  one  or  two  to  three  lines.  The  papules  are 
almost  invariably  found  upon  the  trunk,  and  especially  upon  the  upper 
part  of  the  abdomen  and  the  lower  part  of  the  thorax,  to  which  regions 
they  may  be  wholly  confined.  They  may,  however,  be  absent  from  the 
usual  seats  and  present  elsewhere,  so  that  the  sides  of  the  trunk,  the 


TYPHOID  FEVER.  33 

back,  and  tlie  thiglis  should  always  be  inspected.  They  disappear  upon 
pressure,  but  reappear  promptly  when  pressure  is  removed.  These 
rose-colored  spots  last  three  or  four  days,  and  appear  in  successive 
crops,  each  one  being  made  up,  usually,  of  a  few  spots — a  half-dozen  to 
a  dozen.  Rarely  the  eruption  is  abundant  on  the  trunk,  even  extend- 
ing to  the  extremities  and  head ;  but  there  is  no  direct  correspondence 
between  the  extent  of  the  eruption  and  the  severity  of  the  cases.  Occa- 
sionally the  spots  are  entirely  absent — a  condition  most  frequently  met 
with  in  children,  and  less  often  in  elderly  persons. 

Other  eruptions  are  often  present,  and  their  negative  diagnostic 
value  must  be  kept  in  remembrance.  Minute  pearly  vesicles  {sudamina) 
may  appear.  They  are  limited  to  the  abdomen,  the  axilla,  and  to  the 
inner  surface  of  the  thighs  as  a  rule,  and  are  in  great  measure  due  to 
profuse  sweating. 

A  scarlet-colored  erythematous  eruption  sometimes  appears  at  a  com- 
paratively early  period  in  typhoid  fever.  Urticaria  and  purpura  are 
rarely  seen.  Out  of  250  cases  of  typhoid  fever  among  the  soldiers  in 
the  Spanish-American  war  treated  in  the  Medico-Chirurgical  Hospital 
two  manifested  purpuric  spots.  Extensive  ecchymoses  may  occur,  but- 
are  rare,  and  merely  sym.ptomatic  of  the  hemorrhagic  diathesis.  Cutane- 
ous hoils  and  abscesses  due  to  secondary  infection  with  the  pyogenic 
cocci  are  a  comparatively  frequent  and  late  development  in  the  course 
of  the  disease.  Peliomata  typhosa  in  the  form  of  little  bluish  subcutic- 
ular spots  (the  ''ta-ches  bleuatres  "  of  the  French  writers)  may  appear; 
but  they  are  not  related  specially  to  typhoid  fever,  and  in  a  recent  case 
of  my  own  were  undoubtedly  due  to  pediculi.  G-angrene,  chiefly  of  the 
lower  extremities,  has  been  noted  in  214  cases  (Keen),  and  is  due  to  the 
diffusion  of  the  bacilli  and  their  toxic  products,  to  an  obliterating 
endarteritis,   thrombosis,   or  embolism. 

Profuse  siveats  form  a  conspicuous  symptom  in  many  epidemics  of 
the  disease,  with  or  without  accompanying  fits  of  chilliness  or  rigors, 
and  mark  the  sudoral  form  of  typhoid  fever  (Jaccoud).  Some  of  these 
instances  resemble  ordinary  intermittents.  Edema  of  the  skin  is  some- 
times observed  and  is  due  most  frequently  to  anemia  or  cachexia,  though 
sometimes  to  nephritis.  A  local  form  of  edema  affecting  the  leg  is  not 
uncommon,  and  for  this  form  thrombosis  of  the  femoral  vein  is  chiefly 
responsible.  A  peculiar  "  musty  "  odor  is  exhaled  from  the  skin  in 
some  instances  of  typhoid  fever.  The  patient  assumes  the  dorsal 
decubitus  and  is  exposed,  particularly  in  cases  of  prolonged  duration, 
to  the  danger  of  the  formation  of  bedsores.  They  are  most  jirone  to 
occur  on  the  nates  and  the  heels,  and.  once  started,  they  are  apt  to 
spread  till  they  attain  to  large  dimensions,  with  extensive  undermining 
of  the  skin.  The  condition  is  now  serious.  During  and  after  the  con- 
clusion of  convalescence  the  hair  falls  out,  but,  fortunately,  it  is  invari- 
ably renewed.  The  nails  sometimes  become  roughened  and  brittle, 
while  transverse  pale  lines  or  ridges  can  usually  be  observed  in  them, 
marking  the  impairment  of  nutrition  during  the  disease  {vide  Relapse). 
Jaundice,  due  to  a  variety  of  causes,  is  a  rare  symptom,  and  generally  does 
not  come  on  until  the  middle  of,  or  until  late  in,  the  disease  (Da  Costa). 

(c)  Digestive  System. — The  symptoms  referable  to  the  gastro-intes- 
tinal  canal,  though  not  very  striking  in  most  cases,  are  of  the  utmost 

3 


34  INFECTIOUS  DISEASES. 

importance  and  interest  because  of  their  direct  connection  -with  the 
pathognomonic  lesions  of  typhoid.  Beginning  Avith  the  intestinal  canal, 
and  thence  proceeding  to  the  symptoms  presented  by  the  stomach,  spleen, 
liver,  throat,  and  mouth,  will  be  a  natural  and  convenient  order  in  Avhich 
to  study  the  symptoms  connected  Avith  the  alimentary  tract. 

At  the  onset  of  typhoid  fever  constipation  is  the  general  rule,  and 
this  may  persist  to  the  end  of  the  illness,  though  more  commonly  a 
moderate  diarrhea  appears.  During  the  second  week  of  the  affection 
the  stools  number,  on  the  average,  from  two  to  four  or  more  daily.  It 
is  only  in  comparatively  rare  instances  that  ten  or  twelve  or  more  move- 
ments per  diem  occur,  the  severity  of  the  diarrhea  depending  more  upon 
the  degree  of  catarrh,  particularly  of  the  large  intestine,  that  may 
be  present,  than  upon  the  degree  and  extent  of  the  ulcers.  When, 
however,  as  rarely  happens,  the  ulcerative  process  is  chiefly  limited  to 
the  colon,  it  is  an  important  factor  in  the  production  of  the  diarrhea. 
Indeed,  in  those  instances — not  altogether  rare — in  which  there  is  urgent 
diarrhea  of  a  dysenteric  character.,  the  ulcers  are  especially  marked  in 
the  colon,  with  diphtheritic  inflammation  of  the  mucosa  as  a  frequently 
associated  lesion.     Involuntary  discharge  of  the  feces  may  occur. 

The  stools  present  a  characteristic  yellow  appearance,  suggesting  by 
their  color  and  consistence  a  comparison  with  pea  soup.  They  are  usu- 
ally either  fluid  or  of  the  consistence  of  jelly,  and  are  offensive  and  of 
an  alkaline  reaction.  On  standing  they  separate  into  two  layers — an 
upper,  liquid,  cloudy  layer,  and  a  lower,  thick  yellow,  sedimentary  layer, 
in  which,  on  macroscopic  examination,  remnants  of  food  and  grayish 
yellow  fragments  (necrotic  crusts  of  Peyer's  plaques)  from  a  half  to  an 
inch  in  length  may  be  detected.  Microscopically,  they  have  been  found 
to  contain  undigested  particles  of  food,  epithelial  debris,  blood-corpus- 
cles, crystals  of  triple  phosphates  in  abundance,  and  innumerable  bac- 
teria. Laboratory  experimentalists  have  been  able  to  demonstrate  the 
presence  of  the  typhoid  bacillus  in  the  dejecta.  Tympanites.,  mainly 
affecting  the  colon,  is  a  common  though  rarely  a  striking  feature,  and 
cases  of  a  quite  serious  nature  are  observed  in  which  the  abdomen 
presents  a  concavity  throughout  the  entire  illness.  The  latter  is  less 
unfavorable,  by  far,  as  a  symptom  than  excessive  tympanites,  which 
interferes  with  both  the  respiration  and  heart  action.  Tympanites  is 
apt  to  be  most  marked  in  serious  cases  which  have  diarrhea  as  a  promi- 
nent symptom,  though  the  latter  may  not  even  be  present.  It  is  due  to 
the  generation  of  gas  from  decomposing  food,  and  to  the  arrest  of  peri- 
staltic movements  in  consequence  of  the  degeneration  of  the  muscularis 
of  the  intestines.  Pain  is  absent  in  the  majority  of  cases,  and  when 
present  is  not  intense,  save  in  rare  instances.  Pressure  upon  the  ileo- 
cecal region  usually  causes  a  gurgling  noise,  but,  although  this  symp- 
tom is  commonly  present,  it  is  not  characteristic  of  the  disease.  There 
is  generally  also  a  slight  degree  of  tenderness  of  the  abdomen  under 
pressure,  most  marked  in  the  right  iliac  fossa,  and  hence,  in  all  proba- 
bility, due  to  the  presence  of  ulcers  in  this  region.  Absence  of  tenderness, 
however,  is  not  a  safe  indication  of  the  absence  of  extensive  ulceration. 
Extreme  sensitiveness  generally  denotes  peritonitis  (often  without  per- 
foration), though  the  symptom  may  be  quite  Avell  marked  as  a  result  of 
constipation  only. 


TYPHOID  FEVER.  35 

Intestinal  hemorrhage  occurs  in  from  4  to  7  per  cent,  of  cases,  its 
frequency  varying  with  different  epidemics.  The  hemorrhages  appear 
almost  invariably  during  the  latter  part  of  the  second  and  third 
week,  being  caused  by  the  opening  of  blood-vessels  during  the  necrotic 
or  ulcerative  process.  Bleedings  may  also  take  place  from  the  soft 
and  hyperemic  edges  of  the  ulcer  (vide  supra),  and  when  it  occurs 
quite  early  in  the  disease  it  may  be  due  to  an  excessive  hyperemia  of 
the  lymph-follicles.  The  amount  may  be  so  small  as  to  be  scarcely  dis- 
cernible by  the  naked  eye,  or  it  may  be  from  one  to  two  or  three  pints 
(0.5-1.5  liters),  or  even  more.  In  one  of  my  own  cases  the  total  amount 
of  blood  discharged  from  the  bowel  was  nearly  5  pints  (2.5  liters),  and 
yet  the  patient  recovered.  The  blood  presents  a  dark  hue,  and  that 
which  is  passed  last  may  be  tarry. 

The  significance  of  intestinal  hemorrhage,  however  slight,  is  always 
grave.  On  the  other  hand,  recovery  is  possible  even  if  the  hemorrhage 
be  copious  and  oft-repeated,  as  is  shown  by  the  case  before  cited  from 
my  own  experience ;  and  in  general  terms  it  may  be  said  that  death 
supervenes  in  from  30  to  40  per  cent,  of  all  cases.  R.  G.  Curtin  has 
recorded  60  cases,  of  which  46.6  per  cent,  died ;  he  argues  that  cold  ap- 
plications to  the  skin  and  the  necessary  disturbance  in  giving  a  cold  bath 
tend  to  produce  melena.  A  fatal  result  may  occur  as  the  direct  effect 
of  a  profuse  hemorrhage.  When  death  does  not  follow  immediately, 
however,  the  signs  of  collapse  (more  or  less  intense)  and  of  anemia 
appear;  yet  intestinal  hemorrhage  sometimes  exerts  a  favorable  influence. 
In  a  number  of  instances  I  have  observed  stupor  and  delirium  quickly 
giving  place  to  perfect  consciousness.  Lastly,  when  typhoid  fever  occurs 
in  the  hemorrhagic  diathesis  melena  may  manifest  itself  in  connection 
with  hemorrhage  from  other  outlets. 

Perforation,  which  almost  invariably  produces  fatal  diffuse  peritonitis, 
is  the  accident  most  to  be  dreaded.  It  does  not  bear  a  fixed  relation  to 
the  severity  of  the  affection,  but  in  the  2000  Munich  cases  (vide  supra) 
perforation  occurred  in  114 ;  and  according  to  Fitz,  who  tabulated 
4680  cases  of  typhoid  fever,  there  is  a  mortality  of  6.58  per  cent,  from 
perforation  of  the  bowel.  It  is  much  more  common  in  males  than  in 
females,  and  appears  in  a  ratio  of  about  71  to  29.  Age  has  a  decided 
influence,  the  complication  being  most  marked  between  ten  and  forty 
years  old,  whilst  in  children  it  is  rare ;  and,  though  perforation  may 
occur  at  any  time  in  the  course  of  typhoid  fever,  it  is  most  common  be- 
tween the  second  and  fourth  weeks  of  the  disease.  In  the  cases  ana- 
lyzed by  Fitz  perforation  was  found  in  the  ileum  in  81.4  per  cent.,  in 
the  large  intestine  in  12.9  per  cent.,  in  the  vermiform  appendix  in  2.5 
per  cent.,  and  in  the  jejunum  in  1.29  per  cent.  The  accident  is  usu- 
ally announced  by  the  sudden  advent  of  acute  pain  in  the  abdomen, 
quickly  followed  by  the  symptoms  of  collapse  ;  and  the  fact  that  diffuse 
peritonitis,  following  perforation,  may  develop  insidiously  must  be 
recollected.  The  abdominal  muscles  become  rigid,  sensitive  to  touch, 
and  later  tympanites  develops.  Fluctuation  can  sometimes  be  elicited. 
On  percussion  splenic  and  hepatic  dulness  is  often  absent,  but  hepatic 
dulness  is  also  wanting  when  the  distended  intestines  lie  in  front  of 
the  liver.  The  collapse  of  the  circulatory  system  is  evidenced  by  the 
pinched  features,  hollow  cheeks,  vomiting,  and  the  small,  frequent  pulse. 


36  INFECTIOUS  DISEASES. 

Leucocytosis  is  a  valuable  diagnostic  symptom.  Wilson  has  emphasized 
the  importance  of  an  early  diagnosis  and  the  immediate  resort  to 
operative  intervention. 

No  other  complication  is  so  grave  as  peritonitis.  Its  causes  have 
been  pointed  out  previously  {vide  p.  21),  but  from  a  clinical  point  of 
view  a  division  of  all  the  cases  into  two  classes — those  due  to  perfora- 
tion and  those  due  to  other  agencies — is  desirable.  The  instances  that 
develop  independently  of  actual  perforation  are  not  of  infrequent  occur- 
rence. They  usually  assume  the  local  or  circumscribed  form  of  peri- 
tonitis, which  is  occasioned  by  direct  extension  of  the  inflammatory  pro- 
cess from  the  intestinal  ulcers.  The  condition  presents  corresponding 
areas  of  tenderness  under  gentle,  and  especially  under  prolonged,  pres- 
sure. It  is,  however,  confessedly  difficult  to  diagnose  between  the  intra- 
and  extra-intestinal  states,  which  are  accompanied  by  sensitiveness  to 
gentle  palpation,  particularly  when  peritoneal  inflammation  exists  in  a 
mild  form.  Generalized  peritonitis  may  succeed  to  the  circumscribed 
variety  in  consequence  of  the  extension  of  inflammation  to  the  peri- 
toneal sac,  and  without  perforation. 

The  mesenteric  lympli-glands  may  soften  or  suppurate  {vide  Pathol- 
ogy), and,  as  before  mentioned,  may  be  the  exciting  cause  of  a  recru- 
descence, or  they  may  rupture  and  cause  diffuse  peritonitis. 

The  Spleen. — With  few  exce})tions  the  spleen  is  enlarged  in  ty- 
phoid fever,  the  edge  usually  being  palpable  below  the  margin  of  the 
ribs,  on  or  before  the  commencement  of  the  fastigium.  It  generally  goes 
on  increasing  in  size  till  near  the  beginning  of  the  third  Aveek,  and 
lessens  during  the  latter  part  of  the  third  and  fourth  weeks.  In  four  of 
Osier's  autopsies  it  weighed  less  than  normally.  Swelling  of  the  spleen 
is  sometimes  absent  after  a  copious  intestinal  hemorrhage,  as  well  as  in 
elderly  typhoid  subjects.  As  before  mentioned,  the  enlargement  in 
many  cases  is  not  demonstrable  by  percussion  wlien  the  tym})anites  is 
excessive,  but  by  means  of  careful  palpation  we  can  in  most  cases  satisfy 
ourselves  of  its  existence  or  non-existence,  despite  the  great  distention 
of  the  bowel.  Suppurative  infarcts,  or  softening  of  the  spleen  may 
start  a  peritonitis.  Rarely,  rupture  of  the  organ  may  occur,  which  is 
manifested  usually  by  intense  pain  in  the  splenic  region.  A  slight 
swelling  of  the  liver  can  sometimes  be  detected.  Among  the  least  fre- 
quent of  complications  is  jaundice  {vide  supra),  and  abscess  of  the  liver 
also  rarely  occurs. 

The  Stomach. — The  stomach  offers  no  characteristic  symptoms.  Of 
the  anorexia,  which  is  constant  until  recovery  begins,  enough  has 
been  said,  but  during  convalescence  the  appetite  returns,  becoming  even 
voracious.  Nausea,  and  vo)niting  may  occur  during  any  stage  of  the 
disease,  and  are  most  common  at  the  beginning,  but  when  they  appear 
as  late  symptoms  they  are  probably  excited  either  by  gastric  ulceration 
or  by  peritonitis.  Nausea  is  usually  traceable  to  definite  causes — either 
to  errors  in  diet  or  to  the  use  of  irritating  medicaments,  but  that  vomit- 
ing does  occur  from  unknown  and  inevitable  causes  in  very  rare  in- 
stances I  am  fully  convinced.  This  sort  of  vomiting  Avas  present  in  the 
afore-mentioned  case  reported  by  myself  in  Avhich  there  were  profuse 
hemorrhages.     It  may  become  a  serious  or  even  fatal  symptom. 

The  Pharynx. — The  phai-ynx  frequently  shows  catarrhal  irritation, 


TYPHOID  FEVER.  37 

and  the  patient  may  complain  of  dryness  or  a  burning  sensation  in  the 
throat.  Actual  sore  throat  may  be  present  at  the  time  of  onset,  and 
this  may  be  associated  with  a  diifuse  erythematous  rash,  suggesting 
scarlatina. 

The  Tonsils. — There  is  a  special  form  of  typhoid — tonsillo-typhoid 
or  pharyngo-typhoid — in  which  there  appear  upon  the  tonsils  peculiar 
patchy  elevations,  whitish  in  color,  which  undergo  subsequent  ulcera- 
tion. It  is  not  improbable  that  these  lesions  result  from  the  local  action 
of  the  specific  bacillus  in  an  unusual  situation.  Thrush,  affecting  the 
mouth,  throat,  and  even  extending  to  the  esophagus,  not  infrequently 
arises  as  a  complication.  The  tongue  is  heavily  coated,  as  a  rule,  with 
a  yellowish-white  fur ;  later  it  clears  off"  near  the  edges  and  tip,  while 
the  center  becomes  dry  or  brown  and  sometimes  fissured.  The  lips 
are  also  dry,  sometimes  fissured,  and  often  covered  with  dry,  black 
crusts  (sordes).  Ulcerative  stomatitis  may  occur  if  the  mouth  be  not 
kept  clean.  Under  these  circumstances  secondary  lesions  evincing 
unpleasant  and  even  serious  symptoms  may  also  arise  in  organs  more 
or  less  remote  from  the  mouth,  and  among  these  is  parotitis,  which  is 
most  probably  caused  by  the  staphylococcus  or  streptococcus  reaching 
the  parotid  gland  by  way  of  Steno's  duct.  The  condition  is  betrayed 
by  such  symptoms  as  pain,  redness,  and  finally  by  fluctuation,  with  an 
elevation  of  the  bodily  temperature.  It  is  a  late-appearing  develop- 
ment, and  is  usually  unilateral,  though  it  may  be  bilateral.  Suppura- 
tive otitis  media,  a  rarer  complication,  arises  in  a  similar  manner,  the 
pathogenetic  agents  passing  from  the  throat  to  the  ear  through  the 
Eustachian  tube. 

(d)  Respiratory  System. — As  pointed  out  in  the  section  on  Pathology, 
bronchitis  is  almost  invariably  present,  but  in  the  majority  of  instances 
the  cough  is  slight.  The  condition  is  recognized  by  the  existence  of 
numerous  sibilant  rales.  Very  rarely  is  it  a  striking  feature  in  the 
early  stage  of  typhoid  fever,  and  then,  except  this  fact  be  remembered, 
room  for  error  of  diagnosis  exists.  Moreover,  in  cases  that  are  im- 
properly treated  the  bronchial  secretions  are  apt  to  accumulate,  and  a 
well-marked  bronchitis  may  be  the  result.  It  may  be  said,  however, 
that,  as  a  rule,  bronchitis  does  not  assume  a  severe  type  in  cases  which 
receive  proper  attention  from  the  beginning,  provided  the  patient  be 
not  unusually  stupid  or  unconscious.  When  the  nervous  phenomena 
are  pronounced,  however,  and  the  patient  maintains  the  dorsal  decubitus 
(expectorating  little  or  nothing),  bronchitis  of  a  severe  grade  and  aff"ect- 
ing  the  smaller  bronchi  is  almost  inevitable.  The  occurrence  of  an 
intense  generalized  bronchitis  is  also  favored  by  certain  other  con- 
ditions, such  as  corpulence,  advanced  age,  emphysema,  etc. ;  and  these 
are  the  cases  that  are  apt  to  lead  to  lobular  infiltration — the  so-called 
aspiration  pneumonia. 

Lobular  pneumonia  may  take  on  a  putrid  nature  and  the  consoli- 
dated area  may  become  gangrenous.  As  a  sequel,  pleurisy  with  effusion 
or  empyema  may  originate  in  consequence  of  the  infiltrated  lobules 
being  contiguous  to  the  pleura.  If  these  lobules,  occupying  the 
periphery  of  the  lung,  become  gangrenous,  perforation  of  the  pleura, 
leading  to  'pyopneumothorax,  may  result.  Lobular  pneumonia  may  be 
attended   with   hurried  breathing  or  troublesome    cough.     More    com- 


38  INFECTIOUS  DISEASES. 

monly,  the  local  symptoms  are  either  altogether  wanting  or  feebly 
marked,  and  this  is  especially  true  of  the  severer  forms  of  lobular  pneu- 
monia, which  occur  in  patients  in  whom  profound  nervous  prostration 
coexists  with  more  or  less  complete  unconsciousness.  Sole  reliance  is 
to  be  placed  upon  the  results  of  a  physical  examination,  which  even  in 
the  absence  of  subjective  symptoms  should  be  repeated  daily.  Points 
or  surfaces  of  dulness,  most  marked  near  the  bases  of  the  lungs  and 
frequently  on  both  sides,  are  found  on  percussion.  Fine  moist  rales, 
most  marked  toward  the  bottom  of  the  thorax,  form  a  very  character- 
istic sign,  and  are  heard  in  every  direction  on  auscultation.  In  order 
to  ensure  a  certain  diagnosis  of  lobular  pneumonia  both  the  circum- 
scribed dulness  and  moist  rales  must  be  found  present  in  the  same 
situation. 

Lobar  pneumonia  is  a  not  uncommon  complication.  In  a  small  per- 
centage of  cases  it  develops  early,  and  is  most  probably  the  result  of  a 
special  concentration  of  the  poison  in  the  lungs,  giving  rise  to  the  so- 
called  pneumo -typhoid  fever  {vide  infra.  Varieties).  These  cases  are 
often  mistaken  for  primary  lobar  pneumonia.  Their  onset  may  or  may 
not  be  marked  by  a  rigor,  but  it  is  usually  more  gradual  than  that  of 
primary  lobar  pneumonia.  Characteristic  typhoid  symptoms  soon  follow, 
and  at  the  end  of  the  first  week  or  thereabouts  the  pulmonary  symptoms 
gradually  abate,  while  those  most  characteristic  of  typhoid  (enlarged 
spleen,  roseate  spots,  etc.)  occupy  the  foreground.  Lobar  pneumonia 
more  often  develops  as  a  late  complication — in  the  second  or  third  week, 
or  even  during  convalescence — but  it  is  not  attended  by  the  usual  phe- 
nomena (rigor,  cough,  rusty  expectoration,  intense  chest-pain,  etc.),  and 
hence  may  be  easily  overlooked.  The  temperature  may  be  either  quite 
elevated  or  at  times  only  moderate.  The  diagnosis  is  to  be  made  from 
the  physical  signs,  together  with  the  peculiar  temperature-curve,  which 
may  present  marked  irregularities.  Pulmonary  infarction  and  abscess 
of  the  lungs  are  occasional  complications. 

Hypostatic  congestion  of  the  lungs,  due  to  enfeeblement  of  the  cardio- 
pulmonary circulation,  is  a  comparatively  frequent  concomitant,  appear- 
ing in  the  third  week  of  the  disease.  It  is  generally  bilateral,  affecting 
the  base  of  the  lungs,  and  is  promoted  by  the  effects  of  gravitation.  It 
is  almost  always  associated  with  more  or  less  edema  of  the  lungs.  The 
subjective  symptoms,  including  fever,  are  usually  negative,  while  the 
objective  signs  are  those  of  partial  or  complete  consolidation  of  the 
bases  (defective  resonance  or  dulness,  broncho-vesicular  breathing,  Avith 
moist  rales).  3Iiliary  tuberculosis  rarely  develops  as  either  a  complica- 
ting affection  or,  it  may  be,  as  a  sequel.  A  spasmodic  or  jerking  inspi- 
ration when  pneumonia  does  not  exist  is  a  precursor  of  coma  (Flint). 

Laryngitis,  indicated  by  hoarseness,  is  an  occasional  complication. 
The  laryngeal  ulcers  may  extend  in  depth  to  the  perichondrium,  and 
promote  that  grave  though  not  necessarily  fatal  condition,  pyerichondritis 
leading  to  necrosis  of  the  cartilages  with  edema  of  the  glottis.  The 
symptoms  of  laryngeal  stenosis  are  apt  to  develop. 

Epistaxis  appears  early  in  a  large  number  of  cases,  and  is  a  valuable 
diagnostic  symptom.  It  may  also  occur  during  the  fastigium,  and  par- 
ticularly toward  the  latter  part,  when  it  is  of  little  or  no  diagnostic,  but 
of  grave  prognostic,  significance.     It  is  apt  now  to  be  troublesome,  and 


TYPHOID  FEVER.  39 

may  even,  as  in  a  case  I  saw  recently  with  Dr.  I.  Newton  Snively,  be 
so  persistent  as  to  lead  to  a  fatal  issue. 

(e)  The  circulatory  system  presents  no  characteristic  symptoms.  The 
heart-sounds  are  but  little  affected,  as  a  rule.  In  cases  of  asthenic  type 
and  in  severe  typical  instances  the  first  sound  of  the  heart  may  grow 
quite  feeble  and  ultimately  resemble  the  second  (embryocardia).  Under 
these  circumstances  a  soft  systolic  murmur  may  be  faintly  heard  along 
the  left  border  of  the  sternum.  Among  occasional  complications  pre- 
sented by  the  heart  is  pericarditis,  and  still  less  frequent  is  endocarditis. 
Myocarditis  is  somewhat  more  common.  The  sudden  development  of 
circulatory  collapse  in  the  course  of  typhoid  fever,  as  previously  noted, 
may  be  due  chiefly  to  myocardial  inflammation  ;  and  there  may  be  a 
brief  though  alarming  derangement  of  the  heart  action,  due  to  func- 
tional disturbances  of  the  sympathetic  and  pneumogastric  nerves. 

The  2^uhe  is  accelerated,  but  not,  as  a  general  rule,  in  proportion  to 
the  height  of  the  temperature  until  late  in  the  affection.  Its  average 
rate  is  from  84  to  108,  but  it  may  go  much  higher,  and  when  the  pulse 
is  maintained  at  130  or  more  for  days  together  it  is  of  ominous  import. 
The  temperature,  moreover,  may  be  of  average  height,  while  the  pulse 
is  normal  or  only  slightly  quickened  throughout;  and  hence  the  increase 
in  the  pulse-rate  cannot  be  due  solely  to  the  elevation  of  temperature. 
As  before  intimated,  the  extreme  debility  which  comes  on  during;  the 
third  week  in  severe  cases  may  have,  as  one  of  its  manifestations,  a  very 
rapid  pulse,  reaching  to  160  or  more  (the  so-called  running  pulse),  and 
with  or  without  marked  irregularity.  '^\\^i  irregularity  is  sometimes 
observed,  either  during  the  height  or  decline  of  the  affection,  but  as  a 
rule  this  soon  disappears,  and  proves  of  no  serious  consequence.  Marked 
temporary  accelerations  are  often  caused  by  undue  exertion  or  mental 
excitement.  The  lowered  arterial  tension  is  shown  by  a  dicrotism  of 
the  pulse — a  symptom  which  is  not  characteristic  of  typhoid  fever,  how- 
ever, since  it  is  well  marked  in  other  acute  infectious  diseases,  though 
less  frequently.  During  convalescence  the  pulse  often  becomes  sub- 
normal in  rate,  and  hrachycardia  is  oftener  a  sequel  of  typhoid  than  of 
any  other  acute  infectious  disease. 

Venous  thrombosis  occurs  in  1  per  cent,  of  all  cases  (Murchison). 
Its  most  frequent  seat  is  the  left  femoral,  and  the  next  most  frequent 
the  right  femoral  vein,  and  it  is  the  immediate  result  of  cardiac  weak- 
ness, except  perhaps  in  those  rare  instances  that  arise  early  in  typhoid. 
For  the  latter  no  definite  cause  has  as  yet  been  found.  Coming  on,  as 
it  usually  does,  during  convalescence,  it  manifests  itself  by  swelling 
and  edema  of  the  extremity  affected.  There  are  pain  in  the  thighs  and 
calves,  and  tenderness  (on  pressure)  over  the  course  of  the  femoral 
vein,  and  often  in  the  region  of  the  calf  of  the  leg  as  well.  It  causes 
fever  of  a  moderate  grade  and  irregular  type,  and  then  in  the  course  of 
from  two  to  three  weeks  the  swollen  member  may  be  reduced  to  its 
normal  dimensions.  This  complication  is  usually  not  of  a  serious 
nature.  Occasionally,  however,  clotting  extends  into  the  pelvic  veins, 
or  even  into  the  vena  cava,  when  the  condition  becomes  more  serious, 
and  sudden  death  has  resulted  from  the  detachment  of  emboli.  The 
thrombus  may  undergo  suppuration,  to  which  systemic  septic  infection 
may  be  a  secondary  event. 


40 


INFECTIOUS  DISEASES. 


Thromhosis,  and  less  frequently  embolism,  in  the  arteries,  combined 
with  renal,  splenic,  and  pulmonary  infarcts,  may  be  encountered  in 
typhoid  fever. 

The  large  or  small  arteries  may  become  obliterated,  either  by  em- 
bolism or  thrombosis,  in  extremely  rare  instances,  but  whether  the 
thrombosis  under  these  circumstances  is  brought  about  by  a  peculiar 
condition  of  the  blood  which  favors  clotting,  or  by  a  localized  arteritis, 
or  in  consequence  of  the  operation  of  these  combined  factors,  is  not 
definitely  known.  If,  as  is  usual,  the  femoral  artery  be  involved,  the 
blood-supply  to  the  foot  and  leg  is  cut  off  and  gangrene  of  those  parts 
must  follow.     The   condition   may   be   bilateral.     It    mav  be  detected 


WEEKS           I           II          III        IV          V 

VI        VII      VIII       IX         X          WEEKS 

100< 

90% 

«0l! 

70< 

6Q% 

50* 

t  000  000                                           \  f           fl 

'.i'-',ei  '      -  -    -"  i"  -t'z  ":":.     2  000  000 

40* 

::::::::::::.:::::::!;;:. :;;;;::!± 

:::::::::::::::::::::::::!:':::::±: 

30^ 

1000  000    ~~—'-  -"-'-'-'-  :::  ::"~::":"::::::;:± 

20* 

8  000       i-;i:iii::i:;i-iii::ii;-i"i           i 

lOOit 
90!< 
SOjC 
70% 
60^ 
50^ 
40^ 
30^ 
20% 


Fig.  4.— Chart  illustrating  the  blood-changes 
middle  curve,  hemoglobin ; 


1  typhoid 
jwer curv 


fever :  upper  curve,  red  corpuscles ; 
e,  white  corpuscles. 


early,  owing  to  the  absence  of  a  femoral  pulse,  before  the  signs  of  gan- 
grene appear,  but  the  condition  is  highly  dangerous.  Recovery  ensues 
in  perhaps  more  than  half  of  the  cases. 

The  blood  presents  certain  changes,  some  of  which  are  valua])le  for 
diagnostic  purposes.  In  those  rare  cases  in  which  copious  diarrhea  or 
profuse  sweats  are  present  the  red  corpuscles  may  be  relatively  increased 
in  number  during  the  febrile  period,  owing  to  loss  of  water.  There  is, 
however,  in  the  majority  of  instances,  little  or  no  decrease  in  the  num- 
ber of  red  corpuscles  till  the  end  of  the  second  Aveek.  They  are  mark- 
edly diminished,  as  a  rule,  during  convalescence.  Indeed,  tlie  oligo- 
cythemia may  attain  to  an  immoderate  degree.  In  one  of  Osier's  cases 
the  number  of  red  corpuscles  was  as  low  as  1,300,000  per  c.mm.,  but  I 
have  personally  never  found  the  blood-count  under  1,800,000. 

There  is  a  greater  relative  decrease  in  the  amount  of  hemoglobin 
than  in  the  number  of  red  corpuscles,  and  the  restoration  of  the  hemo- 
globin in  the  convalescent  period  takes  place  more  slowly  than  that  of 


TYPHOID  FEVER.  41 

the  red  corpuscles.  The  number  of  white  corpuscles  remains  at  or  a 
little  below  the  health  standard  until  late  convalescence,  when  it  sinks 
to  a  moderate  degree — furnishing  a  count  of  about  2000  per  c.mm. 
This  fact  is  an  important  aid  in  the  diiferentiation  of  typhoid  fever  from 
acute  inflammations  and  infectious  (febrile)  affections  accompanied  by 
exudation,  in  which  leukocytosis  is  marked,  and  from  all  suppurative 
processes  in  which  the  polynuclear  neutrophiles  are  moderately  increased. 
In  typhoid  fever  there  is  also  a  relative  preponderance  of  the  mono- 
nuclear forms  in  addition  to  the  absolute  decrease  of  the  leukocytes. 
The  blood-characters  in  typhoid  are  shown  in  the  accompanying  chart 
(Fig.  4). 

( / )  Nervous  System. — The  persistent  headache  that  is  almost  always 
present  is  among  the  most  prominent  symptoms  during  the  first  week, 
but  it  diminishes  steadily  during  the  early  part  of  the  second,  as  a  rule. 
It  affects  the  temporal,  occipital,  and  cervical  regions,  and  when  the 
onset  is  comparatively  sudden,  pain  in  the  back  is  also  a  more  or  less 
conspicuous  feature  during  the  first  few  days  of  the  illness.  In  a  small 
class  of  cases,  however,  the  effects  of  the  typhoid  bacilli  or  their  toxins 
are  manifested  solely  in  the  nervous  system  from  the  very  onset.  In 
such  there  are  violent  headaches,  retraction  of  the  head,  rigidity,  pho- 
tophobia, and  muscular  twitchings  (rarely  convulsions) — all  of  which 
symptoms  indicate  meningitis.  The  diagnosis  of  meningitis  as  a  com- 
plication must  be  made  with  extreme  caution,  since,  no  matter  how  com- 
plete the  clinical  picture  may  be,  the  post-mortem  examination  usu- 
ally reveals  a  total  absence  of  meningeal  inflammation.  It  must  not 
be  forgotten,  however,  that  meningitis  is  one  of  the  rarest  of  the 
complications  of  typhoid  fever.  Vertigo  may  accompany  the  head- 
ache, but  it  seldom  outlasts  the  latter.  Before  delirium  manifests  it- 
self wakefulness  and  restlessness  at  night  are  very  annoying,  and  later 
the  same  symptoms  may  be  observed  associated  with  the  delirium.  In 
cases  of  moderate  severity  mental  dulness,  and  even  actual  hebetude,  are 
almost  invariably  present.  Questions  are  apt  to  be  answered  inconsist- 
ently and  in  monosyllables,  and  the  patient  sleeps  poorly,  notwithstand- 
ing the  pseudo-somnolent  state  in  which  he  almost  constantly  appears. 

Delirium  is  frequent  in  the  severer  cases.  It  is,  however,  not  an 
uncommon  event  for  those  of  moderate  severity  to  be  free  from  this 
symptom  throughout  the  attack.  It  is,  as  a  rule,  most  marked  at  night 
or  at  some  time  when  the  patient  is  left  alone.  His  delusions  may 
impel  him  to  attempt  to  leave  his  bed,  but  more  commonly  there  is 
mild  or  noisy  delirium,  with  more  or  less  restlessness.  He  may  lie 
somnolent,  soliloquizing  in  a  loud  whisper  (muttering  delirium),  and 
this  so-called  typhomania  may  gradually  give  place  to  actual  coma  to- 
ward the  close  of  the  middle  period  of  the  disease.  In  not  a  few  cases 
— mild  or  severe — coma  is  developed  suddenly,  and  is  often  a  mortal 
symptom.  Still  another  unfavorable  sign  is  a  picking  at  the  bed-clothes 
or  a  grasping  at  imaginary  objects  (carphologia). 

The  delirium  may  assume  an  hysteric  type,  the  patient  usually  ex- 
hibiting the  saddest  emotions,  and  if  he  be  an  alcoholic  he  may  be 
seized  with  delirium  tremens.  In  a  case  of  typhoid  fever  that  I  saw 
recently  with  Dr.  S.  W.  Morton  hysteric  delirium  developed  during 
convalescence,  but  did  not  last  more  than  twenty-four  or  thirty-six  hours. 


42  INFECTIOUS  DISEASES. 

The  motor  nerves  also  present  notable  disturbances  in  association 
with  the  sopor  and  the  forms  of  delirium  previously  described.  Slight 
twitchings  of  the  muscles  of  the  face  and  extremities  are  quite  common, 
and  when  they  affect  the  tendons  of  the  wrist  and  fingers  the  term  sub- 
suhus  tendinum  is  applied.  The  lips,  tongue  (especially  when  pro- 
truded), lower  jaw,  and  even  the  extremities,  are  often  in  a  state  of  con- 
stant tremor.  During  this  motor  irritability  the  reflexes  are  increased, 
but  when  profound  coma  comes  on  they  are  either  largely  diminished  or 
totally  abolished.  The  toxins  and  chemical  secretions  of  the  typhoid 
bacillus,  acting  poisonously  upon  the  nervous  centers,  are  undoubtedly 
the  cause  of  the  nervous  symptoms  in  typhoid. 

Nervous  complications  and  sequeke  may  arise.  Chief  among  these 
is  paralysis,  which  is  most  probably  due  to  neuritis.  The  lesion  may 
involve  one,  two,  or  more  nerves,  and  in  this  way  we  may  have  either  a 
paralysis  of  one  limb  or,  more  rarely,  a  true  paraplegia.  Aphasia  may 
be  a  sequel,  particularly  in  children.  Hemiplegia,  due  to  hemorrhage 
or  a  localized  encephalitis,  may  occur  either  as  a  complication  or 
sequence  of  the  disease.  Following  typhoid  fever,  the  patient  may  ex- 
hibit evidences  of  mental  enfeeblement,  and  even  insanity  where  a  pre- 
disposition to  this  condition  has  existed;  and  insanity  is  relatively  more 
common  after  this  disease  than  after  any  others  belonging  to  the  same 
class.  I  have  seen  four  instances,  all  of  which  recovered,  while  Osier  has 
seen  five,  four  of  which  ended  similarly.  It  is  in  most  cases,  as  pointed 
out  by  Wood,  a  confusional  insanity,  due  to  exhaustion  and  impairment 
of  the  nutrition  of  the  nerve-centers,  while  in  a  smaller  contingent  it 
takes  the  form  of  a  true  melancholia.  After  the  conclusion  of  typhoid, 
as  well  as  during  its  course,  neuralgia  affecting  the  occipital  and  other 
cranial  nerves  is  not  infrequent.  Great  hyperesthesia  of  the  skin  and 
muscles  is  common  durin^r  convalescence,  attacking  the  lower  extremities 
by  preference  (Strlimpell).  The  so-called  "  typhoid  spine  "  (Gibney) 
has  also  been  observed,  and  consists  in  an  acute  inflammation  of  one  or 
more  vertebr;\?  following  typhoid.  The  chief  symptoms  are  pain  in  the 
back  and  hips  of  a  lancinating  character.  The  point  of  origin  appears 
to  be  the  small  of  the  back ;  thence  the  pains  extend  paroxysmally  up 
and  along  the  spine  and  to  the  abdomen.  They  subside  gradually, 
leaving  the  back  weak  and  painful  on  attempts  at  turning  in  bed,  etc. 
Plantar  and  other  skin-reflexes  increase,  and  the  knee-jerks  are  pre- 
served. G.  E.  de  Schweinitz  has  described  at  length  the  ocular  compli- 
catiuns  and  sequehv  of  typhoid  fever.  Aftections  of  the  conjunctiva  and 
cornea  and  retinal  hemorrhage  are  perhaps  the  most  fre(juent,  although 
optic  neuritis  and  afl'ections  of  the  uveal  tract  also  occur. 

(//)  The  Urinary  System. —  Urine. — The  urine  is  lessened  in  quantity 
and  high-colored,  with  an  increased  specific  gravity  up  to  the  arrival  of 
the  stage  of  decline.  About  this  time,  and  rarely  earlier,  it  grows 
light  in  color,  larger  in  quantity  than  the  normal,  and  the  specific 
gravity  is  relatively  diminished.  Both  urea  and  uric  acid  are  increased 
during  the  earlier  stages,  and  sometimes  throughout  the  attack,  while 
during  convalescence  both  are  diminished.  On  the  other  hand,  the 
chlorids  are  diminished  during  the  active  stages  of  the  disease  and  in- 
creased during  its  decline.  Afebrile  albuminuria '\s  quite  common,  but 
is  of  no  clinical  importance. 


TYPHOID  FEVER.  43 

Acute  nephritis  may  develop  as  a  complication  in  the  earlier  or  later 
course  of  the  disease,  and  can  be  recognized  to  a  certainty  only  by  a 
thorough  appreciation  of  the  urinary  phenomena.  The  urine  is  dimin- 
ished in  quantity,  being  often  scanty,  and  there  may  be  retention.  It 
contains  characteristic  morphologic  elements  (albumin,  casts,  blood,  and 
epithelium).  The  development  of  the  typhoid  state  in  this  affection  is 
rendered  much  more  probable  in  the  presence  of  this  complication,  and, 
moreover,  uremic  symptoms  often  put  in  an  appearance  at  this  juncture, 
and  then  the  situation  is  really  serious.  Acute  nephritis  may  arise  at 
one  or  other  of  three  different  periods,  and  its  significance  varies  with 
the  time  of  onset :  (a)  at  the  beginning  of  the  fever,  when  it  often 
obscures  the  true  nature  of  the  malady.  This  is  the  iiephro-typhoid  of 
the  German  authors,  and  will  be  referred  to  hereafter  [vide  infra,  Varie- 
ties) ;  {h)  in  the  early  part  of  the  fastigium  or  the  second  week  of  the 
disease.  Coming  on  at  this  time — an  event  which  I  have  observed  in  two 
instances — its  relation  to  the  typhoid  bacillus  or  its  toxin  is  not  definable. 
It  is  probable,  however,  that  it  is  to  be  ascribed  to  the  local  effect  of 
the  toxin  upon  the  renal  tissues.  Both  of  my  own  instances  proved 
fatal,  and  in  both  an  autopsy  was  refused.  Wagner  ^  has  had  5  cases 
of  recovery  in  succession,  but  the  high  mortality  mentioned  by  Am  at — 
10  deaths  in  12  cases — is  the  more  common  experience.  (<?)  Acute  neph- 
ritis may  arise  as  a  sequel  of  typhoid,  when,  with  the  usual  symptoms 
of  acute  nephritis,  there  is  almost  invariably  associated  a  decided  edema. 
In  this  category  of  cases  recovery  is  to  be  expected.  The  lymphoma- 
tous  nephritis  of  Wagner  {vide  supra,  Pathology)  is  usually  without 
symptoms. 

Diabetes  mellitus  is,  in  extremely  rare  instances,  developed  after 
typhoid.  Hematuria  has  also  been  observed  as  an  occasional  symptom 
of  the  hemorrhagic  diathesis. 

The  diazo-r eaction  o^WnrMch.  is  an  aid  in  diagnosis,  but,  unfortunately, 
may  be  present  also  in  acute  phthisis,  meningitis,  measles,  and  other 
fevers;  and  the  only  reliable  change  is  a  rose-red  (pink)  hue  of  the  foam. 
To  obtain  it  two  solutions  (a  and  h)  are  needed :  We  mix  1  part  of  solu- 
tion (a),  which  consists  of  a  0.5  per  cent,  solution  of  sodium  nitrite,  with 
40  parts  of  solution  (b),  which  consists  of  2  grams  of  sulfanilic  acid,  150 
c.c.  of  hydrochloric  acid,  and  1000  c.c.  of  distilled  water.  To  this  an 
equal  volume  of  urine  is  added,  and  the  contents  of  the  test-tube  are 
then  thoroughly  shaken.  A  layer  of  ammonium  hydrate  is  now  super- 
imposed, and  at  the  line  of  contact  a  ruby  or  pink  ring  develops.  More- 
over, it  is  present  in  only  about  70  per  cent,  of  the  cases.  A  brownish 
ring  is  given  by  normal  urine. 

There  is  a  post-typhoid,  diphtheritic  pyelitis  in  which  the  pelves  and 
calices  of  the  kidneys  are  primarily  the  seat  of  membranous  exudation, 
and  later  of  erosion  and  ulceration.  The  urine  generally  contains 
blood  and  pus.  Osier  has  met  with  this  condition  in  3  autopsies,  in  1 
of  which  it  was  associated  with  extensive  membranous  inflammation  of 
the  bladder. 

Simple  vesical  catarrh  is  a  rare  complication,  except  as  the  result  of 
catheterization  for  retention. 

Orchitis  and  epididymitis  as  well  as  ovaritis  are  occasional  sequels. 

^  Deutsche  Archivfiir  klin.  Med.,  Bds.  xxv.  and  xxxvii. 


44  INFECTIOUS  DISEASES. 

(h)  The  Joints. — Typhoid,  septic  and  rheumatic  arthritis  may  occa- 
sionally arise  as  a  complication.  The  first  is  usually  mon-articular  (par- 
ticulariv  in  the  hip) ;  the  last  two  commonly  polyarticular.  Keen  has 
collected  "'in  all  84  cases  involving  the  joints." 

(/)  The  Bones. — Periostitis,  due  to  injury  and  muscular  strain  and 
often  leading  to  necrosis,  is  a  not  very  rare  sequel  of  typhoid.  The 
favorite  seats  are  the  tibia  and  ribs,  though  in  a  case  of  my  own  at  the 
Philadelphia  Hospital  it  affected  the  os  calcis.  Osteomi/elitis  may  also 
occur.  Keen  has  collected  216  cases  in  which  the  bones  were  attacked. 
( ;)  The  Muscles. — As  in  the  case  of  the  heart,  so  the  voluntary 
muscles  exhibit  hvaline  degeneration  ;  also  abscesses,  in  consequence  of 
secondary  infection  or  of  infection  with  the  typhoid  bacillus  itself. 
Typhoid  abscesses  likewise  result  from  perforations  in  all  portions  of 
the  gut. 

Associated  Acute  Infectious  Diseases.— Malarial  fever  may  be  com- 
bined with  typhoid,  though  the  relationship  is  not  a  vital  one.  In  an 
analysis  of  2122  cases  of  malaria  typhoid  fever  Avas  associated  in  8.^ 
Many  instances  of  so-called  typho-malarial  fever  would  be  shown  to  be 
pure"^  typhoid  by  a  careful  blood-examination,  as  the  presence  of  chills, 
sweats,  and  an  intermittent  temperature-curve  are  sometimes  observed 
in   this  disease  (>'i<Je  supra). 

Pseudo-membranous  inflammation,  as  above  intimated,  may  occur  in 
the  naso-pharynx,  larynx,  gall-bladder,  and  genitals.  Measles,  scarla- 
tina, and  chicken-po.r  have  also  been  knoAvn  to  arise  in  the  course  of,  or 
during  convalescence  from,  typhoid  fever. 

Erysipelas  is  a  rare  secondary  affection  coming  on  either  during  the 
height  of  the  affection  or  (more  frequently)  after  its  close.  Typhus 
fever  may  be  associated  with  typhoid,  but  is  an  exceedingly  rare 
occurrence. 

CUnical  Varieties  of  Typhoid  Fever. — These  are  numerous,  and  may 
grow  out  of  peculiarities  manifested  during  the  course  of  the  affec- 
tion, as  may  be  observed  not  only  in  different  epidemics,  but  also  in  the 
same  epidemic.  The  groups  of  cases  described  here  have  reference  par- 
ticularly to  the  degree  of  severity  of  the  type,  which  vai'ies  between 
the  wide  limits  of  extreme  mildness  on  the  one  hand  and  extreme  severity 
on  the  other.  The  course  of  the  disease  may  also  be  modified  by  the 
occurrence  of  one  or  more  of  its  manifold  complications. 

(1)  The  Mild  or  Rudimentary  Form  (Typhus  Laevissimus). — Of  this 
variety  many  cases  occur,  and  especially  among  children.  The  charac- 
teristic typhoid  symptoms  are  scanty,  and  at  times  even  entirely  Avanting. 
The  spleen  is  almost  always  enlarged,  the  roseate  spots  are  sometimes 
present,  while  the  temperature  is  moderately  elevated  and  often  partakes 
of  the  same  character  as  that  of  true  typhoid.  The  fever,  however, 
may  pursue  the  remittent  type.  Com])lications  presented  by  special 
organs  are  usually  absent,  but  grave  accidents  (intestinal  hemorrhage, 
perforation)  are  not  impossible. 

The  diagnosis  is  always  difficult,  owing  to  the  feeble  development 
of  the  characteristic  symptoms,  and  in  the  total  absence  of  the  latter  is 
out  of  the  question  ;  but  the  recognition  is  assured  if  a  causal  connec- 

^  "  The  Complications  of  Malaria,"  Journal  of  the  American  Medical  Association,  vol. 
xxiv.  p.  919,  by  the  author. 


TYPHOID  FEVER.  45 

tion  between  them  and  typical  cases  can  be  shown  to  exist,  and  if  the 
Widal  test  gives  a  positive  result. 

(2)  The  abortive  form  has  a  sudden  onset,  and  is  often  marked  by 
fits  of  shivering.  The  characteristic  features  of  the  disease  (enlarge- 
ment of  the  spleen,  abdominal  symptoms,  rose  spots,  etc.)  appear  earlier 
than  in  the  usual  type,  and  soon  become  quite  well  marked.  The  fas- 
tigium  is  short,  and  the  temperature,  from  the  seventh  to  the  twelfth 
day  of  the  illness,  declines  by  a  prompt  lysis,  with  profuse  sweating. 
With  the  rather  rapid  fall  of  temperature  there  is  a  no  less  rapid  im- 
provement in  every  other  leading  symptom.      Convalescence  is  speedy. 

(3)  The  Ambulatory  Form  (Latent  or  Walking  Typhoid). — The  pa- 
tient continues  to  walk  about,  either  experiencing  but  slight  disturbance 
or  being  unwilling  to  take  to  his  bed.  Such  cases  do  not  come  under 
the  care  of  the  physician  in  many  instances.  Others,  on  account  of 
debility,  anorexia,  diarrhea,  and  other  vague  symptoms,  finally  consult 
their  physician,  who  may  discover  the  presence  of  all  the  characteristic 
features  of  the  disease.  A  third  contingent,  belonging  to  this  form, 
continue  to  move  about,  or  even  to  follow  their  usual  vocations,  till 
seized  suddenly  with  profuse  intestinal  hemorrhage  or  general  diffuse 
peritonitis  following  perforation.  The  likelihood  of  these  grave  devel- 
opments is  much  greater  in  the  case  of  persons  who  go  about  or  travel 
long  distances  while  sufi'ering  from  this  disease. 

(4)  The  afebrile  is  an  exceedingly  rare  form  of  the  afi'ection — in  this 
country  at  least.  Liebermeister,  however,  has  met  with  a  number  of 
cases  at  Basle,  the  symptoms  being  lassitude,  depression,  headache, 
neuro-muscular  pains,  anorexia,  slow  pulse,  furred  tongue,  constipa- 
tion or  diarrhea,  with  enlargement  of  the  spleen  and  roseate  spots. 
These  cases  are  often  confined  to  bed,  and  there  are  occasional  attempts 
at  evening  exacerbations  of  temperature  (100.5°  F. — 38°  C).  Sub- 
normal temperatures  are  sometimes  associated,  but  I  have  seen  only  two 
cases  that  I  regarded  as  belonging  to  this  form. 

(5)  Severe  or  Grave  Forms. — These  may  be  dependent  either  wholly 
or  in  great  part  upon  the  degree  of  virulence  of  the  typhoid  poison. 
Under  these  circumstances  there  will  be  a  profound  intoxication  of  the 
system,  as  shown  by  high  temperature,  violent  nervous  symptoms,  and 
great  prostration.  The  grave  types  may  arise  in  the  course  of  cases  of 
average  severity  from  the  development  of  serious  complications.  Again, 
to  serious  forms  belong  those  cases  that  begin  with  the  characteristic 
symptoms  of  a  localized  inflammation — e.  g.  the  cerehro-spinal  form,  in 
which  the  nervous  symptoms  greatly  predominate  at  the  onset ;  the 
nephro-typlioid  (before  alluded  to),  in  which  the  preliminary  symptoms 
are  those  of  acute  Bright's  disease ;  the  'pneuyno-typlioid  {vide  supra), 
which  begins  with  the  manifestations  of  a  more  or  less  frank  pneumonia. 

Pleuro-typJioid. — The  cases  begin  as  an  acute  pleurisy,  having  its 
special  characteristics,  and  these  are  followed,  soon  or  late,  by  the  diag- 
nostic evidences  of  typhoid  fever.  Talamon  ^  distinguishes  these  cases 
from  simple  pleurisy  by  the  intensity  and  continuous  course  of  the 
fever,  by  the  general  depression,  headache,  and  vertigo,  and  by  the 
sleeplessness.  Should  any  doubt  remain,  it  will  be  dissipated  by  the 
eighth  or  the    ninth  day  by  the    presence  or  absence  of  rose-colored 

^  La  Medecine  moderne,  Paris,  1891. 


46  INFECTIOUS  DISEASES. 

spots,  by  the  enlargement  of  the  spleen,  and  of  the  sero-reaction  {vide 
itifra). 

The  sudoral  form  and  tonsillo-typhoid  (before  described)  also  belong 
to  this  category.  Many  circumstances  connected  with  the  individual 
influence  decidedly  the  general  course  of  the  affection,  and  these  may 
be  expressed  in  part  in  the  several  forms  following,  which  are  based 
upon  such  factors  as  age,   habits,  etc. 

(6)  Typhoid  Fever  in  Children. — The  onset  is  rather  more  abrupt 
than  in  the  adult,  and  certain  prodromal  symptoms  are  very  generally 
absent  (epistaxis,  chilliness).  On  the  other  hand,  bronchial  and  nervous 
symptoms  are  often  quite  pronounced.  Again,  during  the  fastigium 
some  of  the  usual  typhoid  features  may  be  missing — e.  g.  diarrhea  and 
tympanites — while  the  eruption  may  either  be  entirely  wanting  or  less 
copious  than  in  older  subjects.  Intestinal  hemorrhage  is  rare  and  per- 
foration almost  never  occurs;  but,  as  previously  pointed  out,  aphasia  is 
a  more  common  sequel  than  in  adults.  The  same  is  true  of  arthritis 
and  the  bone-lesions.     The  mortality  is  not  over  1  per  cent. 

(7)  Typhoid  Fever  in  the  Aged. — The  course  of  the  affection  presents 
no  regular  type.  The  temperature  is  not  as  high  as  usual,  but  there  is 
marked  advnamia  and  serious  danger  from  certain  complications,  such 
as  pneumonia,  nephritis,  coma,  and  the  like. 

The  diagnosis  is  difficult,  owing  to  the  prominence  of  the  nervous 
and  pulmonary  symptoms  on  the  one  hand,  and  the  frequent  absence  of 
the  more  characteristic  symptoms  of  typhoid  on  the  other  (rash,  enlarge- 
ment of  the  spleen,  and  peculiar  temperature-curve). 

Diagnosis. — Unless  all  the  chief  characteristic  features  be  pres- 
ent with  a  clear  history,  it  is  a  golden  rule  not  to  make  a  positive  diag- 
nosis. Obviously,  then,  the  physician  at  the  first  visit  cannot,  in  many 
cases,  diagnosticate  typhoid  with  absolute  certainty.  In  the  majority 
of  instances  he  is  called  after  the  case  has  progressed  to  or  near  the 
close  of  the  first  week.  If  the  case  have  been  a  typical  one,  the  history 
of  the  gradual  development  of  the  disease,  marked  by  such  symptoms 
as  languor,  anorexia,  headache,  dulness,  slight  chills,  increasing  fever, 
and  sometimes  nose-bleed,  will  be  obtained,  and  justify  a  strong  sus- 
picion of  typhoid.  When,  in  addition,  diarrhea  and  the  objective  symp- 
toms, splenic  enlargement,  tympanites,  gurgling,  with  tenderness  in  the 
ileo-cecal  region,  are  present,  the  diagnosis  of  typhoid  is  made  highly 
probable.  After  the  lapse  of  a  few  days — the  beginning  o\  the  second 
week — the  roseate  spots  and  sero-reaction  (the  latter  sometimes  earlier, 
vide  infra)  usually  appear,  and  then  all  doubt  is  removed.  In  atypical 
cases  a  positive  opinion  must  often  be  withheld  till  an  advanced  stage  is 
reached.  In  such  instances  the  sudden  occurrence  of  intestinal  hemor- 
rhage or  a  characteristic  decline  by  lysis  is  exceedingly  helpful.  To 
show  a  causal  relation  between  an  obscure  case  and  one  that  is  clearly 
typhoid  leaves  little  to  be  desired.  The  diagnosis  should  include  the 
particular  stage  of  the  disease. 

Briefly,  the  most  trustworthy  diagnostic  features  are  the  gradual  on- 
set, peculiar  temperature-curve  (made  up  of  the  "step-ladder  "  stage  of 
development,  the  continued  type  of  the  fastigium,  and  the  decline  by 
lysis),  enlarged  spleen,  the  rose-colored  spots,  and  the  sero-reaction. 

Serum-diagnosis. — Investigations  by  Pfeiffer  upon  the  specific  bac- 


TYPHOID  FEVER.  47 

tericidal  substances  developed  in  the  blood  of  animals  immunized  by 
injection  of  typhoid  bacilli  have  furnished  a  reliable  means  of  diagnosis 
of  this  disease  from  blood-serum.  It  remained,  however,  for  Widal  and 
others  to  show  that  if  to  a  drop  of  blood-serum,  or  to  a  drop  of  "water 
containing  a  solution  of  dried  blood  from  a  typhoid  patient,  a  moderate 
number  of  typhoid  bacilli  were  added,  a  specific  reaction  occurred. 

Johnston  of  Montreal  has  simplified  the  technic :  The  blood  is  ob- 
tained upon  a  clean  glass  slide  from  a  needle-prick  of  the  ear  or  finger 
of  the  suspected  case.  It  is  allowed  to  dry,  and  is  then  carried  to  the 
laboratory.  A  loop  of  bouillon-culture  of  genuine  typhoid  bacilli  is 
placed  upon  a  clean  cover-glass,  and  to  this  is  added  a  large  loopful  of 
a  watery  solution  of  the  dried  blood-specimen.  The  cover-glass  is  in- 
verted over  the  concavity  of  a  hollow  slide  and  sealed  at  the  edges  with 
melted  vaselin.  Under  the  microscope,  with  a  high-power  dry  lens  or 
with  a  one-twelfth  oil-immersion  lens,  a  rapid  clumping  of  the  bacilli  in  the 
hanging  drop  can  be  observed,^  and  their  motions  cease  almost  instantly. 

It  is  of  paramount  importance  that  the  technic  be  perfect.  Again, 
"Widal  himself  observes  that  this  reaction  is  not  limited  to  the  bacillus 
typhosus — "  That  it  can  occur,  but  in  different  degrees,  with  related 
species."  Although  the  question  has  been  much  discussed,  it  Avould 
seem  that  the  balance  of  testimony  goes  to  prove  that  the  reaction  is 
one  of  infection,  and  not  of  immunity. 

Diagnostic  Value. — A  review  of  all  preceding  work  in  the  Widal 
reaction  reveals  the  broad  fact  that  there  is  a  general  consensus  of 
opinion  as  to  its  great  clinical  value.  The  large  statistics  of  Kneass 
and  Stengel,  based  on  2283  cases,  and  published  in  the  American  Year- 
Book  of  Medicme  and  Surgery  for  1898,  coupled  with  more  recent 
available  figures,  show  the  presence  of  the  reaction  in  95.2  per  cent.,  and 
no  reaction  in  non-typhoid  cases  in  98  per  cent.  Widal,  however, 
obtained  universally  positive  reactions  in  162  cases  of  typhoid  fever. 
Cabot  and  Lowell^  found  the  results  to  be  negative  in  204  cases  of 
disease  other  than  typhoid.  Whilst  somewhat  contradictory  results  are 
occasionally  recorded  in  the  literature,  accurate  technique  and  the 
observance  of  coincident  cessation  of  motion  and  clumping  in  the  cult- 
ures place  the  diagnosis  of  typhoid  fever  beyond  question. 

Of  230  cases  examined,  219  gave  a  positive  result  (Anders  and 
McFarland).  In  128  of  these  cases  this  result  was  obtained  prior  to 
the  appearance  of  the  rose  spots,  or  before  the  eighth  day;  in  36  cases 
the  first  reaction  occurred  during  the  second  week ;  in  45,  between  the 
seventeenth  and  twenty-first  days  of  the  disease ;  in  8,  not  until  the 
twenty-fifth  day,  and  in  2  cases  as  late  as  the  twenty-eighth  day  of  the 
illness. 

Interfering  Conditions. — In  the  first  place,  a  previous  attack  of 
typhoid  fever  may  produce  a  reaction  that  may  lead  the  careless  observer 
into  error.  In  39  cases  of  pure  typhoid  tested  at  periods  of  from  one 
to  eighteen  months  after  defervescence,  13  reacted  positively  (Cabot  and 
Lowell).  It  may  be  possible  for  the  scene  to  be  dominated  by  some 
other  morbid  process  (tuberculosis,  etc.)  when  typhoid  fever  is  present. 
Again,  exceptional  cases  occur  with  a  characteristic  symptom-complex 

1  Medical  News,  Nor.  14,  1896. 

2  Boston  lied,  and  Surg.  Jour.,  Feb.  18,  1899. 


48  INFECTIOUS  DISEASES. 

and  course,  yet  give  no  reaction  throughout.  Brill  has  reported  17 
cases  of  this  sort ;  in  such  cases,  however,  the  examinations  must  be 
repeated  until  after  convalescence  is  completed,  since  the  appearance  of 
the  reaction  may  be  greatly  retarded. 

The  cases  that  begin  with  the  well-defined  local  inflammatory  lesions 
previously  referred  to  (tonsillo-typhoid,  pneumo-typhoid,  pleuro-typhoid, 
nephro-typhoid)  cannot  be  recognized  at  the  outset.  The  same  local 
inflammatory  condition  may,  independently  of  typhoid  fever,  be  com- 
bined with  a  genuine  typhoid  state.  In  all  instances  of  typhoid  fever 
in  which,  at  the  time  of  onset,  localization  occurs  the  degree  of  fever 
and  prostration  are  apt  to  be  out  of  proportion  to  the  local  symptoms, 
and  the  former  are  apt  to  continue  after  the  subsidence  of  the  latter.  A 
careful  observation  of  the  symptoms  after  the  first  week  will  usually 
detect  undoubted  symptoms  of  typhoid.  I  have  found  that  the  Widal 
test  decides  some  of  these  cases. 

Cultures  may  be  obtained  by  puncturing  the  spleen  ;  but  the  wisdom 
of  this  procedure  is  very  questionable,  since  the  bacilli  may  be  obtained 
in  quantities  from  the  stools  in  50  per  cent,  of  the  cases. 

Differential  Diagnosis. — (1)  Typhus  fever  is  to  be  differentiated  by  its 
appearance  as  an  epidemic,  by  its  sudden  onset,  by  the  deeper  stupor, 
the  besotted  expression  of  the  features,  the  injected  conjunctiva,  the 
contracted  pupils,  the  appearance  on  the  fourth  day  of  macuhe  which 
are  speedily  transformed  into  petechioe ;  by  the  shorter  course  and  the 
abrupt  termination  by  crisis. 

(2)  Acute  miliary  tuberculosis  has  been,  and  still  is,  frequently  mis- 
taken for  typhoid  fever.  The  former  is  to  be  differentiated  from  the 
latter  by  the  greater  frequency  of  the  pulse  and  respirations,  the  prom- 
inence of  the  cough,  and  in  some  instances  by  the  bloody  expectoration ; 
by  the  pronounced  cyanosis,  the  presence  (sometimes)  of  choroidal  tu- 
bercles, and  the  existence  (constantly)  of  leukocytosis,  Avhich  does  not 
occur  in  typhoid.  Blood-examinations  have  occasionally  shown  the 
presence  of  the  tubercle  bacillus.  There  is  an  absence  of  the  peculiar 
temperature-curve,  of  the  characteristic  lenticular  spots  and  the  Widal 
reaction,  and  abdominal  symptoms  of  typhoid. 

(8)  Malarial  fevers  may  assume,  more  or  less  nearly,  the  continued 
form,  and  there  are  also  typhoids  that  affect  a  remittent  or  an  inter- 
mittent type  of  malarial  fever.  The  latter  can  always  be  differentiated 
by  the  therapeutic  test  with  quinin,  and  by  a  careful  blood-examination 
for  Laveran's  hematozoa,  which  are  present  in  the  blood. 

Should  typlto-malarial  fever  be  suspected,  and  should  the  typhoid 
symptoms  be  unequivocal,  the  finding  of  the  malarial  organism  Avill  dif- 
ferentiate the  hybrid  from  pure  typhoid. 

(4)  Relapsing  fever  is  distinguished  by  its  abrupt  onset  with  rigor, 
high  fever,  pain  in  the  epigastrium ;  by  its  brief  duration,  termination 
by  crisis,  and  the  occurrence  of  a  relapse  at  the  end  of  a  week ;  by  the 
absence  of  the  characteristic  eruption  and  sero-reaction  ;  by  the  fever- 
curve  ;  and  by  the  nervous  symptoms  of  typhoid.  The  finding  of  the 
spirilla,  however,  reliably  discriminates  relapsing  fever. 

(5)  Meningitis. — In  striking  contrast  with  the  specific  typhoid  symp- 
toms meningitis  exhibits  marked  hyperesthesia,  intolerance  of  light  and 
sound,   exaggerated  reflexes,   and  often  muscular  rigidity   before  the 


TYPHOID  FEVER.  49 

stage  of  effusion ;  also  restlessness,  peevishness  (unlike  the  dulness  ob- 
served in  typhoid  patients),  vomiting,  and  constipation  {vide  Acute 
Miliary  Tuberculosis).  The  temperature  maintains  a  lower  level  on  the 
average,  and  is  more  irregular  in  type  than  in  typhoid;  the  pulse  is 
more  irregular,  and  the  nervous  symptoms  assume  greater  prominence 
in  the  earlier  stages,  particularly  headache  and  delirium.  On  the  other 
hand,  true  typhoid  symptoms  are  wanting  in  meningitis. 

(6)  Tuberculous  meningitis  gives  a  characteristic  previous  or  family 
history,  occurs  in  young  subjects,  and  the  tendon  and  cutaneous  reflexes 
exhibit  wide  variations  as  to  intensity,  within  brief  periods  and  throuo-h- 
out  the  whole  attack.  An  examination  with  the  ophthalmoscope  may 
reveal  choroidal  tubercles.  There  is  a  leukocytosis  and  the  Widal 
reaction  is  missing. 

(7)  Catarrhal  enteritis  in  children,  with  prominent  abdominal  symp- 
toms, may  simulate  typhoid  fever  very  closely.  In  the  former  the 
symptoms  are  all  gastro-intestinal,  save  perhaps  the  occurrence  of  slight 
febrile  disturbance  and  certain  nervous  phenomena,  w"hile  typhoid  fever 
manifests  a  wider  range  of  symptoms  (some  of  which  are  peculiarly  its 
own — notably  the  greater  prostration,  marked  fever,  enlargement  of  the 
spleen,  the  sero-reaction,  and  the  characteristic  eruption).  In  young 
children  the  last-named  symptom  may  be  either  wanting  or  atypical,  in 
which  case  the  existence  of  enlargement  of  the  spleen  coupled  with 
other  phenomena,  particularly  the  Widal  reaction,  will  suffice. 

(8)  Salpingitis  on  the  right  side  may  resemble  typhoid.  In  the  former 
there  is  usually  a  clear  history  either  of  antecedent  vaginitis  or  of  an 
abortion,  and  there  exist  special  evidences  of  local  peritonitis,  with 
which  may  be  associated  the  typhoid  state,  but  not  the  classic  features 
of  typhoid  fever.  A  digital  examination  per  vaginum,  however,  is 
necessary  to  certitude  of  diagnosis  in  salpingitis. 

The  diagnosis  between  typhoid  fever  and  typhoid  pneumonia,  and 
appendicitis  will  be  considered  hereafter. 

Prognosis. — As  in  all  other  acute  infectious  diseases,  so  in  typHoicl, 
the  prognosis  depends  upon  three  main  considerations  : 

(1)  The  severity  of  the  type  of  the  infection,  which  is  indicated  in 
great  measure,  though  not  solely,  by  the  degree  of  fever.  A  tempera- 
ture of  106°  F.  (41.1°  C.)  is  a  serious  symptom,  and,  if  maintained  at 
this  point  for  a  few  days,  an  almost  certainly  mortal  one.  I  have  not 
seen  a  single  instance  in  which  the  temperature  has  touched  106°  F. 
(41.1°  C.)  for  two  or  three  successive  days  that  has  recovered.  If  the 
temperature  mounts  to  and  keeps  at  105°  F.  (40.5°  C.)  for  a  longer 
period  than  three  or  four  days,  the  prognosis  should  be  made  Avith  due 
reserve.  Temperatures  above  106°  F.  (41.1°  C.)  I  would  regard  as 
offering  no  hope  of  recovery.  When  the  fastigium  is  prolonged,  even 
though  the  fever  be  not  exceptional,  the  prognosis  is  usually  grave ; 
while,  on  the  other  hand,,  marked  nocturnal  remissions  are  of  favorable 
omen.  A  sudden,  deep  fall,  however,  implies  danger  (intestinal  hemor- 
rhage, collapse). 

The  researches  of  Isaac  Ott  have  taught  us  not  only  that  fever  is  due 
to  an  agent  from  within  or  without,  which  deranges  the  harmony  of  the 
thermotaxic,  thermogenetic,  and  thermolytic  apparatuses,  increasing 
primarily  tissue-metabolism,  but  also,  that  while  high  temperature  is  an 


50  INFECTIOUS  DISEASES. 

indication  of  danger  in  specific  fevers,  it  is  not  always  the  cause  of  it. 
He  regards  high  temperature  as  being  only  a  part  of  an  infectious  proc- 
ess, and  points  out  that  the  thermotaxic  centers  of  the  cortex  may  be  so 
disordered  as  to  alter  the  harmony  between  the  heat-production  and  heat- 
dissipation.  Under  these  circumstances  a  specific  fever  of  severe  form 
may  be  associated  with  a  slight  elevation  of  temperature. 

The  power  of  resistance  to  the  influence  of  a  greatly  elevated  tem- 
perature is  quite  reliably  indicated  by  the  condition  of  the  heart.  So 
long  as  the  pulse  is  regular  and  its  rate  does  not  exceed  110  or  120 
beats  per  minute,  the  outlook  is  favorable.  When,  however,  the  pulse 
maintains  an  average  rate  of  130  or  more — a  condition  with  which  there 
is  usually  associated  some  degree  of  cyanosis,  pulmonary  congestion,  and 
edema — the  outcome  is  to  be  regarded  as  doubtful.  Collapse  is  apt  to 
follow  the  occurrence  of  sudden  complications  (perforation,  hemorrhage), 
but  it  may  also  arise  independently  of  such  a  cause.     It  is  ominous. 

Serious  types  are  also  shown  by  the  occurrence  of  certain  nervous 
symptoms,  that  may  assume  unusual  gravity.  This  is  particularly  true 
of  delirium,  stupor,  and  the  symptoms  of  motor  irritation. 

(2)  Circumstances  of  the  Patient. — Certain  individual  peculiarities 
render  the  jirognosis  highly  unfavorable.  It  is  had  in  xerj  fat  persons. 
In  such  cases  there  is  a  great  and  constant  danger  of  sudden  collapse, 
and  this  fact  also  holds  to  a  less  degree  with  reference  to  those  persons 
who  are  subjects  of  certain  chronic  diseases  (Bright's  disease,  heart-dis- 
ease, gout,  emphysema). 

Age  is  an  influential  modifying  factor.  After  puberty  the  gravity  of 
the  disease  increases  with  increasing  j-ears.  Indeed,  it  may  be  said  that, 
as  a  rule,  typhoid  luis  an  unfavorable  prognosis  in  ])ersons  past  forty 
years,  and  chiefly  for  the  reason  that  at  this  time  of  life  there  nre  dan- 
gers from  an  added  liability  to  pulmonary  complications  and  failure  of 
cardiac  reserve.  In  children  [vide  Clinical  A'arieties)  tiie  tendency  to 
hemorrhage  and  peritonitis  is  reduced  to  a  minimum,  while  the  disease 
shoivs  little  tendency  to  assume  a  grave  type.  Hence  childhood  is  the 
most  favorable  period. 

The  puerperal  state  renders  a  typhoid  patient  liable  to  many  acci- 
dents and  peculiar  complications,  and  it  seems  that  independently  of 
pregnancy  the  disease  is  more  fatal  among  females  than  males.  Chronic 
alcoholism  is  apt  to  be  complicated  with  deliriiDn  tremens,  often  pre- 
ceded by  pneumonia,  and  to  the  latter  disease  the  patient  is  very  prone, 
perhaps  to  an  equal  extent  with  heart-degeneration  and  exhaustion. 

Environment  aff'ects  the  prognosis,  poor  sanitary  arrangements  and 
poor  attention  greatly  diminishing,  and  the  opposite  conditions  greatly 
augmenting,  the  chances  for  recovery.  Improved  methods  of  treatment 
in  recent  years  have  also  effected  a  decided  loAvering  of  the  death-rate. 
Here  it  may  be  said  that  the  average  mortality  of  typhoid  is  from  8  to 
10  per  cent.,  as  against  15  to  20  per  cent,  fo.rmerly.  It  must  ever  be 
remembered,  hoAvever,  that  epidemics  diff'er  widely  as  to  their  mortality 
list — a  fact  Avhich  makes  a  precise  statement  regarding  the  ({uestion  an 
impossibility. 

(8)  The  third  and  last  consideration  is  the  presence  or  absence  of 
dangerous  complications  and  accidents.  These  have  all  been  enumerated 
and  their  prognostic  significance    stated  (supi-a).     Merely  to  reiterate 


TYPHOID  FEVER.  51 

some  of  those  that  lend  fresh  peril  to  the  typhoid  patient,  arranging 
them  with  some  regard  for  the  order  of  their  relative  gravity,  may  prove 
helpful  to  the  student.  They  are — perforation  with  diffuse  peritonitis, 
intestinal  hemorrhage,  lobar  pneumonia,  lobular  pneumonia,  sudden  col- 
lapse (due  to  cardiac  weakness),  excessive  tympanites  (often  with  marked 
diarrhea),  and  hypostatic  congestion  of  the  lungs. 

Relapses  of  Typhoid  Fever. 

A  relapse  is  a  repetition  of  all  the  characteristics  of  typhoid  after 
the  latter  has  run  its  course.  As  a  rule,  the  return  occurs  from  one 
week  to  ten  days  after  the  beginning  of  convalescence,  though  it  may 
be  either  earlier  or  later ;  and  occasionally  a  relapse  develops  before  the 
temperature  has  become  normal.  This  is  termed  an  intercurrent  relapse. 
The  cause  of  relapses  is  a  reinvasion  of  the  blood  by  the  typhoid  bacilli 
or  their  secretions ;  but  whether  this  is  attributable  to  a  reinfection  from 
without  or  from  within  (most  probably  the  latter)  cannot  be  definitely 
stated.  The  pathologic  lesions  differ  in  no  essential  way  from  those  de- 
scribed as  belonging  to  the  primary  attack,  but  the  stages  through  which 
they  pass  are  not  quite  so  long. 

In  the  interval  between  the  primary  attack  and  the  relapse  there  may 
be  present  suspicious  features,  such  as  a  slight  enlargement  of  the  spleen, 
a  trivial  evening  rise  of  temperature,  an  unnatural  apathy  or  dulness, 
and  a  more  profound  prostration  than  is  usual.  In  the  majority  of  in- 
stances, however,  there  are  no  premonitory  symptoms.  The  onset  is 
rather  more  sudden  than  in  primary  typhoid.  The  temperature,  how- 
ever, rises  in  the  characteristic  ''step-ladder"  fashion,  reaching  the 
fastigium  in  two  or  three  days,  and  the  same  relative  abridgment  of  the 
fastigium  and  defervescence  is  observed.  It  follows  that  a  relapse  has  a 
shorter  duration  than  a  primary  attack,  and,  indeed,  it  rarely  exceeds 
two  or  three  weeks.  The  temperature  may,  however,  touch  a  higher 
limit  in  the  relapse  than  in  the  primary  attack;  but.  with  rare  exceptions, 
when  the  ])rimary  typhoid  is  of  average  or  even  a  greater  than  average 
severity,  the  temperature  in  the  relapse  does  not  reach  an  equal  height. 
The  characteristic  rash  appears  earlier — from  the  second  to  the  fourth 
day — and  is  somewhat  darker  and  coarser  than  that  of  the  first  attack. 
The  spleen  swells  rapidly.  The  intercurrent  relapse  sets  in  while  the 
temperature  is  declining ;  the  fever  again  rises,  and  may  become  higher 
than  in  the  primary  attack. 

Diagnosis. — Upon  the  points  that  are  distinctive  of  a  primary  attack 
of  typhoid  fever  rests  the  important  diagnosis  between  a  relapse  and  a 
recrudescence  {spurious  relapse).  The  latter  is  usually  attributable  either 
to  errors  in  diet,  to  undue  muscular  exertion,  or  to  great  mental  excite- 
ment ;  and,  whilst  it  occurs  during  convalescence,  it  seldom  lasts  longer 
than  one,  two,  or  three  days,  and  is  not  characterized  by  the  diagnostic 
symptom-group  of  a  relapse  (peculiar  temperature-curve,  enlarged  spleen, 
and  specific  eruption). 

The  prognosis  of  relapses  depends  very  much  upon  the  severity 
of  the  primary  attack,  those  following  severe  attacks  being  relatively 
milder  than  those  that  follow  the  rudimentary,  primary  attacks. 

The    frequency   of  relapses    differs    widely   in    different    epidemics. 


52  INFECTIOUS  DISEASES. 

Hence  the  fact  that  the  percentage  of  relapses  as  estimated  by  diifer- 
ent  authors  ranges  from  3  to  15  per  cent,  need  excite  no  surprise.  The 
relapse  may  repeat  itself  once,  twice,  or  even  thrice,  and  two  relapses 
occur  in  about  1  per  cent,  of  the  cases.  In  a  case  which  I '  reported 
three  successive  and  typical  relapses  occurred.  The  pale  line  or  ridge 
which  was  mentioned  (vide  Clinical  History)  as  noticeable  in  the  nails 
after  typhoid  occurs  similarly  after  each  relapse,  and  in  the  afore-men- 
tioned case  of  my  own  four  distinct  whitish,  transverse  ridges  were 
noted.     Da  Costa  has  recorded  five  relapses  in  two  cases. 

Recurrences. — The  term  recurrence  should  be  applied  only  to 
those  instances  in  which  successive  attacks  are  separated  by  longer  or 
shorter  intervals  after  complete  recovery  from  a  previous  or  the  primary 
attack.  Typhoid  fever  usually  bestows  complete  and  lasting  immunity 
against  subsequent  attacks,  but  this  is  not  an  invariable  rule.  Eichhorst 
has  studied  600  cases,  and  found  that  in  28  of  the  number  (4.T  per  cent.) 
a  second  attack  occurred.  He  also  cites  a  case  in  which  three  or  four 
attacks  occurred  in  the  same  individual.  I  have  seen  two  typical 
attacks  of  typhoid  fever  in  two  different  persons,  the  intervals  between 
the  cases  having  been  five  and  eight  years  respectively.  Very  rarely 
three  separate  attacks  have  occurred  in  the  same  person,  and  a  second 
is  usually  milder  than  the  first  attack. 

Treatment. — (a)  Prophylaxis. — Modern  hygienic  resources  happily 
enable  us  to  minimize  the  number  of  occurrences  of  typhoid,  and 
reports  of  the  typhoid  cases  in  a  city  may  be  taken  as  a  safe  indicator 
of  its  sanitary  status.  On  the  same  principle  it  has  been  found  that 
whatever  tends  to  better  the  sanitary  arrangements  of  a  city  diminishes 
to  a  corresponding  extent  the  prevalence  of  the  disease,  particularly  im- 
provements affecting  the  water-supply  and  drainage.  Such  facts  as 
these  show  typhoid  fever  to  be  a  preventable  affection. 

The  best  means  that  can  be  employed  during  the  attack,  with  a  view 
to  limiting  the  spread  of  typhoid,  is  (Iif<i)it\>ction,  and  the  following  brief 
description  comprises  its  essential  points  as  applied  particularly  to  this 
disease : 

Disinfection  in  typhoid  may  conveniently  be  divided  into  (a)  that  of 
the  excreta  (stools,  urine,  vomitus,  and  sputum) ;  (6)  of  the  bed  and 
its  coverings ;  (c)  of  the  patient  and  the  sick-room.  While  all  of  these 
subdivisions  are  of  the  greatest  importance  in  the  treatment  of  a  ease, 
the  disinfection  of  the  excreta  [it)  is  perhaps  most  fretfuently  overlooked 
or  most  carelessly  performed,  and  hence  the  importance  of  the  state- 
ment that  all  stools  and  urine  voided  by  the  ])atient,  as  well  as  all 
vomitus  and  sputa,  should  invariably  be  treated  in  the  following  man- 
ner :  The  excreta  should  be  received  in  a  vessel  that  can  be  thoroughly 
disinfected  inside  and  out  with  any  one  of  several  standard  solutions, 
of  which  that  of  chlorinated  lime  is  the  most  effective  and  satisfactory. 
Bichlorid  of  mercury  (1  :  500)  also  may  be  used,  but,  as  it  recjuires  a 
much  longer  time  and  forms  an  insoluble  compound  with  the  albumins 
in  the  feces  and  sputa,  it  is  inferior  to  the  solution  of  chlorid  of  lime, 
which  is  now  very  generally  used  in  a  strength  of  six  ounces  per  gallon 
of  water.  A  5  per  cent,  solution  of  carbolic  acid  is  also  much  em- 
ployed, and  has  proved  of  decided  value. 

'  Medical  and  Surgiail  Reporter,  vol.  xlvii.  p.  06. 


TYPHOID  FEVER.  53 

It  is  my  custom  to  order  that  one  pint  of  the  chlorinated  lime  solu- 
tion be  placed  in  the  bed-pan  (or  other  appropriate  receptacle)  before 
the  discharges  are  received  therein,  and  from  one  to  two  pints  after. 
The  whole  is  thoroughly  mixed  by  stirring  and  shaking,  care  being 
taken  that  all  solid  masses  are  broken  up.  The  vessel  is  then  allowed 
to  stand  for  three  hours  before  it  is  emptied  into  the  water-closet.  If 
the  mercuric-chlorid  solution  be  employed,  at  least  six  hours  must  be 
allowed  for  thorough  action  upon  the  excreta.  The  urine  must  be 
treated  in  the  same  conscientious  manner  as  the  feces,  vomitus,  and 
sputum. 

ih)  It  should  be  an  invariable  rule  to  change  the  bed-  and  body-linen 
daily,  and  as  often  as  soiled.  The  mattress  should  be  protected  by  a 
rubber  cover,  and  this,  together  with  the  soiled  linen  and  blankets, 
should  be  received  in  a  sheet  that  has  previously  been  dipped  in  a  5  per 
cent,  solution  of  carbolic  acid.  The  rubber  sheets  are  to  be  washed 
with  the  carbolic-acid  solution,  but  all  other  bed-clothes  must  be  boiled 
for  half  an  hour.  When  the  patient  leaves  the  sick-room  the  mattresses 
are  to  be  fumigated  and  aired  daily  for  a  week,  and  the  rubber  covers 
and  bedsteads  washed  with  a  solution  of  mercuric  chlorid  (1 :  1000). 

((?)  After  every  stool  the  patient  must  be  thoroughly  cleansed  with  a 
compress  of  cloth  or  cotton  w'et  with  a  solution  of  mercuric  chlorid 
(1  :  2000)  or  of  carbolic  acid  (1  :  40).  The  bed-pan  and  hopper  are  to 
be  treated  in  the  same  manner,  and  the  cloths  used  are  to  be  immedi- 
ately burned.  Fitz  recommends  that  the  feeding  utensils  be  cleansed 
in  boiling  Avater  immediately  after  using.  It  is  very  important  that  the 
sick-room  should  have  thorough  daily  ventilation,  and  with  this  end  in 
view  it  is  of  advantage  to  devote  adjoining  rooms  to  the  use  of  the  pa- 
tient, in  order  that  the  Avindows  may  be  opened  in  the  one  not  occupied 
by  him,  and  the  other  ventilated  through  it. 

Finally,  since  it  is  well  known  that  many  epidemics  are  directly 
traceable  to  the  drinking-supply  of  water  and  milk,  it  is  necessary  that 
all  Avater  and  milk  used  by  the  patient  and  other  members  of  the  house- 
hold be  boiled  for  half  an  hour  before  being  ingested,  and  if  an  epi- 
demic be  prevailing,  the  Avhole  community  should  join  in  this  valuable 
precaution. 

The  municipal  authorities  possess  in  thorough  filtration  a  power  that 
might  and  should  be  used  to  advantage,  as  has  been  well  shown  by  the 
improvement  effected  in  certain  water-supply  and  sewer  systems — e.  g. 
in  Vienna,  where  by  purification  of  the  water-supply  the  death-rate  in 
typhoid  fever  Avas  reduced  from  12.5  per  10,000  to  1.1  per  10,000. 

Isolation  of  Patients. — I  am  of  the  firm  belief  that  it  is  advisable  to 
isolate  typhoid  cases  as  far  as  possible — e.  g.  in  hospitals,  to  keep  them 
in  special  wards ;  in  private  families,  in  special  apartments,  into  which 
none  but  the  attending  physician  and  the  nurse  should  enter.  There  is 
incontestable  proof  that  typhoid  fever  is  feebly  contagious,^  and,  more- 
over, that  it  obeys  the  laws  of  contagious  diseases. 

Prophylactic  Inoculations. — Encouraging  results  have  also  folloAved 
the  preventive  inoculation  of  healthy  persons  Avith  typhoid  virus,  and 
Pfeiffer  believes  that  this  mode  of  prophylactic  treatment  promises  to 
render  great  service  in  future  epidemics.     Iwanon  has  successfully  im- 

^  For  illustrative  cases  see  Philadelphia  Hospital  Report,  1891,  vol.  i.  p.  149. 


54  INFECTIOUS  DISEASES. 

munized  monkeys,  and  Pfeiffer  has  had  considerable  success  in  inocu- 
lating human  subjects  "svith  the  virus. 

[h)  Treatment  of  the  Attack. — (1)  The  general  conduct  of  the  case, 
including  skilful  nursing,  is  of  paramount  importance  to  the  typhoid 
patient.  He  should  be  put  to  bed  as  soon  as  the  indications  point  to 
this  disease,  and  kept  there  continuously  in  the  recumbent  posture  till 
the  end  of  the  attack.  The  sick-room  should  have  a  sunny  exposure  if 
possible ;  should  be  cool  and  well  ventilated,  though  free  from  strong 
currents  ;  and  perfect  cleanliness  both  of  the  room  and  of  the  utensils 
employed  in  the  management  of  the  case  should  be  attempted.  The 
bed  should  be  provided  with  a  woven-wire  mattress,  upon  which  should 
be  placed  one  of  hair.  A  rubber  cloth  is  spread  beneath  the  sheet,  and 
the  latter  kept  smooth  in  order  to  lessen  the  danger  from  bed-sores.  A 
seriously  ill  patient  should  lie  on  an  air-cushion  or.  better  still,  a  water- 
bed,  and  to  avoid  bed-sores  he  should  be  instructed  to  turn  gently  to 
either  side  from  time  to  time.  His  back,  hips,  and  heels  should  be 
bathed  frequently  with  a  mixture  of  alum  and  salt  in  dilute  alcohol. 
The  use  of  the  bed-pan  and  urinal  is  an  absolute  necessity.  "When  a 
good  nurse  cannot  be  had,  the  attending  physician  must  note  in  writing 
the  directions  regarding  the  disinfection  of  the  excreta,  bed-linen,  and 
utensils,  as  well  as  regarding  the  exhibition  of  the  food,  medicine,  etc. 
The  mouth  and  throat  should  be  kept  clean,  since  by  so  doing  we  obvi- 
ate unpleasant  and  even  dangerous  complications  (apthous  ulcer,  thrush, 
parotitis,  lobular  pneumonia,  etc.),  and  in  mild  cases  the  patient  him- 
self can  attend  to  this,  though  not  in  severe  attacks.  In  the  latter  the 
nurse  or  attendant  should  wash  the  mouth  and  tongue  several  times  daily 
with  a  solution  of  boric  acid  (3  per  cent.),  and  the  throat  may  be  sprayed 
at  equal  intervals  with  a  similar  solution.  A  frequent  moistening  of  the 
tongue  and  mouth,  and  particularly  the  lips,  with  glycerin  and  water 
(equal  parts)  gives  great  comfort  when  they  are  dry  and  parched. 

(2)  An  appropriate  liquid  diet  is  highly  serviceable,  and  the  best 
article  of  food  is  milk,  which  it  is  well  to  dilute  with  plain  water  (or 
lime-water),  since  aerated  waters  are  objectionable  in  that  they  some- 
times increase  the  meteorism.  The  daily  quantity  should  not  be  less 
than  three  pints,  and  it  is  important  that  the  stools  be  examined,  since, 
if  the  milk  be  not  thoroughly  transformed,  curds  or  (on  microscopic  ex- 
amination) numerous  fat-globules  will  be  seen,  in  which  case  a  smaller 
amount  should  be  given.  If  curds  or  fat  are  still  seen,  the  milk 
should  be  peptonized.  Experience  teaches  that  milk  is  often  better 
taken  and  better  borne  when  a  little  brandy,  coffee,  or  tea  is  added  to 
it.  When  milk  cannot  be  taken  or  digested  in  sufficient  amount,  either 
whev,  sour  milk,  or  buttermilk  may  be  tried ;  and  if  these  be  distaste- 
ful, we  may  replace  them  (wholly  or  in  part)  by  meat-juices  or  broths 
of  various  sorts,  together  with  one  of  the  standard  infants  foods  made 
Avith  milk  or  water.  Albumin-water,  prepared  by  straining  egg-white 
through  a  cloth  and  adding  an  eipial  part  of  water,  has  given  much 
satisfiiction  in  my  hands.  It  may  be  made  pleasant  to  the  taste  by 
flavoring  with  vanilla  or  lemon,  and  with  meat -juice  and  broths  will 
often  support  a  patient  during  the  most  trying  period  of  the  attack. 
There  are  typhoid  subjects  who  cannot  (on  account  of  vomiting,  etc.) 
take  per  oram  suflBcient  nourishment  to  support  life.     In  such  cases  we 


TYPHOID    FEVER.  55 

may  substitute  or  supplement  the  usual  method  of  feeding  by  rectal 
alimentation,  when  from  3  to  4  ounces  (96.0-128.0)  of  peptonized  milk, 
J  ounce  (16.0)  of  meat-juice,  and  a  little  egg-white  may  be  combined, 
and  employed  at  intervals  of  four  hours.  In  the  case  referred  to  pre- 
viously, in  which  large  hemorrhages  occurred,  vomiting  was  a  distress- 
ing symptom,  and  the  patient  was  nourished  at  times  in  part,  and  then 
altogether,  by  nutrient  enemata.  The  latter  mode  of  feeding  in  this 
disease  may  be  the  means  of  saving  life.  In  early  convalescence  the 
patient  may  take  well-cooked  plain  rice,  entire  eggs  (diluted),  or  thin 
custards.  Solid  food  should  not  be  allowed  till  the  temperature  has 
been  at  the  normal  grade  for  one  week  at  least.  When  defervescence 
is  much  prolonged  and  the  patient  becomes  very  weak  or  presents  the 
fever  of  exhaustion,  the  administration  of  soft  food  (eggs,  finely  scraped 
meat)  is  often  followed  by  notable  improvement.  The  return  to  a  full, 
solid  diet  should  invariably  be  gradual. 

Pure  cold  water  is  an  excellent  drink  for  fever  patients,  and  it  should 
be  given  to  them  regularly ;  it  has  a  positive  value  as  a  diuretic  in  this 
and  all  other  infectious  diseases.  Coffee,  tea,  and  lemonade,  sweetened 
with  glycerin  or  saccharin,  are  admissible. 

(3)  Stimulants  are  useful  in  about  50  per  cent,  of  the  cases.  When  the 
heart  becomes  enfeebled,  owing  to  exhaustion,  alcohol  should  be  used  re- 
gardless of  the  temperature.  In  severe  types  whiskey  is  the  best  form  ; 
in  milder  ones  some  good  wine,  such  as  port,  sherry,  or  madeira.  It  is 
well  to  begin  with  a  moderate  daily  quantity,  and  then  increase,  if 
necessary,  until  the  indication  is  fulfilled.  If  the  patient  so  desires,  we 
may  use  brandy  instead  of  whiskey,  and  it  is  usually  toward  the  close 
of  the  second  or  during  the  third  week  of  the  disease  that  the  indica- 
tions for  the  use  of  alcohol  arise.  It  is  not  only  the  best  spur  for  a 
flagging  heart,  but  is  of  equal  value  in  combating  unfavorable  nervous 
symptoms  due  to  the  typhoid  septicemia ;  and  the  time  for  commencing 
its  use  may  be  indicated  first  by  the  latter  symptoms  {e.  g.  delirium, 
coma,  tremor).  The  quantity  to  be  administered  must  be  regulated  by 
its  effects,  which  must  be  carefully  studied  in  every  instance,  since  it 
may  act  injuriously,  and  even  aggravate  the  symptoms,  though  this  is 
seldom  the  case.  Threatened  collapse  may  be  met  by  full  doses  of 
alcohol  (I  ounce  (16.0)  every  hour),  combined  with  strychnin  (gr.  yV 
(0.004)  every  three  hours),  exhibited  subcutaneously  till  the  depression 
has  been  counteracted.  Effective  doses  of  diffusible  stimulants,  as 
champagne,  are  useful  during  periods  of  sudden  circulatory  depression. 
Other  cardiac  stimulants  are  worthy  of  trial  for  their  favorable  supple- 
mentary action  (digitalis,  sulphuric  ether). 

(4)  Hydrotherapy. — There  is  at  the  present  day  general  agreement 
among  medical  authors  that  the  best  mode  of  treating  typhoid  fever  is 
by  means  of  the  cold  hath,  which  was  originally  introduced  by  Currie 
of  London  (more  than  a  century  ago),  and  reintroduced  and  success- 
fully practiced  by  Brand  of  Stettin.  There  are  obstacles  m  the  way  of 
carrying  out  hydrotherapy  in  private  families,  but  since  convenient  and 
inexpensive  portable  tubs  have  been  devised  by  Batt  and  Furbush  of 
Philadelphia,  Burr  of  Chicago,  and  others,  most  of  the  valid  objections 


56  INFECTIOUS  DISEASES. 

to  the  metliod  have  been  removed.  At  all  events,  the  benefits  offered 
to  the  patient  by  this  method  are  so  great  and  varied  that  it  becomes 
the  duty  of  every  physician  Avho  treats  typhoid  fever  to  be  prepared  to 
employ  it.  The  beneficial  influences  of  the  baths  are  as  follows :  (1) 
They  absorb  the  body-heat  directly,  thus  reducing  the  temperature  and 
overcoming  the  ill  effects  of  high  fever,  this  action  becoming  more 
marked  after  a  day  or  two  of  the  treatment ;  (2)  They  improve  the  ner- 
vous symptoms,  also  render  the  mind  clear ;  they  diminish  mental  dul- 
ness,  stupor,  muscular  tremors,  and  twitchings,  and  induce  sleep ;  (3) 
They  strengthen  the  heart,  thus  obviating  the  danger  of  sudden  cir- 
culatory collapse  and  the  conseijuences  of  increasing  cardiac  Aveakness 
(hypostatic  congestion  of  the  lungs,  venous  thrombosis,  etc.) ;  (4)  They 
stimulate  the  respirations,  whereby  the  inspirations  are  deepened  and 
the  tendency  to  pulmonary  complications  greatly  lessened,  especially 
severe  bronchitis,  lobular  pneumonia,  etc. ;  (5)  The  renal  function  is 
invigorated,  and  as  a  result  the  elimination  of  typhotoxins  by  the  kid- 
neys is  increased  (Ro(iue  and  Weil);  (6)  On  account  of  the  cleanliness 
of  the  skin  which  they  ensure,  bed-sores  rarely  occur  ;  (7)  They  may 
shorten  the  stay  in  the  hospital  or  sick-room,  but  not  the  stay  in  bed, 
except,  perhaps,   in  the  lighter  types. 

Unquestionably,  the  good  effects  of  the  Brand  method  receive 
striking  confirmation  from  statistical  reports  which  have  been  pre- 
pared by  Brand  himself,  Jlirgensen,  and  others  abroad,  and  by  Baruch, 
Osier,  Wilson,  and  others  at  home.  According  to  the  warmest  European 
advocates  of  the  method,  the  mortality  is  less  than  0.5  per  cent.,  and  no 
deaths  occur  in  cases  that  come  under  treatment  before  the  fifth  day. 
The  results  among  American  clinicians,  however,  have  been  less  flatter- 
ing, though  strikingly  uniform,  and  show  an  average  mortality  of  7.3 
per  cent.  Of  102  cases  of  my  own  treated  by  cold  and  by  graduated 
cold  baths,  8  died — giving  a  death-rate  of  7.8  per  cent.  During  five 
years  408  cases  have  been  treated  by  the  bath-method  in  the  Royal 
Victoria  Hospital,  Montreal,  with  a  mortality  of  4.4  per  cent. 

The  details.,  which  we  will  now  consider,  connected  with  the  adminis- 
tration of  this  plan  of  treatment  are  of  the  utmost  importance.  The 
tub  is  to  be  brought  to  the  bedside  of  the  patient,  and  in  hospital  prac- 
tice both  bed  and  tub  should  be  screened  while  the  bath  is  in  progress. 
After  removing  the  night-dress  and  placing  a  large  napkin  around  the 
loins,  the  patient  should  be  lowered  into  the  bath  by  a  sheet  held  at 
each  corner  by  an  attendant  (and,  if  seriously  ill,  with  the  least  pos- 
sible disturbance),  and  there  carefully  supported  and  held  while  in  the 
bath.  If  sleeping,  the  patient  must  be  awakened  and  the  bath  de- 
layed for  ten  or  fifteen  minutes.  Young  subjects  and  adults  in  light 
cases  of  the  disease  may  be  handled  properly  by  two  persons,  but  I  do 
not  approve  of  allowing  the  patient  to  step  from  the  bed  into  the  bath, 
hoAvever  light  the  case.  While  in  the  bath  the  skin-surface,  particu- 
larly that  of  the  back  and  limbs,  is  constantly  rubbed  by  the  attendants, 
in  order  to  stimulate  the  peripheral  circulation  and  as  far  as  possible  to 
avert  chilliness  and  discomfort.  The  head  of  the  j)atient  rests  upon  a 
rubber  air-cushion.  At  first  he  should  be  kept  in  the  bath  five  to 
eight  minutes;  later,  ten  or  fifteen  minutes,  according  to  the  severity 
of  the  case.     The  head  and  face  are  bathed  at  once  from  a  basin,  and  a 


68  INFECTIOUS  DISEASES. 

cold  compress  is  applied  to  the  forehead,  and,  if  prominent  nervous 
symptoms  be  present,  often  associated  with  high  temperature,  water  at 
70°  F.  (21.1°  C.)  or  lower  should  be  poured  from  an  elevation  of  about 
six  inches  upon  the  head  and  nape  of  the  neck  several  times  during  the 
bath.  The  ears  must  be  stopped  with  cotton  when  douching  is  practiced. 
If  while  in  the  water  the  patient  complains  bitterly  of  the  cold  or  is 
very  restless,  a  stimulant  may  be  administered — fsj  (32.0)  of  whiskey, 
diluted — and  if  this  fails  he  must  be  lifted  into  bed  and  further  stimu- 
lated. If  he  be  very  young,  highly  sensitive,  or  elderly,  it  is  best  to 
place  him  at  the  commencement  in  water  of  a  temperature  of  85°  or 
90°  F.  (29.4°-32.2°  C),  and  then  gradually  cool  it  down  to  80°  F. 
(26.6°  C).  After  he  has  become  accustomed  to  the  bath  he  may  be 
immersed  in  water  at  the  temperature  of  80°  F.  (26.6°  C),  to  be  re- 
duced to  75°  F.  (23.8°  C.)  or  even  70°  F.  (21.1°  C),  below  which  it  is 
unnecessary  to  go  save  in  the  rarest  instances.  This  is  the  gradually 
cooled  bath  of  Ziemssen.  In  the  rigid  Brand  method,  which  is  now  gen- 
erally adopted,  and  which  I  employ  except  in  the  above-mentioned 
instances,  the  patient  is  lifted  at  once  into  a  bath  at  70°  F.  (21.1°  C.) 
and  kept  there  for  fifteen  minutes.  The  patient  is  to  be  removed  from  the 
bath  to  the  bed  (previously  protected  by  a  blanket  and  mackintosh), 
wiped  off  gently,  after  which  the  sheet,  blanket,  etc.  are  withdrawn  and 
he  is  covered  with  a  blanket.  If  now  reaction  be  retarded,  some  hot 
broth  or  about  an  ounce  of  Avhiskey  should  be  administered  and  active 
friction  applied  to  the  back  and  extremities. 

The  effect  of  the  bath  is  best  shown  by  the  rectal  temperature, 
which  is  taken  half  an  hour  after  the  conclusion  of  the  bath,  and  again 
a  half  hour  later  if  the  patient  be  not  asleep.  Usually  the  temperature 
will  be  found  to  be  two  or  three  degrees  lower  than  before  the  plunge 


Fig.  6.— Portable  bath-tub  in  use. 


(see  Fig.  5).  In  obstinate  and  severe  cases  the  fall  may  be  less  than 
one  degree,  in  which  case  it  is  advisable  either  to  prolong  the  bath  to 
twenty  minutes  or  to  reduce  still  further  the  temperature  of  the  water. 
Protracted  warm  baths  are  highly  recommended  by  Reisse  and  others 
when  cold  baths  are  badly  borne  or  are  unproductive  of  good  results. 
In  light  cases  the  cold  bath  should  be  repeated  every  six  or  eight 
hours ;  in  severe  ones,  every  three  or  four  hours,  but  more  fre(iuently 
than  once  in  three  hours  is  not  advisable,  even  in  the  worst  cases. 


TYPHOID  FEVER.  59 

Sufficient  water  to  immerse  the  patient  to  the  neck  (about  30  gallons — 
114  liters)  should  be  used.  During  the  night  the  patient  should  be 
allowed  to  sleep  for  six  or  eight  hours  if  he  can  do  so. 

As  before  stated,  there  are  a  number  of  convenient  and  satisfactory- 
portable  tubs  in  the  market,  but  that  devised  by  Dr.  C.  L.  Furbush  of 
Philadelphia  possesses  certain  leading  advantages  (Figs.  6,  7).  The 
frame  is  made  of  light  wood,  and  when  folded  is  4  inches  (10.156  cm.)  in 


Fig.  7.— Portable  bath-tub,  folded. 

depth,  14  inches  (35.546  cm.)  in  width,  and  5  feet  10  inches  (1.778  m.) 
in  length,  so  that  it  can  be  placed  in  a  closet  or  beneath  a  bed.  Less 
than  two  minutes  are  required  to  prepare  the  bath,  which  the  patient 
receives  while  lying  in  bed.  When  in  use  the  ends  are  fastened  by 
brass  pins  hung  on  small  chains,  and  these  hold  the  frame  in  a  fixed 
position.  The  tub  proper  is  made  of  double-faced  sheeting,  reinforced 
in  the  middle,  so  as  to  resist  the  greatest  amount  of  pressure.  The 
sides  of  the  sheet  have  a  casing  through  which  is  passed  a  wooden  rod 
4  feet  4  inches  long  (1.320  meters),  and  outside  of  this  a  margin 
of  IJ  inches  (3.808  cm.)  is  left  for  the  brass  eyelets,  through  Avhich 
passes  a  rubber  cord  which  is  covered  with  woven  cotton.  This  cord, 
which  is  attached  to  the  sheet,  is  held  to  the  frame  by  special  brass 
fittings  along  the  lower  sides  of  the  latter.  By  the  use  of  the  cord 
and  wooden  rods  we  have  an  even  tension  on  both  sides,  combined 
with  ample  resistance  to  withstand  the  pressure  of  the  water.  An  ad- 
justable head-rest  fits  into  the  end  of  the  frame.  The  wooden  rod  also 
enables  the  attendant  to  roll  up  the  sheet  quickly  after  the  bath. 
Through  the  bottom  of  the  sheet  a  1-inch  rubber  tube  is  fitted  with  a 
stopper,  and  by  means  of  this  the  tub  can  be  emptied  much  sooner  than 
by  a  siphon.  The  frame  is  covered  Avith  ivory-enamel  paint,  and  can  be 
cleansed  easily,  and  the  entire  weight  of  the  outfit  is  25  pounds  (11.33 
kgms.). 

Brand  recommends  that  the  baths  be  commenced  when  the  tempera- 
ture in  the  rectum  reaches  102.2°  F.  (39°  C).  The  height  of  the  tem- 
perature, per  se,  is  not  to  be  invariably  regarded  as  an  absolute  indi- 
cation for  the  employment  of  the  cold  bath,  since  the  facts  must  be 
recollected  that  the  essential  efi"ect  is  a  stimulation  of  the  nerve-centers 
which  preside  over  the  organic  functions,  respiration,  circulation,  etc. 
Moreover,   cold   baths   exert  a  marked   preventive   effect  in   obviating 


60  INFECTIOUS  DISEASES. 

serious  symptoms  and  complications.  I  continue  the  baths  until  the 
evening  temperature  remains  below  101°  F.  (38.3°  C). 

The  contraindications  to  the  use  of  baths  are — (1)  Intestinal  hemor- 
rhage, -which  is  in  itself  attended  with  danger  and  requires  absolute 
quiet  for  a  time  (four  days),  when  the  baths  may  be  resumed  if  there  is 
no  recurrence.  (2)  Peritonitis,  the  occurrence  of  which  always  excites 
suspicion  of  perforation.  Here,  again,  rest  and  all  that  the  term  im- 
plies must  be  procured.  (3)  Extreme  Cardiac  Weakness. — The  excite- 
ment in  the  necessary  handling  of  the  patient  connected  with  the  bath 
might  prove  fotal,  as  I  have  witnessed  in  one  instance.  This  condi- 
tion is  sometimes  met  with  in  cases  that  come  under  observation  at  a 
late  period,  and  have  not  been  brought  under  proper  treatment  from  the 
start,  or  in  cases  arising  in  aged  and  previously  enfeebled  subjects.  (4) 
Cases  that  have  progressed  to  an  advanced  stage  (the  third  week  of  the 
disease)  should  not  be  immersed.  Dangerous  and  even  fatal  collapse 
has  been  observed  to  follow  cold  baths  under  these  circumstances. 

Suh.^titutcs  for  the  Cold  Bath. — The  prejudice  which  exists  against 
the  cold-bath  treatment — at  least  in  America — sometimes  proves  insur- 
mountable. Again,  there  are  many  physicians  who  do  not  avail  them- 
selves of  the  means  at  command  for  carrying  out  hydrotherapy.  In 
consequence  of  these  facts  substitutes  for  the  cold  and  the  gradually 
cooled  baths  are.  unfortunately,  quite  commonly  in  vogue.  Among 
them  cold  sponging  of  the  body  of  the  patient  is  often  resorted  to, 
though  it  secures  for  him  few  and  trivial  advantages  as  compared  with 
those  of  the  baths.  If  this  method  be  employed,  the  water  should  be 
of  the  temperature  of  the  air  of  the  room  or  ward.  The  limbs  should 
be  sponged  and  dried  in  succession,  and  then  the  trunk.  AVhenever  the 
temperature  reaches  102.5°  F.  (39.1°  C.)  this  measure  is  to  be  insti- 
tuted, each  sponging  being  continued  until  the  desired  effect  has  been 
produced  (a  reduction  of  the  temperature  of  1^°  to  2°  F.  or  1°  C),  unless 
the  patient  gives  signs  of  uneasiness,  when  it  must  be  cut  short.  It 
may  be  repeated  as  often  as  required.  To  the  water  used  for  the  appli- 
cations equal  parts  of  vinegar  or  spirits  should  be  added.  The  efficacy 
of  the  cool  sponging  is  greatly  enhanced  by  the  simultaneous  applica- 
tion of  the  ice-cap.  either  constantly  or  during  alternate  hours. 

If  this  method  fails,  as  it  often  does  in  severe  types,  the  cold  pack 
may  form  a  satisfactory  substitute ;  and  I  have  found  it  of  great  use 
with  children,  in  whom  the  reaction  after  a  cold  bath  is  often  delayed 
or  imperfect.  The  patient  is  placed  upon  a  cot  previously  prepared  by 
spreading  over  it  a  blanket,  which  is  in  turn  covered  with  a  sheet  doubled 
and  wrung  out  of  water  of  the  recjuired  temperature,  70°  to  80°  F. 
(21.1°-26.6°  C).  The  sheet  and  blanket  are  now  wrapped  about  the 
patient  evenly,  and  he  is  left  in  the  pack  for  a  period  varying  from  a 
half  to  one  hour.  Free  diaphoresis  generally  ensues,  and  this  aids  in 
maintaining  the  fall  of  temperature.  The  effect,  in  most  instances,  is 
to  reduce  the  body-heat  two  degrees  or  more,  and  the  treatment  may  be 
repeated  at  intervals  of  three  or  four  hours  if  needful.  The  wet  sheet 
alone  may  surround  the  patient,  and  be  sprinkled  at  short  intervals  with 
a  watering-pot  containing  water  of  a  temperature  of  70°  F.  (21.1°  C). 
In  desperate  cases  in  which  cold  baths  are  for  adequate  reasons  out  of 
the  question  ice-water  enemata  may  be  tried.     If  carefully  administered, 


TYPHOID  FEVER.  61 

they  accomplish  a  reduction  of  the  temperature  sometimes  by  two  or 
more  degrees.  Leiter's  coils  may  be  applied  to  the  head,  chest,  or  ab- 
domen, and  form  the  most  convenient  method  of*  applying  cold. 

Guaiacol  has  been  used  for  its  potent  antipyretic  effect  by  H.  Gr. 
McCormick  and  others,  from  10  to  30  minims  (0.666-2.0)  being 
applied  to  the  skin  surface.  I  have  seen  its  use  folloAved  by  rigors, 
hyperpyrexia,  etc.,  but  McCormick  has  adopted  the  rule  of  using  suffi- 
cient only  to  lower  the  temperature  to  100°  F.  (37.7°  C),  and  has  thus 
avoided  all  ill  effects. 

(5)  Internal  Antipyretics. — Internal  antipyretics  are  also  eflFectual 
agents  in  combating  immoderate  temperatures,  and  certain  of  them,  it 
must  be  confessed,  have  a  powerful  influence.  Moreover,  they  soothe 
and  moderate  the  nervous  symptoms  and  act  more  or  less  potently  as 
antiseptics.  But  even  the  most  reliable  of  this  group  of  medicaments 
(phenacetin,  acetanilid,  and  antipyrin)  are  open  to  the  serious  objection 
that  they  depress  cardiac  power,  and  on  account  of  this  I  do  not  use 
them  in  hospital  practice  (where  the  Brand  method  can  be  rigidly  car- 
ried out),  and  very  rarely  indeed  at  any  time  in  private  practice. 

When  the  Brand  method  cannot  be  employed,  or,  as  rarely  happens, 
it  is  ineffective  and  there  is  present  a  high  fever  with  decided  nervous 
symptoms,  internal  antipyretics  are  alloAvable  if  properly  administered. 
The  safest  among  them  is  phenacetin,  of  which  5  grains  (0.324)  may 
be  given  at  a  dose  (preferably  about  3  P.  M.),  and  repeated  after  four 
hours  should  the  first  dose  fail  of  the  desired  efiect.  Acetanilid  is  more 
effective  than  phenacetin,  but  is  not  quite  so  free  from  injurious  action 
as  the  latter.  It  may  be  prescribed  in  doses  of  2  to  4  grains  (0.129- 
0.259),  to  be  followed  by  a  second  dose  of  equal  size  in  four  hours  if 
necessary.  The  heart  is  always  to  be  guarded  by  the  use  of  stimulants 
when  internal  antipyretics  are  exhibited. 

(6)  Intestinal  Antiseptics. — Unquestionably  these  neither  destroy  the 
bacilli  nor  counteract  the  ill  effects  of  their  toxins,  since  both  become 
active  after  they  pass  beyond  the  intestinal  mucosa ;  but  they  are  indi- 
cated in  an  affection  in  which  extensive  intestinal  ulceration  and  moder- 
ate tympanites  are  usual  manifestations.  The  bowel  antiseptic  which  I 
have  employed  quite  extensively,  and  with  uniformly  good  results,  is 
salol,  this  drug  being  broken  in  the  intestinal  canal  into  carbolic  and 
salicylic  acids,  and  being  capable  of  controlling  meteorism  as  nothing 
else  has  done  in  my  hands.  The  dose  is  2  to  3  grains  (0.1296-0.1944) 
every  three  hours,  preferably  administered  in  capsule.  With  it  I  usu- 
ally combine  quinin  in  doses  of  1  to  2  grains  (0.0648-0.1296)  each. 
Henry  speaks  strongly  in  favor  of  thymol.  Wilcox '  urges  that  chlorin 
is  capable  of  disinfecting  the  intestinal  tract.  Systematic  lavage  of  the 
intestinal  tract  is  advisable  in  excessive  tympanites. 

Lactopitenin  (gr.  vij-xv — 0.4536-0.9720  per  dose),  in  starch  capsules, 
up  to  1\  drams  (6.0)  daily,  according  to  the  indications,  is  highly  rec- 
ommended (Jaksch).  Carbolic  acid,  iodin,  and  other  antiseptic  agents 
have  their  advocates,  but  my  own  experience  with  them  has  been 
limited. 

Turpentine  fulfils  in  some  cases  a  leading  indication.  When  the 
tongue  is  dry  and  brown,  the  abdomen  distended,  the  general  prostra- 
1  Medical  News,  Feb.  11,  1899. 


62  INFECTIOUS  DISEASES. 

tion  marked,  and  often  muttering  delirium  present — symptoms  of  the 
typhoid  state — the  use  of  this  agent,  together  with  alcoholics,  consti- 
tutes the  best  mode  of  treatment.  Turpentine  is  best  given  in  a  capsule 
in  the  form  of  white  turpentine — dose,  3  to  5  grains  (0.19-i-4-0.3240) 
every  three  hours.  Its  routine  administration,  however,  is  to  be  un- 
qualifiedly condemned. 

(7 )  Curative  Inoculations  with  Cultures  of  Serum. — The  brilliant  results 
obtained  from  the  use  of  antitoxic  serum  in  diphtheria  and  certain  other 
affections  have  led  to  attempts  at  curative  inoculations  in  typhoid  fever. 
Though  their  specific  virtue  is  yet  to  be  demonstrated,  it  is  deemed 
proper  to  state  the  results  which  have  been  obtained  as  concisely  as  pos- 
sible. E.  Friinkel  and  Manchot  have  treated  57  cases  of  typhoid  fever 
with  a  sterilized  liquid  derived  from  a  culture  of  the  bacillus  of  Eberth 
in  thymus  bouillon  and  heated  to  140°  F.  (60°  C).  Of  this,  i  c.cm.  was 
injected  deeply  into  the  gluteal  region,  with  favorable  results. 

Hughes  and  Carter  treated  a  number  of  cases  with  blood-serum  de- 
rived from  convalescent  cases,  but  apart  from  a  decided  lowering  of 
temperature  the  general  course  of  the  disease  was  not  perceptibly  modi- 
fied. Wasserman  and  others  have  shown  that  the  organs  of  animals, 
some  inoculated  experimentally,  some  not.  contain  protective  substances. 
Pursuing  this  line  of  investigation,  Jez '  found  that  he  was  able  to 
obtain  from  the  organs  of  animals  inoculated  with  typhoid  bacilli  sub- 
stances capable  of  exercising  protective  and  curative  influences  upon 
typhoid  infection.  The  mode  of  producing  the  extract  was  as  follows : 
Guinea-pigs  were  given,  at  short  intervals,  several  intraperitoneal  injec- 
tions of  bouillon-cultures  of  typhoid  bacilli  of  progressively  increasing 
virulence.  When  tolerance  was  established  the  animal  was  killed  and 
its  thymus  gland,  spleen,  bone-marrow,  brain,  and  spinal  cord  removed, 
finely  divided,  and  rubbed  up  in  a  mortar  with  a  solution  consisting  of 
sodium  chlorid,  alcohol,  glycerin,  and  a  small  amount  of  cai'bolic  acid. 
Subsequently  a  small  amount  of  pepsin  also  was  added  advantageously. 
After  standing  on  ice  for  twenty-four  hours  the  mixture  Avas  carefully 
filtered,  a  clear,  reddish  fluid  resultinor.  which  did  not  cause  afr^lutina- 
tion  and  sedimentation  of  typhoid  bacilli  nor  inhibit  their  growth, 
though  exhibiting  the  faculty  in  marked  degree  of  neutralizing  typhoid 
toxin.  This  anti-typhoid  extract  was  employed  in  the  treatment  of  18 
cases  of  typhoid  fever,  being  administered  by  the  mouth  in  doses  of  from 
a  teaspoonful  to  a  tablespoonful  every  two  hours,  subcutaneous  injections 
proving  less  serviceable.  In  the  cases  thus  treated  the  characteristic 
temperature-curve  was  lost,  the  pyrexia  becoming  remittent  and  soon 
disappearing ;  the  pulse  declined  in  frequency  and  increased  in  strength, 
diarrhea  ceased,  the  tongue  cleared,  the  general  condition  improved,  and 
convalescence  speedily  set  in.  Unpleasant  secondary  effects  were  not 
observed,  even  when  larger  doses  of  the  extract  Avere  employed.  The 
usual  hygienic  and  dietetic  and  other  precautionary  general  measures 
Avere  not  neglected. 

(8)  Treatment  of  Individual  Symptoms  and  Complications. — Headache. 
— Early  in  typhoid  the  headache  demands  relief.  Absolute  rest  and 
cold  to  the  head  frequently  suffice.  Depressant  analgesics  are  to  be 
avoided  so  far  as  may  be,  though  it  sometimes  becomes  necessary  to 

*  Wiener  med.  Wochen.,  Feb.  18,  1899,  p.  345. 


TYPHOID  FEVER.  63 

resort  to  them.  At  such  times  those  least  objectionable  are  to  be  selected. 
I  have  found  that  a  mixture  containing  sodium  bromid  (gr.  x  to  xv 
— 0.6480  to  0.9720)  and  the  deodorized  tincture  of  opium  (Uliij  to  v — 
0.1998  to  0.3330)  in  each  dose,  given  at  intervals  of  three  or  four  hours, 
exercises  a  striking  palliative  influence.  In  occasional  instances  the 
above  mixture  fails,  and  then  phenacetin  (gr.  ij  to  iij — 0.1296  to 
0.1944)  may  be  substituted  for  the  opium  in  the  same  combination  or 
separately  in  capsule. 

Insomnia. — The  cold  baths  or  other  measures  calculated  to  relieve 
the  headache  often  procure  for  the  patient  refreshing  sleep.  It  is  im- 
portant not  to  allow  him  to  go  too  long  without  sleep,  since  this  tends 
to  the  development  of  a  pronounced  "  typhoid  state  "  and  its  concomi- 
tants. When  the  agents  recommended  for  the  headache  fail,  I  employ 
morphin  hypodermically  in  small  doses  (gr.  -^  to  l — 0.004  to  0.008) 
during  the  evening  hours,  with  excellent  results,  and  have  yet  to  wit- 
ness the  unpleasant  after-effects  or  the  unfavorable  influence  upon  the 
secretions  that  have  been  described  by  some  authors.  Codein,  sulfonal, 
and,  more  recently  trional  and  chloralamid,  have  proved  useful. 

Chloral  is  more  certain  in  its  action  than  the  above  agents,  but  I 
have  abandoned  its  use  for  the  reason  that  it  apparently  produced  cir- 
culatory collapse  in  two  instances. 

Delirium. — Since  the  introduction  of  the  Brand  method  delirium 
rarely  calls  for  special  medication.  I  have  observed,  in  common  with 
others,  particularly  during  the  advanced  stages,  that  in  cases  in  which 
the  circulation  was  feeble  and  in  w^hich  typhomania  was  a  prominent 
feature,  the  administration  of  stimulants  with  a  free  hand  completely 
dispelled  the  nervous  phenomena.  If  alcohol  fails,  ether  (Ttlx — 0.666 — 
at  a  dose)  may  be  given  hypodermically,  and  repeated  in  one  or  two 
hours  if  necessary.  To  combine  with  the  arterial  some  nervous  stimu- 
lant (inusk,  valerian)  will  be  found  serviceable,  particularly  in  cases 
in  which  the  delirium  assumes  an  hysteric  type.  Of  special  value  in 
meeting  this  symptom  are  the  bromids,  hyoscyamus,  the  persistent  use 
of  ice  to  the  head,  and  the  other  agents  suggested  for  the  headache  and 
insomnia. 

Voiniting  is  rarely  troublesome.  Its  chief  cause  is  the  irritation  of 
the  gastric  mucosa,  which  may  be  caused  by  improper  diet  or  medica- 
tion. The  best  measure  for  the  relief  of  this  symptom,  after  the 
removal  of  the  cause,  is  the  use  of  ice,  taken  in  small  pieces  and  swal- 
lowed. If  vomiting  occur  during  the  period  of  development,  minute 
doses  of  calomel,  combined  with  sodium  bicarbonate,  may  be  pre- 
scribed with  good  effect.  If  it  occur  during  the  fastigium,  the  amount 
of  milk  taken  should  be  reduced  by  one  half,  peptonized,  and  then 
diluted,  preferably  with  lime-water.  If  the  patient  experience  a  strong 
aversion  to  milk,  it  must  be  suspended  temporarily  and  liquid  beef- 
peptonoids  or  broths  substituted.  Dry  champagne  may  be  administered 
simultaneously.  Excessive  irritability  of  the  stomach  calls  for  perfect 
rest  of  the  organ  for  a  period  of  not  less  than  twenty-four  hours,  the 
patient  being  meanwhile  supported  by  rectal  alimentation  and  subcu- 
taneous medication. 

Diarrhea  more  than  any  other  single  symptom  claims  special  atten- 
tion.    Two  to  four  movements  daily  do  not  constitute  diarrhea  and  do 


64  INFECTIOUS  DISEASES. 

not  demand  treatment,  but  if  this  number  of  stools  be  exceeded,  the 
condition  should  receive  consideration.  It  may  be  caused  by  overfeed-, 
ing  or  by  improper  food — as  shown  by  the  stools,  as  a  rule — in  which 
case  regulation  of  the  diet  is  curative.  It  is  often  due  to  ulcerated  and 
catarrhal  lesions  of  the  intestines,  and  particularly  the  large  bowel,  and  in 
such  cases  requires  medical  interference.  Unquestionably,  the  use  of 
proper  intestinal  antiseptics  and  such  as  possess  the  property  of  insolu- 
bility to  a  high  degree  is  most  valuable.  Astringents  may  be  combined 
with  the  latter  or  given  separately.  The  subjoined  formulse  have 
yielded  better  results  in  my  own  hands  than  numerous  others  which 
have  been  tried  : 

^i.  Bismuth,  salicylat.,       .5ij(8.0); 
Betanaphtol,  sj    ("i-O)- 

M.  et  ft.  capsulae  No.  xxiv. 
Sig.   One  to  be  taken  every  three  hours. 
Or, 

^^.   Salol.,  31  (4.0); 

Bismuth,  subgallat.,     .5ij  (8.0). 
M.  et  ft.  capsulae  No.  xxiv. 
Sig.   One  every  two  or  three  hours. 
Or, 

i^.  Plumbi  acetat.,  gr.  xxiv  (1.555) ; 

Ext.  opii,  gr.  iss-ij  (0.097-0.1296). ' 

M.  et  ft.  pil.  No.  xij. 
Sig.   One  every  three  or  four  hours,  as  required. 

The  last  formula  may  be  administered  iu  the  form  of  a  suppository, 
both  ingredients  being  doubled  in  ([uantity. 

Late  in  typhoid  fever,  when  the  ulcers  are  fully  developed,  opium  is 
the  remedy  j;?ar  ezcellenee,  since  it  tends  to  arrest  the  peristaltic  action 
which  keeps  up  the  diarrhea  and  favors  the  spread  of  the  inflammation 
to  the  peritoneum.  I  have  recently  observed  brilliant  results  from  the 
use  of  rectal  injections  of  an  astringent  solution  (tannic  acid  1-2  per 
cent.),  alternated  Avith  an  antiseptic  solution  (salicylic  acid  1-2  per 
cent.),  each  given  once  daily  at  intervals  of  twelve  hours. 

Constipation,  which  is  often  present,  and  particularly  until  the  mid- 
dle of  the  second  week,  is  to  be  relieved  by  simple  enemata  of  soapsuds 
every  second  day.  Calomel  may  be  used  in  the  early  stage  of  dynamic 
cases.  Its  employment  in  this  manner  may  be  followed  by  symptoms 
of  a  milder  type  than  are  ordinarily  encountered.  If  constipation  exists 
during  the  third  week,  accompanied  by  an  oscillating  temperature-curve, 
as  rarely  occurs,  saline  laxatives  in  small  but  repeated  doses  may  cut 
short  the  attack. 

Tympanites. — This  is  sometimes  a  most  distressing  symptom,  and  is 
often  associated  with  marked  diarrhea.  The  claim  has  "been  made  that 
if  turpentine  be  administered  in  suitable  doses  throughout,  both  tym- 
panites and  diarrhea  are  controlled.  Turpentine  is  a  good  remedy,  but 
only  when  certain  indications  exist  {vide  supra),  and  it  is  without  the 
power  to  influence  the  general  course  of  the  affection.  As  a  remedy 
for  tympanites  it  is  excellent  and  richly  deserves  a  trial.     "When  em- 


TYPHOID  FEVER.  65 

ployed  for  this  symptom  alone  I  prefer  to  apply  it  in  the  form  of  stupes 
over  the  abdomen,  although  ^hen,  as  is  frequently  the  case,  the  gases 
occupy  chiefly  the  large  bowel,  turpentine  enemata  should  be  given,  and, 
these  failing,  a  long  rectal  tube  should  be  passed. 

The  meteorism  is  often  increased  by  the  milk  taken,  and  a  change 
of  food  to  meat-juices  and  albumin-Avater  may  be  tried. 

Hemorrliages  from  the  bowels  demand  complete  rest.  The  bowel- 
movements,  if  the  hemorrhage  has  been  copious,  must  be  allowed  to 
pass  into  the  draw-sheet.  The  ice-bag  (suspended  if  possible)  should 
be  applied  to  the  right  iliac  region,  and  ice  freely  given  by  the  mouth. 
Opium,  to  control  peristalsis,  must,  be  given,  and,  by  preference,  hypo- 
dermically.  It  may  be  combined  with  full  doses  of  the  acetate  of  lead. 
Cases  in  which  slight  oozing  appears  from  time  to  time  require  turpen- 
tine. Ergotin  may  be  used  (hypodermically,  to  be  repeated  every  hour) 
in  severe  bleedings.  The  amount  of  food  should  be  greatly  restricted 
for  about  twelve  hours.  For  severe  hemorrhages,  saline  infusion,  either 
by  the  method  of  intravenous  injection  or  by  hypodermoclysis  or  entero- 
clysis,  is  to  be  strongly  advised.  The  saline  solution  not  only  raises  the. 
blood-pressure  in  the  vessels,  but  it  also  has  a  hemostatic  action.  The 
proper  strength  is  7  :  1000,  and  from  10  c.c.  (3  fluidrams)  to  one-half 
liter  may  be  employed  if  the  collapse  is  marked,  and  repeated  several 
times  in  the  course  of  a  day.    Rectal  injections  may  be  somewhat  larger. 

Peritonitis. — When  this  is  due  to  perforation  the  patient  usually 
passes  quickly  beyond  hope  unless  saved  by  timely  surgical  interference. 
Operation  offers  some  hope  of  cure,  and  Avith  the  progress  of  convales- 
cence the  chances  of  recovery  from  this  accident  improve.  Deaver 
regards  the  acute  development  of  pain  and  generalized  abdominal 
rigidity  and  tenderness  as  an  urgent  indication  for  immediate  celiotomy. 
Keen's  statistics  show  that  between  twelve  and  twenty-four  hours  after 
perforation  is  the  most  favorable  time  for  operation,  this  period 
giving  30  per  cent,  of  recoveries.  Rarely,  appendicitis  supervenes  in 
typhoid  fever,  and  presents  nearly  the  same  symptoms  as  when  occur- 
ring independently.  It  usually  demands  prompt  removal  of  the  appendix. 
Peritonitis  due  to  direct  extension  of  the  infectious  inflammation  of  the 
bowel  without  perforation  often  admits  of  successful  treatment.  Saline 
purgatives,  at  the  same  time  controlling  pain  by  means  of  small  doses 
of  morphin,  are  the  measures  to  be  used. 

Pneumonia. — Bronclio-pneumonia  is  to  be  treated  In  the  manner 
indicated  in  the  section  on  this  aff'ection. 

Lohar  Pneumonia. — The  treatment  of  that  form  of  pneumonia  which 
occurs  in  the  advanced  stage  of  typhoid  will  be  considered  hereafter 
{vide  Secondary  Pneumonia).  That  variety  of  pneumonia  which  rarely 
inaugurates  typhoid  requires  the  same  treatment,  until  the  true  typhoid 
symptoms  arise,  as  primary  adynamic  pneumonia  [vide  p.  154). 

The  hypostatic  congestion  of  the  bases  of  the  lungs  is  to  be  met  by 
heart-stimulants  and  by  changing  the  position  of  the  patient. 

Bronchitis. — No  special  measures  are  necessary  when  the  bronchitis 
is  confined  to  the  larger  tubes,  as  in  typical  cases,  while,  if  severe  and 
diffuse,  its  management  is  identical  with  that  of  broncho-pneumonia. 

Laryngitis. — For  this  condition,  counter-irritation  should  be  tried; 
and  if  this  fails,  a  small  blister  may  be  applied  below  the  angle  of  the 


66  INFECTIOUS  DISEASES. 

jaw  on  either  side.  For  edema  of  the  larynx  scarification  and  the 
inhalation  of  simple  or  medicated  steam  are  useful  measures.  Then, 
should  suffocation  become  imminent,  tracheotomy  should  be  performed 
without  delay.  Operation  "gives  a  mortality  of  only  55.5  per  cent." 
(Keen). 

Bed-sores. — The  preventive  measures  have  already  been  considered, 
but  the  smallest  bed-sore  demands  active  treatment.  It  is  to  be  kept 
clean  by  means  of  a  weak  solution  of  some  antiseptic,  and  may  then  be 
dusted  with  a  powder  composed  of  equal  parts  of  boric  acid,  calomel, 
and  bismuth ;  if  sluggish,  with  a  powder  made  up  of  aristol  and  iodo- 
form. I  have  found  unguentum  balsami  peruviani  (1 :  30)  to  be  a  valu- 
able remedy  in  bed-sores.  Should  the  edges  of  the  ulcer  become  under- 
mined, a  drainage-tube  is  sometimes  necessary. 

Thrombosis  of  the  femoral  vein  is  best  treated  by  elevating  the  part 
and  keeping  it  at  perfect  rest.  The  following  ointment  may  also  be 
applied  along  the  course  of  the  vessel : 

^.  Ung.  ichthyol., 

Lanolin,  da.  .^ij  (8.0); 

Ung.  belladonnoe,  q.  s.  ad  3J  (32.0). 

Sig.   Apply  three  times  daily. 

After  the  swelling  has  subsided  an  elastic  stocking  should  be  worn  for  a 
couple  of  months. 

(9)  Management  of  Convalescence. — Some  of  the  points  connected  with 
this  subject  have  already  been  discussed  {diet,  time  for  getting  vp,  etc.). 
I  may  add  that  should  a  recrudescence  occur  the  patient  should  be  kept 
at  rest  in  the  recumbent  posture  and  a  return  made  to  the  liquid  forms 
of  food.  Often  a  moderate  laxative  serves  a  good  purpose,  particularly 
if  an  indiscretion  in  diet  have  been  committed.  The  ulcers  may  not  be 
healed,  though  the  temperature  may  have  been  normal  for  a  week  or  ten 
days ;  hence  the  patient  should  not  be  allowed  to  stir  about  for  a  period 
of  two  Aveeks  after  the  temperature  has  returned  to  the  normal.  At  first 
bis  movements  should  be  slow  ;  he  may  soon,  however,  be  allowed  to 
exercise  gently  in  the  open  air  during  seasons  of  favorable  weather. 
Mental  excitement  is  to  be  avoided,  since  it  may  produce  a  recrudescence 
of  fever.  Occasionally,  during  convalescence  the  diarrhea  persists,  being 
due  to  colonic  ulceration,  and  is  best  treated  by  restricting  the  diet  to 
milk  and  other  light  forms  of  albuminous  food.  The  patient  must  be 
confined  to  bed.  Medicinal  treatment  by  the  oxid  of  zinc  internally 
and  the  use  of  astringent  and  antiseptic  rectal  injections,  as  before  indi- 
cated, usually  proves  successful.  Constipation  may  be  a  troublesome 
symptom  in  convalescence,  and  is  best  relieved  by  simple  enemata.  Most 
patients  require  tonics.  We  should  begin  with  a  vegetable  salt  of  iron 
in  combination  with  a  simple  bitter  (such  as  the  infusion  of  gentian), 
and  later  an  inorganic  salt  of  iron,  with  quinin  and  strychnin,  may  be 
resorted  to.  If  there  be  a  predisposition  to  tuberculosis,  cod-liver  oil 
and  creasote  should  be  given  for  a  period  of  two  or  three  months.  Re- 
lapses are  to  be  treated  as  primary  attacks,  and  recurrences  in  the  same 
manner. 


TYPHUS  FEVER.  67 

Mountain  Fever. 

{Mountain  Sickness.) 

The  term  "mountain  fever"  should  be  regarded  as  applicable  only 
to  that  condition  which  develops  shortly  after  ascent  to  a  very  high  alti- 
tude. There  is  no  definite  patJiology  nor  etiology,  but  the  symptoms  are 
attributable  to  the  effects  of  a  rarefied  air  upon  the  organic  functions 
(respiration,  circulation,  etc.). 

The  symptoms  are  a  much  quickened  pulse,  urgent  dyspnea,  head- 
ache, vertigo,  and  at  times  nausea  and  vomiting.  There  is  a  subfebrile 
movement,  the  temperature  touching  100°  or  even  101°  F.  (38.3°  C). 
Thirst  is  present  and  the  appetite  is  lost.  Malaise  and  a  sense  of  ex- 
haustion on  attempting  exertion  are  experienced.  Hemoptysis  has  been 
noted,  but  rarely.  The  effect  upon  the  human  economy  of  high  altitude 
varies  with  the  extent  of  the  differences  in  individual  reserve  nerve-force. 
Rest  and  acclimatization  will  almost  invariably  restore  healthy  function. 
Mountain  anemia  has  been  described ;  it  is  caused  by  the  ancJiylostoma. 

Different  clinical  observers  have  depicted  as  mountain  fever  various 
forms  of  illness  which  might  have  been  as  properly  referred  to  other 
Avell-recognized  diseases,  especially  tyjjhoid  fever.  The  lesions  of  typhoid 
fever  were  present  in  two  instances  that  were  necropsied.  Woodruff  has 
reported  35  cases  at  Ft.  Custer  in  Avhich  the  grouping  of  symptoms, 
including  the  Widal  reaction,  assured  a  diagnosis  of  typhoid  fever. 
Gwyn  quite  recently  recorded  a  case  in  Avhich  the  clinical  features  of 
typhoid  were  present  (except  the  Widal  reaction),  but  cultures  from  the 
blood  showed  a  "paracolon"  variety  of  bacillus.  Curtin  has  reported 
four  cases  all  evincing  the  signs  and  symptoms  of  lobar  pneumonia.  It 
must  not  be  forgotten  that  high  altitude  may  alter  the  clinical  peculiar- 
ities of  the  acute  infectious  diseases. 


TYPHUS  FEVER. 

{Shijy-fevei-,  Camj)-fever,  Jail  fever,  etc.) 

Definition. — An  acute  contagious  disease  of  unknown  specific  eti- 
ology. It  is  characterized  frequently  by  an  abrupt  invasion,  and  is 
marked  by  rigor,  high  fever,  early  nervous  symptoms  of  great  promi- 
nence, a  maculo-petechial  eruption  appearing  between  the  third  and 
fifth  days,  and  a  termination  by  crisis. 

Historic  Note. — This  affection  has  been  known  from  time  im- 
memorial. In  1759  the  name  typhus,  which  is  at  present  universally 
employed,  was  given  to  it  by  Sauvages.  In  presanitary  times  it  pre- 
vailed extensively  in  epidemic  and  endemic  forms,  particularly  in  Ire- 
land and  Russia,  and  also,  though  less  frequently,  in  the  seaport  towns 
of  our  own  country.  It  constituted  one  of  the  chief  plagues  of  the  olden 
times,  if  not  the  chiefest,  and  its  devastations  among  the  armies  were 
more  destructive  of  human  life  than  even  war  itself. 

In  1812  typhus  fever  first  appeared  in  America  in  the  New  England 
States.  Its  ravages  did  not  cease  until  every  Eastern  State  had  been 
visited  by  the  plague,  when  it  totally  disappeared.   In  1836  it  reappeared 


68  INFECTIOUS  DISEASES. 

in  Philadelphia  in  virulent  form  and  with  deadly  effect.  It  was  at  this 
period  that  Gerhard  began  his  careful  studies,  which  resulted  in  the 
separation  of  typhus  from  typhoid.  During  the  last  half  century  com- 
paratively few  instances  of  typhus  have  been  met  with  in  this  country, 
though  it  still  appears  constantly  in  certain  quarters,  abroad  (Great 
Britain,  the  eastern  portion  of  Germany,  Poland,  Russia,  and  some  parts 
of  Southern  Europe).  All  isolated  cases  and  small  groups  of  cases  that 
have  been  observed  in  very  recent  times  here  have  been  properly  attrib- 
uted to  importations  from  other  countries,  and  chiefly  from  Ireland. 
Since  the  epidemic  in  1836  the  disease  has  not  gained  a  foothold  on  our 
shores,  although  in  the  early  part  of  1893  it  appeared  in  New  York  City, 
and  150  cases  resulted. 

Pathology. — The  various  viscera  present  no  characteristic  lesions. 
After  death  the  eruption  continues  to  be  visible,  and  often  large  ecchy- 
moses  are  observable  on  the  dependent  parts  of  the  body. 

Certain  organs  may  present  pathologic  appearances,  but  they  are 
not  constant  and  are  the  result  of  the  secondary  infection  which  the 
typhus  invites.  The  serous  membranes — the  pericardium  in  particular, 
and  at  times  the  gastro-iutestinal  mucosa — are  the  seat  of  ecchymoses. 
There  is  hyperplasia  of  the  lymph-follicles,  but  no  subsequent  ulcera- 
tion. Hemorrhagic  extravasation  may  also  occur  into  the  muscles,  the 
latter  being  dark  and  often  showing  hyaline  and  granular  changes ;  the 
Iieart-muscle  is  especially  apt  to  undergo  a  granular  degeneration.  .  The 
spleen  is  considerably  enlarged,  soft  (even  diffluent  at  times),  and  of  a 
dark  (frequently  bluish)  red  color.  The  liver  is  somewhat  swollen  and 
may  be  softened,  while  the  Jcidnef/s  not  rarely  manifest  the  changes 
belonging  to  nephritis.  In  other  instances  they  are  merely  congested. 
In  the  lungs  are  found  a  variety  of  lesions  peculiar  to  different  compli- , 
eating  conditions  (bronchitis,  lobular  pneumonia,  lobar  pneumonia,  pul- 
monary congestion  with  or  without  edema),  and  occasionally  pleurisy 
(sero-fibrinous  or  purulent)  may  be  present.  Xervous  lesions  are  con- 
spicuous by  their  absence.  An  effusion,  either  serous  or  sero-hemor- 
rhagic,  into  the  subarachnoid  space  and  the  ventricles  may  be  noted, 
and  quite  commonly  there  is  cer-ebral  congestion.  In  rare  instances 
there  may  be  a  meningitis.  The  blood-changes  are  marked,  the  color 
being  dark,  the  fluidity  much  increased,  while  the  coagulability  is 
greatly  diminished ;  and  the  intima  of  the  aorta  is  frequently  blood- 
stained. 

il^tiology. — The  direct  cause  or  special  micro-organism  connected 
with  the  typhus  contagion  has  not,  as  yet,  been  isolated,  notwithstand- 
ing the  fact  that  the  morphologic  and  biologic  studies  of  the  blood 
obtained  by  Brannan  and  Cheesman  from  the  finger-tips  of  six  patients 
during  the  mild  epidemic  of  typhus  in  1893  showed  the  presence  of  a 
bacillus  that  proved  pathogenic  for  rabbits,  guinea-pigs,  and  white 
mice.^  Lewaschew "  has  also  detected  in  the  blood  of  typhus  patients  a 
distinctive  micro-organism.  Further  observations,  however,  with  a  view- 
to  showing  the  constant  presence  of  these  micro-organisms  in  typhus 
fever,  are  necessary  to  demonstrate  that  they  are  the  specific  cause  of 
the  disease. 

-  Annual  of  the  Universal  Medical  Sciences,  1S93,  p.  60,  section  H. 
*  Ibid.,  p.  61,  section  H. 


TYPHUS  FEVER.  69 

It  is  a  known  fact,  nevertheless,  that  when  typhus  arises  in  a  locality 
in  which  it  was  previously  unknown,  it  is  dependent  upon  a  transference 
of  the  typhus  virus  from  without,  and  does  not  arise  spontaneously ; 
this  cannot  be  too  strongly  emphasized.  The  diiferent  modes  of  con- 
veyance of  this  poison  from  one  place  to  another  are  not  known  posi- 
tively, but  we  can  be  confident  that  its  source  is  in  a  preceding  case, 
and  that  it  may  leave  the  body  in  the  expired  air,  in  the  epithelial 
scales  thrown  oif,  and  in  other  excretory  or  secretory  products  of  the 
body.  The  poison  is  apt  to  be  transmitted  by  contagion  from  the 
patient  to  others  who  approach  him  ;  and  there  is  convincing  proof  that 
it  may  be  transferred  by  means  of  fomites  (wearing  apparel,  articles  of 
furniture,  etc.).  What  its  precise  gateway  into  the  body  is  we  do  not 
definitely  knoAv,  except  that  it  is  more  likely  to  enter  through  the 
respiratory  tract  (by  inhalation)  than  through  the  alimentary  canal. 

Predisposing  Causes. — The  influence  of  insanitary  surroundings 
upon  the  spread  of  this  affection  is  positive  and  vital.  Among  special 
conditions  may  be  mentioned  filth,  poverty,  famine,  and  overcrowding, 
and  here  it  may  be  inferred  that  typhus  is  a  disease  of  the  lower  classes. 
Broadly  speaking,  any  condition  of  the  system  in  which  the  natural 
vitality  and  resistance  to  bacterial  invasion  are  lowered  increases  sus- 
ceptibility to  the  disease,  and  among  additional  influences  which  possess 
considerable  etiologic  influence  are  overwork,  intemperance,  depressing 
emotions,  etc. 

Age  has  no  direct  influence.  Obviously,  however,  the  young  and 
middle-aged  furnish  a  preponderant  proportion  of  cases,  OAving  to  the 
fact  that  they  are  more  liable  to  exposure  to  the  virus  than  during  other 
periods  of  life.  Sex  has  no  positive  influence,  and  the  season  plays  only 
a  minor  part.  Epidemics  may,  however,  occur  rather  more  often  in 
winter  than  in  the  other  seasons,  since  the  homes  of  the  pauper  popula- 
tion are  not  so  well  ventilated,  and  hence  are  less  cleanly  in  winter  than 
during  the  rest  of  the  year. 

Clinical  History. — Incubation. — This  lasts  from  nine  to  twelve 
days.  There  may  be  prodromal  symptoms  during  the  concluding  days 
(one,  two,  or  more  of  this  period),  such  as  .anorexia,  gerieral  malaise, 
etc.,  but  in  most  instances  invasion  is  sudden. 

Pre-eruptive  Stage. — The  early  symptoms  are  either  a  series  of  chills 
or  one  severe  rigor,  accompanied  by  vertigo,  tinnitus,  headache,  muscu- 
lar pains,  profound  prostration,  and  fever.  The  temperature  quickly 
ascends  to  a  high  level,  reaching  104°  or  105°  F.  (40°  or  40.5°  C.) 
as  early  as  the  second  or  third  day.  The  fever  is  continuous  in  type, 
and  in  severe  cases  a  serious  systemic  condition  may  often  be  developed. 
The  pulse  is  accelerated  proportionately  to  the  temperature  and  is  of 
good  volume.  Bronchitis  may  be  present,  the  appetite  is  lost,  and  the 
thirst  is  excessive,  Avhile  a  thick,  yellowish-white  coating  covers  the 
tongue.  Vomiting  occurs,  and  may  be  a  prominent  symptom.  The 
urine  is  often  scanty,  its  specific  gravity  is  increased,  and  it  may  contain 
a  trace  of  albumin.      The  cheeks  are  flushed  and  the  eyes  are  injected. 

Nervous  symptoms  appear  early — ^in  the  AA'orst  cases  at  the  very  onset 
— and  are  quite  pronounced.  At  first  there  may  be  either  mild  or 
active  delirium,  but  soon  there  is  stupor  or  even  actual  coma,  and  the 


70  INFECTIOUS  DISEASES. 

face  takes  on  a  dull,  stupid  look.  With  few  exceptions  the  spleen  on 
palpation  is  found  to  be  enlarged. 

Eruptive  Stage. — Between  the  third  and  fifth  days  of  the  invasion 
the  characteristic  eruption  appears  ivithout  an  accompanying  decline  m 
the  tewperature.  The  rash  conies  out  first  upon  the  trunk  (chest  and 
abdomen),  extending  thence  over  the  rest  of  the  skin-surface  of  the  body, 
but,  strangely  enough,  often  sparing  the  face.  The  crimson-red  maculae 
are  changed  in  two  or  three  days  to  a  darker  hue,  becoming  hemor- 
rhagic (petechise),  and  when  coalescence  occurs  we  have  the  spotted 
effect  that  has  caused  the  name  of  spotted  fever  to  be  given  to  it.  This 
name  is  also  given  to  cerebro-spinal  meningitis,  in  which  the  eruption, 
though  it  resembles  that  in  typhus  fever,  does  not  appear  at  any  given 
time  and  is  extremely  inconstant.  Not  all  of  the  maculae  are  converted, 
but  some  may  remain  as  rose-spots,  and  these  disappear  when  pressed 
upon,  while  the  petechise  do  not.  It  is  chiefly  in  the  milder  grades  of 
typhus  that  the  rose-spots  fail  to  become  petechial  {vide  infra).  The 
skin -surface  between  the  spots  is  sometimes  diffusely  hyperemic, 
and  the  eruption  is  usually  rather  abundant,  though  in  well-authenti- 
cated cases  it  has  been  scanty  or  even  wholly  missing.  Unlike  many 
other  eruptive  diseases  in  the  stage  of  eruption,  the  symptoms  of  typhus 
fever  assume  an  aggravated  type  in  typical  and  severe  cases.  The  tem- 
perature continues  high,  often  reaching  106°  F.  (41.1°  C.)  or  even 
higher,  with  slight  nocturnal  remissions.  The  pulse  becomes- quite 
rapid  (120-140  or  more),  feeble,  and  possibly  irregular  (often  dicrotic), 
and  the  respirations  increase  markedly  in  frequency.  At  this  time 
severe  bronchitis,  leading  to  hroncho-pneuynonia.,  is  apt  to  occur  as  a 
complication.  The  tongue  is  brown,  fissured,  tremulous,  and  occasion- 
ally black  and  rolled  up,  without  power  to  protrude  from  the  mouth. 
Sordes  form  on  the  teeth  and  lips.  The  urine  is  scanty,  high-colored, 
and  often  albuminous,  and  there  may  be  retention  from  paralysis  of  the 
bladder. 

The  nervous  disturbance  is  intense,  and  may  take  the  form  of  typho- 
mania,  leading  to  complete  coma  or  maniacal  delirium.  The  patient 
often  lies  with  eyes  open,  staring  into  space,  yet  unconscious  and  in  the 
condition  known  as  coma-vigil.  The  motor  nerves  show  derangement 
(tremors,  subsultus  tendinum,  etc.),  and  carphologia  (picking  at  the  bed- 
clothes) is  a  common  symptom.  The  decubitus  is  dorsal,  as  a  rule ;  the 
flushed  cheeks  gradually  become  dusky,  the  face  expressionless,  and  the 
pupils  often  contracted.  The  prostration  reaches  an  extreme  degree, 
and  absolute  exhaustion  often  terminates  life. 

As  a  rule,  in  favorable  cases  the  end  of  the  febrile  period  comes  by 
crisis  between  the  fourteenth  and  seventeenth  days  of  the  disease,  and 
the  temperature  drops  in  the  course  of  twenty -four  or  thirty-six  hours 
to  normal.  Immediately  preceding  the  crisis  there  is  generally  a  great 
and  sudden  rise  of  the  temperature  (^^W«ri«^w  criiica),  and  the  decline 
may  be  interrupted  by  slight  irregularities  or  fresh  exacerbations.  The 
occurrence  of  the  crisis  is  marked  by  rapid  improvement  in  the  symp- 
toms in  general.  The  stupor  suddenly  gives  place  to  a  clear  mind 
(sometimes  following  a  profound  sleep),  the  eruption  fides  quickly,  the 
facial  phenomena  disappear  in  inverse  order  of  their  appearance,  and 
the  general  strength  is  rapidly  recovered. 


TYPHUS  FEVER.  71 

Leading  Symptoms  and  CompKcations. — Course  of  the  Fever. — Al- 
though the  temperature,  as  stated  above,  rises  rapidly  on  the  first  day 
of  the  illness,  it  should  be  added  that  the  highest  grade  is  usually 
reached  as  late  as  the  fifth  or  sixth  day.  Maximum  temperatures  of 
105°,  106°,  or  even  107°  F.  (40.5°-41.6°  C.)  are  common.  Hyperpy- 
rexia usually  heralds  a  fatal  termination,  the  temperature  mounting  to 
108°,  109°  F.  (42.7°  C),  or  higher,  though  in  light  cases  the  acme  may 
not  exceed  10-3°  F.  (39.4°  C).  During  the  height  of  the  affection  the 
temperature  pursues  the  continued  type  (slight  morning  remissions), 
with  moderate  oscillations,  till  the  occurrence  of  the  crisis  "whicli  has 
been  described.  The  fall  of  temperature  may  occasionally  be  more 
gradual  than  before  indicated,  though  this  is  a  comparatively  rare  phe- 
nomenon. 

The  lungs  frequently  present  complications  {vide  Pathology),  among 
which  the  most  common  are  bronchitis,  hronclio-pneumonia,  and  hy- 
postatic congestion.  Broncho-pneumonia  is  especially  dangerous,  its 
development  often  preceding  a  fatal  termination,  and  it  may  lead  to 
pulmonary  gangrene.  If  the  gangrenous,  consolidated  areas  connect 
with  the  pleura,  empyema  commonly  results.  Sero-fibrinous  pleurisy 
also  may  occur  as  a  secondary  event,  as  may  lobar  pneumonia,  and  to 
recognize  the  latter  the  local  physical  signs  must  be  fully  appreciated, 
since  the  rational  symptoms  are  feebly  expressed. 

The  heart  in  typhus  continues  to  grow  progressively  weaker  until,  in 
many  cases,  a  fatal  issue  is  reached.  This  is  manifested  by  the  change 
in  the  character  of  the  first  sound,  which  becomes  more  and  more  indis- 
tinct as  the  case  progresses,  A  systolic  murmur  (probably  of  hemic 
origin)  may  be  audible  at  the  apex. 

The  nervous  phenomena  have  been  suflSciently  detailed.  Meningitis 
has  been  met  with,  but  is  very  rare  as  a  complication.  Reference  has 
been  made  to  the  occurrence  of  the  ordinary  febrile  albuminuria  in  this 
disease,  and  it  remains  to  be  pointed  out  that  hemorrhagic  nephritis 
very  rarely  intervenes.  During  the  febrile  period  the  uric  acid  and 
urea  increase  in  quantity,  while  the  chlorids  decrease. 

The  digestive  tract  rarely  presents  distressing  symptoms  and  compli- 
cations. Hematemesis  is  most  common,  and  cancrum  oris  has  been 
noted  occasionally.  Cases  in  which  the  mouth  does  not  receive  proper 
care  are  apt  to  develop  parotitis,  which  often  passes  on  to  suppuration, 
and  septic  processes,  causing  abscesses  in  different  parts  of  the  body 
(joints,  subcutaneous  tissue,  etc.),  may  arise  as  complicating  events. 

Among  the  sequelae,  neuritis,  followed  by  paralyses,  deserves  first 
place,  and  gangrene  of  the  remote  extremities  (toes,  fingers,  etc.)  has 
also  been  observed. 

The  general  course  and  duration  of  typhus  are  variable.  There  is  a 
mild  type  whose  course  is  run  in  from  seven  to  ten  days,  and  in  such  the 
crisis  occurs  soon  after  the  appearance  of  the  eruption,  which  may  not 
proceed  to  the  petechial  stage.  In  this  type  the  development  of  serious 
symptoms  or  grave  complications  is  the  exception,  A  malignant  type, 
however,  also  occurs  {typhus  siderans),  and  this  often  proves  fatal  before 
the  time  for  the  appearance  of  the  rash. 

Some  epidemics  are  characterized  by  the  relative  frequency  of  light 
forms,  and  others  by  the  severer  types  of  the  disease. 


72  INFECTIOUS  DISEASES. 

Diagnosis. — On  the  known  presence  of  an  epidemic  with  special 
causative  factors  (unhygienic  surroundings,  exposure  to  the  poison,  etc.), 
and  with  the  course  and  characteristic  symptoms,  the  diagnosis  of  typhus 
fever  can  he  made.  Of  special  value  is  the  eruption — its  time  of  appear- 
ance (third  to  fifth  day),  mode  of  distribution,  petechial  character,  and 
peculiar  behavior  under  pressure.  The  recognition  of  lighter  types,  on 
the  one  hand,  and  malignant,  on  the  other,  is  not  possible  from  the 
symptoms  alone,  but  it  is  so  from  the  light  afforded  by  a  definite  know- 
ledge of  the  existence  of  an  epidemic  in  the  vicinity. 

Differential  Diagnosis, —  Typlwid  fever  is  distinguished  from  this  affec- 
tion by  {a)  its  gradual  onset,  unaccompanied  by  severe  rigor;  (i)  the 
relatively  diminished  violence  and  the  later  development  of  the  nervous 
symptoms ;  ((')  the  less  intense  lumbo-muscular  pains ;  (r?)  the  less  abun- 
dant eruption,  which  is  non-petechial  and  appears  on  the  seventh  or 
eighth  day ;  and  {e)  the  gradual  convalescence. 

Cerebrospinal  meningitis  may  be  distinguished  by  a  more  intense 
headache,  by  retraction  of  the  head,  hyperesthesia,  intolerance  of  sounds, 
photophobia,  palsies  of  the  eye-muscles  (strabismus),  a  greater  tendency 
to  convulsions,  and.  finally,  by  both  the  absence  of  the  typhus  eruption 
and  the  countenance  absolutely  devoid  of  expression. 

Uremia  is  excluded  by  the  absence  of  the  previous  history  which  it 
always  gives  (headache,  vomiting,  and  diarrhea  extending  over  a  varia- 
ble period  of  time),  by  the  presence  in  typhus  of  high  temperature,  and 
a  petechial  eruption,  and  by  the  absence  of  edema  of  the  extremities 
and  face.  Characteristic  urinary  phenomena  are  associated  in  uremia, 
and  it  must  not  be  forgotten  that  among  the  rarer  complications  of 
typhus  is  acute  hemorrhagic  nephritis. 

In  pneumonia  the  mode  of  onset  is  not  unlike  that  of  typhus,  but 
the  early  development  of  the  local  physical  signs,  the  absence  of  the 
typhus  eruption,  and  the  non-epidemic  appearance  of  the  disease  are 
points  which   serve  to  distinguish  the  former  from 'the  latter  disease. 

Relapses  are  among  the  rarest  of  clinical  events,  and  one  attack,  as 
a  rule,  bestows  immunity  for  life. 

Progtiosis. — To  arrive  at  a  correct  ]>rognosis  it  is  necessar}^  to  con- 
sider (1)  the  degree  of  severity  of  the  particular  type  from  which  the 
patient  is  suffering,  (2)  the  number  and  character  of  the  complicating 
conditions  present,  or  likely  to  occur  if  the  case  be  of  a  severe  grade, 
and  (3)  any  peculiar  circumstances  connected  with  the  individual,  among 
which  his  food-supply  and  his  sanitary  surroundings  are  deserving  of 
chief  mention.  In  general  terms,  typhus  fever  is  a  grave  disease,  but 
its  frequency  of  occurrence,  and  also  its  virulence,  have  been  markedly 
reduced  in  consequence  of  better  sanitation.  The  mortality-rate  has 
been,  during  the  last  half  century,  lowered  immensely,  and  is  between 
10  and  20  per  cent,  at  the  present  day. 

Treatment. — This  need  not  be  discussed  at  length,  since  it  em- 
braces, in  the  main,  the  same  principles  that  Avere  evolved  in  the  treat- 
ment of  typhoid  fever. 

Prophylaxis  demands  thorough  disinfection  and  absolute  isolation.  A 
special  hospital  for  contagious  diseases  is  always  to  be  preferred  to  the 
best  accommodations  obtainable  in  private  families.  When,  however, 
patients  cannot  be  transferred  to  special  hospital  wards  and  must  be 


BE  LAPSING  FEVER.  73 

treated  in  private  houses,  the  sick-room  must  be  kept  clean,  tv ell-ven- 
tilated, and  at  a  temperature  ranging  from  60°  to  65°  F.  (15.5°  to 
18.3°  C).  No  one  other  than  the  doctor  and  nurse  should  be  allowed 
to  occupy  or  even  enter  the  room.  The  thorough  disinfection  already 
described  under  Typhoid  Fever  must  be  enforced  with  equal  care,  and 
the  importance  of  supplying  fresh  air  to  typhus  patients  has  been  abun- 
dantly shown  by  the  great  reduction  in  the  mortality-rate  among  those 
treated  in  tents  as   compared  with  that  in  the  hospital  wards. 

The  general  management,  including  the  use  of  stimulants,  in  this 
disease  does  not  differ  from  that  advised  in  typhoid  fever,  except  that  a 
more  prompt  return  to  solid  food  can  be  made  during  convalescence  than 
in  typhoid.  Fresh  water  should  be  given  freely,  and,  in  view  of  the 
blunted  sensibilities  of  the  patient,  should  be  offered  at  regular  intervals. 
Sydr other apy  constitutes  the  best  means  at  our  command  for  controlling 
(by  virtue  of  its  stimulating  effect  upon  the  cardiac  and  respiratory  cen- 
ters) the  temperature  and  the  nervous  symptoms,  while  at  the  same  time 
it  obviates  dangerous  complications.  In  addition,  the  use  of  antiseptic 
agents  and  tonic  measures  is  to  be  recommended.  The  fact  that  typhus 
is  a  self-limiting  affection,  and  therefore  curable  if  life  can  be  spared 
until  it  has  run  its  usual  course,  gives  those  measures  that  are  intended 
to  combat  exhaustion  high  rank  in  the  treatment  of  this  affection. 


RELAPSING  FEVER. 

{Febris  Recurrens ;  Relapsing  Typhus.) 

Definition. — An  acute  infectious  disease  caused  by  the  spirillum  of 

Obermeier,  and  characterized  by  febrile  periods  which  usually  last  six 
days,  and  are  separated  by  afebrile  periods  of  the  same  duration. 

Historic  Note. — The  first  accurate  account  of  this  affection  was 
published  in  1739,  though  it  is  known  to  have  prevailed  in  Europe  and 
Ireland  prior  to  that  period.  During  the  next  century  numerous  epi- 
demic outbreaks,  more  or  less  extensive,  occurred,  and  in  18-14  the  dis- 
ease made  its  fiirst  appearance  in  America  at  the  Philadelphia  Hospital, 
being  brought  by  immigrants  from  Ireland.  Subsequently  small  groups 
of  cases  occurred,  and  were  reported  by  Flint  and  others,  and  in  1869 
it  prevailed  considerably  in  Philadelphia  (where  it  was  studied  especially 
by  E.  Ehoads  and  William  Pepper)  and  in  other  large  cities  of  the  coun- 
try. This  was  the  last  epidemic  appearance  of  the  disease  in  the  United 
States,  though  in  the  years  1885  and  1886  Russia  was  visited  by  an 
epidemic  of  considerable  magnitude. 

Pathology. — The  solid  organs  of  the  body  present  no  characteristic 
anatomic  changes,  though  when  death  occurs  during  the  febrile  period 
the  various  viscera  (heart,  liver,  kidneys)  are  the  seat  of  cloudy  swelling, 
and  sometimes  of  hemorrhagic  infarct  and  extravasation.  The  spleen 
shows  the  most  constant  alterations,  being  enlarged,  but  in  size  it  ex- 
hibits a  great  variability.  Infarction  is  frequent,  and  the  lymphoid  ele- 
ment of  the  bone-marrow  often  shows  hyperplasia.  If  jaundice  has  been 
present  during  life,  it  is  visible  after  death. 


74  INFECTIOUS  DISEASES. 

Ktiology. — Bacteriology. — In   1873,    Obermeier   discovered   in   the 
blood  of  patients  suffering  from  relapsing  fever  a  special  organism,  the 

spirillum  Obermeieri,  and  subsequent 
--_  investigations   by   others    have   fully 

confirmed  his  observations  with  refer- 
.     ;  ence  to  the  causal  relation  of  this  mi- 

)  ^         cro-organism  to  relapsing  fever.    The 

\  ■     ■  specific  agent,  or  sjnrocheta,  is  a  deli- 

i  cate   filamentous    organism   of  spiral 

\  form  and  much  elongated,  its  length 

~r  '    '  '     ecjualling  four  to  six  times  the  diam- 

eter of  a  red  blood-corpuscle  (Fig.  8). 
Examined  under  the  microscope  dur- 
^'^^         i  ing  a  pyretic  period,  it  is  seen  to  ex- 

hibit active  motion  among  the  blood- 
cells,  this   motion    being    spiral   and 

following  the  long  axis  of  the  organ- 

FiG.  8.-Bacmus  of  relapsing  fever  (from     ism.     It  is  aerobic,  and  may  be  dem- 
human  blood) ;  X 1000  (Gunther).  onstrated   in    drt/  blood  by   staining 

with  anilin  colors,  but  the  spirillum 
has  never  been  found  in  other  fluids  or  secretions  of  the  body.  It  is 
also  apparent  in  the  blood  only  during  the  paroxysms,  and  Dr.  Van 
Dyke  Carter's  careful  studies  have  shown  that  by  inoculation  of  the 
blood  containins:  spirilhvr  org:anisms  or  their  germs  the  disease  mav  be 
conveyed  to  new  or  old  subjects.  Shortly  before  the  crisis  the  spirilla 
disappear  from  the  blood,  and  are,  as  a  rule,  absent  during  the  whole  of 
the  succeeding  apyrexial  period,  and  inoculation  now  fails  to  produce 
the  disease.  After  death  they  are  found  in  all  the  organs,  but  they  have 
not  been  cultivated  successfully  on  artificial  media,  and  little  is  known 
of  their  life-history. 

Predisposing  Causes. — Age. — The  complaint  is  most  common  in  young 
adults  between  fifteen  and  twenty-five  years. 

Sex. — A  larger  proportion  of  males  than  females  is  affected. 
The  disease  is  especially  apt  to  prevail  in  times  of  famine,  and  amid 
antihygienic  surroundings. 

Mode  of  Infection. — Tictin's  studies  indicate  that  the  medium  of  trans- 
mission may  be  through  suctorial  insects  (as  bedbugs). 

Clinical  History. — The  incubation  period  ranges  in  its  duration 
from  four  to  ten  days,  though  sometimes  it  is  even  briefer ;  and  in  this 
stage  certain  symptoms  (malaise,  fugitive  pains,  etc.)  may  appear. 

•  The  invasion  is  quite  ahriipt,  often  occurring  on  awakening  in  the 
morning,  and  commonly  the  attack  is  ushered  in  with  a  severe  rigor, 
though  there  may  be  only  a  repeated  slight  shivering.  The  chief  accom- 
panying s}' mptoms  are  frontal  headache,  vertigo,  severe  pains  in  the  loins 
and  limbs,  and  marked  physical  prostration.  The  temperature  rises 
soon,  and  often  rapidly,  reaching  105°-106°  F.  (41.1°  C),  or  higher 
still,  on  the  first  or  second  day.  The  sTcin  is  dry  and  pungent,  and  pre- 
sents very  soon  either  a  "  characteristic  dirty-yellow  color  "  or  a  dis- 
tinctly bronzed  appearance.  The  cheeks  are  flushed,  the  eyes  sunken, 
and  profuse  perspirations  often  take  place  (sometimes  alternating  with 
chills),  in  consequence  of  which  sudamina  are  frequently  observed.   Other 


RELAPSING  FEVER.  75 

forms  of  eruption  have  been  described,  but  none  that  are  either  constant 
or  characteristic.  In  certain  epidemics  herpes  lahialis  has  been  very  gen- 
erally noticed.  At  first  the  tongue  is  moist  and  coated  with  a  yellowish- 
white  fur,  and  later  it  may  become  brown,  dry,  and  fissured,  with  sordes 
on  the  teeth.  Ulcerative  stomatitis  has  been  observed  occasionally,  and 
catarrhal  pharyngitis  and  mild  tonsillitis  may  be  evidenced  by  pain  on 
swallowing  and  other  symptoms.  Among  the  earlier  symptoms  are  ex- 
cessive thirst,  anorexia,  nausea,  and  vomiting.  The  vomitus  may  be 
yellowish-green,  green;  or  even  black  in  color,  and  consist  of  bile  in 
varying  proportions  (rarely,  also,  blood)  and  gastric  secretions.  Con- 
stipation often  precedes  invasion,  and  is  apt  to  continue  throughout  the 
attack. 

The  pulse  rises  rapidly  with  the  temperature,  though  the  normal 
ratio  between  the  two  is  not  maintained.  At  first  the  pulse  is  full  and 
strong,  and  its  beats  number  from  100  to  140  or  more  per  minute ;  but 
in  serious  cases  it  becomes  weak,  irregular,  or  even  intermittent,  while 
at  the  same  time  the  heart-sounds  grow  more  and  more  feeble  and  indis- 
tinct. Hemic  murmurs  may  be  audible.  The  nervous  derangements 
are  not  of  a  grave  character,  but  the  headache  persists  and  is  severe 
throughout,  and  the  patient  is  restive  and  sleepless.  Delirium  is  not 
common,  and,  though  occasionally  this  symptom  assumes  a  prominence 
toward  the  crisis,  the  intellect  remains  clear  as  a  rule.  The  urine  pre- 
sents the  ordinary  febrile  characteristics,  and  may  contain  albumin  and 
casts.  It  also  contains  bile-pigment  when  jaundice  is  present.  The 
respirations  are  accelerated,  and  immediately  preceding  the  crisis  urgent 
dyspnea  may  be  developed. 

The  physical  signs  during  the  febrile  paroxysms  are  few.  The  epi- 
gastric region  and  the  nerve-trunks  are  tender  to  the  touch,  while  the 
skin-surface  and  certain  muscles  are  often  hyperesthetic.  Palpatioyi 
detects  a  variable  degree  of  enlargement  of  the  spleen  and  liver,  and 
the  signs  of  bronchitis,  of  lobular  pneumonia,  and  of  hypostatic  con- 
gestion of  the  lungs  may  be  present.  The  symptoms  above  detailed 
persist  with  slight  daily  fluctuations  of  temperature  till  there  occurs  a 
turning-point. 

The  Crisis. — This  occurs  from  the  fifth  to  the  seventh  day,  and 
rarely  as  late  as  the  tenth.  It  is  sometimes  heralded  by  a  critical  rise 
of  temperature,  the  mercury  touching  108°  F.  (42.2°  C),  but  evidenced 
chiefly  by  a  rapid  fall  of  temperature  (Avithin  twelve  hours)  to  or  below 
the  normal,  with  profuse  sweating.  Coincidently,  all  other  symptoms 
disappear  with  marvellous  rapidity.  The  critical  sweat  may  be  replaced 
by  diarrhea,  intestinal  hemorrhage,  metrorrhagia,  or  epistaxis,  and  then 
follows  a  speedy  afebrile  convalescence,  so  that  after  the  lapse  of  a  day 
or  two  the  patient  expresses  himself  as  being  well. 

During  the  intervals  between  the  paroxysms  the  skin  may  exhibit  a 
faintly  jaundiced  tint;  there  may  be  trivial  evening  exacerbations  of 
temperature,  particularly  if  complications  be  present  {j,nd  outlast  the 
fever  stage;  and  the  spleen  is  evidently  enlarged.  There  may  be, 
though  rarely,  but  a  single  paroxysm.  As  a  rule,  at  the  expiration  of 
the  second  week  there  will  be  a  recurrence  of  all  the  active  symptoms 
of   the  primary   attack,   including  the  rigor  or  fits   of    chilliness   and 


■76 


INFECTIOUS  DISEASES. 


fever.     Quite  frequently  a  third  pyrexial  stage  takes  place,  and  rarely  a 
fourtli  or  even  fifth. 

The  duration  of  the  first  relapse  is  briefer  than  the  primary  pyretic 
stage,  and  if  there  be  subsequent  relapses,  each  succeeding  one  is  sepa- 
rated from  its  predecessor  by  the  usual  apyrexial  period,  but  is  briefer 


9     10    11     12    1?.    14    15    16    17    18    19    20 


Firat  intermiasioD.  Firgt  rplapse.     Second 

Fig.  9.— Temperature-curve  of  relapsing  fever. 


and  lighter.  Hence,  should  a  fourth  or  a  fifth  febrile  period  occur,  it 
is,  as  a  rule,  quite  rudimentary.  The  relative  duration  and  severity  of 
the  different  febrile  periods,  their  manner  of  recurrence,  and  the  course 
of  the  fever  are  considerations  that  can  best  be  appreciated  by  a  glance 
at  the  accompanying  temperature-chart  {inde  Fig.  9). 

Complications. — These  are  not  frequent.  At  the  head  of  the  list 
stands  lobar  p)teuiiionia,  and  next  comes  hroncho-prieumonia,  which  is 
always  secondary.  Other  conditions,  belonging  to  the  latter  class,  are 
septico-pyemic  processes,  iritis,  irido-choroiditis,  suppurative  parotitis, 
laryngitis,  entero-colitis,  and  neuritis.  In  pregnant  women  abortion 
may  take  place.  Epistaxis  has  been  noted,  and  has  even  proved  dan- 
gerous in  some  epidemics.  Acute  hemorrhagic  nephritis  is  a  very  rare 
but  serious  complication  when  it  does  occur,  and  may  be  dependent 
upon  the  primary  affection.  As  the  result,  most  probably,  of  the  very 
high  temperature  the  heart  may  become  exhausted,  and  the  occurrence 
of  sudden   paralysis  is  not  unknown. 

Clinical  Varieties. — The  difference  in  the  general  course  of  cases  in 
different  e])i demies,  and  even  in  the  same  one,  is,  for  the  most  part,  the 
direct  result  of  the  varying  degrees  of  intensity  of  the  infection.  Thus 
very  light  or  even  rudimentary  cases  occur  in  which  the  whole  course 
may  be  made  up  of  one  or  two  brief  febrile  periods,  and  their  resemblance 
to  ordinai-y  intermittents  may  be  close.  The  so-called  "  bilious  typhoid,'' 
which  is  a  form  of  relapsing  fever,  occupies  the  other  extremity,  being 
of  malignant  type.  It  is  sometimes  characterized  by  the  usual  symp- 
toms of  the  disease,  only  greatly  intensified  ;  but  more  often,  perhaps, 
the  condition  early  merges  into  a  typhoid  state,  to  which  are  added  cer- 


RELAPSING  FEVER.  77 

tain  grave  features  and  complications  (marked  icterus,  hematemesis  and 
hemorrhages  from  other  outlets  of  the  body,  uremia,  sudden  collapse, 
etc.).  Septic  and  pyemic  processes,  including  infarctions,  are  common 
accompaniments,  and  the  outcome  is  frequently  unfavorable. 

Diagnosis. — The  prevalence  of  an  epidemic  in  which  the  cases  pre- 
sent similar  symptoms  ;  the  sudden  onset ;  the  course  and  intensity  of 
the  fever  with  its  concomitants  ;  the  termination  by  crisis  on  or  about 
the  seventh  day  ;  and  the  peculiar  manner  of  repetition  of  the  fever- 
attacks  after  an  afebrile  period  of  equal  duration, — are  points  that  dis- 
tinguish relapsing  fever  from  other  affections  which  simulate  it  more  oi; 
less  closely.  Additional  symptoms  that  are  of  special  value  for  diag- 
nosis are — enlargement  of  the  spleen  and  liver,  a  negative  character  of 
the  nervous  and  a  prominence  of  the  gastric  phenomena,  and  jaundice. 
To  be  able  to  state  that  relapsing  fever  is  positively  present  the  spiro- 
cheta  Ohermeieri  must  be  found  in  the  blood,  and  this  is  particularly 
true  in  the  earlier  cases  of  an  epidemic,  before  they  have  passed 
through  their  typical  relapses.  To  demonstrate  the  presence  of  this' 
parasite 'in  the  blood  during  the  fever-stage  is  not  a  difficult  task.  A 
drop  of  blood  obtained  from  the  finger-tip  is  to  be  examined  microscopi- 
cally without  previous  dilution.  On  account  of  their  size  and  motility 
the  spirilla  can  be  readily  detected,  and  usually  the  attention  of  the  ex- 
aminer is  first  arrested  by  the  peculiar  joggling  movements  of  the  red 
blood-corpuscles.  Then  the  real  disturbing  agents  appear  as  slender 
spirals  with  a  snake-like  motion.  Their  identity  may  be  confirmed  by 
staining  with  anilin  colors,  and,  in  exceptional  cases,  by  injecting  them 
into  the  blood  of  the  monkey,  in  whom  they  produce  the  disease. 

Differential  Diagnosis. —  Tyjjlius  fever  may  be  mistaken  for  relapsing 
fever,  since  both  have  the  same  predisposing  causes,  both  prevail  epi- 
demically, both  are  characterized  by  an  abrupt  onset,  with  or  without 
prodromes,  and  by  a  continued  type  of  fever.  On  the  other  hand,  cer- 
tain points  of  distinction  serve  to  separate  them  reliably.  In  relapsing 
fever  the  eyes  are  clear  but  hollowed,  the  cheeks  are  flushed,  and  there 
is  a  dirty-yellow  tint  of  skin  ;  in  typhus  the  eyes  are  injected,  the 
pupils  contracted,  the  face  wears  a  stupid,  inanimate  expression,  and 
there  is  in  addition  the  characteristic  maculo-petechial  eruption.  In 
relapsing  fever  the  intellect  remains  clear,  or  there  may  be  delirium 
toward  the  height  of  the  febrile  paroxysm ;  in  typhus  stupor  develops 
early,  and  later  there  is  coma  or  coma- vigil,  with  acute  or  low-muttering 
delirium  and  adynamic  symptoms.  In  the  former  disease  the  primary 
period  of  fever  is  briefer  than  in  typhus  by  a  ratio  of  7  to  14.  Re- 
lapses are  the  rule  in  relapsing  fever,  and  the  exception  in  typhus ; 
while  in  the  blood  of  relapsing  fever  patients  may  be  found  the  spiril- 
lum, which  is  absent  in  typhus  fever. 

Pel  and  Ebstein  have  described  a  febrile  condition  which  sometimes 
occurs  in  pseudo-leukemia  and  simulates  that  of  relapsing  fever ;  but  it 
may  be  distinguished  by  the  absence  of  the  spirilla  from  the  blood,  the 
general  enlargement  of  the  lymphatic  glands,  as  well  as  of  the  liver  and 
spleen,  and  the  fact  that  the  pyrexia!  periods  do  not  tend  to  grow 
shorter. 

Prognosis. — The  prognosis  of  relapsing  fever  is  good,  but  of  "bil- 
ious typhoid  "  it  is  bad  indeed.    Apart  from  the  type,  we  must  consider, 


78  INFECTIOUS  DISEASES. 

in  this  as  in  all  other  acute  infectious  diseases,  the  number,  character, 
and  frequency  of  occurrence  of  the  various  complications.  As  stated, 
these  are  few,  infrequent,  and  mostly  benign.  Among  those  signalizing 
danger  are  severe  hemorrhages  (epistaxis,  metrorrhagia,  hematemesis, 
etc.),  premature  labor,  signs  of  uremia  and  syncope,  marked  jaundice 
and  excessive  vomiting,  urgent  diarrhea,  etc.  Perhaps  the  most  fre- 
quent causes  of  death  are  pneumonia  and  acute  hemorrhagic  nephritis. 
Individual  circumstances  exert  an  influence  upon  the  prognosis,  and  of 
those  that  render  it  more  grave  are  the  want  of  good  nursing,  privation, 
a  previously  enfeebled  system,  and  old  age  (the  disease  being  more  fatal 
in  elderly  than  in  younger  subjects). 

The  duration  depends  upon  the  number  of  paroxysms,  since  the 
latter  are  of  definite  length.  In  the  majority  of  cases  there  is  but  one 
relapse,  and  in  this  event  the  disease  lasts  from  eighteen  to  twenty  days. 

Treatment. — The  general  management,  including  the  time  and  use 
of  stimulants,  must  be  based  on  the  same  principles  as  are  employed  in 
typhoid  fever.  The  fever,  as  well  as  the  nervous  and  other  leading  symp- 
toms, is  to  be  opposed  by  the  cold  or  gradually  cooled  bath,  employed  as 
indicated  in  the  article  on  the  treatment  of  the  latter  disease.  If,  as  may 
happen,  there  are  adequate  reasons  why  balneo-therapeutics  cannot  be 
used,  then  cold  spongings,  with  the  ice-cap  or  the  cold  pack,  may  be  tried. 
Internal  antipyretics  may  be  reserved  for  use  in  cases  in  which  the  tem- 
perature is  very  high  and  the  above-mentioned  means  are  impracticable. 
Small  doses  of  phenacetin  (gr.  ij  to  v — 0.1296  to  0.3240)  or  acetanilid 
(gr.  ij  to  iij — 0.1296  to  0.1944)  are  to  be  administered,  at  the  same  time 
guarding  the  heart,  and  the  signs  of  collapse  must  be  promptly  met  by 
the  free  yet  prudent  use  of  stimulants  (strychnin,  alcoholics,  ammonium, 
etc.).  Aomiting  often  induces  marked  debility,  and  calls  for  the  use  of 
ice  or  iced  champagne  and  small  doses  of  cocain,  morphin,  or  dilute 
hydrocyanic  acid,  preceded  by  a  mercurial  laxative.  Counter-irritation 
over  the  epigastrium  is  also  useful.  For  the  intense  muscular  pain, 
restlessness,  and  sleeplessness  nothing  is  so  good  as  morphin  given  sub- 
cutaneously.  and  Dovers  powder  may  be  employed  if  the  pain  be  of 
moderate  .severity.  During  the  intermissions  the  patient  should  be 
kept  indoors  for  ten  days  or  more,  lest  exposure  or  sudden  exertion 
predispose  him  to  a  relapse.  Solid  food  may  now  be  gradually  resumed, 
and  tonics  judiciously  given.  The  treatment  of  relapses  differs  in  no 
way  from  that  of  the  first  febrile  period. 


MALARIAL  FEVER.  79 


MALARIAL  FEVER. 

{Chills  and  Fever ;  Fever  and  Ague;  Swa7np  Fever.) 

Definition. — An  infectious,  non-contagious  disease  caused  by  the 
hematozoa  of  Laveran.  It  is  characterized  by  splenic  enlargement, 
brief  febrile  attacks  "which  recur  periodically,  melanemia,  and  a  tend- 
ency in  protracted  cases  to  irregular  fever  and  extreme  anemia.  The 
follo"«"ing  sub-varieties  Avill  be  discussed:  (1.)  Intermittent  fever ;  (11.) 
Pernicious  i7itermittent ;  (III.)  Remittent  fever ;  (IV.)  Malarial  ca- 
chexia; (Y.)  Mashed  inter ynittents ;  and  (VI.)  Malarial  hematuria. 

Historic  Note. — There  are  few  diseases  with  which  the  profes- 
sion has  been  acquainted  longer  than  with  the  more  typical  forms  of 
malaria,  and  chief  among  the  earliest  known  hot-beds  of  this  disease 
were  the  city  of  Rome,  the  Pontine  marshes  about  the  latter,  and  the 
swamps  along  the  lower  Danube.  Except  in  the  extremes  of  latitude 
there  are  few  localities  in  which  malaria  has  not  been  endemic,  with 
seasonal  epidemic  outbreaks ;  yet  it  is  pretty  generally  believed  that  the 
prevalence  of  the  disease  long  has  been,  and  still  is,  diminishing.  This 
view  is  fully  corroborated  by  my  OAvn  observations. 

A  similar  progressive  decrease,  with  slight  annual  variations,  was 
noted  during  a  period  of  five  years  (from  1885  to  1889)  when  the  cases 
from  four  leading  hospitals  of  Philadelphia  were  considered  together. 
The  total  number  of  cases  for  this  space  of  time  was  1132.  It  was  also 
found  that  a  tracing  representing  the  number  of  cases  of  malaria  ad- 
mitted into  the  Pennsylvania  Hospital  yearly  during  the  period  extend- 
ing from  1853  to  1893,  inclusive,  showed  a  similar  tendency  to  decline, 
though  in  a  somewhat  less  striking  degree.  Osier  has  called  attention 
to  the  fact  that  the  diagnosis  of  malaria  was  much  more  frequently 
made  before  the  discovery  of  the  parasite  than  has  since  been  the  case, 
and  that,  therefore,  early  statistics  of  this  disease  are  apt  to  be  mis- 
leading. 

New  England,  once  a  region  in  which  the  disease  was  very  prevalent, 
now  affords  few  cases.  In  the  southern  portion  of  the  United  States, 
also,  the  severer  forms  of  malaria  prevailed  extensively,  but  a  marked 
tendency  to  progressive  reduction  in  the  number  of  cases  has  also  been 
observed  here.  It  must  not  be  forgotten,  however,  that  in  some  districts 
of  the  United  States,  from  which  malaria  had  disappeared,  it  has  re- 
appeared, while  other  localities,  formerly  free  from  the  disease,  have 
become  more  or  less  malarious.  In  foreign  lands  (England,  France, 
Germany,  etc.)  the  constantly  decreasing  prevalence  and  virulence  of 
this  disease  have  been  noted  by  numerous  careful  observers. 

Pathology. — The  chief  and  most  constant  morbid  lesions  are 
attributable  to  the  direct  effect  of  the  malarial  parasites  upon  the  blood. 
The  symptomatic  anemia  (often  quite  pronounced)  results  from  the  de- 
struction of  red  corpuscles,  which  may  be  observed  in  all  stages,  by  the 
parasites.  There  is  a  marked  tendency  to  an  accumulation  of  pigment 
in  the  blood  and  in  certain  of  the  internal  organs,  particularly  the 
spleen  and  liver.     To  account  for  this  is  the  fact  mentioned  in  the  de- 


80  INFECTIOUS  DISEASES. 

scription  of  the  ameba  {infra)  that  the  hemoglobin  of  the  blood  is  con- 
verted into  melanin  (pigment)  by  the  organisms.  The  malarial  parasite 
also  engenders  a  toxin  ^vhich  may  be  in  part  responsible  for  the  morbid 
lesions  of  the  disease. 

The  spleen  is  engorged  with  blood,  and  at  first  is  swollen  (chiefly 
during  the  febrile  paroxysm),  but  it  soon  becomes  permanently  enlarged 
("  ague-cake  ").  A  rare  accident  in  intermittent  fever  is  rupture  of  the 
spleen.      Hemorrhagic  infarcts  are  occasionally  presented  by  this  organ. 

The  liver  is  also  engorged,  but  not  to  the  same  extent  as  the  spleen. 

The  heart-chambers  may  be  found  to  be  acutely  dilated. 

Ktiology. — (1)  Soil. — It  is  a  generally  accepted  fact  that  a  certain 
condition  of  the  soil,  especially  as  regards  a  considerable  humidity,  is 
essential  to  the  development  of  the  malarial  poison.  Marshes  are  often 
hicrhlv  malarious,  and  particularly  the  swamps,  that  are  overflowed  at 
certain  seasons  and  exposed  to  the  influence  of  the  atmosphere  at  certain 
other  seasons,  are  breeding-places  for  malaria.  Fresh-water  marshes 
favor  the  development  of  the  malarial  organism,  and  are  most  fruitful 
in  influencing  its  gro"svth  when  located  near  the  coast  and  tainted  with 
salt  water.  Again,  marshy  districts  affording  luxuriant  vegetation  are 
notorious  as  malarial  foci.  Keeping  in  remembrance  the  foregoing  facts, 
we  can  readily  see  why  malaria  is  unusually  prevalent  in  certain  coun- 
tries (chiefly  tropical),  and  why  it  is  chiefly  confined  to  the  low-lying  es- 
tuaries and  the  deltas  of  rivers.  The  same  facts  explain  satisfactorily 
why  certain  districts  which  were  very  liable  to  the  aff"ection  should  have 
become,  as  the  result  of  denudation  of  the  virgin  soil  and  its  subserjuent 
drainage  and  cultivation  for  longer  or  shorter  periods,  entirely  free  from 
the  complaint.  On  the  other  hand,  the  upturning  or  removing  the  sur- 
face of  the  virgin  soil  may  be  followed  by  the  appearance  of  malaria  in 
localities  in  which  it  has  been  previously  unknown.  H.  J.  Waring  has 
shown  that  when  the  Avater-level  is  highest  malaria  is  most  prevalent, 
although  he  believes  that  the  plasmodium  is  carried  through  the  atmos- 
phere. On  the  other  hand,  certain  observations  (which  need  confirma- 
tion, however)  indicate  that  malaria  is  at  times  a  Avater-borne  disease. 
The  disease  has  been  met  with  on  dry,  sandy  soils,  and  even  on  dis- 
tinctly rocky  strata. 

(2)  Climate. — Malaria  is  more  prevalent  in  tropical  and  subtropical 
than  in  temperate  climates,  and  more  common  in  the  latter  than  in  the 
polar  zones.  Hence  it  occurs  more  frequently  in  the  southern  than  in 
the  northern  States  of  our  own  country.  Temperature,  per  se.  consti- 
tutes the  indispensable  factor,  the  virus  of  malaria  being  inactive  at 
temperatures  below  65°  F.  (18.3°  C),  while  very  high  temperatures 
may  arrest  the  plasmodial  groivth.  For  the  development  and  propagation 
of  the  malarial  parasite  the  presence  of  an  abundance  of  atmospheric 
oxygen  is  also  apparently  essential,  though  the  influence  of  moisture 
in  the  air  upon  the  malarial  germ  is  little  understood. 

(3)  The  winds  may  transfer  the  poison  from  place  to  place,  but  trees 
planted  in  rows  or  clumps  often  successfully  intercept  the  poison  as  it 
is  being  dispersed  by  air-currents  through  the  lower  strata  of  the  atmo- 
sphere. Strong  winds  tend  to  dry  the  soil  by  hastening  the  surface 
evaporation,  and  become  an  influential  factor  in  combating  one  of  the 
conditions  of  soil  essential  to  the  development  of  malaria. 


MALARIAL  FEVER. 


81 


,ith  in  malarial  districts.  .  I"  *« '^"T"  ^.^"Pf.^^^d  the  results  have 

^:t:z.X  aT;iicrs1ro\t:nX:  inn. .—,  a..„st 

^■'1S'^s:ron^-Int:;:r:^  iS:  Js -t  cases  are  developed  in  the 
autlmn  thTmaximal  period  corresponding  with  the  month  of  Septem- 


rrr.'^rnL=onhetrac,n^^^^^^^^^^ 

1  House-plants  as  Sanitary  Agents,  by  the  Author,  p.  263. 
6 


82  INFECTIOUS  DISEASES. 

but  also  practica7./y  during  the  spring,  although  the  cases  are  seen  to 
increase  during  the  latter  period.  In  the  tropics  the  case  seems  to 
be  different,  and  two  maximum  periods — spring  and  autumn — and  two 
minimum — summer  and  winter — obtain.  Autumn  has,  however,  the 
greater  number  of  cases. 

(6)  G-ravitatioa. — The  malarial  poison  escapes  from  the  soil  into  the 
superjacent  strata  of  air.  That  it  does  not  rise  far  above  the  earth's 
surface  is  shown  by  the  fact  that  persons  occupying  the  upper  stories 
of  a  house  or  living:  on  slight  elevations  are  affected  with  relative 
infrequency. 

(7)  Race  exerts  little  influence  in  other  lands  than  our  own,  but  in 
the  United  States  negroes  are  less  susceptible  than  are  the  whites. 

(8)  Sbx  is  without  effect  when  men  and  women  are  equally  exposed. 
Cases  are,  however,  vastly  more  frequent  among  males  because  of  their 
increased  liability  to  exposure,  and  particularly  while  following  certain 
occupations  (agriculture,  marsh-draining,  etc.).  The  5044  cases  col- 
lected by  myself  gave  the  numerical  proportion  of  6  to  1  in  favor  of 
males. 

The  Malarial  Parasite. — In  1879,  Klebs  and  Tommasi  Crudeli  isolated 
a  loAV  vegetable  organism — the  bacillus  malari^e — and  claimed  it  to  be 
the  special  agent  producing  all  forms  of  malaria.  The  evidence 
afforded  by  subsequent  experiments  of  other  observers,  however,  failed 
to  corroborate  their  investigations,  and  it  remained  for  Laveran  in  1880 
to  discover  the  specific  parasite  in  the  blood  of  patients  affected  with 
malaria.  The  announcement  of  his  discovery  failed  to  attract  Avide- 
spread  attention  until  1883,  when  Marchiafava,  Celli,  and  Golgi  pub- 
lished the  results  of  their  confirmatory^  investigations.  Since  then  the 
claims  of  Laveran  have  been  abundantly  corroborated  by  Councilman, 
Osier,  James,  Dock,  Koplik,  and  others  in  the  United  States,  by  Van 
Dyke  Carter  in  India,  and,  more  recently,  by  numerous  French,  Eng- 
lish, German,  and  Russian  observers.  It  would  seem,  therefore,  as 
though  the  evidence  as  to  the  specificity  of  this  organism  were  almost 
complete,  and,  at  all  events,  it  has  invariably  been  found  to  be  associated 
with  the  different  forms  of  malaria. 

The  malarial  parasite  belongs  to  a  sub-class  of  the  protozoa  known 
as  hematozoa.  Of  the  latter,  three  varieties,  corresponding  with  the 
three  leading  clinical  forms  of  the  affection,  have  been  distinguished, 
and  the  evolution  of  two  of  these  parasites  at  least  takes  place  within 
the  red  blood-corpuscles.  They  enter  the  red  cells  in  the  form  of  small, 
non-pigmented  plasmodia,  exhibiting  ameboid  motion,  and  then  feed 
upon  their  host,  transforming,  at  the  same  time,  the  hemoglobin  of  the 
latter  into  dark  pigment-granules  as  they  develop.  When  the  intra- 
globular  plasmodia  have  consumed  the  red  blood-corpuscles  the  granules 
of  pigment  accumulate  in  the  center  of  the  parasite,  while  on  its  periph- 
ery the  processes  of  subdivision  and  sporulation  are  taking  place, 
forming  fresh  generations  of  hematozoa.  These  young  parasites  assume 
the  form  of  minute,  more  or  less  spheric,  hyaline  bodies,  which  again 
enter  the  red  blood-corpuscles  and  start  on  a  new  cycle  of  development. 
It  is  probable,  as  Golgi  suggests,  that  the  third  variety  is  not  intimately 
connected  with  the  circulating  medium,  but  that  its  evolution  princi- 
pally takes   place   in  the   internal   organs  (spleen,  bone-marrow,   etc.). 


DESCRIPTION    OF  PLATES  I.   and   II.' 

The  drawings  were  made  with  the  assistance  of  the  camera  lucida  from  specimens  of  fresh 
blood.  A  Winekel  microscope,  objective  \-i  (oil  immersion),  ocnlar  4.  was  used.  Fignres  4, 13,  23. 
24.  and  42  of  Plate  1.  were  drawn  from  fresh  blood,  without  the  camera  lucida. 

PLATE  I. 

The  Parasite  of  Tertian  Fever. 

1.— Normal  red  corpu.scle.  * 

2,  3,  4.— YouuK  hvaliiio  forms.    In  4,  a  corpuscle  contains  three  distinct  parasites. 

5,  21.— Beginnint;  of  pij^'inentation.  The  parasite  was  observed  to  form  a  true  ring  by  the  con- 
fluence of  two  pstMi(i(  niodia.  During  observation  the  body  burst  from  the  corpuscle,  which  became 
decolorized  and  disMppcMicil  from  view.  The  parasite  became, almost  immeaiately, deformed  and 
motionless,  as  shuwiriii  Fit;-.  'IX. 

6,  7,  8.— Partly  developed  pigmented  forms.  , 
9. — Full-grown  body. 

10-]4.^Segmenting  bodies. 

15.— Form  simulating  a  segmenting  body.  The  significance  of  these  forms,  several  of  which 
have  been  observed,  was  not  clear  to  i)rs.  Thayer  and  Hewetsou,  who  had  never  met  with  similar 
bodies  in  stained  specimens  so  as  to  bo  able  to  study  the  structure  of  the  individual  segments.  ' 

16,  17. — Precocious  segmentation. 

18,  lit,  20.— Large  swollen  and  fragmenting  extracellular  bodies. 

22.— Flagellate  body. 

23,  24.— Vacuolization. 

The  Parasite  of  Quartan  Fever. 

25.— Normal  red  corpuscle. 
26.— Young  hyaline  form. 

27-34.— Gradual  development  id  the  intracorpuscular  bodies. 

35.— Full-grown  body.  The  substance  of  the  red  corpuscle  is  no  more  visible  in  the  fresh 
specimen. 

.36-H'.t. — Segmenting  bodies. 

40.— Large  swollen  extracellular  form. 

41.— Flagellate  body. 

42. — Vacuolization. 

PLATE   IL 
The  Parasite  of  ^stivo-autumn.\l  Fever. 

1,  2.— Small  rrfrartivc  ring-like  bodies. 

:i-6.— Larger  disklike  and  anielniiil  lurms. 

7.— Ring-likf  body  with  a  tVw  pignunt-granules  in  a  brassy,  shrunken  corpuscle. 

8,  H,  10,  12.— Similar  pigmented  bodies.  • 

11. — Ameboid  body  with  pigment. 

i:;.— Body  with  a  central  elnmp  of  pigment  in  a  corpuscle,  showing  a  retraction  of  the  hemo- 
globin-containing substance  about  the  i)arasit(\ 

14-20.— Larger  bodies  with  eentral  pigment  chimps  or  blocks. 

21-24.— Segmenting  bodies  fri>m  the  spleen.  Figs.  21-23  represent  one  bodv  where  the  entire 
process  of  segmentation  was  observed.  The  segments,  eighteen  in  number,  were  accuratelv 
counted  before  separation,  as  in  Fig.  23.  The  sudden  sei>aration  of  the  segments,  occurring  as 
though  some  retaining  membrane  were  ruptured,  was  observed. 

2:v;!:>.---freseents  and  ovoid  bodies.  Figs.  3(i  and  31  represent  one  bodv,  which  was  seen  to 
extrude  slowly,  and  later  to  withdraw,  two  rounded  protrusions. 

34,  35.— l{ound  bodies. 

36.—"  ffcmmation,"  fragmentation. 

37.— Vaeuoli/atiou  of  a  crescent. 

3R-4f>.— [nagollation.  The  figures  represent  one  organism.  The  blood  was  taken  from  the  ear 
at4.].5p  m  :  at  4.1/ the  body  was  as  represented  in  Fig.  :W.  At  4.27  the  flagella  appeared:  at  1.:;:^ 
two  of  the  flagella  had  alreadv  broken  away  from  the  mother  body 

■Jl^S.— Phagocytosis.    Traced  with  the  camera  Incida. 

c^    M}'^'^'  illustrations  are  reproduced  by  permission  from  the  article  bv  Drs.  Thayer  and  Hewet- 
son  in  The  Johns  Iloptinn  Hospital  Reports,  vol.  v.,  18!)o. 


The  Parasite  of  Tertian  Fever. 


Plate  I. 


i.% 


f'M  ->^.  /C^ 


^ 


^% 


The  Parasite  of  Quartan  Fever. 


35 


^ 


The  Parasite  of  Aestivo  Autumnal  Feven 

-^      3  -   4  -        5 


Plate  II. 


# 


4 


39 


^ 


c& 


<^ 


if"* 


%_^ 


ir-iv-.-- 


MALARIAL  FEVER.  83 

The   special  varieties  of  the   malarial   parasite  will  be  described  sepa- 
rately. 

(1)  The  Ameha  causing  Tertian  Intermittent  Fever. — This  begins 
its  cycle  of  evolution  in  the  red  blood-corpuscle  as  a  small  hyaline 
ameba.  Its  development  is  attended  with  the  appearance  in  its  inte- 
rior of  fine,  brown,  motile  granules  in  the  form  of  pigment,  and 
when  matured  it  about  equals  the  size  of  a  normal  red  corpuscle.  It 
now  assumes  a  spheric  form,  the  pigment  collecting  centrally,  and 
sporulation  into  fifteen  to  twenty  or  more  segments  follows.  The  tertian 
parasites  are  exceedingly  numerous  in  the  blood,  and  pass  through  the 
various  stages  of  their  life-cycle  almost  simultaneously,  the  sporulation 
of  an  entire  generation  occurring  within  the  space  of  a  few  hours 
(Golgi).  The  occurrence  of  the  malarial  paroxysm  follows  the  process 
of  sporulation,  which  is  attended,  most  probably,  with  the  development 
of  a  toxin,  and  the  symptoms  of  the  disease  may  be  attributable  chiefly 
to  the  effects  of  the  latter.  The  red  corpuscle  that  includes  the  parasite 
becomes  enlarged  and  decolorized  as  the  latter  develops.  The  parasite 
of  tertian  intermittent  runs  its  cycle  in  about  forty-eight  hours.  Hence 
infection  by  a  single  generation  would  result  in  sporulation  every  second 
day,  followed  by  the  malarial  paroxysm.  Quite  commonly,  infection  by 
two  groups  of  parasites  occurs  on  successive  days,  and,  since  each  has  a 
definite  period  of  evolution,  a  daily  malarial  paroxysm  is  the  result 
(quotidian  intermittent).  Multiple  infection  with  this  parasite  may 
occur,  but  with  great  rarity. 

(2)  The  Ameha  causing  Quartan  Fever. — This  cannot  be  distinguished 
from  the  tertian  parasite  at  the  beginning  of  its  brief  career,  b^t  later 
differences  are  clearly  perceptible.  Its  ameboid  movements  are  mare 
deliberate,  and  its  pigment-granules  are  coarser,  darker,  and  also  less 
motile  than  those  of  the  tertian  organisms.  Unlike  the  latter,  it  does 
not  attain  the  size  of  the  red  corpuscles,  and  during  sporulation  the  seg- 
ments (five  to  ten  in  number)  encircle  in  an  orderly  Avay  the  central 
pigment-mass  or  clump,  "rosettes  "  of  great  beauty  thus  being  formed. 
The  red  blood-corpuscle  that  harbors  the  quartan  parasite  contracts 
upon  its  destroyer,  appears  shrivelled,  and  its  color  changes  at  the  same 
time  from  the  normal  to  a  deep  greenish  or  bronzed  tint.  It  sporulates 
about  seventy-two  hours  after  it  enters  the  red  corpuscle ;  hence,  if  only 
one  group  of  parasites  be  present,  febrile  attacks  occur  every  fourth  day, 
forming  the  simple  quartan  intermittent.  On  the  other  hand,  double 
quartan  infection  results  in  paroxysms  on  two  successive  days,  followed 
by  an  intermission  lasting  one  day,  while  triple  infection,  or  the  presence 
of  three  groups,  causes  daily  paroxysms — the  quotidian  intermittent. 
Infection  by  more  than  three  groups  of  the  quartan  parasite  may  occur, 
but  is  very  rare. 

(3)  The  Ameha  causing  Fstwo-aiitumnal  Fevers. — The  cycle  of  this 
variety  is  evolved,  chiefly,  in  certain  of  the  internal  viscera,  and  the 
microscopic  examination  of  the  blood  in  the  various  stages  of  the  dis- 
ease does  not  give  a  positive  result,  as  in  the  tertian  and  quartan  types. 
The  organism  invades  the  red  blood-corpuscle,  but  to  Avhat  extent  is  not 
definitely  known.  It  is  a  quite  small  hyaline  body,  its  size  at  maturity 
scarcely  equalling  one-half  the  dimensions  of  the  red  corpuscle,  and  it 
accumulates  very  few  fine  pigment-granules.     The  parasite  is  not  to  be 


84  INFECTIOUS  DISEASES. 

found  in  the  later  stages,  except  in  the  blood  from  certain  internal  vis- 
cera, such  as  the  spleen,  bone-marrow,  etc.  After  the  condition  has 
lasted  a  week  or  more  characteristic  oval  and  crescentic  bodies,  which 
are  more  or  less  refractive,  may  be  observed  in  the  fresh  blood.  These 
so-called  "sickle-form  bodies"  shoAv  central  rods  and  clumps  of  coarse 
pigment,  and  are  especially  connected  Avith  this  category  of  malarial 
fevers.  The  red  corpuscle,  at  whose  expense  the  parasite  develops,  as- 
sumes a  brassy  hue.  frequently  becoming  shrivelled  and  sometimes  notched. 

The  time  occupied  by  the  life-cycle  of  this  parasite  is  not  definitely 
settled,  but  it  generally  varies  between  the  extremes  of  twenty-four  and 
forty-eight  hours.  In  one  of  my  own  cases  the  febrile  paroxysms  re- 
curred every  seventy-two  hours.  For  the  differences  in  the  period  of 
evolution  there  is  no  satisfactory  explanation.  The  transformation  of 
malarial  crescents  into  spheres  and  flagellate  bodies  occurs  in  the  mos- 
quito's stomach,  and  in  ordinary  blood-preparations  and  the  leech  (Ross). 

Cilice.,  or  flagelke,  exhibiting  active  motion,  may  grow  from  all  of  the 
before-mentioned  varieties,  and  not  infrequently  they  become  detached 
and  float  free  in  the  bloo<l-stream.  They  are  most  common  in  blood 
aspirated  from  the  spleen,  but  their  true  significance  is  not  known.  The 
ciliated  forms,  according  to  Manson,  probably  do  not  exist  in  the  blood 
inside  the  body,  but  develop  very  shortly  after  it  is  drawn,  especially  in 
the  estivo-autumnal  type.  Usually  the  presence  of  the  cilia  is  only  indi- 
cated by  occasional  oscillatory  movements  of  the  red  blood-cells  sur- 
rounding the  j^arasite. 

Mode  of  Infection. — The  exact  manner  in  which  the  human  subject  is 
infected  with  the  malarial  parasite  is  not  understood.  It  is  in  no  sense 
a  contagious  disease.  Infection  is  probably  not  direct  from  person  to 
person,  but  the  plasmodium  has  an  extra-corporeal  cycle  in  certain 
species  of  the  mosquito.  Bignami's  and  Bastianelli's  results  allow 
them  to  conclude  that  "the  'genus'  of  mosquito,  anopheles  claviger, 
may  be  made  to  bite  a  subject  suff"ering  from  malarial  fever,  and  then, 
if  kept  at  the  proper  temperature  (30°  C.)  for  the  number  of  days  req- 
uisite for  the  development  of  the  sporozoites,  may  inoculate  healthy 
patients  by  this  bite.  These  patients  will  develop  malaria,  usually 
Avithin  a  certain  time,  the  parasite  being  the  same  as  Avas  present  in  the 
first  instance."  Bignami  believes  that  inoculation  is  the  mode  by  which 
infection  is  usually  acquired.  The  poison  jirohahly  also  eyiters  the 
system  through  the  medium  of  inhalation,  but  not,  perhaps,  through 
the  digestive  tract. 

Immunity. — Persons  who  have  had  malaria  are  more  liable  to  fresh 
attacks  than  before. 

Incubation. — The  period  of  incubation  varies  in  different  cases  and 
according  to  the  different  clinical  types.  Thus  it  is,  on  the  Avhole, 
briefer  in  the  remittent  tlian  in  the  intermittent  forms  of  malarial  dis- 
ease, the  time  usually  ranging  from  five  to  twenty  or  more  days. 

(I.)  Intermittent  Fever. — Symptoms. — The  clinical  history  pre- 
sents itself  under  two  heads :  {a)  the  paroxysms,  and  {h)  the  manner 
in  which  the  paroxysms  recur. 

{a)  The  Paroxijsms. — There  may  be  premonitions  lasting  from  one  to 
several  davs,  and  most  significant,  yet  not  distinctive,  are  headache, 
pain  in  the  nape  of  the  neck,  yaAvning,  a  yelloAvish  complexion,  and  a 
slight  splenic  enlargement.     In  a  large  proportion  of  the  cases,  how- 


MALARIAL  FEVER. 


85 


ever,  the  onset  is  abrupt.  Typical  paroxysms  present  three  stages — 
chill,  fever,  and  stveating.  The  chill  is  intense,  causing  shivering,  and 
often  chattering  of  the  teeth.  Malaise  is  marked,  the  skin  is  cool  and 
pale,  face  slightly  cyanotic,  and  limbs  painful.  This  stage  usually  occurs 
in  the  morning  hours,  though  the  time  of  onset  is  by  no  means  constant ; 
its  duration,  also,  varies  greatly,  generally  lasting  from  one  to  t^vo  hours. 
The  internal  temperature  rises  rapidly;  the  pulse  is  small,  rapid,  and  of 
high  tension. 

The  hot  stage  succeeds  the  chill,  and,  in  striking  contrast  T\ith  the 
first  stage,  the  face  wears  a  decided  flush  and  the  skin  is  burning  hot  to 


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Fig.  11.— Temperature-curve  in  a  case  of  double  tertian  fever.    C.  F.  C,  aged  forty-one  years. 

the  touch.  The  temperature  continues  to  rise,  but  not  so  rapidly  as  in 
the  first  stage.  Its  maximum  level,  usually  from  104°  to  106°  F.  (40° 
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ture be  recorded  frequently  i  Fig.  11).      The  pulse  is  full  and  bounding, 


86 


INFECTIOUS  DISEASES. 


except  in  the  rare  instances  in  Avhich  acute  dilatation  of  the  heart  en- 
sues, when  it  is  quite  feeble  and  sometimes  irregular.  The  length  of  the 
second  stage  exceeds  that  of  the  first,  being  from  three  to  six  hours. 
The  temperature  generally  begins  to  decline  before  the  close  of  the 
febrile  stage. 

AVhen  siveating,  Avhich  soon  becomes  profuse,  sets  in,  the  symptoms 
of  the  hot  stage  are  promptly  relieved.  The  temperature  falls  by  crisis, 
touching  the  normal  level  in  a  few  hours ;  the  decline,  however,  is  less 
rapid  than  the  rise  at  the  beginning  of  the  paroxysm.  The  fall  may  be 
unbroken  by  any  fresh  elevations  of  temperature,  though  more  often  the 
latter  occur,  and  less  frequently  defervescence  occurs  by  steps,  the  tem- 
perature dropping  one  or  more  degrees,  and  remaining  at  the  new  level 
for  a  short  period  (Fig.  12).     It  again  drops  about  an  equal  distance, 


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and  so  on  until  the  normal  is  reached.  Usually,  following  the  parox- 
ysm, the  temperature  becomes  subnormal  (about  97°  F..;  36°  C).  The 
length  of  the  typical  malarial  paroxysm  ranges,  in  all  save  exceptional 
instances,  from  eight  to  twelve  hours. 

(5)  The  Manner  in  lohich  the  Paroxysms  Recur. — The  special  cha- 
racteristic of  this  form  of  intermittent  is  the  regularity  with  which  the 
paroxysms  recur  in  cases  that  are  not  under  treatment.  The  intermis- 
sion, or  time  between  two  successive  paroxysms,  is  most  frequently 
twenty-four  hours  (quotidian  intermittent  fever) ;  almost  as  often  it  is 
forty-eight  hours  (tertian  intermittent) ;  and  less  frequently  it  is  sev- 
enty-two hours  (quartan  intermittent).  If  there  be  two  paroxysms  on 
one  day — a  rare  occurrence — the  term  "double  quotidian"  is  used  to 
designate  the  case.  Of  the  above  types,  as  stated  in  the  life-history  of 
the  parasite,  two  only — the  tertian  and  the  quartan — have  been  clearly 


MALABIAL  FEVER.  87 

distinguished.  The  quotidian  ague  (the  most  frequent  clinical  variety) 
is  generally  due  to  double  infection  by  the  tertian  parasite,  and  very 
rarely  is  it  to  be  attributed  to  the  presence  in  the  blood  of  three  groups 
of  the  quartan  parasite,  resulting  in  daily  sporulation.  It  sometimes 
happens  that  the  paroxysms  recur  a  couple  of  hours  later  each  succes- 
sive day,  when  it  is  called  a  '■'retarding''  intermittent  fever,  or  they 
may  recur  a  little  earlier,  when  the  term  '■'■anticipating"  is  employed. 

Other  3Iore  or  Less  Gliaracteristie  Symptoms. — Apart  from  the  par- 
oxysms and  the  regularity  with  which  they  recur,  splenic  enlargement  is 
almost  always  present,  and  hence  is  of  considerable  clinical  import. 
After  the  first  paroxysm  or  two  the  swelling  is  usually  marked  and 
demonstrable,  especially  by  palpation.  The  organ  can  be  shown  to  in- 
crease in  size  with  each  succeeding  paroxysm.  Tenderness  is  elicited 
on  pressure,  and  commonly  outlasts  the  course  of  the  affection  for  a  con- 
siderable length  of  time.  Moderate  enlargement  of  the  liver  may  be 
present,  but  this  is  neither  so  significant  nor  so  constant  as  enlargement 
of  the  spleen. 

Connected  with  the  skin  are  two  symptoms  of  considerable  diagnostic 
value :  (1)  a  yellowish-hroivn  discoloration^  the  so-called  "  malarial  com- 
plexion," due  to  the  deposition  of  pigment;  and  (2)  herpes.  The  latter 
occurs  usually  on  the  prolabia  or  on  the  nose,  though  rarely  elsewhere. 
Other  skin-eruptions,  as  urticaria,  purpura,  etc.,  have  been  described  by 
authors,  but  they  have  no  real  clinical  worth. 

As  stated  under  Pathology,  acute  dilatation  of  the  heart  may  develop, 
attended  Avith  the  usual  physical  signs  of  this  condition,  but  it  rarely  lasts 
longer  than  the  brief  febrile  paroxysm.  Murmurs  of  functional  origin 
may  also  be  heard  in  the  heart  during  the  attack,  and  the  lungs  upon 
auscultation  sometimes  present  the  signs  of  a  dry  bronchitis. 

The  urine  may  contain  a  small  amount  of  albumin,  and  rarely  there 
is  acute  nephritis.  There  is  a  temporary  increase  in  the  amount  of  urea 
eliminated,  and  this  may  be  observed  from  two  to  six  or  eight  hours  be- 
fore the  chill,  so  that  an  approaching  paroxysm  can  be  foretold  if  a 
quantitative  analysis  of  the  urine  be  made  at  the  proper  time  (Jaccoud). 

Gastro-intestinal  symptoms  may  be  present,  but  are  not  prominent, 
if  we  except  a  diarrhea  which  is  sometimes  considerable.  Catarrhal 
jaundice  may  be  observed,  but  this  is  limited  to  the  graver  forms  of 
intermittent. 

There  is  no  leukocytosis,  but  there  is  a  rapid  diminution  in  the  num- 
ber of  both  red  and  white  corpuscles,  proportionate  "to  the  severity  and 
the  number  of  the  attacks  "  (W.  W.  Johnston). 

Clinical  Varieties. — Besides  the  typical  attacks,  mild  or  rudimentary 
forms  are  met  with,  these  either  being  due  to  slight  infection  or  appear- 
ing as  the  remnant  of  cases  of  usual  severity  after  active  treatment. 
The  separate  stages  of  the  febrile  attacks  are  not  well  marked,  and  one 
or  more  may  be  missing ;  thus  the  chill  may  be  absent  (dumb  ague), 
and  less  frequently  the  sweating  stage  may  fail  to  appear. 

In  children  there  is  no  rigor  noticeable.  They  grow  pale,  the  vis- 
ible mucous  membranes  often  being  slightly  livid  during  the  chill,  and 
the  paroxysms  may  be  initiated  by  a  convulsion  or  by  other  nervous 
phenomena. 

(II.)  Pernicious  Malarial  Intermittent. — This  truly  serious  form 


88  INFECTIOUS  DISEASES. 

occurs  chiefly  in  highly  malarial  districts,  and  rarely  also  in  the  wide- 
spread regions  in  Avhich  the  simple  variety  prevails.  Hence  in  the  United 
States  it  is  encountered  most  frequently  in  the  Southern  and  Southwest- 
ern States.  In  this  form  of  malaria  the  parasites  of  estivo-autumnal 
fever  are  constantly  associated.  The  paroxysms  do  not  recur  with  strict 
regularity,  and  the  primary  paroxysms  are  rarely  pernicious  in  charac- 
ter ;  but  second  or  subsequent  attacks  may,  in  addition  to  the  usual 
symptoms,   present  the  gravest  phenomena. 

Pathology. — This  type  of  malaria  may  arise  (1)  as  a  fresh  infection, 
and  (2)  as  a  reinfection. 

(1)  Infection. — The  blood  is  more  or  less  hydremic,  and  the  blood- 
disks  are  in  all  stages  of  disintegration.  The  spleen  is  considerably 
swollen,  soft,  and  its  parenchyma  is  turbid  and  lake-colored,  all  its 
tissue  elements  being  more  than  naturally  pigmented,  though  this  may 
not  be  macroscopically  appreciable.  Upon  microscopic  examination, 
however,  pigment-granules  and  red  corpuscles  containing  parasites  and 
phagocytes  are  observed,  particularly  in  the  pulp  adjacent  to  the  arte- 
rioles. The  liver  is  enlarged,  soft,  and  turbid,  and  pigmentation  occurs, 
but  it  is  also  microscopic.  In  the  minute  vessels  phagocytes  and  para- 
sites containing  pigment  are  perceptible  within  the  red  corpuscles,  and 
numerous  small  necrotic  areas  have  been  observed.  The  hidneys  show 
microscopic  pigmentation,  most  marked  in  the  vicinity  of  its  blood-sup- 
ply. Minute  areas  of  cell-death  are  sometimes  seen.  The  brain  may 
be  abnormally  colored,  assuming  in  severe  cases  a  chocolate  tint,  and 
in  mild  types  a  lighter  hue.  The  brain-tissue  is  often  anemic,  and 
more  rarely  edematous.  Occasionally  there  is  congestion.  The  minute 
vessels  and  capillaries  are  literally  blocked  with  phagocytes  and  blood- 
disks  more  or  less  disintegrated  (containing  parasites),  and  perivascular 
infiltration  and  minute  hemorrhages  may  rarely  occur,  producing  a  focal 
lesion. 

(2)  Reinfection. — The  blood  is  often  extremely  hydremic.  The  spleen 
may  or  may  not  be  much  enlarged,  and  is  usually  quite  firm,  with  a 
well-marked  pigmentation  that  is  obvious  to  the  naked  eye.  The  liver 
is,  as  a  rule,  increased  in  size  to  a  moderate  extent  only,  and  is  some- 
what indurated,  while  macroscopically  it  is  seen  to  be  deeply  pigmented. 
The  changes  presented  by  the  kidneys  differ  in  no  essential  manner  from 
those  of  the  liver.  The  microscopic  a))pearances  of  the  liver,  spleen, 
and  kidneys,  apart  from  the  fact  that  the  amount  of  pigment  present  is 
relatively  greater,  are  entirely  analogous  to  those  met  Avith  when  a  fresh 
infection  occurs. 

Clinical  Varieties. — Three  varieties  merit  description : 
(a)  Congestive  Chills  {Algid  Form). — These  are  accompanied  by 
raging  gastro-intestinal  symptoms  (vomiting,  purging,  etc.),  inducing 
systemic  collapse,  which  simulates  to  a  nicety  the  algid  stage  of  cholera. 
The  temperature  of  the  interior  of  the  body  is  much  elevated.  True 
dysenteric  symptoms  may  arise,  and  in  a  certain  proportion  of  the  cases 
jaundice,  followed  by  grave  nervous  symptoms,  may  be  a  secondary 
development.  This  condition  is  to  be  discriminated  from  yellow  fever, 
with  which  it  has  frequently  been  confounded.  The  parasites  in  this 
aflfection  center  in  a  special  manner  in  the  gastro-intestinal  mucosa,  in 
the  vessels  of  which  they  may  be  seen  in  unusual  numbers,  sometimes 


MALARIAL  FEVER.  89 

forming  distinct  thrombi.     In  the  United  States  this  is  the  most  com- 
mon among  the  pernicious  forms. 

(b)  Hematuric  Pernicious  Malaria. — In  this  form  the  chill  is  severe 
and  prolonged,  and  during  the  hot  stage  the  urine  is  bloody  and  scanty, 
containing  considerable  albumin,  with  bloody,  epithelial  and  granular 
casts.  Hemorrhages  from  other  outlets  of  the  body  (mouth,  rectum, 
vagina,  nares,  etc.)  may  also  occur,  together  with  larger  and  smaller 
cutaneous  ecchymoses,  and  the  yellowish-brown  malarial  complexion  is 
intensified.  The  mind  may  remain  clear  throughout,  although  the 
patient  is  restless  and  anxious.  Urinary  suppression  may  ensue,  and 
uremic  toxemia  be  superadded ;  the  greatest  dangers  being  cardiac  fail- 
ure, uremia,  and  delirium  (or  coma  independently  of  the  latter).  Death 
is  rarely  the  direct  consequence  of  excessive  loss  of  blood. 

(c)  Comatose  Form. — The  chill  may  be  absent.  Grave  cerebral 
symptoms,  as  acute  delirium  or  sudden  coma,  seize  the  patient  violently. 
The  hot  stage  is  attended  with  high  fever,  and  if  the  patient  survives 
the  paroxysm,  the  violent  nervous  symptoms  either  disappear  suddenly 
with  the  appearance  of  the  sweating  stage,  or  may  outlast  the  latter  by 
several  hours.  Primary  paroxysms  rarely  prove  fatal,  but  recurrences 
bring  imminent  danger.  This  dangerous  variety  is  due  to  an  inordinate 
localization  of  the  malarial  parasites  in  the  brain,  where  they  form  com- 
plete thrombi,  and  induce,  as  a  consequence,  pathologic  lesions  in  the 
adjacent   structures. 

(III.)  Remittent  or  Continued  Malarial  Fevers  (Bstivo- 
autumnal  Fever). — On  account  of  the  intensity  of  the  gastro-intes- 
tinal  symptoms  this  variety  is  also  termed  bilious  remittent  fever.  Its 
severity  exceeds  that  of  intermittent  malarial  fever.  It  prevails  for  the 
great  part  in  warm  and  truly  tropical  climates,  though  it  is  also  seen  in 
its  milder  forms  in  temperate  climates.  The  estivo-autumnal  parasites 
previously  described  are  the  specific  cause  of  the  disease. 

Pathology. — Melanosis  of  the  spleen,  liver,  and  brain  is  generally- 
observed;  on  the  other  hand,  in  rare  instances  in  which  the  specific 
parasite  had  even  been  demonstrated  during  life,  the  internal  organs 
were  found  to  be  non-pigmented  on  autopsy.  The  degree  of  the  pig- 
mentation depends  upon  the  length  of  time  that  the  patient  has  been 
infected,  as  well  as  upon  the  frequency  of  reinfection.  The  spleen,  if 
it  be  a  fresh  infection,  becomes  swollen,  but  is  soft ;  in  protracted  cases 
it  become  permanently  enlarged  and  firm.  On  microscopic  examination 
the  pigment  is  seen  to  be  most  abundant  in  the  splenic  pulp  and  within 
and  around  the  splenic  veins.  The  liver  is  enlarged  in  like  manner. 
The  pigment  that  is  found  in  the  form  of  granular  masses  in  all  the 
hepatic  tissue  elements  (especially  Kupfi"er's  cells,  vessels,  vessel-walls, 
and  perivascular  tissue)  gives  to  the  organ  a  bronzed  appearance 
("bronze  liver  "). 

As  in  pernicious  malaria,  so  in  this  aifection,  the  brain,  and  particu- 
larly the  gray  matter,  is  in  long-standing  cases  of  a  dark  brown  or 
almost  black  color.  Here,  again,  most  of  the  pigment  is  in  and  around 
the  arterioles.  The  latter  are  often  found  stufi'ed  with  phagocytes  and 
blood-disks  which  contain  pigmented  parasites.  Punctate  hemorrhages 
may  occur  in  the  brain.  Other  organs  and  tissues  of  the  body,  includ- 
ing the  lymphatic  glands  and  the  skin,  become  more  or  less  deeply  pig- 


90  INFECTIOUS  DISEASES. 

mented.  The  blood  shows  marked  hydremia,  with  partly  or  wholly  de- 
generated red  blood-disks  in  abundance. 

Symptoms. — There  may  be  prodro7nal  symptoms,  such  as  headache, 
anorexia,  and  epigastric  oppression,  lasting  a  day  or  two,  but  these  signs 
are  variable.  There  may  be  daily  or  bi-daily  paroxysms  of  fever  which 
resemble  the  ordinary  quotidian  and  tertian  intermittent  forms,  with  this 
difference,  however,  that  the  febrile  paroxysms  are  of  longer  duration 
(twenty  hours  or  more).  Both  the  rise  at  the  onset  and  the  decline  at 
the  end  of  the  paroxysm  are  more  gradual  than  in  true  intermittent 
malarial  fever,  and  the  initial  chill  may  even  be  wholly  absent.  The 
febrile  attacks  ai-e  often  "anticipating."  so  that  it  may  happen  that  the 
succeeding  paroxysm  will  begin  before  the  elevated  temperature  of  the 
preceding  touches  the  normal  level,  giving  rise  to  a  remittent  type  of 
fever  which  often  exhibits  considerable  irregularity.  The  remissions 
may  become  shorter  and  shorter,  producing  finally  a  continued  type  of 
curve — continued  malarial  fever. 

In  typical  cases  of  remittent  fever  a  chill  generally  occurs  at  the  on- 
set, but  is  less  severe  than  in  malarial  intermittents.  Shortly  after  the 
chill  the  temperature  rises  rapidly,  so  that  in  ten  or  twelve  hours  it  mav 
reach  104°  or  105°  F.  (40.5°  C).  The  pulse  is  full  and  accelerated  to 
100  or  120,  and  there  is  rending  headache.  Nausea  and  vomiting  are 
common ;  oppression  in  the  epigastrium  is  intense,  and  there  is  well- 
marked  tenderness  in  the  latter  region.  The  spleen  is  found  to  be  en- 
larged on  palpation.  Nervous  stimptoms  (delirium,  coma,  etc.)  may 
develop  speedily,  and  rarely  a  mild  bronchitis  may  also  arise. 

About  midnight  the  remission  in  the  temperature  and  sweating 
begin,  in  consequence  of  which  the  headache  and  gastric  symptoms 
largely  disappear.  The  temperature  usually  drops  to  100°  F.  (37.7° 
C.)  by  the  next  morning,  to  be  followed  by  a  new  exacerbation  of  fever, 
which  commences  about  noon  of  the  second  day.  The  same  symptoms 
now  repeat  themselves.  The  affection  has  usually,  by  this  time,  reached 
its  acme,  and  the  temperature  may  have  risen  to  106°  F.  (41.1°  C). 
Grave  nervous  symptoms  may  also  have  appeared.  The  urine  is  dimin- 
ished in  amount,  often  slightly  albuminous,  and  acute  nephritis  is  ob- 
served in  4.7  per  cent,  of  the  cases  (Thayer);  while  either  a  slight  or 
marked  hepatogenous  jaundice  may  appear.  Herpes  lahialis  is  (juite 
common.  The  nocturnal  remission  again  ensues,  and  in  the  mild  types 
or  in  those  brought  promptly  under  suitable  treatment  the  febrile  parox- 
3'sms  grow  briefer,  resulting  in  an  intermittent  form  of  fever.  The  course 
of  light  cases  is  run,  usually,  within  two  weeks. 

In  severe  types  or  in  neglected  cases  the  separate  febrile  paroxysms 
grow  longer  until  the  remissions  become  slight  and  simulate  continued 
fevers.  These  are  the  cases  that  are  distinguished  by  the  same  symp- 
toms as  those  that  mark  typhoid  fever,  save  the  eru])tion  which  is  pecu- 
liar to  the  latter.  The  discovery  of  Laveran  is  of  the  highest  practical 
value  in  this  category  of  cases.  The  course  of  the  attack,  if  not  pi'op- 
erly  treated,  generally  prolongs  itself  to  three,  four,  or  more  weeks,  and 
under  these  circumstances  the  salient  features  of  pernicious  intermittent 
may  suddenly  appear  and  the  disease  may  terminate  life.  On  the  other 
hand,  mild  forms,  in  which  the  fever  is  of  the  continued  type,  also 
occur,  and  these  yield  promptly  to  the  specific — quinin. 


MA  LABIAL  FEVER.  91 

(ly.)  Malarial  Cachexia. — This  is  an  exceedingly  chronic  condi- 
tion, and  is  usuall}^  a  remnant  of  one  of  the  acute  forms,  particularly  of 
the  ordinary  intermittents.  When  the  latter  are  not  properly  treated, 
they  are  apt  to  drag  on,  and  finally  assume  the  characteristic  features 
of  chronic  malarial  cachexia.  The  condition  may,  however,  develop  in 
truly  malarial  localities  without  the  intervention  of  primary  acute  mala- 
ria.    It  originates,  however,  only  in  truly  malarial  districts. 

The  symptoms  are  varied  both  in  character  and  in  intensity.  There 
is  fever  at  intervals,  but  chills  do  not  occur,  and  the  temperature-curve 
is  typical  neither  of  remittent  nor  intermittent  fever,  but  may  approxi- 
mate either  the  one  or  the  other.  Again,  the  fever  is  sometimes  w^holly 
irregular,  though  its  range  is  not  high,  and  it  seldom  excels  103°  F. 
(39.4°  C).  The  skin  often  presents  the  dirty  yellowish-brown  com- 
plexion to  a  marked  degree.  The  spleen  is  enormously  enlarged  and 
indurated,  and  hypertrophy  with  hardening  of  the  liver  may  also  be 
pronounced.  The  blood  is  profoundly  anemic,  the  count  in  one  of  my 
own  cases  showing  but  1,300,000  red  corpuscles  per  cubic  millimeter. 

Many  of  the  local  and  general  symptoms  that  remain  to  be  given 
(including,  in  part,  the  fever)  are  chiefly  dependent  upon  the  Avell- 
marked  anemia.  Among  general  features  may  be  mentioned  debility, 
frequent  sweatings,  and  dropsy.  Nervous  symptoms  may  also  be  notice- 
able, and  chief  among  these  are  tremors,  neuralgia,  palsies,  vertigo, 
wakefulness,  and  nervous  palpitation  of  the  heart.  Among  the  rarest 
concomitants  of  this  condition  is  paraplegia.  Slight  cough  and  dys- 
pnea evidence  the  presence  of  mild  hroyicJiitis ;  and  anorexia,  nausea, 
diarrhea,  and  other  symptoms  mark  the  presence  of  chronic  gastro- 
intestinal catarrh.  The  joints  and  voluntary  muscles  may  be  painful. 
Hemorrhages  from  the  various  mucous  surfaces  and  into  the  retina  are 
common ;  and  I  have  seen  one  case  in  which  spongy,  easily-bleeding 
gums,  with  cutaneous  ecchymoses  and  numerous  petechias,  pointed  to 
the  existence  of  associated  scorbutus.  Tuberculosis  finally  developed 
and  carried  off  the  patient.  Not  only  the  latter  affection,  but  also 
chronic  dysentery.,  chronic  Bright's  disease.,  and  amyloid  disease,  may 
develop  and  prove  serious"  complications.  These  cases  do  well,  gener- 
ally, if  the  patient  can  be  removed  permanently  from  the  malarial 
district  and  if  proper  treatment  be  persistently  pursued.  In  long- 
standing cases  the  spleen  does  not  return  to  its  natural  dimensions.  In 
all  other  instances,  however,  complete  recovery  may  be  expected,  though 
it  may  require  months  or  even  years  to  bring  it  about. 

(V.)  Masked  Intermittent. — This  presents  itself  in  much  the  same 
forms  as  chronic  malarial  cachexia,  but  with  the  important  difference  that 
there  is  no  fever.  This  type  comprises  a  long  list  of  conditions,  at  the 
head  of  which  stands  neuralgia,  most  frequently  involving  the  supraor- 
bital branch  of  the  trigeminus.  Often  a  striking  periodicity  is  observed, 
the  painful  paroxysms  usually  beginning  in  the  morning  and  terminating 
in  the  late  afternoon  hours,  the  patient's  sufferings  increasing  steadily 
in  intensity  until  just  before  the  close  of  the  attack,  when  they  sud- 
denly abate.  Among  other  nerves  implicated  wdth  relative  frequency 
are  the  occipital,  the  intercostals,  and  the  sciatic.  Except  the  blood- 
appearances  be  chai-acteristic  or  unless  the  attacks  yield  promptly  to 
quinin,  a  certain  diagnosis  of  malarial  neuralgia  should  not  be  ventured. 


92  INFECTIOUS  DISEASES. 

Masked  intermittents  may  assume  the  forms  of  paresthesia,  anesthesia, 
convulsions,  or  paralysis ;  non-febrile  intermittent  malaria  may  also 
appear  under  the  guise  of  edema,  hemorrhages  from  the  various  mucous 
outlets  of  the  body  or  into  the  skin,  intestinal  flux  (diarrhea,  dysentery), 
dyspepsia,  etc.  But,  since  these  affections  may  all  obey  the  law  of 
periodicity,  caution  should  be  used  in  pronouncing  in  favor  of  malarial 
infection.  Indeed,  unless  they  yield  readily  to  the  therapeutic  specific, 
a  positive  statement  had  better  be  withheld. 

(VI.)  Malarial  Hematuria  and  Hemoglobinuria. — I  have  pre- 
viously described  a  hemorrhagic  form  of  pernicious  intermittent  in  many 
cases  of  which  hematuria  is  a  prominent  symptom.  Among  other  gen- 
eral features  are  jaundice,  prostration,  nervous  symptoms,  and  nephritis 
(Plehn).  The  blood  shows  pigmented  parasites  (forming  rosettes)  and 
sometimes  crescents  and  pigmented  leukocytes. 

Boisson  ^  in  3  cases  of  hemoglobinuric  fever,  occurring  in  soldiers 
attacked  with  malaria  in  Madagascar,  found  an  enormous  reduction  in 
the  red  corpuscles,  reaching  670,000  in  1  case,  while  7  out  of  10  red 
cells  contained  parasites.  I  have  observed  several  instances  of  malarial 
hematuria  in  the  Kensington  district  of  Philadelphia,  and  find  that 
they  are  met  with  wherever  the  moderate  forms  of  malaria  prevail. 

The  symptoms  consist  of  a  mild  cold  stage,  a  subfebrile  temperature 
to  which  is  added  hematuria,  or  more  often  hemoglobinuria.  The  par- 
oxysms may  recur  daily,  bi-daily,  or  at  longer  intervals,  and  in  severe 
forms  the  hemoglobinuria  may  be  continuous,  with  aggravations  at  def- 
inite intervals.  The  diagnosu  demands  the  demonstration  of  the  ma- 
larial parasites  in  the  blood,  and  of  the  hemoglobin  in  the  urine.  Tyson 
recommends  Teichmann's  (hemin  crystals)  test  to  show  the  presence  of 
hemoglobin.  The  earthy  phosphates  are  precipitated,  filtered  out,  and 
a  small  portion  placed  on  a  glass  slide  and  carefully  warmed  until  com- 
pletely dry.  A  minute  granule  of  common  salt  is  carried  on  the  point 
of  a  knife  to  the  dried  mass  and  thoroughly  mixed  Avith  it.  Any  excess 
of  salt  is  then  removed,  the  mixture  is  covered  with  a  thin  glass  cover,  a 
hair  interposed,  and  a  drop  or  two  of  glacial  acetic  acid  allowed  to  pass 
under.  The  slide  is  then  carefully  warmed  until  bubbles  begin  to  make 
their  appearance.  After  cooling,  hemin  crystals  can  be  seen  by  the  aid 
of  the  microscope,  and,  though  often  very  small  and  incompletely  crystal- 
lized, are  easily  recognizable  by  an  amplification  of  300  diameters. 
Chemically  thoy  are  hydrochlorate  of  hematin. 

Complications. — The  author's  analysis  of  1780  cases  of  malaria 
showed  complications  in  about  10  per  cent.  The  more  common  among 
these  were  not  particularly  grave  in  nature,  as  may  be  seen  by  a  glance 
at  the  subjoined  list,  in  which  they  are  placed  in  the  order  of  frequency 
of  occurrence :  Enteritis  (16),  nephritis  (14),  rheumatism  (10),  typhoid 
fever  (8),  lobar  pneumonia  (5),  jaundice  (5),  and  dysentery  (4).  The 
opinion  of  the  profession  is,  and  long  has  been,  divided  upon  the  ques- 
tion, "Has  pneumonia  any  special  connection  with  malaria?"  but,  ac- 
cording to  the  results  of  my  own  collective  investigations,  lobar  pneu- 
monia cannot  be  regarded  as  being  frequently  in  association  with  the 
latter  disease.  That  it  is  so  rarely,  however,  cannot  be  denied,  since 
the  diagnosis  in  two  of  the  cases  was  confirmed  by  autopsy. 

^Rev.  de  Med.,  May  10,  1896. 


MALAETAL  FEVER.  93 

Typhoid  fever  is  a  complication  of  malaria,  according  to  these  re- 
searches, but  the  relationship  between  these  two  leading  affections  can- 
not be  close. 

Diagfnosis. — (1)  Of  Intermittents. — This  is  quite  difficult,  unless 
the  brief  febrile  paroxysms,  with  their  characteristic  stages  and  other 
more  or  less  diagnostic  features  (enlarged  spleen,  malarial  complexion, 
and  herpes),  together  with  the  rigid  periodicity  of  the  paroxysms,  be 
present.  The  diagnosis  is  assisted  by  a  knowledge  of  the  fact  that  the 
patient  resides  in  a  malarial  district.  In  cases  in  Avhich  a  microscopic 
examination  of  the  blood  cannot  be  made  early  a  positive  diagnosis  is 
rarely  possible  until  after  the  patient  has  been  observed  long  enough 
to  ascertain  the  manner  in  which  the  paroxysms  recur,  in  addition  to 
noting  the  symptoms  presented.  The  only  unquestionable  method  of 
diagnosis  is  by  means  of  a  microscopic  examination  of  the  blood,  which 
will  show  the  tertian  or  quartan  parasite  [vide  infi'o). 

Differential  Diagnosis. — Non-malarial  affections,  exhibiting  an  inter- 
mittent form  of  fever,  are  often  mistaken  for  malarial  intermittents.  Of 
these  (a)  pyemia  is  very  apt  to  be  thus  confounded,  owing  to  the  fact 
that  it  may  present  a  similar  temperature-range.  It  will  be  observed, 
however,  that  the  chills  recur  at  more  irregular  intervals,  and  in  this 
disease  the  more  profound  prostration  and  other  general  features  during 
the  intervals  between  the  febrile  exacerbations  serve  to  distinguish  it 
from  intermittent  malarial  fevers.  The  etiologic  factors  and  place  of 
residence  are  also  to  be  considered.  In  doubtful  instances  every  effort 
should  be  made  to  examine  the  blood  microscopically,  and,  if  this  be  im- 
possible, the  therapeutic  test  will,  as  a  rule,  remove  the  doubt.  Leu- 
kocytosis is  common  in  pyemia  and  absent  in  malaria. 

(b)  Acute  tuberculosis  and,  more  rarely,  incipient  chronic  tuberculosis 
may  present  a  febrile  movement  in  no  way  differing  from  quotidian 
intermittent,  except  that  in  the  former  the  pyrexia  develops  in  the  after- 
noon, instead  of  the  forenoon,  as  in  the  latter.  A  clear  history,  the 
associated  local  and  general  symptoms,  along  with  the  results  of  a  care- 
ful physical  examination,  usually  render  tuberculosis  probable  and  dis- 
tinguish it  from  malarial  intermittents.  Leukocytosis  is  common  in 
tuberculosis  and  is  absent  in  malaria,  while  in  tuberculosis  the  chills 
recur  despite  the  use  of  quinin,  and  this  is  not  the  case  in  malaria. 

(c)  Ulcerative  endocarditis  may  exhibit  an  intermittent  pyrexia,  but 
in  this  affection  the  history  is  different,  and  the  associated  clinical  fea- 
tures are  more  numerous  and,  as  a  rule,  decidedly  more  grave.  In  en- 
deavoring to  eliminate  a  disease  of  so  serious  a  character  as  ulcerative 
endocarditis,  when  the  symptoms  are  strongly  suspicious  of  the  latter  a 
blood-examination  should  be  made  without  delay.  The  irregular  forms 
of  intermittents  are  difficult  in  the  extreme  to  diagnosticate.  If,  in  sus- 
pected  cases  of  "  erratic  "  malaria,  quinin  is  resisted,  we  cannot  feel  cer- 
tain of  our  diagnosis  unless  we  obtain  the  microscopic  evidence  of  the 
presence  of  the  malarial  parasite  in  the  blood. 

(2)  The  diagnosis  of  remittent  fever  would  be  easily  made  if  it  did  not 
sometimes  bear  a  strong  resemblance  to  typhoid  fever.  On  account  of 
this  fact  its  certain  diagnosis  demands  the  detection  in  the  blood  of  the 
estivo-autumnal  parasite.  This,  at  first,  is  a  small  hyaline,  motile  body 
with  little  pigment,  but  in  cases  lasting  a  week  or  more  assumes  the  oval 


94  INFECTIOUS  DISEASES. 

or  crescentic  shape  with  much  pigment.  In  typhoid  fever  the  history 
points  to  a  more  gradual  onset,  the  remissions  are  less  marked,  and  there 
is  not  the  epigastric  oppression  witnessed  in  remittent  fever.  Again, 
typhoid  has  its  characteristic  eruption.  Remittent  fever  must  not  be 
confounded  Avith  typho-malaria,  nor  with  continued  thermic  fever 
(Guiteras). 

Method  of  Examining  the  Blood  for  the  Malarial  Parasite. — The 
finger  or  lobe  of  the  ear  is  carefully  cleansed,  and  then  slightly  cut 
with  a  sharp  lancet.  The  first  drop  of  blood  is  wiped  away  and  the  sec- 
ond collected  on  the  center  of  a  clean  cover-glass,  which  is  immediately 
placed  upon  a  clean  slide  and  the  blood  alloAved  to  spread  in  a  thin  film. 
The  examination  should  be  made  with  an  oil-immersion  objective.  If 
desirable  to  preserve  the  specimen  or  if  impossible  to  make  the  micro- 
scopic examination  at  once,  smears  should  be  prepared  by  laying  another 
cover  upon  the  first,  allowing  the  blood  to  spread  in  a  thin  layer,  and 
then  sliding  them  apart  quickly  and  drying  in  the  air.  The  specimen 
may  then  be  fixed  in  a  mixture  of  equal  parts  of  alcohol  and  ether, by 
heat  or  one  of  the  other  usual  methods.  The  most  satisfactory  stain  is 
methylene  blue.  A  few  drops  of  a  watery  solution  should  be  placed 
upon  the  cover-glass,  allowed  to  remain  about  a  minute,  and  washed  off 
Avith  clean  water.  The  specimen  can  be  examined  in  water  or  dried  and 
mounted  in  Canada  balsam.  The  organisms  appear  as  small  blue  bodies, 
often  containing  pigment.  Eosin  may  be  used  as  a  counter-stain.  For 
the  crescent  and  oval  forms,  which  are  sometimes  dilBBcult  to  find,  it  may 
be  advantageous  to  allow  a  drop  of  blood  to  dry  upon  the  cover-glass 
without  spreading,  fix  as  before,  and  then  wash  with  dilute  acetic  acid; 
wash  thoroughly  with  water  and  stain  as  before.  The  red  cells  are  dis- 
solved, and  only  the  white  cells  and  the  parasites  remain  upon  the  slide. 

Prognosis. — All  cases  of  uncomplicated  intermittent  fever  under 
prompt  and  proper  treatment  will  probably  recover,  though  fatalities 
sometimes  occur.  It  is  to  be  borne  distinctly  in  mind  that  in  certain 
malarious  regions  and  in  certain  seasons  pernicious  types  are  prevalent, 
but,  since  these  arise  only  after  one  or  more  preceding  mild  attacks, 
they  are  preventable.  Primary  pernicious  attacks  are  moderately  dan- 
gerous, Avhile  recurrences  are  highly  so.  The  mortality-rate  in  this 
variety  of  malaria  is  between  20  and  25  per  cent.,  and  simple  intermit- 
tent fever  may,  if  not  checked,  suddenly  develop  into  the  most  malig- 
nant type  and  result  fatally. 

In  remittent  fever  a  fatal  issue  may  be  due  to  asthenia,  particularly 
when  the  type  is  severe  and  when,  folloAving  the  typhoid  state,  wrong 
notions  as  to  treatment  prevail.  The  severity  of  the  infection  may  be 
estimated  by  appreciating  the  degree  of  fever  and  the  severity  of  the 
nervous  symptoms.  Suppression  of  urine,  followed  by  uremic  symp- 
toms, hemorrhages,  and  intense  jaundice,  are  the  chief  untoward  com- 
plications. 

Treatment. — 1.  For  intermittent  malarial  fever  there  is  an  almost 
infallible  remedy  in  quinin.  "When  shall  its  use  be  commenced?"  is 
a  pertinent  question.  It  Avould  certainly  seem  highly  desirable  to  check 
the  course  of  the  disease  as  soon  as  possible,  and  especially  since  trans- 
mission of  the  simple  intermittents  into  the  pernicious  forms  m;iy  occur 
if  the  disease  be  not  arrested.     At  the  present  day  specific  treatment  is 


MALARIAL  FEVER.  95 

often  delayed  in  order  to  give  full  opportunity  for  making  a  blood-ex- 
amination with  a  view  to  completing  the  diagnosis.  There  is  no  decided 
advantage  in  commencing  the  use  of  quinin  during  the  first  paroxysm, 
when  the  blood  may  be  examined ;  but  on  finding  the  case  to  be  one  of 
malaria,  quinin  should  be  administered  after  the  paroxysm,  so  as  to  pre- 
vent a  recurrence.  For  like  reason,  if  the  history  at  the  physician's 
first  visit,  combined  with  the  symptoms  presented,  make  the  diagnosis 
of  intermittent  malaria  reasonably  certain,  and  there  is  no  opportunity 
to  examine  the  blood  microscopically,  the  principal  antiperiodic  remedy 
should  be  commenced  at  the  close  of  the  paroxysm,  especially  if  the 
patient  be  living  in   an  infected  district. 

The  quinin  cures  malaria  by  acting  directly  upon  the  intracorpuscu- 
lar  hematozoa. 

During  Xh.Q  i^aroxysm^e.  should  aim  to  make  the  patient  comfortable. 
He  is  to  remain  in  bed,  is  to  be  well  covered,  and  external  heat  applied 
during  the  cold  stage ;  and  he  is  to  be  lightly  covered,  given  cooling 
drinks  and  cold  spongings  during  the  hot  stage. 

During  the  apyrexial  intervals  the  patient  may  leave  his  bed,  pro- 
vided that  he  feel  strong  enough,  and,  as  before  intimated,  the  specific 
remedy  is  given  during  the  afebrile  period.  Certain  authors  recommend 
that  the  entire  daily  quantity  be  given  at  one  dose  from  four  to  six 
hours  before  the  succeeding  paroxysm  is  expected,  the  object  being  to 
surcharge  the  blood  at  the  time  when  the  hematozoa  sporulate.  Others 
give  the  remedy  in  divided  portions,  administering  the  last  dose  from 
four  to  six  hours  before  the  next  paroxysm  is  due.  It  may  matter  little 
which  of  these  two  methods  is  pursued,  yet  my  own  experience  leads 
me  to  favor  the  divided  doses  rather  than  the  single  large  ones.  The 
total  amount  per  day  required  to  cut  short  the  intermittents  is  from  16 
to  20  grains  (1.036  to  1.296)  in  most  temperate  climates.  When  this 
fails  more  may  be  given — 24  to  30  grains  (1.555—1.944).  My  own  prac- 
tice has  been  to  administer  immediately  after  the  close  of  the  sweating 
stage  gr.  iv  or  v  (0.259  or  0.324),  repeating  the  same  dose  a  few  hours 
later,  and  the  remaining  8  or  10  grains  (0.518  or  0.648)  (or  one-half  the 
daily  dose)  six  hours  before  the  time  for  the  next  paroxysm.  I  have 
thus  escaped  the  slight  toxic  symptoms  (tinnitus,  deafness,  nausea,  etc.) 
which  are  apt  to  follow  single  large  doses.  The  remedy  is  best  given 
in  capsules,  followed  by  a  few  drops  of  dilute  hydrochloric  acid,  with  a 
view  to  dissolving  the  quinin  in  the  stomach.  After  the  attacks  cease 
to  recur  quinin  should  be  continued  in  amounts  of  6  to  8  grains  (0.388 
to  0.518)  daily  for  several  days.  If  quinin  cannot  be  taken  per  os, 
it  may  be  tried  by  enema  or  by  suppositories  in  appropriately  large 
doses.  Rectal  irritability  may  thus  be  produced,  yet  in  very  young 
subjects,  who  cannot  be  induced  to  sw^allow  capsules,  I  have  for  a  long 
time  administered  quinin  by  suppository. 

The  physiologic  effects  of  the  drug  can  be  quickly  obtained  by 
administering  it  hypodermically.  Hence,  if  there  be  no  time  for  ab- 
sorption from  the  stomach  (four  hours  being  the  shortest  period  it  is  safe 
to  allow),  the  drug  should  be  thus  employed.  For  this  purpose  the 
more  soluble  salts  (hydrobromate,  etc.)  of  quinin  are  to  be  preferred  to 
the  ordinary  and  more  insoluble  sulphate,  which  requires  the  addition 
of  a  mineral  acid. 


96  INFECTIOUS  DISEASES. 

Many  preparations  of  cinchona  other  than  the  salts  of  quinin  may 
be  tried,  and  among  these  cinchonin  administered  in  the  same  manner 
as  the  latter  is  the  best  substitute.  Some  contend  that  the  sulphate  of 
quinidin  has  antiperiodic  power,  almost  equal  to  quinin.  In  prolonged 
cases  the  salts  of  quinin  and  other  preparations  of  cinchona  sometimes 
lose  their  specific  influence,  and  arsenic  is  then  to  be  employed,  either 
alone  or  in  combination  with  the  former  agents.  The  dose  of  th« 
arsenic,  beginning  with  Tlliv  (0.266)  t.  i.  d.  of  Fowler's  solution,  must 
be  increased  until  its  physiologic  effects  are  produced.  Arsenious  acid 
often  does  even  better  service  than  Fowler's  solution.  So  soon  as  the 
disease  is  controlled  the  dose  of  arsenic  is  to  be  reduced.  Administered 
as  above  indicated,  this  remedy  is  most  efficacious  in  malarial  cachexia 
and  masked  forms  of  intermittents ;  it  may  be  combined  with  iron  and 
quinin.  In  cases  of  malaria  that  are  resistant  to  quinin  (often  the  quo- 
tidian forms),  methylene-blue  has  been  found  extremely  active  and  ser- 
viceable. Cardamates  believes  that  it  is  indicated  only  when  quinin  is 
contraindicated,  as  in  hemoglobinuria  or  in  pregnancy  when  abortion 
is  feared.  While  in  charge  of  the  out-patient  service  of  the  Episcopal 
Hospital,  Philadelphia,  I  employed  in  chronic  malarial  cachexia,  with 
very  satisfactory  results,  the  sulphate  of  cinchonidin  in  daily  doses  of 
gr.  XXX— xl  (1.944—2.592).  In  this  class  of  cases  Warburg's  tincture 
(Sss  (16.0)  three  times  a  day)  has  been  warmly  recommended. 

2.  The  Treatment  of  Pernicious  Intermittents. — {a)  Prophi/Iaxis. — By 
treating  all  ordinary  intermittents  actively  after  the  first  paroxysms  the 
occurrence  of  pernicious  forms  can  be  obviated.  Not  to  pursue  this 
course  in  seasons  and  in  localities  in  which  these  serious  types  are  known 
to  prevail,  but  to  delay  for  second  and  third  paroxysms  in  order  to  be 
able  to  study  the  blood,  is  criminal. 

(h)  The  first  per)iicious  attack  must  be  treated  immediately,  and  there 
is  not  a  moment  to  be  lost.  Hence  in  all  varieties  of  pernicious  inter- 
mittents quinin  should  be  administered  hypodermically  until  the  patient 
is  fully  cinchonized — a  condition  that  must  then  be  maintained  for  sev- 
eral days.  In  all  varieties  stimulants  are  to  be  used  freely  if  the  hearts 
action  becomes  feeble,  and  the  patient  is  to  be  well  nourished  through- 
out. There  are  other  details,  though  of  relatively  minor  importance, 
and  they  vary  with  the  individual  forms.  Thus  in  "congestive  chills  " 
external  warmth  is  useful,  and  morphin  combined  with  atropin  should 
be  given  hypodermically,  this  combination  tending  to  allay  gastro-intes- 
tinal  symptoms  as  well  as  to  warm  the  extremities,  and  meeting  really 
important  indications.  Rectal  feeding  must  be  resorted  to  should  the 
stomach  refuse  to  retain  nourishment.  In  the  comatose  form  the  ner- 
vous symptoms  are  most  successfully  combated  by  prompt  and  energetic 
antiperiodic  treatment,  together  with  vigorous  stimulation  and  feeding, 
since  they  are  not  due  to  cerebral  congestion,  but  to  the  intensity  of  the 
infectious  process. 

(c)  During  the  apyrexial  period  every  eflFort  must  be  made  to  prevent 
a  recurrence  of  the  paroxysm,  and  to  this  end  the  patient  must  be  kept 
fully  cinchonized  until  the  time  for  the  next  paroxysm  is  over,  and  then 
be  removed  from  the  malarial  to  a  non-malarial  district. 

3.  Treatment  of  Remittent  Fever. — The  mode  of  treatment  in  this  form 
differs  somewhat  from  that  appropriate  for  intermittents.     At  the  onset 


DYSENTERY.  97 

a  mild  mercurial  is  advantageous  (calomel  gr.  J  (0.0162)  every  hour  for 
three  doses),  followed  by  a  saline  laxative  (Rochelle  salts,  ^ij  ;  8.0). 
During  the  febrile  exacerbations  cool  spongings  of  the  body,  coupled 
with  the  use  of  the  ice-cap,  are  serviceable.  The  gastric  symptoms 
demand  chipped  ice  by  the  mouth  or  small  doses  of  cocain,  and  a  mus- 
tard plaster  externally.  Immediately  after  the  first  remission  sets  in 
quinin  must  be  exhibited,  and  large  doses  are  now  indicated  (gr.  xv 
(0.972),  to  be  repeated  at  8  or  9  a.  M.).  A  third  and  even  a  fourth  dose 
of  the  same  size  may  be  required.  The  exacerbations  of  fever  gener- 
ally yield  to  this  remedy,  but  if,  as  rarely  happens,  they  do  not,  then 
small  doses  of  pilocarpin  (gr.  -|-  to  -I- ;  0.008  to  0.010)  may  be  adminis- 
tered hypodermically  during  the  height  of  the  fever.  This  causes  free 
sweating  in  many  instances,  and  in  consequence  renders  the  remission 
more  marked  and  more  prolonged ;  thus,  in  short,  rendering  the  course 
of  the  affection  speedily  favorable.  The  heart,  hoAvever,  must  be  care- 
fully guarded  when  this  depressing  agent  is  prescribed. 

A  case  that  has  been  allowed  to  run  on  for  one,  two,  or  more  weeks 
is  often  greatly  benefited  by  the  use  of  Warburg's  tincture,  as  before 
recommended,  for  several  days,  when  quinin  may  be  re-employed.  The 
patient,  especially  if  the  case  be  protracted,  must  be  vigorously  fed,  and 
pgr  rectum  if  it  cannot  be  accomplished  by  the  mouth.  In  typical 
cases,  which  are  promptly  controlled  by  quinin,  stimulants  are  rarely 
needed,  or  at  least  not  until  the  convalescent  stage  is  arrived  at.  In 
severe  and  neglected  cases  the  indications  for  their  employment  may 
be  presented  early,  and  they  should  then  be  given,  the  physician  con- 
forming to  the  same  rules  as  in  typhoid  and  other  acute  infectious  dis- 
eases. The  renal  congestion  and  anuria  are  to  be  met  by  internal  dia- 
phoretics (pilocarpin,  etc.)  and  by  saline  laxatives.  Most  efficacious, 
perhaps,  is  a  combined  hot-water  and  steam  bath.  The  patient  is  placed 
in  hot  w"ater,  and  then  a  blanket  is  put  around  the  neck,  its  free  ends 
being  allowed  to  extend  over  the  edges  of  the  tub.  This  may  be  re- 
peated, if  necessary. 

4.  Treatment  of  Malarial  Hematuria. — As  intimated  above,  in  hem- 
orrhagic pernicious  malaria  quinin  is  absolutely  indicated,  if  there 
be  no  uremic  features.  The  use  of  quinin  in  moderate  doses  (gr. 
xvj — 1.036 — daily)  successfully  relieves  the  hemoglobinuria  occurring 
in  connection  with  mild  forms  of  malaria,  and  its  subsequent  use  in 
smaller  doses  (gr.  iij  (0,194)  to  gr.  vj  (0.388)  daily)  will  prevent  a 
recurrence.  It  is  claimed  by  some  writers  that  quinin  may  produce 
hematuria  (Plehn,  Richardson,  and  others),  and  also  that  this  remedy 
is  of  no  value  in  combating  this  symptom.  The  specific  remedy  should 
not  be  abandoned,  however,  and  large  quantities,  such  as  might  act  as 
an  irritant  to  the  renal  tissues,  are  not  necessary  to  effect  a  cure,  except 
in  pernicious  forms. 


DYSENTERY. 


Definition. — An  infectious  inflammatory  disease  of  the  large  intes- 
tine, characterized  anatomically  by  ulceration  of  the  intestinal  mucosa, 
and  clinically  by  frequent  mucous  and  bloody   discharges,   tenesmus, 

7 


98  INFECTIOUS  DISEASES. 

fever  and  prostration  becoming  profound,  a  tendency  to  abscess-forma- 
tion in  the  portal  system,  to  paralysis,  and,  finally,  to  pronounced  anemia. 
It  is  a  truly  epidemic  disease,  yet  it  also  occurs  constantly  in  endemic 
form,  and  particularly  does  this  occur  in  temperate  climates. 

Historic  Note. — Few  diseases  have  been  longer  known  than  dys- 
entery, of  which  we  have  a  description  by  Hippocrates.  Galen  local- 
ized the  chief  seat  of  the  aifection  in  the  colon,  and  in  1626,  Sennertus 
defined  its  sporadic  and  epidemic  character  and  some  of  its  leading  clini- 
eal  features.  To  Morgagni  belongs  the  credit  of  having  made  the  first 
postmortem  anatomic  study  of  the  disease.  Further  and  more  accu- 
rate pathologic  contributions  were  made  in  the  earlier  part  of  the 
present  century  by  Cruveilhier  and  Rokitansky,  and,  more  recently  still, 
the  whole  subject  of  the  morbid  anatomy  of  this  disease  has  been  care- 
fully investigated  by  Virchow,  whose  results  have  settled  most  of  the 
questions  connected  Avith  the  subject.  In  the  United  States  dysentery 
has  prevailed  epidemically  upAvard  of  a  century,  the  time  of  greatest 
prevalence  in  different  districts  having  been  about  the  middle  part  of 
the  present  century  (1847-55).  Woodward  has  given  us  the  only  com- 
plete record  of  the  various  outbreaks  in  this  country,  and  an  account  of 
the  ravages  of  dysentery  in  both  armies  during  the  War  of  the  Rebellion 
is  given  in  his  Report,  which  records  259,071  cases  of  acute  and  28,451 
of  chronic  dysentery.  The  disease  is  far  less  frec^uent  than  formerly, 
owing  to  the  advance  made  in  recent  times  in  sanitary  science,  in  con- 
sequence of  which  some  of  the  predisposing  conditions  have  been  over- 
come. 

Htiology. — As  stated  below,  there  are  three  distinct  clinical  types 
of  the  affection,  each  of  which  has  special  etiologic  factors.  A  few 
general  considerations,  having  reference  to  the  causation  of  the  different 
forms  in  common,  may  be  adduced  here,  and,  as  each  variety  presents 
different  anatomic  lesions  in  leading  particulars,  their  pathology  will  be 
considered  separately. 

Among  disj)0sing  factors,  season  heads  the  list,  dysentery  being  most 
common  in  the  summer  and  autumn  ;  <zront  and  sudden  changes  of  tern- 
perature  are  more  potent  than  e(iual  ciianges  in  humidity.  Climate 
has  a  marked  effect,  and  high  temperature  must  be  regarded  as  a  pow- 
erful agency,  since  the  disease  is  much  more  prevalent  in  warm  than  in 
cold  climates,  though  it  is  met  with  in  epidemic  form  as  far  north  as 
Norway.  3Ialarial  districts  suffer  more  than  non-malarial.  This  may 
be  due  to  the  fact  than  an  attack  of  malaria  may  leave  the  body  of  the 
sufferer  more  receptive  to  the  specific  poison  of  dysentery,  or  the  ex- 
ternal conditions  Avhich  favor  the  development  of  the  plasmodia  may 
also  favor  the  growth  of  the  dysenteric  poison.  The  latter  view  gains 
some  support  from  the  Avell-known  fact  that  water  taken  from  stagnant 
pools  in  marshy  localities  (in  Avhich  malaria  is  apt  to  prevail)  may  give 
rise  to  the  symptoms  of  dysentery.  Unhygienic  conditions,  as  shown  by 
the  local  epidemic  outbreaks  in  jails,  barracks,  institutions,  etc.,  predis- 
pose to  the  affection. 

Among  factors  connected  with  the  individual  are  {a)  catarrhal  con- 
ditions of  the  intestinal  tract,  particularly  if  the  latter  be  caused  by 
unripe  fruit  or  other  unwholesome  forms  of  food;  (h)  Age.  Although 
no  age  enjoys  immunity  against  dysentery,  most  cases  are  met  with  in 


DYSENTERY.  99 

adults  under  thirty-five  years.     Sex  and  race  are  probably  Avithout  ap- 
preciable influence. 

Catarrhal  Dysentery. 

Pathologjo — There  are  two  forms :  {a)  In  this  the  solitary  follicles 
are  affected  chiefly,  and  are  the  seat  of  hyperplasia,  folloAved  by  necro- 
sis, with  the  formation  of  small  ulcers.  This  is  common  in  children. 
(6)  Here  a  purulent  inflammation  of  the  entire  mucosa,  with  more  or 
less  erosion  of  the  surface  and  superficial  ulceration,  exists.  In  both 
forms  the  lesions  are  mainly  confined  to  the  large  intestine,  though  the 
ileum  is  sometimes  implicated  to  a  lesser  extent. 

Special  Ktiologfy. — The  specific  bacillus  of  catarrhal  dysentery  is 
not  known,  but  it  will  probably  be  shown  to  be  the  bacillus  coli  com- 
munis, whicli«tmay  become  pathogenic  when  the  state  of  the  mucosa  of 
the  bowel  is  altered  by  sudden  changes  of  temperature,  etc.  (Arnaud, 
Maurel).  .  Curtis  in  a  recent  outbreak  found  the  bacillus  pyocyaneus 
in  every  specimen  of  water  used  and  in  intestinal  discharges. 

Clinical  History. — There  may  be  prodromes,  lasting  one  or  two 
days,  which  take  the  form  of  a  mild  gastro-intestinal  disorder  (anorexia, 
slight  pains  in  the  abdomen,  followed  by  diarrhea). 

The  characteristic  symptoms  are  mild  colicky  pains  in  the  abdomen, 
followed  by  discharges  from  the  bowel,  which  at  first  number  from 
three  to  six  daily.  Soon  they  become  frequent  and  are  accompanied 
by  straining  and  tenesmus,  and  now  their  number  ranges  from  ten  to 
no  less  than  one  hundred  or  more  per  day.  Indeed,  the  desire  to  go 
to  stool  may  be  almost  constant,  and  the  rectum  is  the  seat  of  intense 
burning  sensations  during  and  after  each  evacuation  of  the  bowel.  The 
character  of  the  discharges  varies  with  the  different  periods  of  the  affec- 
tion. During  the  first  thirty-six  or  forty-eight  hours  they  are  feculent 
(sometimes  scybalous  masses),  rather  copious,  and  intermingled  with  some 
mucus  and  blood.  For  the  next  four  or  five  days  the  stools  are  scanty, 
measuring  from  2  drams  (8.0)  to  ^  ounce  (16.0),  and  are  made  up  of 
a  sero-mucous  fluid  or  of  a  muco-purulent  material  with  blood.  The 
chief  constituents  of  the  stools  are  mucus,  blood,  and  pus,  any  one  of 
which  may  preponderate,  thus  giving  rise  to  mucous  (most  frequently), 
purulent,  or  bloody  stools. 

Microscojyic  examination  of  the  usually  glairy  stools  shows  red 
blood-corpuscles,  numerous  leukocytes,  generally  large,  oval  or  round 
epithelioid  cells  containing  fat-globules,  vacuoles,  and  bacteria  (espe- 
cially those  of  putrefaction).  Occasionally  the  Cercomonas  intestinalis 
is  seen  (Osier). 

A  few  shreds  (portions  of  necrosed  mucous  membrane)  may  appear 
from  time  to  time  in  the  discharges,  and  particularly  in  severe  forms  of 
the  affection.  These  usually  increase  in  number  at  the  close  of  the 
first  week,  and  a  little  later  the  discharges  become  less  frequent  and  the 
amount  of  mucus  and  blood  diminishes.  The  stools  are  now  of  a  greasy 
brown  or  dark-green  appearance,  fecal  matter  reappearing  in  them,  and 
soon  they  are  again  fully  formed. 

Other  Symptoms  deferable  to  the  Aliiventary  Tract. — The  tongue 
has  a  greasy  coating — moist  at  first,  dry  later — and  at  last  may  become 
red  and  glazed.     Anorexia  is  present,  with  excessive  thirst,  and  vomit- 


]00  INFECTIOUS  DISEASES. 

ing  may  rarely  occur.  A  distressing  though  uncommon  symptom  is 
hiccough.  There  will  usually  be  tenderness  over  the  line  of  the  colon, 
but  there  is  an  absence  of  tympanites,  and  the  abdomen  is  apt  to  be  flat 
and  somewhat  tense. 

The  general  symptoms  are  well  marked  in  the  severer  types.  The 
patient  is  much  debilitated,  sometimes  even  collapsed,  as  shown  by  the 
small,  frequent  pulse,  cool  skin-surface,  the  rapid  wasting,  and  weak, 
hoarse  voice.  The  temperature  is  not  much  elevated,  though  it  may 
touch  103°  or  104°  F.  (40°  C.)  at  the  outset,  and  the  curve  is  an  irregu- 
larly remittent  one. 

Diagnosis. — This  can  easily  be  made  upon  the  intestinal  features 
and  from  the  character  of  the  stools — frequent,  small,  slimy  (or  bloody) 
discharges,  accompanied  by  distressing  tenesmus. 

Differential  Diagnosis. — Symptoms  simulating  dysentery  may  appear 
in  the  course  of  certain  rectal  affections,  such  as  strangulated  hemor- 
rlioids,  si/philis,  and  epitlidvnua.  In  these  conditions,  however,  there  is 
a  different  history  and  the  symptoms  of  proctitis  are  usually  less  acute, 
Avliile  a  physical  examination  of  the  rectum  Avill  settle  the  diagnosis  in 
doubtful  cases. 

Prognosis. — The  duration  of  mild  cases  is  from  eight  to  ten  days, 
and  in  severe  types  from  three  to  four  weeks.  The  prognosis  varies  in 
diflerent  epidemics  or  according  to  the  type  of  the  affection ;  but  com- 
monly this  is  not  aggravated  and  recovery  is  generally  to  be  expected. 
Occasionally,  however,  the  disease  is  threatening  to  life.  Besides  the 
systemic  prostration  and  collapse  above  referred  to,  serious  nervous 
symptoms  (great  restlessness,  delirium  followed  by  coma)  may  develop 
and  cause  a  fatal  termination.  When  death  occurs  it  is  usually  due  to 
exhaustion,  and  is  seen  particularly  in  persons  previously  enfeebled  or , 
in  the  very  young  and  the  aged.  Complications  influencing  the  prog- 
nosis are  exceptional  (peritonitis  and  liver-abscess). 

Amebic  Dysentery  (Tropical  Dysentery). 

Bacteriology. — This  form  of  dysentery  is  caused  by  the  amoeba 
coli  or  the  amoeba  di/senterice  (Councilman  and  Lafleur).  The  amoeba 
dysenterine  is  a  unicellular,  motile  organism,  in  size  3  to  7  times  the 
diameter  of  a  red  blood-corpuscle  (15  to  30  micromillimeters).  Its  pro- 
toplasm consists  of  two  zones — an  outer  colorless  (ectosarc)  and  an  inner 
granular  zone  (endosarc),  with  a  visible  nucleus  and  one  or  more  vac- 
uoles. This  micro-organism  was  first  described  by  Lambl  (1859),  but  it 
remained  for  Losch,  and  especially  Kartulis,  to  shoAV  its  close  associa- 
tion with  dysentery.  It  is  now  generally  held  to  be  the  specific  cause 
of  tropical  dysentery.  The  ameba  (amoeba  coli  ynifis)  is  occasionally 
found  in  healthy  individuals,  and  also  in  other  bowel -affections  than 
dysentery  (mucous  enteritis,  simple  diarrhea,  proctitis  due  to  engorge- 
ment), and  two  species  are  recognized — a  virulent  and  a  benign  form 
(Quincke  and  Roos).  The  ameba  is  found  not  only  in  the  discharges, 
but  also  in  the  pus  from  the  secondary  liver-abscesses. 

Hehir  has  found  the  bacilhts  di/sentericus  associated  with  the  amoeba 
coli,  and  considers  it  to  be  pathogenic.  He  describes  it  as  a  short,  straight 
bacillus,  usually  of  a  length  about  equal  to  one-third  the  diameter  of  a 


DYSENTERY.  101 

red  blood-corpuscle,  with  rounded  ends,  sometimes  jointed,  rarely  curved. 
Later  investigations,  however,  have  not  entirely  confirmed  the  claims  of 
this  observer. 

The  mode  of  transference  of  the  ameba  is  not  definitely  known,  though 
the  principal  source  of  the  dysenteric  germs  is  most  probably  the  drink- 
ing-water.    The  poison  is  feebly  communicable  by  contact. 

Amebic  dysentery  is  not  confined  to  the  tropics,  but  is  met  with  also, 
though  less  frequently,  throughout  Europe  and  North  America. 

Pathology. — The  lesions  are  almost  always  situated  in  the  large 
intestine,  although  rarely  the  ileum  is  also  invaded.  The  firstn^isible 
change  is  a  hyperemia  of  the  mucosa,  most  marked  in  the  descending 
colon  and  rectum ;  but  the  changes  which  produce  the  characteristic 
dysenteric  ulcer  begin  with  infiltration  and  swelling  of  the  submucosa, 
followed  by  necrosis,  which  involves  the  overlying  mucosa  with  its  epi- 
thelium (Kruse  and  Pasquale).  How  the  amebse  reach  the  submucosa 
has  not  yet  been  observed.  The  visible  infiltration  occurs  usually  in 
circumscribed  areas  which  are  oval  or  hemispheric  in  shape,  and 
project  above  the  level  of  the  surrounding  mucosa.  The  submucosa 
presents  a  grayish-yellow  appearance,  and  is  soon  thrown  off  in  the 
form  of  a  slough. 

The  ulcers  take  various  shapes — chiefly  irregular,  and  less  frequently 
round  or  oval.  Their  edges  are  ragged  and  undermined,  and  the  floor, 
which  is  more  or  less  covered  with  pultaceous  material,  is  rough  or 
crater-like,  and  formed  by  the  musculature  or  the  outer  serous  coat  of  the 
intestine.  From  the  manner  in  which  the  ulcers  are  formed  it  is  obvious 
that  cellular  infiltration  (followed  by  necrosis)  may  occupy  the  sub- 
mucosa for  a  greater  or  less  distance  beyond  the  borders  of  the  ulcers. 
In  this  way  fistulous  channels  may  be  produced  beneath  the  mucosa  and 
connect  two  or  more  ulcers.  Usually  this  ulcerative  process  affects  only 
certain  portions  of  the  large  gut,  especially  the  flexures — hepatic  and 
sigmoid — and  the  rectum ;  but  it  may  be  general,  and  I  have  seen  an 
instance  of  this  kind.  Similar  cases  are  not  uncommon  in  which  the 
ulcers  are  so  numerous  as  to  include  almost  the  entire  mucosa  of  the 
large  intestine. 

Healing  is  attended  with  the  development  of  fibrous  tissue  along  the 
edges  and  in  the  base  of  the  ulcer,  and  secondary  contraction  of  this 
new  connective  tissue  is  often  productive  of  colonic  stricture,  which  is 
usually  either  partial  or  irregular.  The  cases  that  come  to  autopsy  often 
show  diphtheritic  inflammation  as  a  secondary  or  terminal  condition. 

The  microseope  reveals  proliferation  of  the  fixed  connective-tissue 
cells,  and  the  presence  of  amebge  in  the  walls  and  the  base  of  the  ulcers, 
in  the  lymph-spaces,  and  rarely  in  the  blood-vessels.  Pus  can  only 
occasionally  be  detected. 

The  liver  may  be  the  seat  of  prominent  lesions.  These  are  (a)  ab- 
scesses, which  may  be  single  or  multiple,  the  latter  being  small,  and  the 
former  often  large.  The  single  or  solitary  abscess  is  usually  situated 
near  either  the  upper  convex  or  the  lower  concave  surface,  while  the  ab- 
scess-cavity is  formed  in  a  manner  similar  to  the  intestinal  ulcers.  The 
area  affected  is  at  first  infiltrated ;  it  then  becomes  necrotic,  and  finally 
more  or  less  liquefied.  Upon  the  full  development  of  the  first  stage  the 
part  invaded  is  a  grayish-yellow  pultaceous  mass,  but  in  the  second  or 


102  INFECTIOUS  DISEASES. 

necrotic  stage  the  abscess  contains  a  yellowish  or  greenish-yellow,  spongy 
material  with  beginning  liquefaction.  The  contents  of  the  mature  abscess 
consist  of  a  greenish-  or  reddish-yellow  purulent  material  and  of  rem- 
nants of  liver-tissue.  The  walls  of  the  recent  abscess  are  irregular  and 
raofged,  those  of  an  old  abscess  being  dense  and  fibrous,  and  a  section  of 
the  abscess-wall  shows  an  inner  necrotic  zone,  a  middle  zone  (in  which 
there  is  great  proliferation  of  the  connective-tissue  cells,  compression 
and  atrophy  of  the  liver-cells),  and  an  outer  zone  of  intense  hyperemia 
(Osier).  The  contents  of  the  abscess  show  either  few  or  many  amebse, 
and  oillv  rarely  pus.  When  pus  is  present  it  is  due  to  a  secondary 
infection  by  the  pyogenic  germs.  In  what  way  the  amebse  gain 
access  to  the  liver  is  not  definitely  known,  but  it  is  probable  that  in 
multiple  abscesses  they  are  propagated  along  the  blood-current,  either 
from  the  ulcers  or  from  a  single  primary  focus.  Cultures  are  generally 
sterile. 

(b)  The  parenchyma  of  the  liver  may  be  the  seat  of  numerous  circum- 
scribed necrotic  spots,  which  are  supposed  to  be  due  to  the  action  of  the 
chemical  secretions  of  the  amebse. 

The  lungs  sometimes  show  changes  similar  to  those  in  the  liver, 
which  are  the  result  of  direct  extension  of  the  hepatic  abscess  through 
the  diaphragm  into  the  lower  lobe  of  the  right  lung. 

Clinical  History. — The  mode  of  onset  is  gradual  except  in  a  small 
proportion  of  the  cases,  in  which  it  is  sudden  with  Avell-marked  symp- 
toms. When,  as  generally  happens,  it  is  insidious,  the  initial  symptom 
is  often  a  trivial  diarrhea.  The  affection  is  then  characterized  prin- 
cipally by  intermissions  and  an  exacerbating  diarrhea,  the  liquid 
stools  containing  necrotic  tissue  of  a  grayish-brown  and  sometimes 
yellowish-gray  color.  The  latter  are  often  bloody  and  mucoid,  particu- 
larly at  the  outset,  and  in  fully  developed  cases  are  fluid.  The  number 
of  discharges  per  day  is  exceedingly  variable  in  different  epidemics,  and 
even  in  individual  cases,  though  in  most  instances  they  range  from  six 
to  eight  or  ten  daily. 

Microscopic  examination  of  the  feces  during  the  exacerbations  dis- 
closes amebae  that  are  almost  invariably  endowed  with  motion,  though 
usually  not  when  the  stools  have  become  formed.  Tenesmus  is  not  a 
prominent  feature  in  most  cases,  and  may  be  entirely  absent.  Colicky 
abdominal  pains  are  rare,  and  nausea  and  vomiting  are  equally  so. 

General  Symptoms. — The  febrile  movement  is  usually  present,  but  it 
is  slight  and  exhibits  marked  variations.  In  certain  instances,  however, 
the  temperature  is  below  the  normal  curve  throughout  the  entire  or 
greater  part  of  the  course.  From  the  time  of  onset  there  is  gradual 
though  progressive  loss  of  flesh  and  strength,  and  anemia  usually  be- 
comes well   iii;irke<l. 

Complications. — The  most  common  is  Jupatic  abscess,  and  second- 
ary to  the  latter  may  arise  abscess  of  the  right  lung.  Authors  are  not 
agreed  as  to  the  frequency  of  occurrence  of  liver- abscess '  in  amebic 
dysentery,  but  it  is  certainly  comparatively  rare  in  this  country,  not 
exceeding,  perhaps,  3  per  cent,  of  the  cases.  Peritonitis  may  result 
from  perforation  of  a  dysenteric  ulcer,  causing  death.      The  point  of  per- 

^  For  the  diagnosis  of  this  condition  tlie  reader  is  referred  to  the  section  on  Hepatic 
Abscess  in  the  article  on  Diseases  of  the  Liver. 


DYSENTERY.  103 

foration  may,  however,  be  in  the  rectum,  when  periproetitis  is  the  result ; 
or  it  may  be  in  the  cecum,  when  perityphlitis  is  the  sequel.  In  tropical 
or  subtropical  countries  the  disease  is  often  complicated  with  malarial 
aflfections,  and  in  malarial  regions  intermittent  and  remittent  fevers  are 
among  the  commoner  complications.  The  presence  of  an  intermittent 
fever  is  not,  however,  sufficient  to  warrant  the  assumption  that  malaria 
complicates  dysentery ;  and  in  order  to  show  the  latter  combination  we 
must  be  able  to  demonstrate  the  presence  of  the  plasmodium  malarice. 
In  pyemia  and  in  suppurative  processes  generally — conditions  sometimes 
met  with  in  dysentery — the  temperature-curve  is  often  distinctly  inter- 
mittent. Typhoid  fever  is  a  rare  complication.  The  latter  disease  can- 
not be  said  to  coexist  with  dysentery  unless  all  of  the  characteristic 
symptoms  are  present.  Certain  cases  of  dysentery  are  characterized  by 
the  development  of  the  typhoid  state,  and  pyemia  and  septico-pyemia 
may  appear  late.  Among  special  manifestations  of  the  latter  are  pyle- 
phlebitis, pericarditis,  endocarditis,  pleuritis,  and  rheumatoid  pains  in 
the  joints. 

Diagnosis. — The  slow  course,  marked  by  intermissions  and  exacer- 
bations of  the  bloody  fluid  stools,  the  mild  general  symptoms,  apart 
from  emaciation  and  debility,  are  salient  features,  but  an  assured 
recognition  of  the  affection  demands  a  microscopic  examination  of 
the  stools.  Cases  have  been  recorded  by  Councilman  and  Lafleur 
in  which  the  diagnosis  rested  upon  amebge  being  found  in  the  sputa, 
the  latter  being  complicated  with  pulmonary  and  hepatic  abscesses 
which  discharged  through  a  bronchus,  while  the  intestinal  symptoms 
were  negative. 

Prognosis. — The  prognosis  is  graver  than  in  the  catarrhal  va- 
riety, and  the  mortality-rate  in  certain  epidemics  has  been  frightful, 
particularly  among  soldiers  in  the  field  (amounting  to  70  or  even  80  per 
cent.).  In  sporadic  cases  the  danger  to  life  is  less,  the  mortality-rate  in 
temperate  climates  being  not  over  5  or  6  per  cent.  The  complications 
which  render  the  prognosis  unfavorable  are  various  (peritonitis,  hepatic 
and  pulmonary  abscess,  pyemia  secondary  to  the  latter,  broncho-pneu- 
monia, malaria) ;  death  may  be  due  to  hemorrhage  or  peritonitis,  but  in 
a  preponderating  proportion  of  the  cases  to  asthenia.  A  dangerous 
degree  of  debility  is  indicated  by  great  nervous  depression ;  a  cool, 
clammy  skin ;  a  sunken,  pinched  facies ;  a  dry  tongue ;  a  feeble,  rapid 
pulse ;  and  by  restlessness,  alternating  with  marked  apathy  or  low  mut- 
tering delirium. 

Course  and  Duration. — The  average  duration  ranges  from  eight 
to  ten  weeks  in  uncomplicated  cases ;  the  disease  can,  hoAvever,  be  cut 
short  by  appropriate  treatment.  It  manifests  an  innate  tendency  to 
pursue  a  chronic  course,  interrupted  by  frequent  exacerbations  or  true 
relapses,  and  convalescence  occupies  a  long  period  of  time  in  conse- 
quence of  the  profound  anemia  and  debility  that  supervene. 

Diphtheritic  Dysentery. 

This  is  an  intestinal  inflammation  (usually  colonic),  accompanied  by 
a  croupous,  or  true,  diphtheritic  exudation.  Two  clinical  forms  are 
recognized : 


104  INFECTIOUS  DISEASES. 

Primary  Diphtheritic  Dysentery. 

In  mild  grades  of  this  rare  affection  a  grayish-yellow,  croupous  exu- 
date appears  upon  the  inflamed  mucosa,  with  a  necrosis  of  the  epithelial 
layer  that  is  often  limited  to  the  top  surface  of  the  folds  of  the  colon. 
In  other  instances  the  diphtheritic  infiltration  involves  all  the  layers  of 
the  bowel,  which  now  becomes  greatly  enlarged,  its  mucous  membrane 
beincr  converted  into  a  yellowish-brown,  thick,  elastic  mass,  sometimes 
extending  along  the  entire  length  of  the  large  intestine.  The  changes 
may  be  confined  to  the  circumscribed  areas,  and  thick  sloughs  may  be 
cast  off,  leaving  behind  ulcers  of  corresponding  size  and  depth.  Again, 
these  gross  lesions  ma}'  be  limited  to  certain  sections  of  the  large  bowel, 
as  the  rectum  or  the  flexures  of  the  colon.  In  protracted  cases  cylin- 
ders of  pseudo-membrane  of  considerable  length  may  become  separated 
and  evacuated  with  the  stools. 

Clinical  History. — The  affection  usually  lias  an  acute  onset  and 
one  characterized  l)y  tlie  appearance  simultaneously  of  severe  local  and 
general  symptoms.  There  may  be  an  initial  cliilU  and  there  is  fever, 
which  rises  rapidly,  together  with  a  marked  and  early  appearing  pros- 
tration and  delirium.  Severe  abdominal  pains  are  complained  of,  and 
the  discharges  are  apt  to  be  very  numerous,  containing  shreds  and 
large  sloughs,  or  even  tubular  pieces,  of  false  membrane.  When  these 
elements  are  present  in  the  stools  the  latter  are  of  a  dark -brown  color, 
emitting  a  fetid  odor,  and  generally  containing  more  or  less  blood  and 
mucus.  Tenesmus  may  be  present,  and  particularly  when  the  rectum 
is  involved. 

The  physical  signs  are  often  prominent.  The  belly  in  most  instances 
is  greatly  distended,  and  on  pressure  very  tender — signs  due  to  the  fact 
that  the  lesions  are  situated  chiefly  in  the  large  bowel,  and  not,  as  a 
rule,  to  peritonitis. 

The  diagnosis  rests  upon  the  intestinal  symptoms  and  the  charac- 
ter of  the  dejections,  associated  with  a  grave  general  condition  suddenly 
developed  in  a  i)reviously  healthy  individual. 

The  prognosis  is  almost  wholly  unfavorable.  Occasionally  recov- 
er v  follows,  though  more  frequently  the  disease  takes  on  a  chronic 
course. 

Secondary  Diphtheritic  Dysentery. 

Here  the  lesions  are  similar  in  kind  to  those  of  the  primary  form, 
but  in  the  majority  of  instances  of  a  less  intense  grade.  Rarely  they 
may  be  both  extensive  and  severe.  This  variety  is  met  with  as  a  ter- 
minal condition  in  not  a  few  acute  and  chronic  diseases ;  among  the 
former  it  is  with  great  relative  frccjuency  seen  to  develop  in  pneumonia 
(Bristowe),  and  less  freciuently,  though  in  not  rare  instances,  in  typhoid 
fever,  according  to  my  own  observation.  Among  chronic  affections, 
upon  Avhich  this  condition  may  become  engrafted,  are  nephritis,  organic 
disease  of  the  heart,  and  pulmonary  tuberculosis. 

Clinical  History. — No  characteristic  symptoms  attend  upon  its  in- 
vasion. There  may  be  slight  diarrhea — two  to  four  liijuid  stools  daily 
— but  it  is  not  often  accompanied  by  tormina  and  tenesmus,  and  the 
discharges  rarely   contain  any  noticeable  amount  of   blood  or  mucus. 


DYSENTERY.  105 

Very   rarely  shreds  of  pseudo-membrane    are  passed  with  the  stools. 
Secondary  diphtheritic  dysentery  often  induces   fatal  asthenia. 

The  diagnosis  is  in  most  cases  merely  conjectural. 

Sequelae. — In  all  forms  a  relapse  is  likely  to  occur,  each  attack  in- 
creasing the  liability  of  the  patient  to  subsequent  ones.  Moreover,  in 
persons  who  have  recovered  from  acute  dysentery  we  often  observe  a  dis- 
ordered digestion  and  irritability  of  the  bowels.  Rarely,  chronic  nephritis 
follows  dysentery.  The  most  interesting  sequel,  however,  is  paralysis, 
which  occurs  mainly  in  the  form  of  paraplegia  (S.  Weir  Mitchell). 
Stricture  of  the  bowel  may  be  a  sequel,  but  it  is  surprisingly  rare. 

Treatment. — Prophylaxis. — This  embraces  isolation  and  a  thorough 
disinfection  of  the  discharges,  which  contain  the  specific  germ  of  the 
disease,  as  soon  as  passed.  The  drinking-water  during  the  epidemic 
prevalence  of  dysentery  should  be  thoroughly  boiled,  and  healthy  per- 
sons should  avoid  the  use  of  improper  food,  while  an  unhygienic  envi- 
ronment (overcrowding,  etc.)  is  to  be  corrected  as  far  as  possible.  All 
suiferers  from  dysentery  must  be  kept  in  bed,  and  should  occupy  a  well- 
aired  apartment. 

The  diet  should  consist  of  milk  and  lio^ht  animal  broths  during;  the 
period  of  active  intestinal  symptoms,  and  in  the  amebic  form  of  the  dis- 
ease it  is  well  to  allow  easily  digestible  solids,  as  raw  oysters,  eggs,  well- 
boiled  rice,  fowl,  fish,  and  the  like,  in  small  quantities.  During  con- 
valescence a  return  to  the  usual  dietary  is  gradually  to  be  made. 

Stimulants. — With  the  development  of  asthenia  and  cardiac  failure 
stimulants  must  be  employed,  as  in  other  acute  infectious  diseases,  and 
alcoholics  may  be  supplemented  by  the  use  of  strychnin  in  cases  of 
extreme  debility. 

Medicinal  Treatment. — If  scybalous  masses  be  passing  still,  the  treat- 
ment should  be  commenced  by  administering  a  dose  of  castor  oil  or  a 
saline  purge,  and  this  may  be  repeated  if  necessary.  It  is  well  to  con- 
vert dysentery  into  diarrhea,  thus  cleansing  the  bowel  thoroughly. 
Measures  tending  to  deplete  the  mucosa  of  the  intestine  and  at  the  same 
time  inhibit  undue  peristalsis  are  most  effective,  as  magnesium  sulphate. 
In  the  later  stages  purgatives  are  attended  with  baneful  effects. 

Ipecacuanha  has  long  been,  and  still  is,  regarded  as  possessing  a 
specific  influence  in  cases  of  dysentery.  Its  administration  is  usually 
preceded  by  a  dose  of  opium  (laudanum  or  morphin)  which  is  given 
when  the  stomach  has  been  empty  for  a  few  hours.  Most  authors  rec- 
ommend that  large  doses — gr.  xx  to  3j  (1.29  to  4.0) — should  be  admin- 
istered;  but  it  is  probable  that  a  small  dose — gr.  ■§- to  ^  (0.010  to  0.016) 
every  half  hour — is  quite  as  effective ;  and  in  children  the  smaller  doses 
are  to  be  preferred  and  will  be  found  to  be  quite  efficacious.  Other 
remedies  should  also  be  employed,  and  among  these  opium  is  particularly 
beneficial  in  combination  with  ipecacuanha  or  in  the  form  of  Dover's 
powder,  which  contains  both  agencies.  Three  chief  symptomatic  indi- 
cations are  met  by  the  opium — pain,  restlessness,  and  undue  peristalsis 
— and  to  obtain  the  best  effects  from  the  opiate  it  should  be  adminis- 
tered in  the  form  of  morphin  hypodermically.  In  cases  in  which  tenes- 
mus is  an  unusually  distressing  feature  an  opium  suppository  (gr.  ij — 
0.1296)  or  laudanum  (Tflxxx — 2.0,  by  enema)  exercises  a  beneficial 
effect.     Bismuth  in  full  doses  is  useful'(3ss— j — 2.0-4.0  every  two  hours). 


106  INFECTIOUS  DISEASES. 

and  in  cases  of  sporadic  dysentery  I  have  frequently  found  the  follow- 
ing formula  productive  of  happy  effects: 

I^.  Pulv.  ipecac,  et  opii,  3ss  (2.0) ; 

Bismuthi  subnitrat.,  |ss  (16.0) ; 

Salol,     .  3SS  (2.0). 

M.  et  ft.  chart.  No.  xij. 
Sig.   One  every  hour  or  two. 

Xaphthalin  and  mercuric  chlorid  are  recommended  in  highest  terms. 
Bosc  and  Vedel  employed  in  4  cases  intravenous  injections  of  sodium 
chlorid,  7  :  1000  being  the  maximum  strength.  The  injections  should 
be  made  early,  and  repeated,  so  that  they  will  develop  sustained  general 
reaction  and  a  modification  of  the  general  condition  which  can  lead  to 
recovery.  Care  should  be  taken  as  to  the  quantity  used  and  the  rapidity 
with  which  it  is  injected  (|  to  3  ounces  each  minute  should  not  be  exceeded). 

Antiseptic  irrigation  of  the  bowel  would  be,  if  properly  carried  out, 
a  curative  measure,  since  by  this  means  we  may  destroy  the  amebse,  and 
solutions  of  numerous  antiseptic  substances  and  astringents  have  been 
recommended  for  this  purpose.  Unfortunately,  the  bowel  is  frequently 
so  irritable  as  to  seriously  interfere  with  this  mode  of  medication.  If, 
on  this  account,  large  injections  cannot  be  given,  small  ones  should  be 
substituted  and  the  (juantity  gradually  increased.  Preliminary  to  their 
use  we  may  also  employ  cocain  in  the  form  of  a  suppository,  or  a  small 
quantity  of  a  solution  of  cocain  (4  per  cent.),  or  a  laudanum  enema 
(nixxx — 2.0,  in  starch-water),  after  which  a  large  injection  may  be  toler- 
ated if  administered  slowly  and  the  flow  be  interrupted  at  brief  inter- 
vals. Among  the  best  agents  are  silver  nitrate  (gr.  ss-j — 0.032- 
0.064 — ad  sj — 32.0),  tannic  acid  (1  to  2  per  cent.),  salicylic  acid  (1 
to  2  per  cent.),  and  mercuric  chlorid  (1  :  6000).  I  have  for  a  number 
of  years  been  in  the  habit  of  employing  these  astringents  and  antisep- 
tic solutions  alternately,  administering  each  once  daily.  The  tannic- 
acid  and  the  salicylic-acid  solutions  are  best  borne  during  the  more 
active  stages  of  the  disease.  The  temperature  of  the  water  should,  at 
first,  range  from  100°  to  110°  F.  (37.7°-43.3°  C),  and  subsequently 
this  may  be  slightly  reduced.  The  patient  during  the  administration 
of  the  enemata  should  assume  the  dorsal  position  or  that  upon  the  left 
side,  but  in  either  case  with  the  hips  well  elevated,  so  as  to  aid  the 
flow  by  gravitation.  In  amebic  dysentery  warm  injections  of  (juinin 
(strength  1 :  1000-1 :  5000)  have  been  used  with  good  effects  by  some 
authors,  but  with  directly   contrary  effects  by  others. 

Local  means  in  the  form  of  hot  fomentations,  light  poultices,  and 
turpentine  stupes  often  afford  much  comfort.  The  various  complications 
must  be  met  by  appropriate  treatment,  as  under  other  circumstances. 

Chronic  Dysentery. 

This  form  of  the  disease  almost  always  succeeds  an  acute  attack. 
Very  rarely  is  it  chronic  from  the  start,  and  particularly  if  it  be  the 
amebic  variety. 

Pathology. — In  most  instances  the  large  intestine  is  still  the  seat  of 


DYSENTERY.  107 

ulceration.  Some  of  the  ulcers  shoAv  no  signs  of  healing  ;  in  others  this 
process  is  going  on  ;  while  in  still  others  it  is  completed  and  puckered 
cicatrices  are  presented.  The  ulcers  are  deeply  pigmented,  as  is  the 
unulcerated  mucosa,  which  often  presents  a  slate-gray  or  blackish  color. 
The  submucous  and  muscular  coats  are  hypertrophied,  as  a  rule,  with 
occasional  narrowing  of  the  lumen  of  the  bowel,  and  cystic  degeneration 
of  the  intestinal  glands  is  sometimes  observed.  It  is  to  be  noted  that  in 
a  certain,  though  small,  percentage  of  the  cases  ulceration  does  not  occur, 
the  mucosa  everywhere  presenting  an  uneven,  puckered  aspect,  due  to 
deposits  of  fibrous  tissue. 

Symptoms  and  Diagnosis. — Many  of  the  most  characteristic  fea- 
tures of  the  acute  form  are  either  but  feebly  expressed  or  altogether 
wanting.  This  is  particularly  true  of  the  tormina  and  tenesmus.  Cer- 
tain elements  found  in  the  stools  of  the  acute  type  (blood,  shreds  of  pseudo- 
membrane,  and  tissue)  are  also  rarely  present.  True  dysenteric  symp- 
toms, however,  may  arise  during  acute  exacerbations,  with  or  without 
pain'  or  tenesmus ;  then  from  three  or  four  to  a  dozen  or  more  fluid 
dejections  are  passed  daily.  The  latter  are  often  frothy  (when  starchy 
articles  of  food  are  taken),  being  composed  chiefly  of  fecal  matter  and 
undigested  particles  of  food,  with  considerable  mucus  ;  and  in  severe 
forms  blood  and  pus  may  be  constantly  present  in  the  discharges.  In 
many  cases  the  stools  are  semifluid  (pultaceous),  and  rarely  they  contain 
scybala  ;  or  the  rather  frequent  liquid  or  semifluid  discharges  may  alter- 
nate with  constipation.  In  such  instances  the  lesions  are  apt  to  be  situ- 
ated in  the  lowest  portion  of  the  large  intestine.  The  character  of  the 
discharges  is  much  influenced  by  the  sort  of  food  taken  ;  thus  when  a 
mixed  dietary  is  partaken  of,  they  are  thin,  more  frequent,  and  contain 
more  undigested  masses  of  food.  Cfaseous  distention  of  the  intestines  is 
often  an  annoying  symptom. 

The  physical  signs  are  negative,  save  for  slight  tenderness  along  the 
line  of  the  colon. 

Associated  symptoms  referahle  to  other  organs  are  not  without  value 
in  the  diagnosis.  The  gastric  digestion  is  poor,  the  appetite  generally 
impaired  (though  variable),  and  the  tongue  is  clean,  red,  and  glazed, 
presenting  the  appearance  of  raw  beef.  There  are  progressive  emacia- 
tion and  asthenia,  which  eventually  reach  an  extreme  degree.  The  skin- 
surface  becomes  dry,  harsh,  and  cool,  the  facies  grim,  the  pulse  exceed- 
ingly feeble,  the  mental  faculties  greatly  weakened  in  the  advanced 
stage ;  and,  as  in  the  acute  form  so  in  the  chronic,  death  is  usually  due 
to  asthenia — with  this  difference,  that  in  the  latter  the  end  is  reached 
more  slowly.  Rarely  peritonitis  in  consequence  of  perforation  of  the 
bowel  is  the  immediate  cause  of  death. 

Differential  Diagnosis. — The  disease  is  discriminated  from  chronic 
diarrhea.,  often  with  great  difficulty.  In  chronic  dysentery  there  is  the 
history  of  an  antecedent  acute  attack,  with  the  appearance  from  time  to 
time  of  exacerbating  periods  when  mucus,  pus,  and  often  blood  are 
contained  in  the  discharges.  The  latter  are,  at  the  same  time,  more  fre- 
quent and  apt  to  be  accompanied  by  more  or  less  abdominal  pain  and 
tenesmus,  and  the  presence  of  these  features  would  serve  to  eliminate 
chronic  diarrhea.  From  tuberculous  ulceration  of  the  intestines  it  is  dis- 
tinguished by  the  absence  of  any  history  of  tuberculosis,  family  or  per- 


108  INFECTIOUS  DISEASES. 

sonal,  and  of  tuberculous  new  growths  in  other  portions  of  the  body, 
pai'ticularly  the  hmgs. 

The  complications  are  the  same  as  in  acute  dysentery,  if  we  except 
the  greater  liability,  due  to  the  great  and  protracted  weakness  of  the 
patient,  to  certain  serious  intervening  diseases  (chronic  nephritis,  tuber- 
culosis, pneumonia).  Ulceration  of  the  cornea  has  frequently  been 
noted. 

The  duration  is  lon^,  the  disease  lastinnj  for  many  months  or  even 
several  years. 

Treatment. — This  should  be  directed  mainly  to  the  local  condition, 
and  should  consist  in  methodic  irrigation  of  the  bowel  with  a  view  to 
promoting  tlie  healing  of  the  ulcers.  Formerly  it  was  sought  to  accom- 
plish the  latter  indication  by  the  use  of  certain  remedies  internally,  as 
silver  nitrate,  balsam  of  copaiba,  bismuth  subnitrate,  etc.,  but  the  only 
preparation  which  I  have  found  useful  is  the  zinc  oxid  (gr.  v-x — 0.324— 
0.648)  three  times  daily.  The  latter  preparation  is  decidedly  palliative, 
sometimes  even  curative. 

Intestinal  irriiiation  is  to  be  tried,  and  various  disinfectants  and 
astringent  remedies  should  be  alternated  as  advocated  in  the  acute 
form.  Among  individual  remedies  the  silver  nitrate  (gr.  ss-ij — 0.032— 
0.129 — ad  .5j — 32.0)  every  second  day  is  doubtless  the  best.  On  interven- 
ing days  antiseptic  remedies  may  be  used  in  solution,  such  as  mercuric 
chlorid  (1 :  6000)  or  salicylic  acid  (1  to  2  per  cent.) ;  and  of  other  use- 
ful agents  I  mav  mention  tannic  acid,  alum,  acetate  of  lead,  creolin,  and 
quinin  sulphate. 

Prior  to  the  use  of  any  of  the  above-mentioned  enemata  the  bowels 
should  be  well  flushed  with  a  large  injection  of  tepid  water,  so  as  to 
remove  the  fecal  and  other  irritating  materials.  The  same  details  are  to 
be  observed  in  carrying  out  this  mode  of  treatment  as  in  the  acute  forms 
of  dysentery.  Gallay^has  related  the  curative  effects  of  large  enemata 
of  a  solution  of  crystallized  silver  nitrate  in  distilled  water,  a  scruple  to  a 
quart  (1.296  per  liter),  to  which  20  or  30  drops  of  laudanum  have  been 
added.  Amelioration  follows  the  third  or  fourth  washing,  but  a  course 
of  sixty  is  recommended  to  secure  permanent  relief.  I  agree  with  the 
late  Austin  Flint  that  the  lower  part  of  the  rectum  should  be  examined 
with  the  speculum,  and  appropriate  topical  applications  made  if  ulcers  in 
this  situation  be  discovered. 

The  dietetic  treatment  in  chronic  dysentery  is  of  the  utmost  import- 
ance, and  the  lightest  forms  of  albuminous  foods  are  to  be  adhered  to 
strictly,  to  the  exclusion  of  vegetable  substances.  Milk  is  excellent  when 
it  can  be  taken.  It  is  well  to  examine  the  stools,  and  if  on  microscopic 
examination  curds  or  numerous  fat-globules  appear,  the  amount  of  milk 
should  be  reduced  or  skim-milk  substituted.  Other  forms  of  food  that  are 
allowable  and  useful  are  egg-white,  meat-broths  or  beef-juice,  whey,  and 
the  like.  The  patient  should  wear  flannels  next  the  skin,  so  as  to  protect 
against  the  vicissitudes  of  weather,  and,  while  open-air  exercise  is  useful, 
it  should  be  moderate.  During  inclement  weather  the  patient  should 
remain  in-doors.  I  have  known  change  of  climate,  with  proper  regula- 
tion of  the  mode  of  living,  to  be  productive  of  rather  brilliant  results. 

'  "Radical  Cure  for  Chronic  Dvsenterv  of  Recurrent  Tvpe,"  British  Med.  Journal, 
No.  1779,  p.  276. 


CHOLERA.  109 

Tonics  and  alcoholic  stimulants  are  sometimes  required  to  assist  the  appe- 
tite, digestion,  and  systemic  strength,  and  among  the  most  efl&cacious  tonic 
remedies  are  iron,  strychnin,  mineral  acids,  and  arsenic,  which  may  be 
used  in  succession. 


CHOLERA  (EPIDEMIC). 

{Asiatic  Cholera;    Cholera  Algida,  etc.) 

Definition. — Cholera  is  an  acute,  infectious,  epidemic  disease.  Its 
specific  cause  is  the  spirillum  of  Koch,  and  its  most  characteristic  symp- 
toms are  copious  watery  dejections,  painful  cramps,  collapse,  and  suppres- 
sion of  the  excretions.     In  some  localities  it  is  endemic. 

Historic  Note. — During  the  Middle  Ages  cholera  made  deplor- 
able ravages,  chiefly  along  the  belts  of  the  Ganges,  and  has  probably 
been  endemic  in  India  for  centuries.  Only  during  the  present  century, 
however,  has  the  disease  been  widely  known  in  Europe  and  America,  and 
when  it  has  appeared  it  has  always  been  in  the  epidemic  form.  The 
march  of  epidemics  has  been  from  east  to  west,  and  always  along  the  lines 
of  commerce  and  travel  by  land  or  sea,  sometimes  spreading  over  the  en- 
tire globe.  While  interesting,  it  would  not  be  profitable  to  the  student  to 
detail  here  the  progress  of  the  various  epidemics  of  cholera  in  Europe  and 
America.  It  will  suffice  to  state  the  years  in  which  the  chief  of  these 
occurred :  in  1831-32,  in  1835-36,  in  1847-49,  being  brought  by  immi- 
grant ships  from  Europe  ;  in  1852  in  Europe  (touching  our  shores  in  1854 
and  prevailing  extensively) ;  in  1859  (Europe),  in  1866-67  (mild  out- 
breaks in  America),  in  1869-73  (America  in  1873),  in  1884  (in  Europe), 
and  in  1892-93  (abroad).  It  is  seen  that  there  have  been  no  epidemic 
visitations  in  America  since  1873,  though  a  few  small  groups  of  cases 
have  on  several  occasions  been  brought  to  our  shores. 

Pathology. — The  body  is  generally  much  emaciated,  the  features 
sharp  and  drawn,  and  the  skin  of  the  dependent  parts  presents  a  mottled 
appearance.  A  post-mortem  rise  of  temperature  often  occurs.  The  tis- 
sues are  dry,  owing  to  the  draining  of  the  liquids  of  the  body,  and  hence 
putrefaction  is  delayed.  The  kidneys,  liver,  and  heart,  as  well  as  other 
organs  in  a  less  degree,  show  excessive  cloudy  swelling  and  often  consid- 
erable fatty  degeneration  of  the  parenchymatous  tissues.  Rigor  mortis 
comes  on  directly  after  death,  is  persistent,  and  the  muscles  often  con- 
tract so  as  to  cause  the  body  to  assume  various  uncommon  positions. 

The  Visceral  Lesions. — The  chief  of  these  are  confined  to  the  intestinal 
canal,  and  depend  greatly  upon  the  period  of  the  disease  at  which  death 
occurs.  In  the  early  stage  the  serosa  of  the  small  bowel  is  congested, 
presenting  a  roseate  hue.  The  muscularis  is  relaxed.  The  mucosa  is  the 
seat  of  catarrh,  being  deeply  injected,  swollen,  at  times  edematous,  and 
often  coated  in  the  early  stage  with  more  or  less  tough  mucus.  Shortly 
the  coils  of  intestine  are  filled  with  an  almost  transparent  or  slightly  tur- 
bid liquid  ("rice  water"),  and,  occasionally  a  small  amount  of  clotted 
blood  is  seen  in  the  bowel.  The  solitary  follicles  and  Peyer's  patches  are 
at  first  swollen,  and  may  later,  in  rare  instances,  become  ulcerated.     De- 


110  INFECTIOUS  DISEASES. 

nudation  of  the  epithelial  lining — most  probably  a  post-mortem  change — 
is  the  rule,  and  large  or  small  ecchyraotic  spots  are  visible  in  the  intestinal 
mucosa.  If  the  patient  has  died  late  in  the  disease  (stage  of  reaction), 
patches  of  false  membrane  (diphtheritic),  sometimes  dark-brown  in  color 
and  fetid,  may  be  found  anywhere  along  the  intestinal  canal,  though 
chiefly  in  the  large  bowel ;  and  this  secondary  croupous-diphtheritic  pro- 
cess may  attack  other  mucous  surfaces  (bile-ducts,  vagina,  etc.).  The  bacilli 
are  observed  in  the  mucous  membrane  of  the  intestine  and  in  the  dejections. 

The  stomach  shows  changes  similar  in  character  to  those  found  in  the 
intestines.  At  first  the  mucosa  is  congested ;  then,  as  the  result  of  trans- 
udation, it  becomes  filled  with  "rice-water"  material.  Soon  the  hyper- 
emic  mucosa  becomes  swollen  and  ecchymoses  appear.  At  last  the  organ 
is  empty  and  collapsed. 

The  esophagus  also  exhibits  about  the  same  changes,  though  with  an 
absence  of  the  characteristic  transudation. 

The  spleen,  contrary  to  its  condition  in  other  infectious  diseases,  is 
small  as  a  rule,  though  if  death  occur  late  it  may  show  some  degree  of 
enlargement  with  softening. 

The  liver  presents  marked  passive  hyperemia  and  cloudy  swelling, 
with  minute  spots  of  beginning  fatty  change.  Desquamation  of  the 
epithelium  of  the  cystic  mucosa  may  occur  and  lead  to  a  blocking  of  the 
bile-ducts. 

The  kidneys  show  important  lesions,  being  enlarged  from  passive  con- 
gestion, especially  the  cortex,  and  the  capsule  being  somewhat  adherent. 
They  exhibit  cloudy  swelling  and  decided  coagulation-necrosis.  Desqua- 
mation of  the  epithelium  in  the  uriniferous  tubules  is  extensive.  Micro- 
scopically, the  histologic  changes  are  those  of  acute  nephritis  in  the  cases 
in  which  death  takes  place  in  the  advanced  stage. 

The  bladder-changes  differ  in  no  way  from  those  of  other  mucous  mem- 
branes. Its  mucosa  is  congested,  ecchymotic,  and  sometimes  the  seat  of 
diphtheritic  deposit.  The  ui'eters  and  the  pelves  of  the  kidneys  may  also 
present  identical  appearances. 

The  Circulatory  System. — The  pericardium  is  dry,  the  parietal  layer 
being  covered  with  an  adhesive  secretion,  while  the  visceral  layer  is  the 
seat  of  more  or  less  ecchymosis.  The  heart  is  dry  and  anemic-looking. 
The  left  ventricle  is  contracted,  while  the  right  is  often  distended  with 
blood  and  soft  clots,  the  latter  sometimes  extending  to  the  pulmonary 
artery  and  the  superior  and  inferior  vense  cavse.  Outside  of  the  heart 
the  veins,  including  the  cerebral  sinuses,  contain  most  of  the  blood.  The 
latter  is  thicker  than  normal,  and  its  color  darker,  resembling  "the  juice 
of  huckleberries :"  its  specific  gravity,  albumin,  and  corpuscles  are  all 
increased,  while  its  saline  constituents  and  coagulability  are  decreased. 

Respiratory  Organs. — The  larynx,  trachea,  and  bronchi  are  hyperemic, 
and  at  first  covered  with  tenacious  mucus  ;  later  they  may  present  ecchy- 
moses and  diphtheritic  processes. 

When  death  occurs  before  the  sta^e  of  reaction  the  lungs  are  bloodless 
and  collapsed,  and  the  mouth  of  the  pulmonary  artery  may  be  distended 
with  blood.  If  life  is  prolonged  until  the  third  stage,  the  lungs  may  show 
congestion  and  edema  (particularly  at  the  bases)  or  pulmonary  infarction. 
The  post-mortem  of  a  case  in  this  stage,  and  especially  during  convales- 
cence, may  exhibit  the  lesions  of  broncho-  or  lobar  pneumonia. 


CHOLERA.  Ill 

The  brain  and  its  membranes  may  be  the  seat  of  hyperemia,  except 
when  death  takes  place  at  a  late  period,  and  then  the  brain-substance 
may  be  more  or  less  bloodless  and  edematous. 

i^tiology. — The  causes  are  {a)  specific  and  {h)  predisposing. 

(a)  The  specific  cause  is  the  comma  bacillus  of  Koch,  which  is  found 
in  the  intestinal  canal  of  persons  ill  of  cholera.  Recent  investigations 
into  the  bacteriology  of  the  affection  show  that  almost  uniformly  the 
cholera  spirillum  is  associated  with  certain  bacteria,  most  commonly  the 
bacillus  coli  communis.  It  has  also  been  shown  pretty  clearly  that  true 
cholera  is  a  nitrite-'poisomng,  the  result  of  the  growth  of  the  specific 
spirillum.  The  comma  spirillum  is 
not  found  in  any  other  disease.  Its 
form  is  that  of  a  slightly  curved  rod, 
and  its  length  about  half  that  of  the 
tubercle   bacillus,  but   it  is  thicker 

and  sometimes  has  the  form  of  the  v.-^    '^^xAir^y'^^/fjf   /"^  \\ 

letter    S    (Fig.    13).      It   is    to    be      '  }    ^   ^'^S^^rJ^iyr^ '"^^  \ 
classed    as    a    spirocheta,    and    has  ,    ><^^      '^-^^'^S^jS^^ 

been   grown   successfully  on  media  j^      •  J^^^^f^^  • '     ~  » 

of  various  sorts  and  equally  success-  '  X"*^  V^-^e^^^*^    .        */ 


fully  inoculated  upon  inferior  ani-  ♦^  ,  .        ^■.  t      ^ A. 

mals.  'i^te,      "Z^  ?  .              -f-  ■    ■ 

The    organism    is    found    in    a  ^m        .'M*,         ^* 

variety  of  positions — in   the   intes-  '  ^^*«S^      .    * 
tine,  the  dejecta  (even  quite  early), 

and    in    great    profusion     in     the       ^'*'- ^^""^''TtooolHanthe?).*''"  "''"'''^^ ' 
pathognomonic     rice-Avater     stools. 

Kemp  in  his  review  has  shown  that  the  comma  bacillus  is  often  absent 
from  the  evacuations,  and  that  in  these  cases  the  bacterium  coli  is  usu- 
ally present  and  sometimes  streptococci.  He  believes,  however,  that 
the  apparent  absence  is  due  to  faulty  technique.  To  find  it  in  the 
vomitus,  however,  is  rare.  On  the  other  hand,  it  may  be  seen  in  the 
stools  of  well  persons  during  epidemics,  displaying  virulent  proper- 
ties. 

Cholera  spirilla  have  been  repeatedly  found  in  the  outer  world,  and 
almost  invariably  in  water.  C.  Frankel  during  the  European  epidemic 
of  1892  studied  them  in  floAving  water,  and  in  other  epidemic  outbreaks 
they  have  been  found  in  the  water  used  for  drinking-purposes. 

(b)  Predisposing  Causes. — (1)  Locality. — Near  to  the  sea-coast  cholera 
is  more  common  than  in  the  inland  districts  or  towns,  and  the  frequency 
of  occurrence  lessens  with  increasing  altitude,  this  fact  possibly  being 
due  to  a  gradual  decrease  in  soil  humidity  and  porosity. 

(2)  Atmospheric  Temperature. — The  spirillum  of  cholera  can  only 
flourish  in  a  warm  temperature  or  in  a  warm  climate ;  hence  the  dis- 
ease is  endemic  in  certain  tropical  and  subtropical  climates  only ;  and 
hence  we  see  in  temperate  latitudes  the  epidemic  jyrevalenee  of  the  dis- 
ease only,  and  that  during  the  warm  season. 

(3)  Seasons. — From  what  has  been  stated  it  may  be  seen  that  cholera 
can  have  no  permanent  home  except  in  very  warm  climates  in  which  all 
the  other  essential  conditions  prevail.  For  equally  obvious  reasons  it  is 
more   common  in  the  warm   than  in  the  cold  months,  most  epidemics. 


112  INFECTIOUS  DISEASES. 

both  in  Europe  and  America,  having  occurred  toward  the  close  of  sum- 
mer and  in  the  early  autumn. 

(4)  Age,  as  a  rule,  has  no  decided  effect.  It  should  be  stated,  how- 
ever, that  old  people  are  very  prone  to  the  affection.  Sex  is  without 
perceptible  influence. 

(5)  Debilitating  Causes. — Whenever  the  private  conditions  corre- 
spond to  rigid  scientific  re(iuirements  during  epidemic  outbreaks 
cholera  becomes  less  prevalent  and  also  less  virulent.  On  the  other 
hand,  the  deplorable  state  of  municipal  sanitation,  individual  disregard 
of  proper  hygienic  rules,  nervous  depression,  intemperance,  overcrowd- 
ing, etc.  all  predispose  markedly  to  the  disease. 

(6)  Mere  attacks  of  intestinal  disorder  due  to  improper  diet,  cold, 
etc.  are  potent,  and  are  the  sole  agencies  by  means  of  which  the  disease 
is  disseminated. 

Modes  of  Infection. — The  spirilla  leave  the  body  with  the  stools,  but 
the  most  frequent  bearer  of  cholera-poison  is  the  drinking-water.  Natur- 
ally, the  individual  susceptibility  varies  greatly  (many  persons  being 
even  insusceptible),  and  yet  the  degree  of  contamination  of  the  drink- 
ing-water and  the  virulence  of  epidemics  are  almost  strictly  proportion- 
ate. As  an  illustration,  Vienna  had  enjoyed  exemption  from  cholera  for 
nineteen  years — a  fact  attributed  to  the  excellent  quality  of  the  drink- 
ing-water and  to  hygienic  improvements.  In  the  same  city  the  mor- 
tality-rate in  the  more  recent  epidemics  has  been  small  (7  per  1000)  for 
a  like  reason.  On  the  other  hand,  in  1872  there  occurred  in  a  single 
commune  (Hamburg),  which  had  a  polluted  water-supply  (the  Elbe)  and 
no  filtration  plant,  17,862  cases,  with  the  enormous  death-rate  of  42.3 
per  cent.  Biernacki  demonstrated  the  presence  of  spirilla  in  the  spring- 
water  of  a  house  in  which  13  cases  of  cholera  occurred. 

The  choleraic  poison  may  be  conveyed  with  the  water  used  for  washing, 
cooking,  and  other  purposes  to  other  fluids  imbibed  b}'  man  (beer,  milk, 
tea,  etc.),  and  also  to  food-stuffs  taken  by  him  (lettuce,  cresses,  and 
other  raw  vegetables,  fruits,  meats,  bread,  butter,  etc.).  The  organisms 
live  and  maintain  their  virulence  on  these  articles  of  food  from  four  to 
seven  days  at  least.  The  infection  may  reach  the  esophagus  with  the 
water  used  for  washing  the  mouth  or  teeth,  or  that  used  for  washing  the 
utensils,  dishes,  food-receptacles,  etc.  Again,  the  hands,  commonly 
those  of  laundresses  and  nurses,  may  become  soiled  in  the  careless 
handling  of  bed-linen  or  garments  worn  by  cholera  patients  or  the  stools, 
and  convey  the  poison  to  the  mouth  or  lips,  to  be  carried  into  the 
stomach  along  Avith  the  drink  or  food.  It  is  quite  possible  that  flies 
may  transfer  the  infectious  element  to  food-articles  (Simmonds). 

Cholera  is  not  contagious  from  mere  contact  with  those  ill  of  the 
disease.  The  disease  is  not  ac(iuired  by  inhalation  (Shakespeare),  and, 
since  desiccation  rapidly  kills  the  .spirillum,  there  is  little  probability 
that  the  latter  is  wafted  by  the  wind-currents  or  is  air-borne.  Nor  is 
there  any  clinical  evidence  to  show  that  the  poison  may  enter  the  sys- 
tem through  the  skin-surface.  Probably  the  germs  are  swallou'ed,  and 
the  acid  gastric  juice  may  then  destroy  them  if  the  size  of  the  dose  of 
the  poison  is  not  too  large,  or  a  sufficient  number  may  pass  into  the 
intestinal  canal  and  there  manifest  pathogenic  powers.  It  is  to  be  borne 
in  mind  that  after  the  spirillum  reaches  the  intestine,  whether  or  not  an 


CHOLERA.  113 

attack  of  cholera  is  the  result  depends  both  upon  the  size  of  the  poison- 
ous dose  and  upon  the  personal  degree  of  immunity. 

Opposed  to  the  drinking-water  theory  of  this  disease  is  that  of  Pet- 
tenkofer,  which  contends  that  the  spirilla  found  in  the  serous  evacua- 
tions of  cholera  patients  must  enter  an  appropriate  soil  and  there  under- 
go further  development  before  becoming  truly  pathogenic.  While  soils 
possessing  a  certain  degree  of  moisture  and  perviousness  and  contami- 
nated with  organic  matter  favor  the  growth  and  multiplication  of  the 
specific  organism,  these  telluric  conditions  are  not  essential,  as  is  shown 
by  the  virulence  of  the  intestinal  discharges  when  swallowed  in  ample 
quantity.  Pettenkofer  also  claims  that  the  fully  developed  poison  rises 
from  the  subsoil  into  the  lower  atmospheric  strata  as  a  miasm,  especially 
at  the  time  of  the  subsidence  of  the  ground-water  level  in  summer. 

Immunity  is  not  conferred  by  a  previous  attack  of  cholera.  Pfeifier 
and  Marx  have  proved  the  existence  in  the  blood-serum  of  human  beings 
of  bactericidal  bodies  (not  a  true  antitoxin)  that  cause  rapid  destruction 
of  the  cholera  bacilli.  To  these  anti-bodies  is  ascribed  the  "  Pfeiffer  serum 
reaction,"  by  means  of  which  the  vibrios  are  differentiated  from  other 
micro-organisms.  Pfeiffer  and  Marx  have  also  shown  that  the  virus  of 
cholera  can  be  effectively  preserved  by  a  0.5  per  cent,  solution  of  car- 
bolic acid,  and  that  it  in  no  way  impairs  its  immunizing  properties. 

Clinical  History. — The  incubation  period  varies  from  a  few  hours 
to  five  days.  During  this  prodromal  period  the  patient  is  either  quite 
well  or  (during  the  latter  portion)  exhibits  certain  local  symptoms.  These 
are  occasionally  nausea,  a  feeling  of  distress  in  the  abdomen,  increased 
peristalsis  which  may  be  visible  or  palpable,  slight  pain  and  tenderness, 
and  either  a  mild  or  a  decided  diarrhea.  The  discharges  are  feculent, 
colored,  and  semifluid,  or  more  rarely  quite  fluid,  and  may  be  quite 
copious.  These  symptoms  ma}^  all  be  present,  though  oftener  a  few, 
and  rarely  a  single  one,  is  noted  ;  moreover,  they  are  not  distinctive 
unless  seen  during  an  epidemic  and  unless  the  patient  have  been  exposed 
to  the  poison.  Prostration  may  be  rarely  marked  and  there  may  be 
slight  muscular  cramps.  The  so-called  premonitory  diarrhea  may  ter- 
minate in  recovery  at  the  end  of  from  one  to  three  days  ;  but  if  not,  it  is 
followed  by  an  attack  of  true  cholera.  This  has  three  stages:  the  stage 
of  serous  diarrhea,  the  algid  stage  or  collapse,  and  the  stage  of  reaction. 

(1)  Stage  of  Serous  Diarrhea. — The  dejections  are  generally  painless, 
very  frequent,  odorless,  copious,  and  fluid  or  watery,  and  usually  present 
the  characteristic  "  rice-water  "  appearance.  Rarely  they  are  distinctly 
colored  with  bile,  and  in  severe  cases  with  blood,  and  rarely  also  are  they 
frothy.  Suspended  in  them  are  numerous  small,  whitish,  mucous  flakes  ; 
their  reaction  is  neutral  or  alkaline,  and  they  contain  a  small  percentage 
of  solid  constituents  made  up  largely  of  albumin  and  sodium  chlorid. 
The  microscope  brings  to  view  epithelium,  mucus,  triple  phosphates,  and 
numberless  micro-organisms,  of  Avhich  latter  the  only  ones  characteristic 
are  the  comma  bacilli  (spirilla)  of  Koch.  In  cholera  sicca  these  serous 
evacuations  are  absent.  Death  comes  quickly,  and  post-mortem  exami- 
nation shows  the  intestine  to  be  filled  with  rice-water  material,  which  is 
probably  retained  because  of  speedy  paralysis  of  the  musculature. 

Gastric  symptoms  appear  early.  Vomiting  soon  becomes  frequent, 
and  at  first  the  vomitus  may  be  bilious ;  later  it  is  characteristically 

8 


114  INFECTIOUS  DISEASES. 

serous  and  excessive  in  amount.  Thirst  is  almost  intolerable,  anorexia 
is  complete,  and  the  tongue  often  has  a  thick  coating  which  early 
becomes  dry.  Gastro-intestinal  pain  is  not  severe,  but  a  feeling  of  press- 
ure or  burning  in  the  abdomen  is  experienced,  and  occasionally  there 
are  griping  pains  with  tenesmus.  The  physical  sU/ns  are  few.  The 
belly  is  usually  flat  and  flaccid,  though  it  may  be  scaphoid  and  hard, 
and  in  some  cases  palpation  detects  fluctuation. 

Painful  cramjys  in  the  muscles  form  an  early  characteristic  symptom. 
They  affect  the  voluntary  muscles  of  the  legs,  calves,  and  feet,  more 
rarely  the  arras  and  hands  also.  Their  duration  is  momentary,  but 
they  recur  at  intervals,  and  are  due  to  the  local  action  of  the  toxins. 

Owing  to  the  withdrawal  of  fluid  from  the  lymphatics  and  blood- 
vessels the  tissues  become  dry  and  shrivelled  and  the  blood  much  thicker. 
This  condition  of  the  blood  obviously  increases  the  labor  of  the  heart, 
which  beats  rapidly,  and  there  may  be  at  first  a  distressing  palpitation  ; 
but  soon  the  heart  grows  more  and  more  feeble  and  venous  stasis  ensues. 
The  pulse  is  at  first  rapid,  soft,  and  small ;  it  may  then  be  lost  at  the 
wrist.  The  cardiac  impulse  and  heart-sounds  may  disappear  with  in- 
creasing asthenia. 

The  fades  and  general  appearance  also  indicate  loss  of  fluid.  The 
cutaneous  surfaces  of  the  face  and  extremities  grow  cool:  there  is  rapid 
general  emaciation,  which  may  become  mo.«t  pronounced,  and  the  skin  is 
wrinkled.  The  complexion  assumes  a  livid  or  blue-gray  tint,  while  the 
lips  become  quite  dark.  The  extremities  are  cyanotic  (the  finger-tips  in 
particular),  the  orbits  are  deeply  sunken,  the  cheeks  hollow,  the  features 
intensely  pinched,  the  voice  husky  and  feeble,  and  there  is  utter  prostra- 
tion. The  surface-temperature  drops  below  the  normal,  even  to  96°  or 
95°  F.  (35.5°-35°  C),  while,  per  contra.,  the  internal  or  rectal  tempera- 
ture rises -to  102°  F.  (38.8°  C.)  or  over.  The  mind  may  remain  clear 
until  the  close,  but  oftener  the  patient  is  apathetic,  and  in  grave  cases  this 
condition  may  deepen  into  stupor  or  even  actual  coma.  The  reflexes  are 
greatly  diminished;  restlessness  and  jactitation  may  rarely  appear. 

The  urine  becomes  very  scanty  and  is  highly  concentrated,  the  stand- 
ing specimen  depositing  a  heavy  sediment.  On  analysis  albumin  and 
casts  (chiefly  granular)  are  found.  In  the  serious  forms  the  kidneys  fail 
to  eliminate  tlic  urea,  :iii(l  tlicrc  is  finally  complete  anuria. 

(2)  Stage  of  Algidity  or  Collapse. — The  symptoms  which  characterize 
this  grave  condition  are  the  same  as  those  noted  under  the  latter  part  of 
the  first  stage,  only  intensified.  Asthenia  is  extreme ;  the  pulse  is  miss- 
ing and  the  heart  beats  faintly;  the  voice  is  lost;  respirations  are  per- 
ceptibly shallow  ;  lividity  is  intense ;  the  surface  ice-cold  ;  and  there  is 
usually  stupor  or  even  coma.  The  excessive  serous  discharges  have  given 
place  to  more  dribblings  from  the  now  relaxed  anus.  During  this  stage, 
which  may  last  a  few  or  many  hours,  the  faint  glimmerings  of  the  vital 
spark  are  often  extinguished. 

(3)  Stage  of  Reaction. — This  sets  in  promptly,  and  when  reaction  fol- 
lows the  first  stage  directly  the  case  may  pursue  a  favorable  course,  with 
return  to  accustomed  health  by  the  end  of  a  week  or  ten  days.  The 
first  urine  passed  is  usually  albuminous  and  contains  tube-casts  and  some- 
times blood-cells.  Relapses  into  the  stage  of  collapse  may  occur  and  be 
repeated ;  in  many  instances,  however,  this  stage  is  bo^h  protracted  and 


CHOLERA.  115 

dangerous.  It  is  aptly  termed  cholera  tyj)hoid,  since  a  genuine  typhoid 
state  of  the  system  with  more  or  less  fever  develops.  The  skin  may  pre- 
sent so-called  choleraic  eruptions  (macular,  roseolar,  erythema,  purpura). 
Recovery  may  now  take  place,  or  a  great  diversity  of  local  secondary 
inflammations  may  supervene  {vide  Complications). 

Acute  nephritis,  which  may  or  may  not  be  an  essential  part  of  the 
process,  may  arise  in  this  stage  and  lead  either  slowly  or  directly  to 
uremic  poisoning,  as  shown  by  the  projection  upon  the  scene  of  grave 
nervous  phenomena — headache,  vomiting,  delirium  or  coma,  and  con- 
vulsions.    A  fatal  result  may  be  looked  for. 

Complications. — In  this  place  are  to  be  enumerated  the  conditions 
due  to  secondary  infection,  including  (commonly)  septic  and  pyemic 
processes.  Diphtheritic  inflammations  afi"ecting  mucous  surfaces,  but 
especially  the  throat,  colon,  and  the  external  genitals,  are  among  the 
more  common.  Bronchitis,  pneumonia,  and  pleurisy  may  arise,  and 
erysipelas  and  parotitis  are  not  rare.  During  convalescence  digestive 
disorders  may  show  themselves,  and  indiscretions  in  diet  may  precipi- 
tate a  relapse. 

Clinical  Types. — («)  "Premonitory  Diarrhea." — This  type  has  been 
outlined  in  the  foregoing  discussion,  and  will  not  need  further  description. 

{b)  "  Cholerine,"  in  Avhich  the  symptoms  are  similar  to  those  of  cholera 
nostras.  Many  of  the  symptoms  characteristic  of  true  cholera  are  also 
present,  particularly  the  cramps  and  prostration,  cold  extremities,  and 
scanty  albuminous  urine.  The  stools,  however,  are  not,  as  a  rule,  typical 
of  the  disease,  but  are  feculent  in  character,  as  in  ordinary  cholera  mor- 
bus.    The  duration  is  from  seven  to  ten  days,  subject  to  relapses. 

((?)  The  more  typical  forms — both  moderate  and  severe — have  been 
described  under  the  Clinical  History  {supra). 

(d)  The  Foudroyant  or  Asphyxia  Form. — This  may  kill  instantly  ; 
more  frequently  the  patient  lives  for  a  few  hours,  with  or  without  vomit- 
ing and  purging,  Qholera  sicca  should  be  classed  with  this  type.  The 
virulence  of  the  cholera-poison  explains  the  intensity  of  the  symptoms. 

Differential  Diagnosis. — This  is  difiicult  in  the  absence  of  an 
epidemic  unless  bacteriologic  and  microscopic  tests  be  made,  and  yet 
these  alone  difi"erentiate  a  sporadic  case.  The  disease  most  commonly 
mistaken  for  cholera  (especially  cholerine)  is  cholera  viorhus,  and  the  fol- 
lowing points  pertaining  to  the  latter  disease  will  eliminate  it :  1.  jS^o 
connection  with  a  previous  case,  but  a  frequent  history  of  dietetic  impru- 
dence. 2.  Absence  of  "rice-water"  stools,  which  remain  turbid  with 
feces  or  covered  with  bile  or  blood.  3.  Presence  of  colicky  pains,  but 
absence  of  painful  tonic  cramps  of  legs  and  feet.  4.  Absence  of 
cyanosis  and  collapse,  as  a  rule,  and  of  urinary  suppression.  5.  No 
cholera  spirilla  in  the  stools. 

Arsenic-poisoning  and  other  forms  oi  g astro-enteritis  must  be  discrimi- 
nated by  the  history,  the  character  of  the  stools,  the  absence  of  violent 
muscle-cramps  and  of  the  efi"ects  of  great  loss  of  fluid  (cyanosis,  shrunken 
body,  profound  collapse,  etc.).  Chemical  tests  are  not  to  be  neglected  if 
the  history  points  to  any  form  of  corrosive  poisoning. 

Prognosis. — This  is  dependent  mainly  upon  the  type.  Thus  "  chol- 
erine "  is  very  rarely  fatal,  while,  on  the  other  hand,  the  asphyxic  form  is 
almost  as  rarely  survived.    It  is  impossible  to  state  the  average  mortality. 


116  INFECTIOUS  DISEASES. 

since  it  varies  with  each  epidemic,  but  it  has  been  found  to  range  from  20 
to  80  per  cent.  Many  deaths  occur  during  the  latter  part  of  the  first 
day  or  during  the  algid  period ;  still  more  during  the  stage  of  reaction, 
the  dangers  of  the  latter  period  being  as  follows :  asthenia,  cholera 
nephritis  with  uremia,  and  the  various  complications  {vide  supra).  The 
personal  circumstances  which  render  an  attack  grave  are  old  age,  alcohol- 
ism, previous  ill-health,  and  debility.  On  the  other  hand,  the  death-rate 
may  readily  be  lowered  by  prompt  and  judicious  treatment. 

Treatment. — Prophylaxis. — Prevention  is  of  greater  importance  than 
cure,  and  is  easily  accomplished  as  compared  with  the  eradication  of  the 
disease.  It  has  been  owing  in  great  measure  to  the  efficient  quarantine 
system  of  the  United  States  that  cholera  has  not  gained  a  foothold  on  our 
shores  since  1873. 

Individual  Prophylaxis. — In  the  first  place,  those  nursing  the  sick 
can  prevent  the  spread  of  cholera  by  prompt  and  thorough  disinfection  of 
the  vomitus  and  stools,  as  Avell  as  of  the  receptacles  containing  them  and 
anything  that  may  be  soiled  by  them.  The  dejecta  may  be  disinfected 
by  pouring  upon  and  mixing  with  them  an  equal  part  of  a  5  per  cent, 
solution  of  carbolic  acid  or  an  equal  volume  of  a  freshly  prepared  solution  of 
chlorid  of  lime.  The  discharges  thus  treated  must  be  covered  and  allowed 
to  stand  from  fifteen  minutes  to  half  an  hour,  and  then  emptied  into  a  pit 
in  the  earth  containing  quicklime,  with  which  they  should  also  be  covered. 
It  is  of  the  utmost  importance  to  guard  against  a  pollution  of  the  water- 
supply  by  these  pits.  Soiled  clothing,  linen,  etc.  should  be  promptly 
disinfected,  and  bedding  had  better  be  burned ;  none  but  the  attendants 
should  be  permitted  to  enter  the  sick-room.  The  dishes  used  should 
be  disinfected  immediately  after  use  or  before  leaving  the  sick-chamber. 
Shakespeare  further  recommends  that  the  remains  of  the  patient's  meals  . 
should  be  disinfected  and  destroyed.  After  handling  the  patient  or  any- 
thing that  he  has  soiled  the  attendants  should  first  disinfect  and  then 
carefully  wash  their  hands,  these  ablutions  being  performed  invariably 
before  eating.  After  vomiting  and  after  an  evacuation  of  the  bowels  the 
mouth  and  the  parts  around  the  anus  should  be  wiped  with  a  cloth  wet 
with  a  solution  (1 :  2000)  of  mercuric  chlorid.  If  convalescence  super- 
vene, the  patient  should  be  kept  isolated  for  a  week  and  the  stools  should 
be  disinfected  during  that  time. 

Persons  exposed  should  use  boiled  milk  and  water  only.  Certain 
forms  of  food  must  be  avoided,  especially  salads  and  unripe  fruits ;  also 
alcoholic  stimulants.  All  uncooked  food  may  be  pernicious.  Such  per- 
sons should  lead  regular  lives,  avoiding  fatigue,  excesses,  etc.,  and  in- 
testinal disturbance  must  be  met  speedily  by  the  use  of  antiseptics, 
opiates,  and  astringents.  In  India,  Ilaffkine^  has  used  a  protective  virus 
with  encouraging  results.  Thus,  "  of  1735  persons  not  inoculated  in  a 
certain  section,  174  took  the  disease  and  113  died,  whereas  of  500  inoc- 
ulated but  21  were  aifected  and  19  died."  Pie  has  made,  altogether, 
70,000  injections  in  40,000  patients  without  a  single  accident,  and  claims 
that  the  results  have  been  entirely  favorable.  Behring  and  Ransom  have 
also  succeeded  in  obtaining  an  antitoxic  scrum.  Klein  concludes  against 
Half  kine's  anticholera  inoculations,  showing  that  there  is  no  certainty 
as   to  the   protection   against  the  specific  poison  in  the  intestines,  even 

'  Miinch.  med.  WocL,  Jan.  29,  1895. 


CHOLERA.  117 

though  there  may  be  protection  against  the  effect  of  intracellular  poison. 
Klemperer  has  produced  immunity  by  using  a  toxin. 

Treatment  of  the  Attack. — (a)  Premonitory  Diarrhea. — When  the 
prodromal  period  exists  it  must  be  quickly  combated,  and  if  this  were 
attended  to  appropriately  few  cases  of  cholera  would  follow.  In  the 
instances  which  are  not  preceded  by  premonitory  diarrhea  opportunity  to 
prevent  the  attacks  does  not  present  itself.  In  this  stage  a  double  indi- 
cation is  presented — "  to  restrain  the  development  of  the  bacilli  in  the 
intestine  and  to  neutralize  the  cholera-poison."  To  meet  this  Cantani 
proposes  tannic  acid  by  irrigation  (enteroclysis).  He  injects  into  the  in- 
testine ^  to  2-|-  quarts  (liters)  of  water,  or  infusion  of  chamomile  contain- 
ing siss  to  3v  (6.0  to  20.0)  of  tannic  acid,  gtt.  xx  to  xxx  (1.20)  of  laud- 
anum, and  3v-xij  (20.0-50.0)  of  gum  arabic.  The  temperature  of  the 
liquid  should  be  80°-104°  F.  (26.6°-40°  C),  in  order  not  to  chill  the 
patient.  Injections  should  be  repeated  four  times  a  day,  and  in  grave 
cases  after  each  evacuation.^  To  this  should  be  added  a  regulated  liquid 
diet,  with  rest  and  recumbency.  For  the  same  purpose  acetate  of  lead 
and  opium,  or  large  doses  of  bismuth  with  or  without  Dover's  powder, 
have  been  much  employed  with  good  results. 

(h)  Stage  of  Serous  Diarrhea. — The  chief  indication  is  to  restore  to 
the  blood  the  watery  elements  withdi'awn  by  the  diarrhea.  Not  a  moment 
is  to  be  wasted.  Opium,  and  preferably  the  salts  of  morphin,  should  be 
administered  hypodermically,  the  dose  not  being  small,  but  gr.  |-  to  ^ 
(0.0162—0.0216)  to  be  repeated  at  intervals  of  about  eight  hours.  To 
opium  given  per  oram.  or  in  the  usual  way  there  is  a  serious  objection — 
namely,  its  slowness  of  action.  Cantani  advocates  the  injection  of  an 
artificial  serum  [Jiypodermoclyns)  containing  1  dram  (4.0)  of  sodium 
chlorid  and  gr,  xlvj  (3.0)  of  sodium  carbonate  per  quart  (liter)  of  ster- 
ilized water  warmed  up  to  104°  F.  (40°  C.)  into  the  subcutaneous  con- 
nective tissue.  This  solution  may  be  introduced  through  the  cannula  of 
an  ordinary  aspirator,  the  fluid  flowing  by  gentle  pressure.  Shakespeare 
recommends  for  hypodermoclysis  a  fountain  syringe  with  a  long  flexible 
tube  furnished  with  a  cock  ;  with  another  shorter  tube,  one  end  attached 
to  the  cock,  the  other  having  a  needle-pointed  cannula,  a  little,  longer, 
stronger,  and  with  a  somewhat  wider  caliber  than  the  ordinary  hypo- 
dermic needle  (Fig.  14).  The  tube  and  cannula  are  first  perfectly  filled 
with  a  fluid,  and  then  the  cannula  is  inserted  well  in  between  the  skin 
and  deep  fascia  of  the  flanks,  buttocks,  or  interscapular  region.  The 
fluid  should  be  made  to  flow  slowly,  allowing  fifteen  to  twenty  minutes 
for  the  introduction  of  one  quart.  This  is  preferred  to  intravenous  injec- 
tion, in  which  the  liquid  is  difirised  slowly.  The  indications  presented 
by  the  premonitory  stage  must  be  met  as  above  stated. 

The  vomiting  is  to  be  relieved  by  bits  of  ice,  small  amounts  of  brandy 
and  water  at  brief  intervals,  cocain,  or  by  lavage.  In  this  stage  reme- 
dies by  the  mouth  should  be  avoided,  since  they  aggravate  the  gastric  dis- 
turbance. Heat  should  be  applied  externally  with  a  view  to  assisting  the 
peripheral  circulation  as  well  as  the  reaction,  and,  on  the  other  hand,  to 
obviate  collapse.  Warm  baths  have  been  recommended  for  this  pur- 
pose. Stimulants  must  be  used  to  fulfil  the  same  indications.  They  are 
of  superior  value  even  to  the  above-mentioned  measures,  and  are  to  be 

^  Annual  of  the  Universal  Medical  Sciences,  1893. 


118 


INFECTIOUS  DISEASES. 


given  hypodermically,  and  either  brandy,  ammonia,  or  strychnin  may  be 
employed  in  large  doses. 

(c)  Stage  of  Algidity. — If  this  develop,  the  case  is  desperate.  In 
this  stage  the  following  measures  and  procedures,  Avhich  have  been  de- 
tailed in  the  treatment  of  the  preceding  stage,  are  to  be  persevered  with : 


Fig.  14.— 1,  fountain  svringre ;  2,  cuck  :  ",  attachment  for  cannula ;  4,  needle :  5,  cannula ;  6,  soft- 
rubber  rectal  tube,  with  two  lateral  opeuiuf.'s.  one  a  half  inch  from  the  end  (not  visible),  the  other 
two  inches  from  the  end.  The  latter  is  to  be  introduced  by  a  combined  rotatory  and  pushing 
motion  to  the  depth  of  ten  inches  in  enteroclysis,  and  the  fluid  then  allowed  to  enter  the  colon 
slowly. 

enteroclysis  and  hypodermoclysis,  hypodermic  stimulation,  and  the  ex- 
ternal application  of  heat.  Additionally,  intravenous  injections  of  fluids 
have  been  strongly  urged  by  its  champions.  For  this  purpose  the  fol- 
lowing standard  of  saline  fluid  may  be  chosen  :  sodium  bicarbonate  1 
part,  sodium  chlorid  6  parts,  boiled  Avater  1000  parts.  The  temperature 
of  the  fluid  when  injected  varies  according  to  circumstances  from  1004° 
to  104°  F.  (38°-40°  C),  more  frequently  the  latter  (Shakespeare). 
The  quantity  demanded  may  be  1  or  2  quarts  (liters),  and  the  injec- 
tion may  need  to  be  repeated  in  from  one  to  three  or  four  hours. 
Despite  the  physician's  best  efforts,  patients  in  this  period  usually 
succumb. 

(d)  Stage  of  Reaction. — During  this  stage  the  tannic  acid  may  be 
replaced  by  a  solution  of  salt  in  water  (10  or  15  per  cent.)  for  entero- 
clysis (Cantani),  and  it  may  be  well  to  continue  hypodermoclysis  in  some 
instances.  Further  than  this,  the  treatment  is  essentially  symptomatic. 
Food  of  the  blandest  sort  and  in  small  (|uantities  must  be  allowed  at 
fre(iuent  intervals  if  we  would  avoid  enteritis  and  other  unfavorable  com- 
plications. Tonic  remedies  should  be  given  cautiously,  and  rest  and 
careful  nursing  insisted  upon.  Complications  must  be  met  in  accordance 
with  general  principles. 


YELLOW  FEVER.  119 

YELLOW  FEVER. 

[Febris Jiava ;   Gelbjieber,  Ger.) 

Definition. — Yellow  fever  is  an  acute,  highly  infectious  (but  non- 
contagious) endemic  and  epidemic  disease.  It  is  characterized  by  a  sharp 
period  of  invasion,  followed  by  a  period  of  remission,  and  the  latter  in  turn 
by  a  relapse  and  certain  symptoms  peculiar  to  the  affection  (black  vomit, 
jaundice,  suppression  of  urine). 

Historic  Note. — Yellow  fever  is  endemic  only  Avithin  certain  geo- 
graphic limits,  where  it  also  prevails  epidemically  when  the  conditions 
are  favorable.  According  to  general  belief,  it  first  appeared  in  1647  in  the 
Barbadoes  (West  Indies).  Subsequently,  it  was  conveyed  along  the  chan- 
nels of  commerce  until  it  became  widely  disseminated,  and  chiefly  in  sea- 
port towns.  In  169&  an  English  vessel  carrying  slaves  transported  the 
disease  to  Mexico  from  the  Atlantic  coast  of  Africa.  Guiteras  classified 
the  areas  of  infection  thus :  (1)  The  focal  zone,  in  which  the  disease  is 
never  absent,  including  Havana,  Vera  Cruz,  Rio,  and  other  Spanish- 
American  ports.  (2)  Perifocal  zones,  or  regions  of  periodic  epidemics, 
including  the  ports  of  the  tropical  Atlantic  coast  in  America  and  Africa. 
(3)  The  zone  of  accidental  epidemics,  between  the  parallels  of  45°  N.  and 
35°  S.  latitude.  Yellow  fever  was  brought  to  the  United  States  (Boston) 
in  1693,  and  since  then  has  invaded  in  epidemic  form  numerous  sea-coast 
cities,  being  carried  thence  to  a  number  of  inland  towns.  The  belief  that 
the  disease  never  originates  outside  of  certain  territorial  limits  was  ad- 
vanced for  the  first  time  by  the  College  of  Physicians  of  Philadelphia 
(1797),  and  the  efficacy  of  rigid  quarantine  regulations  in  preventing  con- 
veyance of  the  poison  by  vessels  having  yellow-fever  cases  on  board  was 
pointed  out  by  the  same  organization. 

Pattiology. — The  skin  is  jaundiced  (hepatogenous)  and  often  large 
or  small  ecchymotic  spots  are  observed,  but  neither  the  internal  viscera 
nor  the  blood  shows  characteristic  lesions  in  cases  of  average  intensity. 
In  severe  forms  congestion,  hemorrhage,  and  degeneration  are  the  changes 
noted,  especially  in  the  liver  and  the  gastro-intestinal  mucous  membranes. 

After  death  the  liver  is  anemic,  as  a  rule,  but  in  the  early  stages  of 
the  disease  it  is  markedly  hypei-emic.  Its  color  varies,  ranging  from  pale 
yellow  to  an  orange  hue,  and  punctiform  extravasations  cause  mottling  of 
the  surface.  Its  size  varies  little  from  the  normal.  Parenchymatous  de- 
generation of  the  hepatic  tissue  is  common,  though  in  places  it  may  be 
entirely  normal.  The  liver-cells  are  swollen,  containing  fat  and  granular 
matter  with  indistinctness  or  absence  of  nuclei. 

The  gastro-intestinal  mucosa  is  the  seat  of  numerous  minute  hemor- 
rhages, similar  spots  of  extravasation  being  found  on  the  various  serous 
membranes  of  the  body  (meninges,  pericardium,  pleura,  etc.).  Hemor- 
rhagic infarctions  may  be  found  in  the  various  internal  viscera.  The 
lesions  of  acute  catarrh  are  seen  in  pronounced  form  in  the  gastric  mucosa, 
which  may  also  present  erosions.  The  black-vomit  material  is  found  in 
the  stomach,  and  less  frequently  also  in  the  smaller  intestines,  which  pre- 
sent the  evidences  of  acute  catarrh  of  their  mucous  walls. 

The  spleen  is  dark  and  friable,  but  is  not  enlarged.  The  kidneys 
show  the  lesions  of  parenchymatous  nephritis,  the  microscope  revealing 


120  INFECTIOUS  DISEASES. 

cloudy  swelling  of  the  epithelium  of  the  tubules  with  fatty  degeneration, 
and  the  tubules  themselves  being  occupied  by  casts,  chiefly  granular. 
The  heart-muscle  looks  pale,  and  may  be  the  seat  of  granular  and  fatty 
degeneration.  The  brain  and  its  meninges  are  hyperemic,  and  degenera- 
tive changes  have  been  described  in  the  sympathetic  ganglia  (Schmidt). 

The  blood  is  dark,  and  many  of  the  red  corpuscles,  having  disorganized, 
set  free  hemoglobin,  as  in  malaria.  Certain  significant  lesions  of  a  gen- 
eral character — such  as  a  fatty  degeneration  of  the  walls  of  the  small 
blood-vessels  and  the  capillaries — have  been  noted  by  competent  ob- 
servers, and  these,  by  allowing  filtration  of  blood-serum  through  the  vessel- 
walls,  may  account  in  great  measure  for  the  concentration  of  the  blood. 

Btiology. — Bacteriology. — J.  Sanarelli  has  described  a  specific  organ- 
ism of  this  disease,  and  named  it  the  bacillus  icteroides.  It  is  a  slender 
rod,  from  2  //  to  4  jx  long,  motile  and  ciliated  ;  it  decolorizes  by  Gram's 
method,  and  grows  upon  various  media  at  room-temperatures.  It  has  little 
resistance  to  moist  heat,  but  strongly  resists  dry  heat,  desiccation,  and 
sea-water.  This  micro-organism  is  not  detectable  in  all  cases,  especially 
in  the  cadaver,  for  the  reason  that  in  the  majority  of  cases  secondary 
infection  with  the  streptococci  and  staphylococci  occurs. 

The  organism  is  pathogenic  for  most  lower  animals,  and  produces  the 
symptoms  (fever,  vomiting,  heniatemesis)  as  well  as  the  characteristic 
lesions  of  the  disease. 

Among  predisposing  causes,  season  heads  tlie  list.  The  disease  prevails 
chiefly  in  summer,  being  completely  arrested  by  one,  or  at  most  tw^o,  se- 
vere frosts.  The  affection  is  to  a  far  greater  degree  under  the  influence 
of  the  temperature  tlian  of  any  other  meteorologic  element,  re(|uiring,  as 
it  does,  at  least  72°  F.  (22.2°  C).  The  persistence  of  the  disease  on 
board  ships  is  due  to  the  combined  presence  of  humidity,  heat,  darkness, 
and  lack  of  air.  The  poison  is  more  virulent  at  night  than  in  the  day- 
time;  and  unhygienic  conditions  (overcroAvding,  filthiness,  ill-ventila- 
tion) predispose.  Age  and  race  have  some  degree  of  influence,  children 
being  more  liable  than  adults,  males  than  females,  and  whites  than 
blacks.  Other  factors  worthy  of  special  mention  arc — intemperance, 
pliysical  exhaustion,  sexual  excesses,  fear,  depressing  ^notions,  etc.  The 
poison  may  be  carried  to  short  distances  by  currents  of  air,  and  may  be 
transferred  over  any  distance  hj  fomites — clothing,  baggage,  letters,  and 
packing-cases  being  the  most  frequent  carriers.  The  march  of  an  epi- 
demic may  be  interrupted  or  even  completely  arrested  by  apparently 
trivial  agencies — e.  g.  watercourses,  rows  or  clumps  of  shrubbery  or 
underbrush,  high  fences  or  walls,  and  so  on.  One  attack  usually 
bestows  permanent  immunitjj,  and  natives  of  an  infected  district  are  far 
less  liable  to  the  disease  than  newcomers. 

Clinical  History. — Incubation  Stage. — This  varies  greatly,  ranging 
from  one  day  to  two  or  even  three  weeks.  During  the  incubation  certain 
general  symptoms  may  appear,  such  as  languor,  headache,  anorexia,  etc., 
lasting  several  days. 

Invasion  Stage. — The  onset  is  abrupt,  an  initial  chill  usually  occurring, 
but  it  is  very  seldom  severe  or  prolonged,  a  reactionary  fever  following 
promptly  and  the  temperature  rising  to  103°,  104°,  or  even  105°  F. 
(40.5  C).  The  temperature  is  apt  to  be  highest  at  the  beginning,  and 
then  falls  gradually,  hyperpyrexia  being  rare.     The  chill  and  fever  are 


YELLOW  FEVER.  121 

accompanied  by  headache  and  pains  in  the  loins  and  legs,  often  of  great 
severity,  and  a  little  later  restlessness,  mental  confusion,  and  a  delirium 
that  is  sometimes  violent  in  character  may  develop.  In  the  majority  of 
instances,  however,  the  mind  remains  clear.  The  pulse  is  accelerated, 
but  not  in  proportion  to  the  height  of  the  temperature ;  it  is  full  and 
strong  at  the  start,  and  may  fall  while  the  fever  is  rising.  The  face  is 
flusJied,  Avith  slight  icteroid  addition.  The  ei/es  are  suffused  and  intoler- 
ant of  light.  The  tongue  may  or  may  not  be  coated,  and  nausea  and 
vomiting  may  occur,  the  latter  being  one  of  the  most  characteristic 
symptoms  of  the  disease.  Associated  with  these  symptoms  there  are 
epigastric  oppression  and  burning  sensations,  with  decided  tenderness. 
The  vomitus  may  be  blood-streaked  or  contain  chocolate-colored  parti- 
cles, and  occasionally  unaltered  blood  is  vomited.  Constipation  is 
usually  present,  the  stools  showing  a  deficiency  of  bile.  The  urine  is 
diminished  in  amount,  dark-colored,  and  often  contains  a  slight  amount 
of  albumin :  this  earli/  transient  albuminuria  is  a  very  characteristic 
symptom.  The  initial  stage  may  last  from  six  or  eight  hours  to  two  or 
three  days,  or  even  longer,  and  is  longer  in  the  milder  forms  of  the  dis- 
ease. With  the  termination  of  this  stage  the  fever  remits  and  the  other 
symptoms  disappear  with  surprising  rapidity,  the  pulse  becoming  remark- 
ably slow. 

Stage  of  Remission. — From  this  moment  convalescence  may  begin  and 
proceed  to  full  recovery  without  interruption,  the  happy  event  being  often 
marked  by  critical  discharges.  In  most  instances,  however,  the  patient 
presents  certain  symptoms  and  signs  of  ill-health  during  this  period  (more 
or  less  prostration,  epigastric  distress  with  tenderness,  mental  dulness  or 
even  stupor,  and  a  yellowish  tint  of  skin  and  urine),  which  lasts  from  a 
few  to  twenty-four  hours,  when  another  stage  Avith  its  more  striking  symp- 
toms supervenes. 

Stage  of  Secondary  Fever  or  Collapse. — The  patient  becomes  extremely 
weak,  presenting  the  signs  of  profound  collapse.  The  surface  of  the  body 
is  cool  (extremities  often  positively  cold),  the  skin  in  nearly  all  instances 
assuming  a  yellow  or  bronzed  tinge,  from  which  the  disease  receives  its 
name.  The  pulse  is  rapid  and  compressible,  and  soon  vomiting  becomes 
very  distressing.  Hemorrhage  into  the  stomach  generally  occurs,  the 
blood  being  acted  upon  by  the  gastric  secretions,  and  producing  the 
material  which  is  expelled  as  the  characteristic  ^^  black  vomit."  Occa- 
sionally unaltered  blood  may  be  vomited ;  the  stools  also  may  be  tarry. 
In  the  worst  cases  hemorrhages  from  other  mucous  surfaces  are  common 
(epistaxis,  hematuria,  metrorrhagia,  etc.),  and  cutaneous  hemorrhages 
also  now  occur.  In  this  stage  the  tongue  becomes  dry,  brown,  or  even 
black ;  less  frequently  it  is  smooth,  red,  and  fissured,  and  sordes  may 
often  be  observed  on  the  teeth  and  lips. 

In  most  cases  the  urine  is  deficient,  containing  albumin  and  casts 
(with  careful  centrifugation),  and  in  rare  instances  there  is  complete 
anuria.  The  latter  may  precede  the  development  of  grave  7iervous 
symptoms,  as  convulsions,  or  even  coma,  which  may  be  uremic. 

In  some  instances  the  temperature  rises  during  this  period  (secondary 
fever),  and  in  favorable  cases  terminates  by  lysis,  or  it  may  assume  the 
typhoid  form  and  result  fatally.  In  all  cases  that  pursue  a  favorable 
course  convalescence  is  slow  and  gradual,  and  may  be  uninterrupted  by 


122  INFECTIOUS  DISEASES. 

relapses,  but  this  is  an  unusual  course  of  affairs.  The  duration  of  the  en- 
tire attack  (composed  of  three  stages)  is  variable,  though  as  a  rule  it 
covers  about  one  Aveek. 

Clinical  Varieties. — Many  different  varieties  have  been  described, 
each  characterized  by  one  or  more  prominent  features,  but  none  seem 
more  justifiable  than  Finlay's^  classification,  in  which  he  distinguishes 
three  forms:  (1)  the  acclimation  fever,  or  non-albumin  uric  yelloio  fever  ; 
(2)  i\iQ  plain  albuminuric  yellow  fever  ;  (3)  the  melano-albuminuric  yel- 
low  fever,  characterized  by  the  presence  of  blood  or  "black  vomit"  in 
the  stomach  or  intestines.  • 

Diagnosis. — The  symptoms  that  justify  a  diagnosis  in  the  initial 
stage,  provided  an  epidemic  be  prevailing,  are  the  sudden  onset,  head- 
ache, severe  lumbar  pains,  peculiar  facies  and  pulse,  nausea,  and  vomit- 
ing of  bile.  In  the  early  stage  intense  capillary  congestion  of  the  sur- 
face of  the  body  is  diagnostic  and  indicative  of  a  severe  form  of  the 
disease.  In  the  third  stage  the  coexistence  of  jaundice,  the  black  vomit, 
and  suppression  of  urine,  with  evidences  of  collapse,  makes  the  diag- 
nosis easy. 

Serum-diagnosis. — AVoodson  and  P.  E.  and  J  J.  Archinard  have 
applied  the  Widal  reaction  (agglutination-test)  in  100  cases,  and  their 
conclusions  are  that  the  serum-diagnosis  of  yellow  fever  is  practicable 
and  important,  and  may  be  used  on  the  second  day.  A  dilution  of 
1 :  40,  with  a  time-limit  of  one  hour,  is  preferable. 

Pernicious  malarial  fever  has  not  the  deep  jaundice,  the  slow  pulse, 
the  peculiar  temperature-curve,  the  intense  capillary  congestion  of  the 
surface  of  the  body,  the  black  vomit,  the  early  albuminuria,  and  the  clear 
mind — all  symptoms  that  mark  yellow  fever.  On  the  other  hand,  the 
organism  of  Laveran  is  pathognomonic  of  pernicious  malarial  fever,  as 
is  the  effect  of  quinin  upon  the  disease.  Kemp  has  made  a  microscopic, 
spectroscopic,  and  chemical  study  of  the  black  vomit  of  yellow  and 
malarial  fevers,  and  found  that  the  pigment  in  each  case  was  derived 
from  the  blood,  which  had  been  acted  upon  by  the  gastric  juices.  The 
vomitus  in  malarial  fever,  however,  contains  in  addition  considerable 
quantities  of  bile-pigments  and  bile-salts.  Avhich  are  wanting  in  that  of 
yellow  fever.  Further,  in  the  hitter  the  vomited  matter  is  much  more 
highly  acid. 

Prognosis. — Different  epidemics  show  widely  different  death-rates, 
and  the  most  potent  factor  is  the  particular  type  of  the  disease  in  indi- 
vidual epidemics.  Some  have  been  characterized  by  the  lighter  forms 
of  the  affection,  and  in  such  the  death-rate  has  been  low  (1  per  cent.). 
In  other  epidemics  the  type  has  been  so  virulent  as  to  make  the  mor- 
tality list  high,  even  to  100  per  cent.  In  general,  mild  epidemics  give 
a  mortality  of  5  to  10  per  cent.,  and  severer  forms  one  of  30  to  50  per 
cent.     The  death-rate  is  lower  in  priyate  than  in  hospital  practice. 

Among  the  gravest  symptoms  intense  capillary  congestion,  coming  on 
during  the  first  stage,  deserves  special  emphasis.  Equally  serious,  in 
most  cases  in  which  they  occur,  are  suppression  of  uriyie,  intense  jaundice, 
and  uremic  toxemia.  The  black  vomit  is  not  as  fatal  a  sign  as  the 
symptoms  previously  mentioned. 

It  has  been  noted  that  a  larger  number  of  men,  proportionately,  than 

*  Edinburgh  Medical  Journal,  Edinburgh. 


YELLOW  FEVER.  123 

women  and  children  succumb  to  the  disease,  and  that  it  is  less  fatal 
amoncr  necrroes  than  among  whites. 

Treatment. — The  measures  that  are  employed  in  yellow  fever  may 
be  considered  under  three  main  heads:  (1)  Prophylaxis;  (2)  general 
management ;  and  (3)  medicinal  measures. 

(1)  Prophylaxis. — The  patient  must  be  quarantined,  and  if  the  area  in 
a  city  that  is  infected  be  definitely  known,  it  should  be  shunned  by  well 
persons,  and  particularly  "if  the  latter  are  not  acclimated.  Persons  living 
in  infected  localities  who  have  not  been  immunized  by  a  previous  attack 
had  better  go  elsewhere  if  such  a  course  be  practicable.  Every  available 
means  to  prevent  a  dissemination  of  the  poison  by  fomites  must  be 
enforced,  and  most  important  is  the  thorough  disinfection  of  all  personal 
belongings,  bed-  and  body -linen,  mattresses,  clothing,-  etc.  The  room 
occupied  by  the  patient  must  also  receive  proper  attention. 

Protective  inoculation  with  the  serum  obtained  from  a  horse  or  an  ox 
vaccinated  Avith  the  bacillus  icteroides  has  proved  effectively  prophylactic 
in  a  severe  outbreak  in  an  insanitary  prison.^ 

(2)  General  Management. — The  suflFerer  from  yellow  fever  must  be  put 
to  bed  at  once,  and  an  abundance  of  fresh  air  (without  exposure  to  strong 
drafts)  must  be  supplied,  The  medicaments  and  the  nourishment  are  to 
be  administered  through  a  tube  or  spout-cup,  so  as  to  obviate  raising  the 
patient's  head.  Body-  and  bed-linen  should  be  kept  scrupulously  clean, 
being  changed  frequently,  and  the  patient  must  not  be  allowed  to  leave 
his  bed  on  any  account.  The  diet  should  be  of  the  lightest  sort  and 
entirely  liquid,  beginning  Avith  peptonized  milk,  koumiss,  or  light  broths, 
and  in  small  quantities. 

(3)  Medicinal  Measures. — At  the  outset  it  is  well  to  gently  stimulate 
the  various  excretory  organs,  and  mild  laxative  diaphoretics  and  diuretics 
answer  this  purpose.  Hydrotherapy  may  be  employed  to  maintain  the 
nervous  tonicity  and  reduce  the  temperature,  but  when  the  spontaneous 
fall  of  temperature  sets  in  this  method  must  be  promptly  discontinued. 
During  the  first  stage  the  neuralgic  pains,  which  attack  principally  the 
head,  loins,  and  nerve-trunks,  are  to  be  relieved  by  morphin  given  hypo- 
dermically ;  and  for  the  same  symptom  Bemiss  highly  recommends 
quinin  by  the  rectum  (gr.  xx — 1.296).  Intestinal  antiseptics  may  also 
be  used  throughout  the  attack  (salol,  betanaphtol,  etc.). 

During  the  stage  of  remission  the  powers  of  the  system  are  to  be  fully 
maintained  by  a  suitable  dietary  and  by  tonics  and  stimulants  if  required. 

In  the  last  stage,  supportive  measures  must  not  be  forgotten,  every- 
thing that  aids  the  vital  powers  being  brought  into  prompt  requisition. 
Rectal  nutrient  enemata  should  be  employed  if  marked  gastric  irrita- 
bility prohibits  feeding  by  the  mouth.  Stimulants  are  demanded,  and 
these  should  also  be  administered  per  rectum  if  not  retained  by  the 
stomach,  or  they  may  in  some  measure  be  administered  hypodermically. 
The  stomach  is,  as  a  rule,  tolerant  of  iced  champagne. 

If  irritability  of  the  stomach  be  present,  ice  and  hydrocyanic  acid 
may  be  tried.  Sodium  bicarbonate  (gr.  x  to  xx — 0.648  to  1.296)  in 
Vichy,  Apollinaris,  or  Seltzer  water  is  a  most  useful  remedy,  and  Stern- 
berg has  used  it  in  combination  with  mercuric  chlorid  with  success  in  the 
following  formula : 

1  Philada.  Med.  Jour.,  Sept.  18,  1898. 


124  INFECTIOUS  DISEASES. 

^i.   Sodii  bicarb.,  3iv(16.0); 

Hydrarg.  bichlorid.,  gr.  ss.  (0.032); 

Aquffi  purae,  Oj  (480).— M. 

Sig.  For  a  severe  case  two  teaspoonfuls  every  hour,  day  and  night ; 
for  a  mild  case,  every  hour  by  day  and  every  two  hours  by 
night ;  administer  always  ice-cold. 

Perhaps  the  chief  indication  for  the  use  of  sodium  bicarbonate  is 
the  extreme  acidity  of  the  various  secretions,  especially  the  gastric  and 
renal.  Sternberg  contends  that  by  fulfilling  this  indication  we  prevent 
in  great  measure  the  occurrence  of  acute  nephritis  and  suppression  of 
the  urine.  Hemorrhages  and  other  symptoms  must  be  treated  by  the 
usual  means.  During  convalescence  tonics  are  to  be  administered,  and 
the  customary  diet  can  gradually  be  resumed. 

Serum-therapeutics. — Prof.  Sanarelli  records  favorable  results  from 
the  use  of  his  antitoxic  serum.  The  fever  and  the  albuminuria  quickly 
disappear,  the  other  symptoms  more  gradually;  but  convalescence  is 
well  established  after  the  injection  of  20  cu.  cm.  (5  fluidrams)  and  Go 
cu.  cm.  (2  fluidounces)  of  the  serum  respectively.  In  most  cases  the 
serum  was  injected  directly  into  a  vein,  but  hypodermoclysis  Avill  prob- 
ably give  equally  happy  results.  If  commenced  early,  the  treatment  is 
less  apt  to  be  resisted.  The  experience  of  Sanarelli  has  been  confirmed 
by  other  observers.  In  66  per  cent,  of  the  total  number  treated  a  cure 
was  obtained. 


CEREBRO-SPINAL  MENINGITIS. 

{Spotted  Fever;   Cerebrospinal  Fever.) 

Definition. — An  infectious  disease,  caused  most  probably  by  the 
Micrococcus  lanceolatus.  It  is  characterized  anatomically  by  inflamma- 
tion of  the  meninges  of  the  brain  and  spinal  cord,  and  clinically  by  an 
ii'regular  course,  a  moderate  febrile  movement  with  somewhat  character- 
istic and  profound  nervous  symptoms  (excruciating  headache,  pain  in  the 
back  and  upper  part  of  the  spine,  contraction  of  the  muscles  of  the 
nucha,  hyperesthesia,  delirium,  and  ofttimes  coma).  The  disease  may 
occur  sporadically  or  in  epidemics,  or  may  even  assume  pandemic  pro- 
portions. 

Historic  Note. — Cerebro-spinal  meningitis  was  first  recognized 
and  described  as  late  as  the  beginning  of  the  present  century  (1805)  by 
Viesseux  of  Geneva.  During  the  next  decade  numerous  limited  epi- 
demics were  observed  both  in  Europe  and  the  United  States,  and  subse- 
quently recurring  epidemic  and  pandemic  visitations  were  noted,  though 
at  comparatively  long  and  variable  intervals  of  time.  In  nearly  all  the 
lai'ge  cities  in  this  country  it  may  be  said  to  have  become  endemic,  and 
in  Philadelphia  since  1863  ;  yet  the  affection  is,  without  doubt,  becoming 
less  and  loss  prevalent. 

Pathology. — The  cases  that  prove  speedily  fatal  do  not  present 
gross  characteristic  changes,  but  by  the  aid  of  the  microscope  leukocytes 
are  discovered  immediately  around  the  cerebral  vessels,  and  round  cells 
in  the  cortex  of  the  brain.     In  some  cases  the  characteristic  evidences  of 


CEREBROSPINAL  MENINGITIS.  125 

encephalitis  are  already  noticeable.  On  the  other  hand,  the  cases  in 
which  death  occurs  after  the  disease  has  been  fully  developed  show  the 
lesions  of  suppurative  inflammation  of  the  meninges  of  the  brain.  The 
arteries,  veins,  and  sinuses  are  much  engorged  ;  the  ventiricles  are  dis- 
tended with  liquid,  but  the  pia  mater  is  principally  aifected,  its  vessels 
being  greatly  enlarged,  and  a  more  or  less  copious  sero-fibrinous  or  sero- 
purulent  exudate  occurring  into  the  meshes  of  its  network.  The  longer 
the  duration  of  the  case  the  more  purulent  is  the  exudation.  The  ven- 
tricles of  the  brain  are  filled  with  a  similar  exudation,  and  red  blood- 
globules  may  be  present  at  an  advanced  stage.  The  color  of  the  exu- 
date is  at  first  almost  clear  (being  composed  of  serum) ;  it  then  changes 
to  a  milky  turbidity,  to  a  pale  yellow,  and,  lastly,  takes  on  a  greenish- 
yellow  color  ("leek-green  ").  The  subarachnoid  space  may  be  occupied 
by  a  uniform  layer  composed  of  fibrin  and  pus,  which  exhibits  the  great- 
est thickness  alono-  the  long-itudinal  fissure. 

The  brain-matter  is  congested,  and  sometimes  softened  in  spots,  and 
on  section  the  gray  matter  may  present  punctate  extravasations.  When 
resolution  occurs  recovery  may  be  complete,  but  more  frequently  the  pia 
mater  remains  thickened. 

The  exudation  may  follow  the  auditory  and  optic  nerves  along  their 
lymph-sheaths,  and  pus  has  been  found  in  the  internal  ear  as  well  as  in 
the  chambers  of  the  eye. 

The  membranes  of  the  spinal  cord  manifest  lesions  identical  Avith 
those  of  the  brain.  They  are  vascular  engorgements,  followed  by  sero- 
fibrinous, and  later  still  by  sero-purulent,  exudation  beneath  the  arach- 
noid. The  changes  are  more  marked  on  the  posterior  than  the  anterior 
surface  of  the  cord,  and  the  exudate  increases  in  amount  in  passing  from 
above  downward,  in  severe  cases  sometimes  assuming  the  form  of  a  sheath 
which  completely  surrounds  the  cord  throughout  its  entire  length.  The 
*  pia  mater  is  congested,  and  may  be  thickened,  shaggy,  and  in  places 
adherent  to  the  cord,  of  which  the  gray  matter  may  be  the  seat  of  serous 
infiltration,  and  rarely  of  softening. 

Barker  describes  certain  changes  that  occur  in  the  nerve-cells  and 
the  ventral  horns  of  the  nucleus  dorsalis  (Clarkii)  of  the  spinal  cord  in 
epidemic  cerebro-spinal  meningitis. 

The  lungs  may  exhibit  the  changes  peculiar  to  bronchitis  or  pneu- 
monia. In  the  heart  endocarditis  may  be  noted,  though  rarely,  and  both 
the  pleura  and  the  pericardium  may  show  inflammatory  lesions  and  con- 
tain a  serous  or  sero-purulent  exudation.  I  have  noted  one  malignant 
case  in  which  hemorrhages  into  the  serous  membranes  and  into  the  skin 
had  taken  place.  The  spleen  may  be  moderately  enlarged,  the  increase 
in  size  and  the  degree  of  fever  being  proportional,  and  the  liver  is  hyper- 
emic.  The  kidneys  are  congested,  and  bacterial  forms  have  been  found 
associated  in  the  latter  with  the  lesions  of  acute  nephritis  and  hemor- 
rhage— conditions  of  which  they  were  most  probably  the  cause. 

^Etiology. — Bacteriology. — It  is  claimed  that  the  micrococcus  lance- 
olatus  is  the  specific  cause  of  cerebro-spinal  meningitis.  Flexner  and 
Barker  found  the  micrococcus  uniformly  present  in  all  cases  in  an  epi- 
demic which  occurred  at  Lonacoming,  a  mining  town  in  Maryland.^  Other 
bacteria  are,  however,  constantly  found  associated  (streptococcus  pyogenes, 
^  Annual  of  the  Universal  Medical  Sciences,  1895,  vol.  ii.  A-60. 


126  INFECTIOUS  DISEASES. 

staphylococcus  aureus,  etc.).  Councilman  concludes  that  the  epidemic 
form  is  due  to  the  meningococcus  intracellularis,  discovered  by  Weich- 
selbaum  in  1887,  and  believes  that  it  is  a  distinct  organism.  Welch, 
however,  suggests  that  the  meningococcus  and  the  pneumococcus  are 
possibly  varieties  of  the  same  bacterium.  It  is  possible  that  the  former 
is  not  the  sole  specific  cause  of  this  disease,  but  that  the  pneumococcus, 
and  possibly  other  organisms,  may  also  produce  it. 

Predisposing  Causes. — (1)  Age. — Most  cases  occur  in  children  and 
young  adults,  though  no  age  enjoys  perfect  immunity. 

(2)  Climate. — The  disease  is  unknown  in  tropical  climates,  but  has  oc- 
curred in  all  parts  of  the  temperate  zone,  and  is  most  prevalent  in  the 
more  northerly  portions  of  the  latter. 

(3)  Season  is  not  an  important  factor,  though  the  disease  prevails 
lai-gely  in  cold  Aveather. 

(4)  Unhygienic  Influences. — Those  who  live  under  unfavorable  sanitary 
influences  are  especially  liable,  and  hence  the  disease  often  appears  in 
ill-ventilated  and  overcroAvded  habitations— among  the  poorer  classes, 
among  soldiers  crowded  together  in  barracks,  and  among  prisoners.  Pro- 
longed marching,  and  excessive  physical  or  mental  exertion,  may  heighten 
the  susceptibility  to  the  disease.  In  certain  epidemics  the  disease  has 
raged  exclusively  in  villages. 

Modes  of  Conveyance. — Precisely  how  the  contagion  is  transferred  from 
an  infected  person  to  a  healthy  one  is  not  known,  but  the  disease  is 
probably  not  contagious.  There  is  evidence  to  show  that  the  poison  may 
be  conveyed  hj  fomites,  though  this  seems  to  be  limited  to  the  cases  fur- 
nishing intensely  virulent  poison.  The  organism,  owing  to  its  feeble 
vitality,  probably  could  not  lead  a  saprophytic  existence.  As  to  the 
manner  in  which  the  virus  gains  entrance  to  the  system,  our  knowledge 
is  imperfect  also. 

Clinical  History. — The  period  of  incubation  is  brief,  though  un- 
known. The  i>rmlrotiial  siimptoms  are  variable  in  diflferent  epidemics, 
and  may  even  be  absent  when  the  invasion  is  sudden,  a  patient  in  vigor- 
ous health  often  being  stricken  down  as  though  by  a  blow.  In  some 
rapidly  fatal  cases  there  is  a  short  prodromal  ])erio(l,  during  which  the 
patient  complains  of  lassitude,  headache,  rachialgia,  muscle-  and  joint- 
pains,  and  sometimes  nausea  and  vomiting.  In  ordinary  forms  the  pro- 
dromes may  last  from  a  few  hours  to  a  week  or  more,  and  the  patient's 
complaint  may  l)e  limited  to  cervical  and  occipital  pains  lasting  a  day  or 
two  ;  then,  Avithout  any  initial  chill,  the  invasion-period  supervenes.  In 
milder,  and  usually  in  sporadic,  cases  the  symptoms  consist  chiefly  of 
languor  and  debility,  headache,  pain  in  the  back  and  limbs,  vertigo, 
vomiting,  and  sometimes  diarrhea. 

Most  cases  begin  abruptly,  between  noon  and  midnight.  The  most 
distinctive  and  violent  features  are  chill  (often  severe),  fever  of  a  moder- 
ate grade,  a  full  and  somewhat  accelerated  pulse,  raging  headache,  and 
vomiting.  In  children  the  ushering-in  symptom  may  be  a  convulsion. 
These  symptoms  are  followed  soon  by  pain  in  the  back  and  cervical 
portion  of  the  spine — an  early  and  characteristic  symptom.  Attempts  at 
flexion  or  rotation  of  the  head  increase  the  pain  in  the  neck,  and  in  like 
manner  movements  of  the  body  augment  the  spinal  pains.  Later,  the 
muscles  in  the  cervical  region  contract,  at  the  same  time  becoming  rigid. 


CEREBROSPINAL  MENINGITIS.  127 

and  produce  the  condition  of  opisthotonos.  The  patient  may  be  unable 
to  swallow  on  account  of  the  excruciating  pain  which  the  act  is  apt  to 
excite. 

The  temperature  is  but  moderately  elevated.  In  a  certain  percentage 
of  the  cases  it  rapidly  rises  to  104°  or  105°  F.  (40.5°  C),  but  soon  falls  to 
102°  or  103°  F.  (38.8°  or  39.4°  C),  at  which  level  it  is  maintained  with 
irregular  undulations  until  defervescence,  which  takes  place  by  lysis.  In 
fatal  cases  death  is  preceded  by  a  sudden  great  elevation  of  temperature 
to  108°  and  even  110°  F.  (43.3°  C).  There  may  be  a  rapid  fall  of  tem- 
perature, followed  by  collapse.  In  the  very  young  the  thermometric 
range  is  lower  than  in  adults. 

The  pulse  is  but  slightly  accelerated,  if  at  all,  in  the  early  stages  of 
the  disease.  Later,  in  twenty-four  to  thirty-six  hours,  it  may  in  severe 
cases  leap  to  120  or  even  140,  its  chief  characteristic  being  the  variability 
in  its  rate.  In  the  early  stage  it  is  of  good  volume  and  tension ;  later, 
it  may  be  soft  and  compressible,  and  in  serious  cases  it  becomes  small 
and  feeble.     Leukocytosis,  moderate  or  severe,  may  atte^id. 

The  respirations,  as  a  rule,  increase  in  frequency  and  are  sometimes 
quite  irregular ;  but  marked  dyspnea,  with  slowing  of  the  respirations, 
may  be  observed  during  the  advanced  stage,  being  due  to  pressure  ex- 
erted by  the  exudation  upon  the  respiratory  center.  Cheyne-Stokes 
breathing  and  sighing  respirations  may  be  present. 

Nervous  Symptoms. — The  headache  is  racking  and  often  persistent, 
though  it  is  subject  to  remissions ;  and  is  intensified  by  light  and  sounds, 
being  so  violent  as  to  cause  the  patient  to  groan  even  while  profoundly 
comatose.  There  is  vertigo  in  nearly  all  instances.  The  pain  referred 
to  the  spine  may  be  general  or  limited  to  either  the  lumbar  or  cervical 
region  (rarely  the  dorsal),  and  the  general  myalgic  pains  are  often  in- 
tense, especially  in  the  extremities  and  the  abdominal  region.  With 
the  cephalalgia  and  abdominal  pain  may  be  associated  vomiting.  Hyper- 
esthesia is  a  prominent  symptom,  the  gentlest  touch  being  extremely 
painful ;  anesthesia  may  also  be  noted,  though  less  frequently,  and 
usually  follows  the  hyperesthesia.  Any  voluntary  muscular  movements, 
however,  excite  pain.  In  some  cases  delirium  appears  early,  and  in 
others  rather  late,  while  in  the  worst  types  death  often  occurs  before  de- 
lirium develops.  On  the  other  hand,  in  a  small  percentage  of  cases  this 
symptom  is  absent  throughout  the  entire  course,  and  always  its  character 
and  intensity  exhibit  a  remarkable  variety.  It  may  be  mild  or  it  may 
take  the  form  merely  of  incoherent  answers  to  questions.  Active  delirium, 
however,  is  common  and  is  accompanied  by  hallucinations,  during  which 
the  patient  shouts  loudly,  and,  unless  restrained,  gets  out  of  bed.  This 
form  of  delirium  occurs  in  paroxysms  that  are  most  apt  to  appear  at 
night,  and  in  the  female  it  is  sometimes  hilai-ious  or  hysteric.  An 
erotic  tendency,  with  priapism  or  seminal  emissions,  has  rarely  been  ob- 
served in  males.  The  "maudlin  "  delirium  of  the  drunkard  is  sometimes 
seen,  but  sooner  or  later  somnolence  appears  and  may  deepen  quickly  into 
coma,  the  latter  symptom  perhaps  being  temporary,  though  more  often  it 
continues  until  recovery  or  death.  As  before  stated,  vomiting  is  common, 
though  it  may  appear  late  in  the  disease ;  it  is  doubtless  of  cerebral 
origin. 

Symptoms  of  motor  irritation  are  among  the  prominent  phenomena  of 


128  INFECTIOUS  DISEASES. 

the  disease,  twitching  of  single  muscles  or  groups  of  muscles  often  being 
seen,  and  occasionally  muscular  tremors.  Muscular  contraction  is  an 
almost  constant  feature.  After  a  few  days  a  tonic  spasm  of  the  muscles 
of  the  extremities  sets  in,  as  the  result  of  which  the  arms  are  bent  upon 
the  chest,  the  forearm  upon  the  arm,  and  the  thumb  upon  the  palm  :  the 
thigh  is  also  flexed  on  the  abdomen  and  the  leg  on  the  thigh.  The  opis- 
thotonos previously  alluded  to  may  be  followed  by  trismus,  which  can  be 
considered  a  mortal  symptom.  Convulsions  do  not  occur  in  adults,  but 
are  common  in  children  ;  occasionally,  however,  there  are  paralysis,  especi- 
ally of  the  muscles  of  the  face,  and  paretic  hemiplegia. 

Organs  of  Special  Sense. — Photophobia  is  a  prominent  symptom,  and 
the  condition  of  the  pupils  is  very  variable.  They  may  be  dilated  or 
contracted  (more  frequently  the  former)  or  remain  normal ;  and  in  the 
majority  of  cases  they  are  unequal  in  size  and  react  poorly  to  light. 
These  pupillary  changes  may  come  on  early  or  late.  Strabismus  is  fre- 
quent, being  usually  temporary,  though  it  may  recur  several  times  during 
the  attack.  Rarely  it  is  permanent.  Conjunctivitis  of  moderate  inten- 
sity and  keratitis  may  occur,  the  former  being  more  frequent  than  the 
latter,  however ;  and  ptosis  is  almost  always  present.  Intense  purulent 
irido-choroiditis  sometimes  occurs  ;  either  temporary  or  permanent  blind- 
ness is  met  with,  and,  much  more  rarely,  nystagmus  is  noted.  Among 
optical   sequeliC   are  cataract  and  atrophy  of  the  eyeball. 

Deafness  is  by  no  means  an  infrequent  symptom,  there  being  an  early 
intolerance  of  sound  and  a  marked  tinnitus  aurium.  Later,  suppurative 
inflammation  of  the  middle  ear,  followed  by  rupture  of  the  tympanum 
and  otorrhea,  may  occur.  The  internal  ear  may  be  similarly  involved, 
and  in  such  cases  the  gait  may  become  uncertain  from  implication  of  the 
semicircular  canals.  The  deafness  may  after  recovery  be  found  to  be 
permanent,  though,  as  a  rule,  it  is  incomplete. 

Cutaneous  symptoms  appear,  some  of  which  possess  considerable  diag- 
nostic worth.  Pallor  and  lividity  of  the  skin  and  visible  mucous  mem- 
branes often  characterize  the  period  of  invasion,  and  shortly  after  the 
onset  herpes  facialis  appears  in  more  than  half  the  cases.  This  symptom 
is  significant  for  diagnosis.  The  separate  lesions  are  extensive,  and  often 
coalescence  of  two  or  more  is  witnessed.  Herpes  facialis  belongs  in  a 
peculiar  sense  to  cerebro-spinal  meningitis — herpes  labialis  to  malaria, 
jind  less  frequently  to  pneumonia  and  meningitis.  A  petechial  eruption 
is  common,  and  has  been  most  frequently  met  with  in  the  early  epidemics, 
and  more  frequently  in  America  than  in  Europe.  To  this  symptom  the 
disease  owes  the  name,  long  since  given  to  it,  of  "spotted  fever."  It 
may,  however,  be  absent,  and  when  present  it  is  sometimes  limited  to  a 
small  superficial  area,  though  more  frecjuently  it  is  diff'use.  At  first  the 
eruption  may  be  bright-red  (erythematous),  later  becoming  darker,  or  it 
may  be  distinctly  petechial  from  the  start ;  purpuric  spots  of  considerable 
size  and  sometimes  lai*ge  ecchymoses  may  appear,  but  these  are  most 
common  in  the  more  malignant  types.  Other  forms  of  eruption  are  also 
seen  (sudamina,  urticaria,  ecthyma,  erythema,  erysipelas,  etc.),  but  are 
devoid  of  diagnostic  value.  Gangrene  of  the  skin  is  occasionally  noticed, 
and  in  some  cases  bed-sores  are  liable  to  arise ;  but  there  is  no  fixed  time 
for  the  skin-lesions  of  cerebro-spinal  fever  to  appear,  and  their  duration 
is  exceedingly  variable. 


CEREBROSPINAL  MENINGITIS.  129 

Of  gastro-intestinal  symptoms  vomiting  is  the  most  common.  It  usu- 
ally lasts  only  for  a  brief  period  at  the  onset,  though  it  may  recur  later 
at  longer  or  shorter  intervals,  and  is  of  nervous  origin.  The  appetite 
may  be  good,  but  in  many  cases  it  is  soon  lost,  the  tongue,  in  a  large  pro- 
portion of  the  instances,  being  only  slightly  coated.  In  cases  assuming 
the  adynamic  or  typhoid  type  the  tongue  is  apt  to  become  dry  and  of  a 
brown  color,  with  the  formation  of  sordes.  Under  these  circumstances 
the  abdomen  is  tympanitic  and  the  bowels  relaxed,  and  diarrhea  may  be 
urgent,  resisting  all  efforts  aimed  at  its  relief.  Retraction  of  the  belly 
is  common,  and  constipation  instead  of  diarrhea  is  the  general  rule ;  the 
spleen  may  often  be  felt  a  little  distance  below  the  costal  margin. 

Renal  symptoms  are  not  prominent,  though  the  amount  of  urine  passed 
is  often  above  the  normal  despite  the  febrile  movement.  It  may  be  below, 
though  rarely,  while  in  still  other  cases  it  is  found  to  be  about  normal ; 
and  retention  on  the  one  hand  and  incontinence  on  the  other  have  been 
observed.  Albuminuria  is  sometimes  met  with,  and  sugar  has  been 
detected  in  the  urine  in  rare  instances. 

Complications. — Many  of  these  have  already  been  mentioned  in 
the  portrayal  of  the  symptoms,  particularly  those  taking  the  form  of 
destructive  inflammations  of  the  eye  and  ear  and  the  paralyses  of  the 
cranial  nerves.  The  purulent  inflammations  of  the  serous  sacs  which 
were  referred  to  in  discussing  the  pathology  (pleurisy  and  pericarditis) 
are  among  the  frequently  associated  conditions,  and  secondary  bron- 
chitis is  also  common. 

Pneumonia  (lobar  and  lobular)  is  a  frequent  and  much-dreaded  com- 
plication.    Atelectasis  may  occur. 

Hemorrhagic  nejjhj^itis,  usually  of  mild  type,  may  appear  as  a  com- 
plication. 

Special  and  Atypical  Forms. — (1)  Mild  or  Rudimentary. — In 
this  type  the  characteristic  signs  are  either  undeveloped  or  wanting,  and 
the  diagnosis  is  possible  only  during  the  prevalence  of  epidemics,  which 
furnish  typical  cases.  The  symptoms  vary  and  are  indefinite,  but  per- 
haps the  most  constant  and  significant  are  severe  headache,  languor,  ver- 
tigo, nausea,  and  occasionally  vomiting.  Fever  and  contraction  of  cervi- 
cal muscles  are  absent,  as  a  rule.  The  duration  of  rudimentary  cerebro- 
spinal fever  is  brief,  the  more  noticeable  symptoms  rarely  exceeding  three 
or  four  days. 

(2)  The  Abortive  Form. — Here  the  initial  symptoms  are  severe,  but 
after  two  or  three  days  they  rapidly  subside,  leaving  the  patient  conva- 
lescent. The  disease  is  cut  short  by  the  acquisition  of  immunity,  and 
not  as  the  result  of  medical  interference. 

(3)  Intermittent  Form. — In  this  variety  the  symptoms,  however  in- 
tense, remit  or  almost  wholly  intermit  every  day  or  second  day;  these  re- 
missions are  followed  by  a  decided  exacerbation  or  recurrence  of  the  dis- 
tressing features  of  the  disease.  Intermissions  may  occur  at  the  begin- 
ning of  a  case,  though  more  often  they  occur  at  an  advanced  stage  and 
tend  to  prolong  its  course.  There  is  not  observed  the  strict  periodicity 
that  is  seen  in  malaria,  and  neither  is  the  temperature-curve  typical  of 
the  latter  disease  nor  are  the  malarial  organisms  found  in  the  blood. 

(4)  Typhoid  Form. — In  a  certain  though  small  proportion  of  the  cases 


130  INFECTIOUS  DISEASES. 

the  special  features  are  characteristic  of  the  "  typhoid  state,"  but  their 
course  is  more  protracted  than  is  usual. 

(5)  Fulminant  or  Apoplectic  Form. — The  symptoms  characterizing  this 
most  malignant  type  of  the  affection  are  rather  inconstant.  There  may 
be  severe  chill,  loss  of  consciousness,  followed  by  deep  coma  and  death, 
the  whole  course  occupying  the  space  of  a  few  hours  only.  I  saw  two 
such  cases  in  the  same  family :  the  first,  a  girl  of  five  years,  was  stricken 
at  2  p.  M.  and  died  at  9  P.  M.  ;  the  other,  a  boy  of  seven  years,  was 
taken  ill  on  the  following  day  about  the  same  hour,  and  died  at  10  p.  m. 
Other  instances  pursue  a  somewhat  slower  course,  though  manifesting  the 
most  striking  malignancy.  These  begin  with  intense  chills,  violent  head- 
ache, vomiting,  early  stupor,  great  prostration,  contraction  of  muscles  of 
the  neck,  moderate  fever,  and  a  feeble,  progressively  slowing  pulse  until 
it  sometimes  reaches  50  or  even  40  beats  per  minute.  The  eruption, 
when  it  appears,  takes  the  form  of  purpura.  This  form  is  most  apt  to  be 
met  with  early  in  an  epidemic,  and  with  few  exceptions  proves  fatal. 

Diagfnosis. — The  most  important  symptoms  for  diagnosis  are  the 
abrupt  onset :  intense  pains  (eervico-occipital  and  lumbar) ;  prostration  ; 
vomiting  ;  vertigo ;  somnolence,  alternating  Avith  local  or  general  tonic  or 
clonic  convulsions;  delirium  (often  sportive  in  type) ;  tonic  contraction 
of  the  muscles  of  the  neck,  extending  to  the  back  ;  marked  hyperes- 
thesia ;  a  slow,  followed  by  a  more  rapid  though  variable,  pulse ;  irregu- 
lar temperature-curve ;  and  certain  eruptions  (petechial,  herpetic). 

Lumbar  Puncture. — The  most  accurate  method  of  diagnosticating 
this  disease  is  by  lumbar  puncture.  A  wire  should  be  inserted  into  the 
needle,  and  if  the  fluid  does  not  flow  upon  its  withdrawal,  the  dura  mater 
has  probably  not  been  penetrated.  The  fluid  obtained  is  to  be  examined 
not  only  macroscopically,  but  also  microscopically  and  bacteriologically. 
Kernig's  sign  is  found  present  in  nearly  all  cases.  It  is  obtained  in 
two  ways:  {a)  In  the  recumbent  posture  the  thigh  may  be  flexed  at  a 
right  angle  with  the  pelvis,  when  it  is  found  impossible  to  extend  the 
leg  upon  the  thigh  ;  (6)  in  the  sitting  posture  (the  patient  being  propped 
up  in  bed),  an  attempt  to  extend  the  leg  on  the  thigh  excites  a  contrac- 
ture of  the  flexors  which  prevents  the  full  straightening  of  the  leg. 

Differential  Diagnosis. — (1)  Tubercular  Meninr/itis. — In  this  aff"ection 
there  is  usually  a  tuberculous  history — either  personal  or  family — with 
prodromes  extending  over  many  days  (occasional  vomiting,  unnatural 
peevishness,  constipation).  The  invasion-period  lacks  the  sudden  onset 
of  meningitis.  There  is  greater  retraction  of  the  abdomen  than  in  the 
latter  disease,  Avhile  the  arching  of  the  neck,  the  general  myalgic  pains, 
and  the  hyperesthesia  are  less  ;  the  herpetic  and  petechial  eruptions  are 
rare  in  tuberculous  and  common  in  cerebro-spinal  meningitis ;  while 
Cheyne-Stokes  breathing  and  the  well-marked  changes  of  pulse  belong 
peculiarly  to  the  tubercular  form.  By  the  aid  of  the  ophthalmoscope 
choroidal  tubercles  may  sometimes  be  detected. 

(2)  Pneumonia. — This  affection  may  be  complicated  with  a  meningitis 
that  affects  chiefly  the  cerebral  cortex.  Hence,  while  there  will  be  motor 
spasm  (more  or  less  localized)  and  tremors,  there  will  also  be  less  retrac- 
tion of  the  head  and  less  myalgic  pain  than  in  cerebro-spinal  meningitis. 
Again,  pneumonia  precedes  the  development  of  the  meningeal  symptoms. 

(3)  Typhoid  Fever. — The  cerebral  type  of  this  affection  may  simulate 
closely  meningitis.     In  both  may  be   observed  fever,  delirium,  somno- 


CEREBROSPINAL  MENINGITIS.  131 

lence,  retraction  of  the  neck,  spasm,  tremor,  and  profound  prostration. 
The  mode  of  onset,  however,  is  diiferent,  being  slower  in  typhoid  and 
unaccompanied  by  vomiting,  muscular  spasm,  or  hyperesthesia.  In 
typhoid  there  is  also  the  characteristic  mental  dulness ;  the  fever  is 
higher,  with  a  typical  fever-curve ;  the  roseate  eruption  is  characteristic, 
and  there  is  greater  enlargement  of  the  spleen. 

Sequelae. — The  leading  sequelae  are  permanent  blindness  (due  to 
optic  neuritis  with  atrophy)  and  deafness,  which  sometimes  terminates  in 
deaf-mutism  ;  and  in  many  cases  headache  outlasts  the  disease  for  months. 
Chronic  hydrocephalus  and  mental  enfeeblement  are  not  rare  sequels 
(Ziemssen).  Various  local  paralyses  are  observed,  probably  due  to  cer- 
tain peripheral  lesions  (neuritis  and  perineuritis). 

Immunity. — Permanent  immunity  is  rarely  conferred  by  the  occur- 
rence of  cerebro-spinal  meningitis,  relapses  being  common,  and  second 
(recurrent)  attacks  having  been  occasionally  observed. 

Duration  and  Prognosis. — In  very  mild  forms  the  duration  is  from 
one  to  four  or  five  days.  The  most  malignant  type  runs  an  even  shorter 
course,  when,  as  is  the  rule,  it  terminates  fatally.  If  recovery  ensues,  it 
is  after  a  long,  serious,  and  protean  illness.  The  abortive  form  is  neces- 
sarily of  brief  duration.  In  the  ordinary  type  convalescence  usually  sets 
in  at  the  end  of  one  or  two  weeks,  but  a  slow  convalescence,  hindered  by 
numerous  complications  and  sequelae,  is  the  rule. 

Apart  from  the  fuhniJia^it  form,  which  nearly  always  proves  fatal,  the 
severity  of  the  infection  may  be  appreciated  by  noting  the  degree  of  fever 
and  the  intensity  of  the  nervous  symptoms,  especially  the  vomiting,  coma, 
headache,  opisthotonos,  character  of  the  respirations,  etc.  Complications 
may  likewise  affect  the  prognosis,  pneumonia,  and  suppurative  inflamma- 
tions of  the  pleura  or  pericardium,  rendering  it  particularly  grave.  Cir- 
cumstances connected  with  the  individual  are  also  potent,  and  particu- 
larly the  age.  In  children  under  two  years  the  disease  is  very  fatal,  this 
period  giving  the  highest  mortality-rate ;  between  tv^o  and  five  and  after 
thirty  years  it  is  a  more  serious  disease  than  during  young  adult  life. 
The  death-rate  of  cerebro-spinal  fever  varies  greatly  in  different  epidemics, 
ranging  from  25  per  cent,  in  the  mildest  to  80  per  cent,  in  the  severest. 

Treatment. — (1)  General  Management. —  The  patient  should  be  iso- 
lated, and  the  sick-room  must  be  quiet  and  somewhat  dark.  All  excite- 
ment is  to  be  avoided ;  the  patient  must  not  be  allowed  to  leave  his  bed 
until  convalescence  is  firmly  established ;  and  the  rules  for  preventing 
the  spread  of  infectious  diseases  are  to  be  strictly  enforced. 

The  diet  should  be  composed  of  nutritious  liquids,  such  as  milk  and 
animal  broths,  etc.,  and  as  soon  as  convalescence  begins  the  dietary  should 
be  increased  by  the  addition  of  semisolid  substances  (rice,  eggs,  milk- 
toast,  etc.),  and,  finally,  the  more  easily  digestible  solids.  The  period 
of  convalescence  may  be  much  abridged  by  systematic  feeding. 

Medicinal  Treatment. — Many  and  widely  various  modes  of  treatment 
have  been  recommended  by  as  many  different  authors,  but  in  my  opinion 
it  is  best  to  treat  individual  cases  according  to  the  special  indications  pre- 
sented. I  regard  it  as  extremely  improbable  that  any  case  of  this  affec- 
tion has  been  benefited  by  venesection.  Cold  or  gradually  cooled  baths 
are  of  great  value,  and  warm  baths  will  prove  highly  beneficial  by  les- 
sening the  tendency  to  tonic  spasm  of  the  muscles. 

Among  medicinal  agents  narcotics  are  the  most  useful.     Morphin 


132  INFECTIOUS  DISEASES. 

hypodermically  affords  prompt  relief  from  intense  headache,  myalgic 
pains,  muscular  contraction,  and  other  nervous  symptoms.  If  the  res- 
pirations be  irregular,  atropin  may  be  combined  with  the  opiate ;  and  if 
the  heart  threatens  to  fail,  strychnin  may  be  administered.  In  young 
children  Ave  must  rely  upon  the  bromids  rather  than  the  opiates.  In 
older  children  vre  may  employ  opium  if  we  do  so  cautiously,  and  I  have 
found  the  deodorized  tincture  of  opium  and  paregoric  to  be  the  best 
preparations. 

For  the  tonic  contraction  of  the  muscles,  especially  when  associated 
with  violent  cerebral  symptoms,  cannabis  indica  should  be  tried.  Con- 
vulsions call  for  warm  baths  or  ether-inhalations.  Mercury  has  been, 
and  still  is,  firmly  advocate"!  by  certain  authors,  and.  cerebro-spinal  men- 
ingitis being  an  infectious  disease,  this  drug  may  be  given  for  its  anti- 
septic virtue  (mercuric  chlorid  gr.  ^  (0.002)  every  four  hours  to  an 
adult ;  calomel,  gr.  ^ — ^  (0.005— 0.0U4)  every  four  hours  to  children). 
Belladonna  and  ergot  have  been  employed  to  diminish  the  congestion 
of  the  cerebro-spinal  capillaries.  They  should  be  administered  in  the 
early  stages.  Antipyrin,  acetanilid,  and  phenacetin  are  objectionable, 
since  they  depress  the  circulation. 

Stimulants  are  required  if  signs  of  henrt-exhaustion  appear.  They 
may  be  freely  exhibited  in  accordance  with  the  customary  rules. 

After  effusion  of  the  exu<late  has  taken  place  the  narcotics  are  to  be 
replaced  by  agents  that  promote  absorption,  as  potassium  iodid. 

The  local  means  are  also  important.  When  tub-baths  are  not  available, 
cold  should  be  used  locally,  since  it  is  both  of  value  and  very  grateful  to 
the  patient.  An  ice-bag  is  to  be  put  on  the  head,  and,  if  possible,  long 
ice-bags  placed  along  the  spine.  In  rare  cases  of  sthenic  type  we  may 
employ  small  blisters  at  the  nape  of  the  neck  or  over  the  mastoids :  these 
should  be  applied  early,  though  they  are  also  useful  during  the  stage  of 
effusion.  In  the  usual  form  of  the  disease  it  is  better  to  apply  the 
thermo-cautery  lightly  over  the  mastoid  region.  If  the  patient  be  not 
too  much  enfeebled,  we  may  abstract  a  small  amount  of  blood  by  means 
of  leeches  or  by  a  few  wet  cups  placed  behind  the  ears. 

Convalescence  is  prolonged,  and  requires  to  be  diligently  and  judi- 
ciouslv  treated.  We  must  relv  upon  the  generally  accepted  tonics — iron, 
cod-liver  oil,  arsenic,  and  strychnin  ;  the  potassium  iodid  and  the  mer- 
cury also  being  continued  for  their  influence  in  promoting  the  absorp- 
tion of  the  exudate.  Special  attention  is,  however,  to  be  paid  to  the 
hygienic  management  of  this  period.  An  abundance  of  fresh  air,  sun- 
shine, and  easily  assimilable  food  must  be  furnished  at  all  hazards,  and 
electricity  and  massage,  judiciously  employed,  will  hasten  recovery. 


LOBAR  PNEUMONIA. 

[Croupous  or  Fibrinous  Pneumonia ;  Pneumonitis;   Lung  Fever.) 

Definition. — An  acute  infectious  disease  caused  by  the  Jlicrococciis 
lanceulatus,  which  produces  a  specific  inflammation  of  the  parenchyma  of 
the  lung  and  marked  constitutional  disturbances — chill,  extreme  prostra- 
tion, and  fever  which  terminates  by  crisis.  There  are  different  forms  of 
lobar  pneumonia,  classified  according  to  their  clinical  or  pathologic  pecu- 


LOBAR  PNEUMONIA.  133 

liarities,  as  primary  lobar  pneumonia,  secondary  lobar  pneumonia,  and 
lobar  pneumonia  with  the  formation  of  new  connective  tissue,  etc.  I 
shall  describe  the  third  form  separately  (p.   510). 

Pathology. — Usually  the  lesions  are  confined  to  the  whole  of  one 
lobe :  less  frequently  to  the  whole  of  one  lung,  and  rarely  to  parts  of 
both  lungs.  From  Jurgensen's  analysis  of  6666  cases  the  following 
statement,  showing  the  different  situations  of  the  lesions  and  their  relative 
frequency,  was  taken :  Right  lung,  about  54  per  cent.  ;  left  lung,  about 
38  per  cent. ;  and  both  lungs,  about  8  per  cent.  In  the  right  lung  the 
lower  lobe  was  involved  in  22  per  cent.,  the  upper  in  12  per  cent.,  the 
middle  in  nearly  2  per  cent.,  and  the  whole  lung  in  about  9  per  cent.  In 
the  left  lung  the  lower  lobe  was  involved  in  about  23  per  cent.,  the  upper 
in  about  7  per  cent.,  and  the  whole  lung  in  about  8  per  cent.  Both  lungs 
were  implicated  in  8  per  cent. 

The  lesions  of  pneumonia  are  those  of  three  stages  :  (a)  Stage  of  con- 
gestion or  engorgement ;  (b)  Red  hepatization  (consolidation) ;  and  (c) 
Gray  hepatization. 

{a)  Stage  of  Engorgement. — The  part  or  parts  implicated  are  of  a  dark- 
red  color,  and  firmer  to  the  feel,  but  less  resilient  and  crepitant,  than 
normal.  The  cut  section  drips  a  blood-stained  serum,  and  dark  blood 
exudes  from  the  distended  capillaries.  The  air-cells  do  not  collapse, 
though  they  are  not  solid,  since  excised  pieces  float ;  but  the  weight  of  the 
lung-tissue  is  much  increased  and  the  air-sacs  are  distended  with  the 
corpuscular  exudate.  Collapsed  portions  may  be  observed  which  may 
readily  be  insufilated  from  the  bronchus,  and  areas  of  extravasation  may 
occasionally  be  noted  near  the  pulmonary  pleura. 

On  microscopic  examination  the  alveolar  epithelium  is  seen  to  be 
swollen,  the  capillaries  greatly  distended,  and  the  air-cells  filled  with 
alveolar  epithelial  cells,  red  corpuscles,  and  a  few  leukocytes.  Similar 
elements  occupy  the  small  bronchi. 

(b)  Red  Hepatization. — The  affected  tissue  is  solid,  airless,  and  firm, 
resembling,  as  the  term  indicates,  liver-tissue.  It  is  reddish  brown  (ma- 
hogany) in  color,  presenting  a  dry,  mottled  appearance,  and  when,  as  is 
usual,  an  entire  lobe  is  involved,  it  is  more  voluminous  than  normal  and 
its  surface  is  often  furrowed  by  the  impress  of  the  ribs.  Being  airless, 
the  affected  portion  does  not  crepitate,  and  its  weight  and  specific  gravity 
are  increased.  It  cannot  be  inflated  ;  is  extremely  friable,  and  its  lace- 
rated surface  presents  a  finely  granular  aspect,  this  latter  appearance 
being  due  to  the  minute  plugs  of  inflammatory  matter  (fibrin)  which  fill 
the  air-spaces.  The  air-passages  and  small  bronchi  are  distended  with 
similar  material,  and  granular  masses  can  be  removed  from  the  air-cells 
of  a  cut  or  lacerated  surface  by  carefully  scraping  the  latter.  If  death 
takes  place  during  this  stage,  the  ante-mortem,  dry,  inflammatory  exudate 
soon  softens,  and  may  flow  from  the  cut  section  as  a  grumous,  viscid  fluid  ; 
the  consolidated  tissue  sinks  rapidly  in  water.  The  pulmonary  pleura  is 
covered  with  a  fine  sheet  of  fibrin,  and  in  cases  complicated  by  marked 
pleurisy  the  fibrinous,  inflammatory  exudate  forms  a  thick  coating  upon 
the  pleural  membrane,  and  the  sac  may  contain  liquid  effusion. 

Microscopic  examination  shows  the  air-spaces  filled  with  clotted  fibrin, 
in  whose  meshes  are  held  red  blood-corpuscles,  pus-cells,  and  changed 
alveolar  epithelium.   The  interlobular  connective  tissue  may  be  infiltrated 


134  INFECTIOUS  DISEASES. 

with  leukocytes  and  fibrillated  fibrin,  but  the  blood-vessels  in  the  walls 
of  the  alveoli  remain  pervious.  The  pneumococci  (micrococci  lanceolati), 
less  fre((uently  also  streptococci  and  staphj^lococci,  are  detectable. 

(c?)  Gray  Hepatization. — In  this  stage  the  fibrinous  exudation  becomes 
decolorized,  the  surface  at  first  resembling  granite  in  color,  and  later 
appearing  uniformly  gray.  Associated  with  this  change,  and  following 
it,  there  is  fatty  and  granular  degeneration  of  the  inflammatory  exudate, 
in  consequence  of  which  the  latter  becomes  moist  and  soft.  The  exudate 
loses  its  granular  character,  while  at  the  same  time  the  friability  of  the 
lung-tissue  is  further  increased,  and  from  the  surface  of  the  cut  section 
there  flows  usually  a  grayish-white  or  yellowish-white  purulent  liquid. 
Not  less  than  one-half  of  the  fatal  cases  die  in  the  early  part  of  this 
statue.  The  pleura  that  invests  the  involved  tissue  is  usually  covered 
with   a   fine  fibrinous   exudation. 

Microscopic  examination  shows  the  air-cells  stuffed  with  leukocytes, 
while  the  other  histologic  elements  (fibrin,  red  blood-cells,  etc.)  have 
disappeared;  and  the  full  development  of  gray  hepatization  marks  the 
beginning  of  resolution,  though  the  latter  process  may  in  reality  begin 
with  the  commencement  of  the  former.  The  exudate  is  now  softened 
into  a  liquid  material,  with  disintegration  of  cellular  elements,  and  is 
absorbed  by  the  lymphatics.  Resolution  usually  corresponds  in  time  with 
the  occurrence  of  the  crisis,  though  it  may  begin  later.  Again,  the  pro- 
cess may  be  much  jiroloiiged.  Among  unfavorable  terminations  are — 
(1)  Purulent  Infiltration. — Here  the  lung-tissue  becomes  \Qvy  soft,  fri- 
able, and  is  bathed  in  purulent  material ;  and  microscopic  observation 
shows  the  pus-cells  densely  infiltrating  the  interalveolar  tissue  and  filling 
the  air-spaces  as  well.  This  ini])airs  the  nutrition  of  the  lung-tissue,  and 
may  thus  cause  rupture  of  the  sei)ta,  jiroducing 

(2)  Abscess. — This  is  to  be  attributed  to  subsequent  infection  by 
streptococci,  and  hence  is  a  complicating  lesion.  The  abscesses  vary  in 
size  within  the  widest  limits,  most  frequently  being  situated  near  the  base 
of  the  lung,  and  may  occupy  the  periphery  and  rupture  into  the  pleural 
sac,  causing  pyo-pneumothorax.  In  most  instances  the  abscess-cavity 
has  a  fistulous  connection  with  a  bronchus,  but  occasionally  the  abscesses 
become  encapsulated  in  fibrous  tissue,  their  contents  undergoing  first 
caseous,  and  then  calcareous,  degeneration.  Rarely  they  open  into  the 
pericardium,  and  still  more  seldom  externally.  They  may  be  small  and 
multiple,  in  which  case  they  sometimes  coalesce,  forming  large  abscesses. 

(8)  Gangrene  may  rarely  follow,  but  is  due  to  a  specific  cause,  and 
hence  does  not  belong  peculiarly  to  the  ])neumonic  process. 

(4)  Induration. — A.  Frankel  states  that  in  a  few  instances  (about  1 
per  cent.)  pneumonia  ends  in  induration,  and  is  found  upon  section  to  be 
smooth  and  its  tissue  resistant.  The  surface  of  the  cut  section  sometimes 
shows  a  peculiar  transparency,  Avith  characteristic  yellow  specks,  due  to 
the  collection  of  cells  which  have  become  fatty. 

Microscopically,  the  alveoli  are  seen  to  be  blocked  up  by  connective 
tissue  resembling  ])olypi  and  containing  vessels.  By  its  structure  it  re- 
calls the  process  of  organization  in  a  thrombus,  and  is  probably  due  to 
secondary  infection.     It  may  also  be  observed  after  broncho-pneumonia. 

Changes  in  Other  Viscera. — The  Iteart  often  appears  pale  and  is  flabby, 
but  upon  microscopic  examination  the  muscular  cell-fibers  of  the  organ 


LOBAR  PNEUMONIA.  135 

are  not  found  to  be  degenerated,  except  in  rare  and  usually  protracted 
cases.  The  cardiac  chambers,  particularly  the  right,  are  distended  with 
firm,  tough  clots,  which  are  usually  removable  en  masse  from  the  great 
vessels  in  the  form  of  arboreal  casts.  The  blood  tends  to  coagulate, 
owing  to  the  fact  that  its  fibrinous  elements  are  vastly  increased. 

Pericarditis  occurs  in  about  5  per  cent,  of  the  cases,  and  is  relatively 
more  frequent  in  left-sided  or  double  pneumonia.  Endocarditis  is  more 
common,  especially  the  ulcerative  form,  which  was  present  in  11  out  of 
100  autopsies  (Osier).  With  malignant  endocarditis  the  lesions  of  men- 
ingitis are  often  combined,  but  as  a  separate  complication  meningitis  is 
rarely  encountered. 

The  spleen  is  congested,  moderately  enlarged,  and  softened,  and  the 
liver  is  likewise  hyperemic  and  somewhat  swollen.  In  the  kidneys  are 
found  the  lesions  of  parenchymatous  inflammation,  and  with  remarkable 
frequency  also  those  of  chronic  interstitial  inflammation.  A  catarrhal 
state  of  the  gastro-intestinal  mucosa  (often  with  jaundice)  is  common; 
and  a  frequent  complicating  change  is  croupous  inflammation  of  the  colon. 
A  true  diphtheritic  colitis,  however,  occurs  but  seldom. 

etiology. — Bacteriology. — The  generally  accepted  specific  cause  of 
pneumonia  is  the  Micrococcus  lanceolatus  of  Frankel.  It  is  a  lance- 
shaped  (slightly  elliptic)  coccus,  united  in  pairs  (a  fact  to  which  it  owes 
its  name  of  diplococcus),  and  is  present  occasionally  in  the  nose,  Eu- 
stachian tubes,  and  larynx  of  healthy  individuals.  Xetter  found  it  in  20 
per  cent,  of  the  specimens  of  buccal  secretion  taken  from  well  persons, 
and  to  the  presence  of  this  germ  is  to  be  ascribed  the  form  of  septicemia 
induced  in  animals  by  inoculation  with  saliva.  It  is  present  in  about  90 
per  cent,  of  all  instances  of  pneumonia,  and  in  persons  who  have  had 
the  disease  it  is  detectable  for  many  months  or  even  years.  It  is  gen- 
erally present  in  pure  culture,  but  may  be  associated  with  pyogenic  organ- 
isms. It  is  probable  that  Friedlander's  bacillus  and  other  micro-organ- 
isms (Eberth's  bacillus,  streptococcus  of  erysipelas)  may  also  have  the 
power  to  cause  the  disease ;  and  Wassermann  ^  suggests  that  specific 
forms  of  pneumonia  may  coexist  in  the  same  individual,  as,  for  example, 
lobar  pneumonia  and  influenzal  pneumonia.  The  micrococcus  lanceo- 
latus (Fig.  15)  can  be  readily  demonstrated  in  the  sputum  by  treating 
a  cover-slip  preparation  "  with  glacial  acetic  acid,  and  then,  after  washing 
off  the  acid,  dropping  on  anilin  oil  and  gentian-violet,  which  is  to  be 
poured  ofi"  and  renewed  two  or  three  times." 

The  Pneumococcus  iji  Other  Diseases. — It  has  been  found  in  pure 
culture  in  pleuritis  (including  empyema),  pericarditis,  meningitis,  peri- 
tonitis, endocarditis,  synovitis,  broncho-pneumonia  (principally  in  adults), 
acute  abscess,  and  other  conditions. 

The  mode  of  infection  is  probably  by  inhalation.  The  first  and  chief 
effects  of  the  germ  are  local — in  the  lung,  though  it  may  reach  more 
distant  portions  of  the  body.  To  the  widespread  distribution  of  the 
pneumococcus  is  due,  in  part,  the  septicemic  process  sometimes  observed. 
It  may  cause  toxic  features  and  speedy  death  without  consolidation  of 
lung-tissue.  Usually,  then,  the  disease  is  a  local  one  at  the  start,  but 
soon  the  toxins  of  the  micrococcus  lanceolatus  become  diff"used  through- 
out the  system,  producing  a  general  disturbance.     Secondary  infection 

^  Deutsche  medicinische  Wochenschrift,  Leipzig,  Nov.  23,  1893. 


136  INFECTIOUS  DISEASES. 

with  other  specific  organisms  (streptococci,  staphylococci,  etc.)  commonly 
occurs  in  the  various  organs  of  the  body. 

Predisposing  Causes. — (1)  Endemic  Influence. — That  endemics  of  pneu- 
monia, often  of  serious  type,  may  occur  in  solitary  buildings  (barracks, 
tenement-houses,  institutions,  etc.)  cannot  be  successfully  denied,  and 
here  the  disease  appears  to  make  for  itself,  rarely,  a  permanent  home. 
We  may  attribute  these  outbreaks  to  defects  in  the  local  sanitary  con- 
ditions. 

(2)  Epidemic  Influence. — From  time  to  time  pneumonia  prevails  exten- 
sively, and  appears  to  spread  throughout  a  considerable  percentage  of  the 
entire  population  of  urban  and  rural  districts.  It  may  also  originate  in 
the  endemic  form  in  tenement-houses  and  institutions,  and  increase  in  its 
scope  until  it  assumes  an  epidemic  cliaracter.     The  epidemic  form  of 


•*. 


Fig.  15.— Diplococcns  pneumonia,  from  the  heart's  blood  of  a  rabbit ;  X  1000  (Frankel  and  Pfeiffer). 

pneumonia  is  at  times  confined  to  private  homes  (house  epidemics),  and 
in  the  winter  of  1894  I  saw,  with  Dr.  W.  K.  Mattern  of  Philadelphia, 
3  cases  develop  in  rapid  succession  in  one  family.  A  Sister  of  Charity, 
after  nursing  two  of  the  patients  faithfully  for  a  period  of  ten  days,  was 
also  attacked  and  died  of  the  disease.  It  is  possible  that  the  house-epi- 
demic form  may  spread  by  contagion.  An  instructive  epidemic  is 
reported  by  W,  B.  Rodman,  who  states  that  118  cases  of  pneumonia, 
with  25  deaths,  occurred  in  a  prison  population  of  735.  B.  Robinson ' 
insists  upon  his  view  that  pneumonia  is  contagious. 

(3)  Geographic  Distribution. — Pneumonia  may  be  said  to  be  an  al- 
most universally  distributed  affection.  It  prevails,  however,  more  exten- 
sively in  certain  countries  than  in  others,  and  occurs  more  frequently  in 

'  Lajicd,  April  16,  1898. 


LOBAR  PNEUMONIA.  137 

certain  sections  of  the  same  country  than  in  others.  Thus,  Delafield^ 
points  out  the  fact  (based  on  the  eighth  and  ninth  census  reports)  that  in 
the  United  States  the  disease  is  of  more  frequent  occurrence  in  the  South 
than  in  the  North.  Climate,  j9gr  se,  does  not,  however,  exercise  a  notable 
influence. 

(4)  Season. — Of  5905  cases  collected  by  Seitz  in  Munich,  36.8  per 
cent,  occurred  in  the  spring,  32  per  cent,  in  winter,  15.7  per  cent,  in 
autumn,  and  15.3  per  cent,  in  the  summer.  The  period  of  maximum 
frequency  of  the  aifection  in  temperate  climates  is  usually  from  the  begin- 
ning of  February  to  May,  inclusive,  and  the  next  most  frequent  period 
is  from  December  until  February.  In  London  most  cases  appear  between 
the  end  of  March  and  the  end  of  June  (Herringhan).  The  period  of 
greatest  frequency  will  be  found  to  correspond  in  time  with  the  period  of 
the  greatest  vicissitudes  of  temperature  and  humidity,  though  it  cannot 
be  affirmed  positively  that  there  is  an  essential  connection  between  the 
latter  condition  and  pneumonia. 

(5)  "  Catcliing  cold  "  is  often  followed  by  pneumonia,  but  frequently 
there  is  no  such  history.  In  this  condition  the  mucosa  of  the  respiratory 
passages  is  so  altered  as  to  become  more  susceptible  to  infection  with  the 
pneumococcus,  and  hence  the  so-called  "cold"  is  a  predisposing  cause. 
Such  facts  as  these  also  explain  why  pneumonia  occurs  with  undue  fre- 
quency in  persons  following  certain  occupations  exposing  them  to  those 
external  influences  that  are  apt  to  excite  "  cold." 

(6)  Traumatism. — Following  injuries,  especially  of  the  chest,  pneu- 
monia occurs  quite  frequently.  Contusions  of  the  thorax  by  lowering 
the  vital  power  and  resistance  of  the  tissues  probably  produce  the  same 
local  efi'ects  as  taking  "cold." 

(7)  Age. — Lobar  pneumonia  is  common  at  all  periods  of  life,  and 
during  the  first  two  years  of  life  lobar  pneumonia  is  quite  frequent.  Be- 
tween two  and  twenty  years  of  age  there  is  less  liability,  and  between 
twenty  and  forty  it  is  again  increased ;  while  from  forty  to  sixty  years 
susceptibility  again  diminishes.  After  the  latter  period  it  augments 
rapidly. 

(8)  Sex. — Males  are,  on  the  whole,  more  frequently  attacked  than 
females,  the  discrepancy  in  the  relative  number  of  cases  being  greatest 
from  the  twentieth  to  the  fiftieth  years  of  age,  and  being  due  to  the  dif- 
ferent degrees  of  liability  to  exposure  in  the  two  sexes. 

(9)  Unhygienic  Surroundings. — The  disease  is  more  frequent  among 
the  lower  than  the  higher  classes — a  fact  due  to  the  improved  hygienic 
environment  of  the  latter,  since,  doubtless,  anything  that  will  lower  the 
vital  energy  will  serve  as  a  predisposing  factor. 

(10)  Circumstances  connected  with  Individuals. — The  alcoholic  is  espe- 
cially prone  to  this  disease,  any  or  all  habits  that  tend  to  depress  the  ner- 
vous system  acting  as  predisposing  causes.  Certain  chronic  diseases  may 
exert  an  influence  (chronic  Bright's  disease,  organic  heart-aS"ections,  car- 
cinoma, diabetes,  etc.) ;  but,  contrary  to  what  is  observed  in  other  acute 
infectious  diseases  (typhoid  fever  in  particular),  susceptibility  is  not  so 
great  among  immigrants  and  new-comers  as  among  the  natives  and  the 
older  residents. 

^  "  Diseases  of  the  Lungs,"  American  Text-Book  of  the  Theoi-y  and  Practice  of  Medicine, 
Pepper,  vol.  ii.  p.  540. 


138  INFECTIOUS  DISEASES. 

(11)  Prior  Attacks. — One  attack  undoubtedly  leaves  the  system  more 
susceptible  to  the  disease,  so  that  repeated  attacks  may  occur  in  the 
same  individual.  And  yet  while  it  is  true  that  persons  have  had  nu- 
merous attacks — ten  or  more — this  predisposing  influence  has  probably 
been  overestimated  by  most  writers. 

Immunity. — The  results  of  the  investigations  of  Behring  and  Kitasato 
with  the  blood-serum  of  animals  which  had  been  immunized  against  tetanus 
and  diphtheria  led  Drs.  G.  and  F.  Klemperer  to  experiment  upon  the  lower 
animals  with  Frankel's  diplococcus.  They  found  that  the  rabbit  could 
be  rendered  immune  by  intravenous  or  subcutaneous  injections  of  large 
amounts  of  the  fluid  bouillon-cultures  or  of  the  glycerin-extract.  From 
10  to  20  c.c.  of  serum  taken  from  a  non-receptive  animal  were  injected 
into  the  veins  of  an  animal  that  was  suff'ering  from  typical  pneumonia 
(artificially  produced),  whereupon  the  symptoms  subsided  rapidly  and  the 
animal  entered  upon  a  speedy  recovery.  The  same  serum,  used  in  a 
similar  manner  upon  healthy  receptive  animals,  rendered  them  non-recep- 
tive. The  important  truth  that  the  serum  of  the  blood  of  patients  dur- 
ing convalescence  from  pneumonia  contains  an  antitoxin  which,  when 
injected  into  the  venous  system  of  infected  animals,  is  found  potent  to 
cut  shoft  the  disease,  has  also  been  demonstrated  by  these  observers. 
They  have  employed  the  blood-serum  of  pneumonic  patients  after  the 
crisis,  injecting  it  into  other  patients  before  the  crisis  with  a  view  to 
inducing  the  latter,  and  success  has  attended  their  efibrts  in  6  cases. 
The  question  of  serum-therapy  for  this  important  aff"ection  in  man  is 
not  finally  cleared  up,  and  is  still  beset  with  difficulties  ;  but  that  the 
pneumococcus  engenders  a  virus — pneumotoxin — which  produces  eleva- 
tion of  temperature,  etc.  has  been  clearly  demonstrated  by  the  Klemperer 
brothers.  Again,  that  this  substance,  acting  upon  the  albuminous  ele- 
ments of  the  body,  generates  an  antipneumotoxin  which  circulates  in  the 
blood  and  neutralizes  the  pneumotoxins  as  they  are  formed,  inducing  the 
crisis,  has  also  been  clearly  proved.  Antipneumotoxin,  however,  has  not 
as  yet  been  isolated. 

Clinical  History. — Prodromes  are  rare,  and  when  present  consist 
merely  of  a  slight  general  indisposition,  lasting  a  day  or  more.  Rarely, 
there  is  cough,  thoracic  oppression,  and  slight  chest-pains  (simple  bron- 
chitis), that  may  or  may  not  be  connected  with  the  pneumonic  process. 
When  this  is  the  case,  however,  the  invasion  may  be  marked  by  sudden, 
great  thoracic  oppression  or  by  a  gradual  development  of  the  local  and 
general  symptoms. 

Usually  the  invasion  is  very  abrupt,  and  marked  by  a  severe  rigor, 
which  has  a  duration  of  from  half  an  hour  to  an  hour,  during  which 
period  the  patient  feels  most  uncomfortable,  and  is,  indeed,  very  ill. 
The  initial  chill  may  occur  at  any  hour  of  the  da}'  or  night,  the  fever 
rising  immediately  and  rapidly,  and  the  temperature  often  mounting  to 
104°  F.  (40°  C.)  or  even  higher  in  the  course  of  a  few  hours.  The  skin 
becomes  harsh  and  dry,  the  face  flushed,  and  the  cheek  on  the  side 
afl"ected  often  shows  a  circumscribed  deep-red  spot.  Prostration  is  pro- 
nounced, and  headache  and  other  nervous  disturbances  (restlessness, 
delirium)  accompany  and  follow  the  ushering-in  symptoms. 

The  thoracic  symptoms  follow  closely  upon  the  termination  of  the 
chill.     Inspiration,  particularly  if  deep,  causes  a  stabbing  pain  in  the 


LOBAR  PNEUMONIA.  139 

affected  side;  the  respirations  are  hurried,  somewhat  jerking  and  shallow 
(panting),  while  the  pain  persists,  and  later  dyspyiea  may  become  marked, 
with  accelerated  breathing.  Cough  sets  in  early,  and  is  dry  and  pain- 
ful during  the  first  day  or  even  longer,  and  may  be  attended  with  expec- 
toration, Avhich  generally  presents  a  characteristic  rusty  or  blood-stained 
appearmice.  The  physical  signs  rarely  appear  before  the  end  of  the 
first  day,  and  sometimes  as  late  as  the  third  (central  pneumonia) ;  in  the 
latter  form  the  local  symptoms,  as  cough,  dyspnea,  and  sometimes  pain, 
are  either  wanting  or  feebly  expressed  during  the  first  three  or  four  days, 
and  the  clinical  picture  is  composed  of  the  general  features  only. 

Anorexia  is  usually  complete :  thirst  is  excessive,  and  there  may  be 
vomiting  at  the  onset,  the  bowels  being  generally  constipated,  though 
diarrhea  may  not  infrequently  be  present.  The  patient  in  most  instances 
lies  upon  the  affected  side  until  the  pain  has  in  great  part  subsided,  and 
then  he  is  apt  to  assume  the  dorsal  position,  exposing  to  full  view  an 
anxious  countenance,  with  a  characteristic  flush  upon  the  cheek,  while 
the  alae  nasi  are  seen  to  dilate  forcibly  during  inspiration.  Very 
frequently  herpes  on  the  lips  or  nose  appears  about  this  time,  and 
forms  a  valuable  diagnostic  symptom.  The  nocturnal  remissions  are 
slight,  the  temperature  being  of  the  continued  type,  and  the  fever  con- 
tinues high— 104°  to  105°  F.  (40.5°  C.)— for  from  five  to  ten  days,  and 
generally  terminates  by  crisis.  The  pulse  is  somewhat  quickened,  but 
the  pulse-respiration  ratio  is  not  maintained.  The  other  general  features 
last  until  the  crisis  occurs,  or  even  increase  in  severity,  but  do  not  out- 
last this  period ;  many  of  the  local  symptoms,  however,  and  particularly 
pain,  are  greatly  improved  before  the  crisis  is  reached. 

As  will  be  seen  hereafter,  the  general  course  of  pneumonia  is  modi- 
fied by  a  variety  of  interfering  conditions  that  have  relation  to  compli- 
cations, individual  circumstances,  severity  of  the  type,  etc.  In  the  in- 
stances in  which  the  crisis  is  reached  convalescence  is  rapidly  established. 
The  crisis  may  be  accompanied  by  special  symptoms,  as  copious  sweat- 
ing or  diarrhea. 

Leading  Symptoms  in  Detail. — Local  or  Respiratory  Symptoms. — In- 
creased frequency  of  the  respirations  is  a  characteristic  symptom,  the  rate 
varying  from  40  to  60  per  minute  in  adults,  and  in  children  from  60  to 
90  or  more.  It  is  panting  in  character,  particularly  when  pneumonia 
occurs  in  old  subjects,  and  both  inspiration  and  expiration  are  brief, 
though  sometimes  separated  by  a  rather  long  pause.  Expiration  is 
usually  accompanied  by  an  audible  "  grunt,"  indicating  great  oppression, 
and  while  actual  dyspnea  is  a  frequent  symptom,  it  may  be  absent  or  as 
the  case  progresses  may  become  either  increased  or  greatly  diminished 
according  to  the  severity  of  the  type. 

The  chief  causes  of  the  rapid  and  labored  breathing  are  the  involve- 
ment of  a  large  portion  of  the  lung,  associated  general  bronchitis,  peri- 
carditis or  extensive  pleurisy,  cardiac  failure,  collateral  congestion  with 
edema,  fever,  and  the  intense  pain  in  the  side. 

The  pulse-respiration  rdtio  is  disturbed,  the  relation  now  beino-  1  to 
2,  or  even  1  to  1.5,  instead  of  1  to  4,  as  in  health  (see  Fig.  16). 

Pain  in  the  affected  side  is  in  most  cases  developed  within  a  few  hours 
after  the  initial  chill,  and  after  lasting  two  or  three  days  gradually  dis- 
appears.    It  is  stabbing  in  character,  and  usually  referred  to  the  region 


140  INFECTIOUS  DISEASES. 

immediately  below  the  nipple  or  to  the  axilla,  and  rarely  to  other  points 
(abdomen,  flank).  In  most  instances  it  is  not  severe  until  greatly  in- 
tensified by  the  cough,  which  always  aggravates  this  symptom,  as  does 
deep  inspiration.  The  pain  is  due  to  implication  of  the  pleura  covering 
the  inflamed  lung,  and  may  be  entirely  absent,  especially  in  the  aged 
and  those  showing  marked  toxemia. 

The  cough,  like  the  chest-pain  and  respiration,  is  somewhat  charac- 
teristic, being  fre(|uent,  short,  dry,  and  voluntarily  repressed,  because  it 
is  attended  with  increased  suffering.  Yet  there  are  cases  that  run  their 
entire  course  without  cough,  and  this  especially  in  the  aged  and  in 
drunkards. 

The  Sputum. — At  first  mucoid  and  frothy,  it  soon  becomes  of  a  cha- 
racteristic rustji  color.  It  consists  of  a  frothy,  fluid  mucus  containing 
an  abundance  of  small  viscid  masses  of  a  yelloAvish-  or  reddish-brown 
color,  from  admixture  of  blood.  The  chief  peculiarity  of  the  sputum  in 
fully  developed  cases  is  its  viscidity  and  tenacity^  often  adhering  to  the 
receptacle  even  though  the  latter  be  inverted ;  owing  to  its  adhesive 
quality  it  is  ejected  from  the  mouth  with  considerable  difficulty  by  the 
patient.  About  the  time  of  the  crisis  the  sputum  usually  becomes  more 
abundant,  distinctly  purulent,  and  its  expulsion  easy,  but  rarely  it  may 
be  absent  after  the  crisis.  In  severe  types  of  the  disease  it  may,  at  the 
outset,  consist  largely  of  pure  blood,  and  in  adynamic  forms  it  is  often 
thinner  and  darker  in  color  (prune-juice).  There  are  cases  in  Avhich 
there  is  an  abundance  of  muco-purulent  expectoration  when  extensive 
associated  bi'onchitis  occurs,  and,  on  the  other  hand,  instances  are  met 
with  in  which  nothing  is  expectorated  save  a  little  light-colored  mucus. 
In  old  persons  or  in  those  previously  enfeebled  there  may  be  no  expec- 
toration whatsoever.  The  amount  is  therefore  exceedingly  variable,  not 
only  in  dift'erent  cases,  but  also  in  different  stages  of  the  affection. 

Under  the  microscope  the  sputum  is  seen  to  contain  red  blood-cor- 
puscles, alveolar  epithelium,  the  3Iicrococcus  Janceohttus  (usually  Avith 
other  micro-organisms),   pus-corpuscles,   and  small  fibrinous  casts. 

General  Features. — The  Fever. — As  I  have  already  stated,  the  fever 
rises  rapidly  during  the  initial  chill,  so  that  in  eight  to  twelve  hours  the 
temperature  reaches  104°  or  105°  F.  (40.5°  C).  It  then  remains  high 
until  the  crisis,  juirsuing  the  continued  type,  with  nocturnal  remissions 
amounting  to  a  degree  or  over,  while  the  daily  fluctuations  correspond 
with  the  normal,  except  that  they  are  now  somewhat  exaggerated.  In 
children  the  rigor  is  almost  always  replaced  by  convulsions.  The  tem- 
perature has  a  lower  average  range  in  persons  previously  debilitated,  in 
old  people,  and  in  drunkards,  than  in  healthy  adults  and  children. 
During  the  febrile  period  there  may  be  observed  a  pronounced  fall  of 
temperature — pseudo-crisis — but  the  temperature  again  rises  to  its  former 
height.  This  may  occur  quite  early,  though  more  often  it  precedes  the 
true  crisis  by  a  day  or  two ;  and  rarely  it  may  take  place  repeatedly, 
and  the  temperature-curve  bear  a  strong  resemblance  to  the  remittent  or 
even  the  intermittent  type,  regardless  of  any  malarial  infection.  The 
temperature  may  be  unusually  high,  106°  F.  (41.1°  C.)  or  even  107°  F. 
(41.6°  C),  these  striking  elevations  sometimes  immediately  preceding 
the  crisis  {perturhatio  critica) ;  but  this  does  not  belong  particularly  to 
pneumonia.     It  is  especially  characteristic  of  pneumonia,  however,  that 


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3 

142  INFECTIOUS  DISEASES. 

the  fever  terminates  by  crisis ;  hence  a  mere  glance  at  the  temperature- 
chart  may  serve  to  complete  the  diagnosis  in  doubtful  cases  (see  page 
141).  The  crisis  may  occur  anywhere  from  the  end  of  the  third  to  the 
fourteenth  day,  but  in  the  majority  of  instances  it  is  on  the  seventh  or 
the  ninth.  The  temperature  usually  falls  during  the  night,  and  the  drop 
is  accompanied  by  copious  perspiration,  so  that  by  the  following  morn- 
ing the  thermometer  is  found  to  register  at  the  normal,  or  more  often  a 
subnormal,  point  (96-95°  F. — 35°  C).  This  fall  in  temperature  may 
also  be  interrupted  by  fresh  though  slight  exacerbations. 

The  duration  of  the  period  of  decline  is  usually  from  eight  to  twelve 
hours.  It  may  be  much  shorter,  but  more  often  is  much  longer,  just  as 
when  the  decline  takes  place  by  lysis.  The  latter  mode  of  termination 
is  usually  due  to  some  complication,  and  when  the  high  fever  persists 
for  an  indefinite  period  (twelfth  to  fourteenth  day  or  longer),  it  is  usu- 
ally owing  to  delayed  resolution. 

Circulatory  Symptoms. — Most  important  is  it  to  study  the  condition 
of  the  heart  and  j^ulse  in  cases  of  pneumonia.  The  average  pulse-rate 
in  typical  cases  is  about  100  to  108  per  minute,  and  when  it  exceeds 
120  there  is  just  cause  for  alarm.  The  rate  may  be  increased  either 
suddenly  or  gradually,  but  in  any  event  augmented  frequency  implies 
danger,  since  it  is  a  certain  indication  of  failure  of  heart-power.  The 
latter  may  be  due  to  the  influence  of  the  poison  secreted  by  the  diplo- 
cocci,  to  previous  organic  disease  of  the  heart,  or  to  some  complicating 
condition  (pericarditis,  collateral  edema),  and  the  period  of  greatest 
liability  is  in  the  advanced  stage  of  the  disease.  At  first  the  pulse  is 
small ;  a  little  later  full  and  bounding,  although  the  latter  character  of  the 
pulse  may  be  associated  with  low  tension  (Van  Santvoord).  In  extensive 
consolidation  the  pulse  is  apt  to  become  small,  due  to  the  fact  that  a  les- 
sened amount  of  blood  reaches  the  left  ventricle  and  systemic  circulation. 
Dicrotism  may  be  noticeable,  and  an  irregularity  in  the  volume  and 
rhythm  of  the  pulse  may  be  observed ;  it  is  an  unpropitious  sign.  In 
the  aged  and  the  weakly,  a  feeble,  frequent  pulse  may  be  present. 

The  heart-sounds  are  clear,  and  owing  to  increased  tension  in  the 
pulmonar}^  vessels  the  pulmonary  second  sound  is  accentuated.  This 
is  the  state  of  thinsrs  throuiihout  in  favorable  cases.  With  failure  of 
the  right  ventricle  (a  not  rare  event)  there  arise  the  signs  of  dilatation 
of  this  chamber  (extension  of  cardiac  dulness  to  the  right,  epigastric 
impulse,  a  low  systolic  murmur,  shortening  of  the  diastole,  or  fetal  heart- 
sounds,  signs  of  venous  stasis,  and  indistinctness  of  the  pulmonary  sec- 
ond sound).  The  strength  of  the  right  ventricle,  upon  which  so  much 
depends  in  pneumonia,  is  indicated  by  the  character  of  the  pulmonic 
second  sound.  A  soft,  low-pitched  murmur  is  sometimes  audible  in  the 
mitral  and  pulmonary  zones. 

The  blood- appearances  are  somewhat  characteristic.  The  researches 
of  Lache^  show  that  leukocytosis  is  of  some  value  in  determining  be- 
tween the  crisis  and  pseudo-crisis,  continuing  in  spite  of  the  f\ll  of  tem- 
perature, etc.  in  pseudo-crisis,  while  it  disappears  with  the  true  crisis. 

Stienon  ^  finds  that  in  the  febrile  stage  the  polynuclear  forms  predom- 
inate, but  as  soon  as  these  diminish  the  eosinophiles  begin  to  increase. 

»  Berliner  klin.  Woch.,  1893,  Nos.  36  and  37. 
*  La  Presse  vied.,  July  13,  1895. 


LOBAR  PNEUMONIA.  143 

The  red  corpuscles  and  hemoglobin  remain  little  changed  during  the 
course  of  the  disease,  but  show  a  marked  decrease  almost  immediately 
after  the  actual  crisis.^  The  prognostic  significance  of  absence  of  leu- 
kocytosis would  seem  to  be  considerable,  as  this  symptom  serves  to  dis- 
tinguish pneumonia  from  influenza,  in  uncomplicated  cases  of  which  it 
does  not  occur.  The  blood-plates  are  also  increased  in  number  (Hayem), 
Da  Costa  has  collected  6  cases  of  phlegmasia  alba  dolens  in  pneumonia. 

Cerebral  Symptoms. — Headache  sets  in  early  and  may  be  a  prominent 
and  persistent  feature.  In  many  cases,  and  particularly  in  children,  the 
disease  is  ushered  in  by  convulsions,  this  symptom  occurring  more  often 
in  the  apical  than  in  the  basilar  form  of  pneumonia.  Delirium  may  come 
on  during  the  acme  of  the  disease  (rarely,  it  may  start  as  an  acute  mania), 
and  may  assume  a  maniacal  form,  but  oftener  in  my  experience  conscious- 
ness has  been  retained.  In  the  drunkard  delirium  tremens  usually  de- 
velops, and  may  anticipate  the  symptoms  referable  to  the  lungs ;  and  I 
fully  agree  with  Osier  in  stating  that  it  should  be  an  invariable  rule,  if 
fever  be  present,  to  examine  the  lungs  in  delirium  tremens.  These  cases 
may  often  be  appropriately  termed  '' ivalMng  jjueumoma,"  since  they 
go  about  until  excitement  gives  way  to  a  coma  that  deepens  into  death. 
In  adynamic  forms  a  low,  muttering  delirium  is  frequent  and  is  some- 
times accompanied  with  more  or  less  coma. 

In  the  so-called  cerebral  pneumonia  the  nervous  phenomena  are  quite 
pronounced,  and  simulate  closely  cases  of  cortical  meningitis.  It  is 
often  associated  with  excessively  high  fever,  except  in  the  aged,  Avhen 
the  cerebral  symptoms  are  also  well  marked,  but  the  fever  is  moderate. 
Most  authors  contend  that  apical  pneumonias  are  apt  to  assume  the 
cerebral  type,  but,  according  to  my  own  experience,  this  dictum  is  cor- 
rect as  relating  to  children  only.  Most  authors  also  state  that  double 
pneumonias  are  characterized  frequently  by  severe  cerebral  symptoms,  yet 
I  have  seen  instances  in  the  adult  without  unusual  nervous  phenomena. 

The  Cutaneous  Symptoms. — As  stated  before,  herpes  is  common  and  its 
diagnostic  importance  is  considerable.  Naso-lahial  herpes  is  but  little 
less  frequent  in  this  disease  than  in  malaria,  being  present  in  about  one- 
third  of  the  cases.  It  usually  comes  out  from  the  second  to  the  fifth 
day  of  the  disease,  and  rarely  may  appear  upon  the  cheek,  lobe  of  the 
ear,  the  genitals,  forearm,  or  upon  the  mucosa  of  the  tongue.  Sweats 
are  not  common  during  the  height  of  the  disease,  but  usually  accom- 
pany defervescence,  when  they  may  be  copious.  The  deep-red  circum- 
scribed spot  upon  one  cheek  {mahogany  flush),  usually  on  the  side  of 
the  affected  lung,  has  already  been  mentioned.  Urticaria  has  been  ob- 
served, though  rarely. 

Digestive  System. — The  mucous  membrane  of  the  mouth  is  dry,  the 
tongue  has  a  coating  of  a  yellowish-white  color,  becoming  dry  and  brown 
in  cases  representing  a  low  form,  and  anorexia  and  thirst  are  present. 
Vomiting  is  not  uncommon  at  the  outset,  and  may  be  repeated,  while 
constipation  is  the  general  rule  and  diarrhea  the  frequent  exception. 
The  above  symptoms  spring  from  the  marked  fever.  Splenic  enlaro-e- 
ment  of  slight  degree  can  usually  be  detected  on  palpation,  but  the  liver 
is  not  perceptibly  increased  in  size. 

^Sadler,  Fortschritte  der  Medicin,  1892;  Leichtenstein,  Ueber  der  Udmoglobin-gehalt 
des  Blute^,  etc.,  Leipzig,  1892. 


144  INFECTIOUS  DISEASES. 

Urinary  Symptoms. — The  urine  is  febrile,  diminished  in  amount, 
and  high-colored,  the  urea  and  uric  acid  being  greatly  in  excess.  On 
the  other  hand,  the  chlorids  are,  according  to  the  older  authors,  either 
diminished  in  amount  or  absent  during  the  febrile  stage,  presumably  for 
the  reason  that  they  pass  into  the  inflamed  lung-tissue.  They  are  not, 
however,  constantly  absent,  and  sometimes  they  are  not  even  lessened, 
in  pneumonia ;  moreover,  their  disappearance  is  not  peculiar  to  this  dis- 
ease. The  above-mentioned  facts  justify  two  important  inferences:  (1) 
The  absence  of  chlorids  is  a  symptom  of  little  diagnostic  value  ;  and 
(2)  their  reappearance  in  the  urine  toward  the  close  of  pneumonia  is  of 
small  prognostic  worth.      Slight  (febrile)  albuminuria  is  common. 

Physical  Signs. — Stage  of  Congestion. — The  density  of  the  lung  is 
increased,  but  the  involved  tissue  is  not  consolidated  and  the  pleura  is 
not  yet  covered  with  fibrin. 

Inspection. — The  movements  of  the  afiected  side  (especially  if  the 
base  be  involved)  are  defective,  the  degree  of  expansion  being  much 
diminished.  In  double  pneumonia  the  costal  type  of  breathing,  com- 
bined with  a  vigorous  play  of  the  abdominal  muscles,  is  observed. 

Palpation. — There  is  a  slight  increase  in  the  tactile  fremitus  over 
the  congested  area. 

Percussion. — The  note  may  be  normal,  though  more  often  it  is 
briefer,  higher-pitched,  or  even  distinctly  tympanitic. 

Auscultation. — The  breath-sounds  are  weak,  and  sometimes  become 
broncho-vesicular  upon  deep  inspiration,  while  over  the  unaffected  lung- 
tissue  they  are  exaggerated.  If,  as  often  happens,  inflammatory  prod- 
ucts due  to  associated  bronchitis  occupy  the  small  bronchi,  subcrepitant 
rales  may  be  audible.  The  crepitant  rale,  however,  is  rarely  heard 
until  the  close  of  the  first  stage  or  until  fibrin  coats  the  pleural  sur- 
faces, and  I  cannot  agree  with  the  view  of  certain  authorities  who  claim 
that  this  rale  is  produced  in  the  air-cells  and  finer  bronchi. 

Stage  of  Consolidation. — Inspection. — There  is  little  or  no  expansive 
motion  of  the  chest  over  the  affected  area,  while  upon  the  unaffected 
side  it  is  increased.  The  volume  of  the  thorax  on  the  diseased  side  is 
increased,  as  shown  by  mensuration,  but  the  intercostal  depressions  are 
not  effaced. 

Palpation  renders  clearly  perceptible  the  defect  or  absence  of  expan- 
sion. Vocal  fremitus  is  usually  much  increased,  though  in  exceptional 
instances  it  is  diminished  or  absent — a  circumstance  which  can,  as  a 
rule,  though  not  invariably,  be  attributed  to  an  associated  pleurisy  with 
more  or  less  eftusion.  Frequently  a  friction-rub  is  felt  before  complete 
consolidation  is  established. 

Percussion. — Varying  degrees  of  duluess  are  obtained  in  this  stage, 
and  before  the  lung-tissue  becomes  thoroughly  solidified  the  note  may 
have  a  tympanitic  quality.  After  complete  consolidation  there  is  usu- 
ally marked  or  absolute  dulness  posteriorly,  while  the  note  may  be  more 
or  less  tympanitic  anteriorly,  where  the  vibrations  are  more  apt  to  reach 
the  air  in  the  larger  bronchi.  A  sense  of  resistance  is  offered  to  the 
pleximeter-finger,  but  not  to  the  same  degree  as  in  the  case  of  a  pleurisy 
with  effusion.  When  tlie  latter  condition  is  associated  the  percussion- 
note  will  be  flat.  Deadness  is  less  marked  in  old  people  in  whose  ribs 
senile  changes  have  taken  place,  which  render  them  more  resonant,  or  in 


LOB  AM  PNEUMONIA.  145 

cases  in  which  the  consolidated  areas  occupy  the  central  portions  of  the 
lung.     Above  the  solidified  part  Skodaic  resonance  is  usually  obtainable. 

Auscultation. — Bronchial  or  tubular  breathing  is  heard,  as  a  rule, 
over  the  solidified  lung,  but  it  may  be  absent  in  consequence  of  the 
plugging  of  the  large  bronchi  Avith  exudate  (so-called  massive  pneu- 
monia). Bronchophony  is  usually  obtainable  over  the  portion  of  the 
lung  affected,  though  this  may  also  be  absent,  and  for  the  same  reason 
as  in  the  case  of  the  bronchial  breathing :  it  sometimes  takes  the  form 
of  egophony.  Subcrepitant  rales,  due  to  associated  bronchitis,  are 
sometimes  heard,  and  the  crepitant  rale  at  the  end  of  inspiration,  sup- 
posedly very  characteristic,  is  best  heard  at  the  beginning  of  consolida- 
tion, when  the  pleura  receives  its  coat  of  fibrin  and  while  the  lung  is 
yet  capable  of  sufficient  movement  to  produce  fine  pleural  friction.  A 
distinct  friction-rub  may  also  be  heard  occasionally. 

Stage  of  Gray  Hepatization. — With  beginning  resolution  the  solid  con- 
tents of  the  air-cells  liquefy  and  are  removed,  so  that  air  now  re-enters  the 
air-cells  and  permits  a  consequent  increase  in  the  movement  of  the  lung. 

Inspection. — The  normal  expansile  movement  of  the  affected  side 
gradually  returns. 

Palpation. — Tactile  fremitus  progressively  diminishes. 

Percussion. — The  dull  or  tympanitic  quality  of  the  note  is  gradually 
lost,  though  the  fact  must  be  emphasized  that  the  abnormalities  in  the 
note  vanish  more  sloAvly  than  the  other  abnormal  physical  signs.  Some 
degree  of  deadness  often  remains  long  after  recovery  is  apparently  com- 
plete. 

Auscultation. — With  increased  movement  of  the  lung  there  may  be  a 
reappearance  of  the  crepitant  rale,  due  to  interplay  of  the  pleural  sur- 
faces, and  the  softened  exudate  in  the  air-cells  gives  rise  to  subcrepitant 
rales,  heard  both  on  inspiration  and  expiration,  with  coarser  rales  over 
the  bronchi.  Bronchial  breathing  gradually  gives  place  to  broncho- 
vesicular,  and  the  latter  in  turn  to  normal  breathing. 

Complications. — Doubtless  many  of  these  are  due  to  the  primary 
infection  by  diplococci. 

Pleurisy  is,  of  necessity,  associated  in  all  instances  in  which  the  con- 
solidation reaches  the  pleura.  It  is  to  be  looked  upon  as  a  direct  result 
of  the  pneumonic  process,  since  in  a  great  proportion  of  cases  examined 
the  presence  of  the  diplococci  has  been  demonstrated.  Cases  are  met 
with,  however,  in  which  the  truly  pneumonic  symptoms  are  overshadowed 
by  the  intensity  of  the  pleuritis,  and  to  these  the  term  pleuro -pneumonia 
has  been  applied.  In  this  form  there  is  often  a  copious  effusion  which 
is  exceedingly  rich  in  fibrin — a  circumstance  which  distinguishes  it  from 
other  forms  of  acute  pleurisy.  There  may  be  the  ordinary  grade  of 
pleurisy  on  the  side  affected  by  the  pneumonia,  and  a  severe  grade  on 
the  opposite  side,  and  when  effusion  occurs  under  the  latter  exceptional 
conditions  it  is  apt  to  be  purulent.  Indeed,  empyema  has  of  late  been 
shown  to  be  a  frequent  complication  of  pneumonia,  but,  as  far  as  my 
own  observation  goes,  it  would  appear  to  rank  as  a  sequel  rather  than  a 
complication,  coming  on  as  it  usually  does  several  days  after  the  crisis. 
Its  development  is  accompanied  by  replacement  of  ordinary  dulness  by 
flatness  with  great  resistance,  and  by  the  disappearance  of  rales  and 
breath-sounds,  normal  and  abnormal.      Other  characteristic  features  of 

10 


146  INFECTIOUS  DISEASES. 

empyema  are  present,  but  in  tBe  event  of  doubt  surrounding  the  diag- 
nosis the  needle  should  be  introduced. 

There  is  a  prompt  rise  of  fever,  the  temperature  leaping  to  103°  or 
104°  F.  (40°  C.)  quickly,  after  which  it  is  decidedly  remittent  in  type, 
but  there  are  no  hectic  chills.  Fistulous  connection  with  a  bronchus, 
however,  and  the  establishment  of  empyema  necessitatis  are  common 
events  in  this  form  of  the  disease,  and  may  be  preceded  by  diurnal 
chills,  sweats,  etc. 

The  occurrence  of  septic  phenomena  is  a  certain  indication  of  second- 
ary infection  by  streptococci.  The  pus  is  absorbed  very  rarely,  and 
more  frequently  becomes  encysted.  I  saw  one  instance  in  which  the 
effusion  measured  8  liters,  while  ordinarily  the  amount  ranges  from  2  to 
5  liters.  Removal  of  the  effusion  by  aspiration  is  promptly  followed  by 
the  disappearance  of  the  fever,  but  reaccumulation  generally  occurs,  with 
another  rise  of  temperature. 

Finally,  if  defervescence  takes  place  by  lysis  or  if  the  "critical" 
decline  is  absent,  a  residual  purulent  or  sero-fibrinous  effusion  may  be 
considered  as  the  likely  cause.  This  latter  complication  is  attended  by 
a  paroxysmal  cough  Avhich  is  excited  by  movement,  and  is  not  usually 
accompanied  by  expectoration,  while  the  temperature  rises,  though  not 
so  high  as  when  the  effusion  is  purulent.  It  remains  to  be  pointed  out 
that  rarely  also  there  is  a  primary  empyema,  due  to  the  pneumococcus. 

Acute  general  bronchitis  may  pre-exist  or  may  arise  as  a  complication, 
and  often  proves  formidable,  intensifying  the  fever  and  increasing  the 
dyspnea,  the  tendency  to  heart-failure,  and  the  cyanosis.  The  expec- 
toration of  mucus  is  freer  than  in  uncomplicated  pneumonia,  and  over 
the  bronchi  moist  rales  intermingled  with  sibilant  and  sonorous  rales 
are  audible. 

Pericarditis. — This  is  one  of  the  most  important  complicating  affec- 
tions. It  results  from  a  direct  extension  of  the  adjacent  pleuritis,  and 
hence  is  more  common  in  left-  than  in  right-sided  pneumonia,  and  chil- 
dren are  more  prone  to  it  than  adults.  Although  generally  of  the  plas- 
tic variety,  it  is  not  infrequently  sero-fibrinous.  and  rarely  the  effusion 
is  purulent.  The  diagnosis  can  be  made  in  the  same  way  as  when  other 
conditions  attend  its  development,  but  it  may  be  readily  overlooked  by 
the  careless  observer.  I  would  say,  however,  that  the  occurrence  of  in- 
creased dyspnea,  with  or  without  precordial  pain,  should  serve  as  a  signal 
and  lend  to  a  physical  examination. 

Endocarditis. — This  is  far  more  frequent  than  pericarditis,  and  par- 
ticularly in  the  ulcerative  form.  Out  of  209  cases  of  malignant  endocar- 
ditis collected  by  0.sler^  54  cases  occurred  in  pneumonia,  and  my  experi- 
ence fully  agrees  with  his  statement  as  to  its  comparative  frequency  in 
this  affection.  There  are  no  reliable  symptomatic  indications  of  this 
condition,  and  of  those  symptoms  that  do  appear  the  physical  signs  are 
least  trustworthy.  Frecfuently  murnmrs  arc  entirely  absent ;  and,  on 
the  other  hand,  the  presence  of  a  murmur,  even  though  it  be  loud  and 
harsh,  is  by  no  means  diagnostic  of  the  complication.  Some  claim  that 
a  rough  diastolic  murmur  is  quite  significant:  this  has  not,  however,  been 
present  in  any  of  my  cases.  The  development  of  septic  manifestations, 
especially  irregular  fever,  chills,  and  sweats,  renders  the  case  highly  suspi- 
cious, and  when  in  addition  there  arises  distinct  evidence  of  embolic  proc- 


LOBAR  PNEUMONIA.  147 

esses  the  diagnosis  becomes  highly  probable.  If,  now,  the  symptoms  of  men- 
ingitis superv^ene,  little  doubt  remains  as  to  the  character  of  the  complica- 
tions, since  meningitis  and  endocarditis  are  often  combined  in  pneumonia. 

Netter,  Weichselbaum,  and  Bignami  have  shown  by  microscopic 
examination  and  cultivation  that  acute  endocarditis  may  be  caused  di- 
rectly by  the  diplococcus  of  pneumonia,  and,  from  the  presence  of  this 
bacillus  in  the  right  ventricle,  that  it  is  far  commoner  than  the  forms 
due  to  other  causes.^ 

Chronic  Endocarditis. — This  predisposes  to  acute  endocarditis,  both 
simple  and  ulcerative,  but,  independently  of  the  acute  form,  pneumonia 
arising  in  the  course  of  chronic  endocarditis  is  apt  to  be  attended  by 
cardiac  failure,  with  venous  stasis  as  the  consequence.  The  murmurs 
of  chronic  valvular  disease  often  disappear  with  the  development  of 
pneumonia. 

Cardiac  clots  (ante-mortem)  may  form,  but  are  rare.  They  result 
from  weakness  of  the  ventricular  wall,  especially  in  the  right  heart ; 
and  are  most  apt  to  arise,  therefore,  in  cases  in  which  the  death-agony 
is  much  prolonged.  Venous  thrombosis  is  rarely  seen,  and  embolism  of 
the  larger  arteries  is  a  rare  complication.  Cerebral  embolism,  causing 
aphasia  and  even  hemiplegia,  has   been  observed,  but  seldom. 

Acute  purulent  meningitis  is  a  comparatively  rare  but  very  grave  com- 
plication. It  is  often  related  etiologically  to  pneumonia,  and  its  symp- 
toms are  not  clearly  defined ;  particularly  is  this  true  when  it  develops 
during  the  invasion-period  and  the  basilar  meninges  are  not  involved. 
Hence  its  diagnosis  is  often  impossible.  The  presence  of  intense  and  per- 
sistent headache,  rigidity  of  the  nucha,  wild  delirium,  followed  by  stupor  deep- 
ening into  profound  coma,  affords  a  basis  for  a  probable  diagnosis.  Its  fre- 
quent association  with  ulcerative  endocarditis  has  been  pointed  out  above. 

Peripheral  neuritis  is  among  the  rare  complications  of  this  disease. 

Parotitis  is  also  sometimes  seen,  and  may  cause  a  fatal  termination  of 
the  case.  I  have  seen  two  instances,  however,  in  which  this  was  a  com- 
plication, and  both  ended  in  recovery.  It  is  thought  to  be  associated 
usually  with  endocarditis,  but  not  in  my  own  cases. 

Arthritis. — This  may  closely  simulate  rheumatism  at  the  start.  It  soon, 
however,  takes  the  form  of  a  purulent  arthritis,  and  may  be  associated 
with  other  suppurative  inflammations  (meningitis,  endocarditis).  The 
pneumococci  have  been  found  in  the  affected  articulation.^  Rheumatism 
may  be  rarely  associated  also,  particulai'ly  in  children. 

Gastro-intestinal  Complications. —  Croupous  gastritis  may  rarely  inter- 
vene, but  croupous  colitis  is  a  more  frequent  concomitant,  giving  rise  to 
tympanites  and  marked  diarrhea,  and  it  may  prove  a  serious  condition. 

Peritonitis  occurs,  but  with  great  rarity. 

Jaundice  may  be  observed  in  all  types  of  the  affection,  though,  on 
the  whole,  it  is  more  frequent  in  serious  than  in  mild  forms  of  the  disease. 
It  is  rarely  intense,  and  has  no  symptoms  as  a  rule  ;  it  is  most  probably  an 
obstructive  (hepatogenous)  jaundice.  I  have  observed  cases  in  which  the 
•evidence  of  a  certain  degree  of  obstruction  was  unmistakable.  N.  V. 
P^trov  has  reported  13  cases  complicated  with  icterus,  and  in  all  observed 
local  lesions  (mainly  catarrhal)  of  the  duodenum  and  the  biliary  canals. 

^  Practitioner,  London,  Aug.,  1894. 

^  Bernheim,  La  3Iedeeine  7nodeme,  Paris,  Feb.  21,  1894.  ^ 


148  INFECTIOUS  DISEASES. 

Acute  nephritis,  generally  of  a  mild  grade,  is  a  rare  sequel  or  compli- 
cation, and  its  recognition  is  entirely  dependent  upon  the  discovery  of' 
albumin  and  casts  in  the  urine. 

Clinical  Varieties  and  Anomalous  Types. — (1)  Typhoid  Pneu- 
monia.— This  relates  to  an  adynamic,  serious  type  of  the  disease  with 
typliuid  symptoms,  and  not  to  typhoid  fever.  It  is  often  secondary  to  low 
fevers,  to  septicemia,  diabetes,  and  chronic  nephritis,  and  is  also  the  vari- 
ety met  with  in  drunkards  and  in  persons  previously  enfeebled.  The 
onset  is  somewhat  gradual.  The  physical  signs  may  be  ill  defined,  but 
the  creneral  features  are  always  striking  and  characteristic.  Prostration  is 
extreme ;  there  are  delirium  and  often  stupor :  the  temperature  may  or 
may  not  be  high  ;  while  the  respirations  and  pulse  are  almost  always  fre- 
quent. The  skin  is  dry,  and  may  show  a  dusky  tint  or  slight  jaundice. 
The  tongue  is  dry,  often  brown,  and  vomiting  is  common;  the  sputa  may 
be  rusty  or  decidedly  hemorrhagic.  Splenic  enlargement  is  often  clearly 
perceptible.     AVlien  recovery  ensues  convalescence  is  tedious. 

(2)  Epidemic  Pneumonia. — This  is  often  of  malignant  type.  The 
symptoms  exhibit  noticeable  variations,  according  to  the  special  etiology 
and  to  different  epidemics.  The  pneumonias  of  epidemic  influenza  are 
complicated  with  or  preceded  by  general  bronchitis.  The  heart-power 
often  becomes  exhausted  early,  and  then  follow  congestion  and  edema  of 
the  lungs.  The  physical  signs  are  often  slight.  In  epidemic  forms  of 
pneumonia  still  other  complications  may  be  pronounced  (cerebral,  intesti- 
nal, etc.).  In  so-called  "  larval  pneumonia  "  the  general  symptoms  are 
mild  and  the  local  signs  ill  defined.  The  epidemic  outbreaks  that  occur 
in  institutions,  tenement-houses,  jails,  etc.  belong  to  this  variety. 

(3)  Latent  Pneumonia. — To  this  class  belong  central  pneumonias 
{vide  General  Symptomatology).  In  ^hege  instances  the  sputum  is  to  be 
stained  and  examined  microscopically,  when  the  pneumococcus  will  be 
found.  When  pneumonia  arises  in  the  course  of  emphysema  a  physical 
examination  often  orives  negative  results,  the  dilated  air-cells  not  being 
filled  with  the  exudate  ;  hence  dulness  is  less  marked,  and  tubular  breath- 
ing is  often  absent.  The  sputum  is  gummous  and  rusty,  as  a  rule.  Be- 
fore the  crisis  occurs  consolidation  usually  advances  to  the  periphery. 

(4)  Migratory  Pneumonia. — By  this  is  meant  an  extension  of  the  spe- 
cific inflammation  to  other  parts  of  the  lungs.  Such  extension  may  pre- 
vent the  occurrence  of  the  usual  crisis,  and  often  occasions  an  exacerbation 
of  the  general  pneumonic  features. 

(5)  Bilious  Pneumonia  {"-Malarial  Pneumonia  "). — When  lobar  pneu- 
monia occurs  in  persons  Avho  are  subjects  of  malarial  poisoning,  the  initial 
chill  is  prolonged  and  the  fever  paroxysmal  or  remittent.  Jaundice  and 
vomiting  are  common. 

(6)  In  children,  the  first  symptom  is  often  a  convulsion.  Cerebral 
symptoms  (delirium,  stupor,  coma)  may  appear  early.  The  upper  lobes 
of  the  lungs  are  frequently  involved.  Unless  the  objective  indications  be 
examined  for,  the  disease  is  frequently  overlooked.  The  characteristic 
sputum  is  rarely  seen  in  juvenile  pneumonia. 

(7)  In  old  persons  pneumonia  runs  a  peculiar  course  and  is  danger- 
ous. The  initial  chill  is  often  absent  or  rephiced  by  moments  of  chilliness. 
There  may  be  nausea  and  vomiting.  Prostration  is  profound ;  there  is 
fever,  but  it  does  not  range  high  and   is  apt   to  be  irregular.     Nervous 


LOBAR  PNEUMONIA.  149 

phenomena,  sometimes  prominent,  are  not  uncommon,  but  the  local  symp- 
,toms  (cough,  expectoration,  and  pain)  are  mild  or  "wholly  absent.  The 
area  of  lung-tissue  implicated  is  often  insignificant ;  when  physical  signs 
are  present  there  are  usually  dulness  on  percussion  (with  a  tympanitic 
quality),  tubular  breathing,  and  a  few  subcrepitant  rales.  This  affection, 
as  it  occurs  in  old  people,  is  a  most  deceptive  one,  the  cases  generally 
ending  fatally  after  an  illness   of  an  apparently  mild  degree  of  intensity. 

(8)  Ether-pneumonia. — Opinions  are  divided  as  to  the  frequency  of 
occurrence  of  pneumonia  after  ether-narcosis.  The  aggregate  number  of 
cases  from  all  sources  (57,842)  gives  a  percentage  of  0.07.  My  own 
statistics,  embi-acing  12,842  cases,  give  a  percentage  of  0.23.^ 

Among  the  principal  causes  are — (a)  Season.  According  to  m}'-  inves- 
tigations, over  80  per  cent,  of  the  cases  occur  during  the  winter  and  spring 
months.  The  patient  is  sometimes  carried  from  a  heated  operating-theatre 
through  a  cold  corridor  to  a  room  or  ward  with  a  lower  temperature,  (h) 
"  Catching  cold,"  or  exposure,  as  may  obtain  during  protracted  opera- 
tions, (e)  Bronchitis,  coryza,  or  other  morbid  state  of  the  respiratory 
mucosa  at  the  time  of  anesthesia,  (d)  Dried  secretions  or  incrustations 
of  foreign  matter  that  are  loosened  by  the  ether  and  drawn  downward  into 
the  lungs,  particularly  if  the  head  be  not  kept  comparatively  low  and 
turned  from  time  to  time,  (e)  Abdominal  operations  give  the  highest 
percentage  of  cases  of  ether-pneumonia,  and  my  studies  show  that  this  is 
partly  due  to  the  more  protracted  etherization,  thus  rendering  the  bronchi 
more  susceptible.  Moreover,  coughing  excites  great  pain,  and  hence  is 
restrained,  with  retention  of  the  bronchial  secretions. 

The  clinical  features  are  aptly  compared  with  those  of  secondary  pneu- 
monia {vide  p.  157).  The  diagnosis  rests  principally  upon  the  typical 
physical  signs.  Owing  to  the  extreme  latency  of  the  condition,  and  the 
danger  that  the  symptoms  may  be  regarded  as  being  septic  in  nature,  I 
would  emphasize  the  importance  of  a  physical  examination  of  the  thorax 
upon  the  sudden  accession  o^  fever,  particularly  if  associated  with  thoracic 
pain,  however  slight,  following  an  operation. 

Relapses. — These  are  among  the  rarest  of  events,  and  are  usually  rudi- 
mentary. Recurrences  are  ordinary,  however,  second,  third,  fourth,  and 
even  more  attacks  occurring  in  the  same  individual. 

Course  and  Duration. — In  cases  that  recover  the  febrile  stage  lasts 
from  three  to  thirty  or  more  days.  In  most  instances,  however,  deferves- 
cence occurs  on  the  seventh  or  ninth  day,  and  resolution  is  completed 
about  one  week  later,  making  the  tota.1  duration  from  twelve  days  to  two 
or  three  weeks.  Convalescence  may  be  delayed  Avhen  complications  out- 
last the  primary  disease  or  when  sequelae  arise,  and  fatal  cases  are  apt 
to  terminate  on  the  seventh,  eighth,  or  tenth  day  of  the  disease.  The 
course  of  pneumonia  is  often  greatly  modified  by  complications. 

Termination. — [a)  Delayed  Resolution. — The  process  of  resolution  may 
not  begin  until  the  fourth,  sixth,  or  even  tenth  week.  Usuallv  deferves- 
cence  by  crisis  has  taken  place  long  before  the  physical  signs  indicate 
resolution  ;  the  fever  may,  however,  fall  by  lysis.  When  resolution  occurs 
it  may  lead  to  complete  restoration  of  the  functional  and  anatomic  entirety 
of  the  lung-tissue,  or  very  rarely  proliferation  of  the  interstitial  connective 
tissue  may  arise  during  the  period  of  postponed  resolution,  producing  (h) 

^  "Ether-pneumonia,"  University  Med.  Mag.,  August,  1898. 


150 


INFECTIOUS  DISEASES. 


chronic  interstitial  pneumonia,  (c)  Abscess  and  (d)  gangrene  are  also 
sequelae.     For  their  clinical  description,  vide  Diseases  of  the  Lung. 

T.  A.  BoAves  and  H.  M.  Fischer  each  give  notes  of  a  case  of  gangrene 
that  recovered. 

Diagnosis. — The  diagnosis  is  determined  by  special  local  and  gen- 
eral symptoms,  together  with  the  physical  signs.  Of  these,  the  abrupt 
onset  Avith  rigor,  the  course  of  the  fever  with  termination  by  crisis,  the 
stabbing  chest-pains,  the  dyspnea,  the  peculiar  type  of  breathing,  the 
abnormal  pulse-respiration  ratio,  the  cough,  the  rusty  expectoration,  and 
the  signs  of  lobar  consolidation,  are  the  most  characteristic.  Repeated 
physical  examinations  of  the  chest  will  often  detect  consolidation,  though 
local  symptoms  are  entirely  wanting.     Again,  when  in  the  course  of  cer- 


FiG.  17.— Lobar  pneumonia:  1,  unaffected  area  (upper  lobe) ;  2,  consolidated  area  (middle  lobe); 
3,  resolving  area  (lower  lobe) ;  4,  heart  in  normal  position. 

tain  chronic  affections  (cancer,  Bright's  disease,  diabetes,  and  organic 
affections  of  the  heart)  fever  is  developed,  physical  exploration  of  the 
thorax  is  imperatively  demanded. 

Differential  Diagnosis. — This  relates  to  (a)  acute  pneumonic  phthisis, 
{b)  pneumo-typhoid,  (c)  meningitis,  (d)  broncho-pneumonia,  (e)  acute 
pleurisy  with  effusion. 


(a)  Primary  Lobar  Pneumonia. 
There  may  have  been  prior  attacks. 


Acute  Pneumonic  Phthisis. 

Inherited  predisposition  or  previous  tu- 
berculous disease. 


LOBAR  PNEUMONIA. 


151 


(a)  Primary  Lobar  Pneumonia. 
Sudden,  with  severe  rigor  and  rapid  rise 
of  temperature. 

Fever  of  continued  type,  terminating:  by 
crisis. 

No  drenching  sweats,  except  at  time  of 
crisis. 

Herpes  common. 

Not  much  emaciation. 

Pulse-respiration  ratio  considerably  dis- 
turbed. 

Sputum  rusty-colored,  viscid,  and  sticky  ; 

•    contains  pneumococcus. 


Acute  Pneumonic  Phthisis. 

Generally  more  gradual — repeated  fits  of 
chilliness  (rarely  severe  rigor),  often 
following  exposure  or  "cold." 

Fever  of  remittent  type,  often  becoming 
intermittent,  without  crisis. 

Drenching  sweats  present  and  oft  re- 
peated. 

Absent. 

Rapid  emaciation. 

Less  so. 

Sputum  may  be  blood-tinged :  is  more 
purulent  and  copious,  and  contains  nu- 
merous bacilli  and  yellow  elastic  tissue. 


Fig.  18. — Acute  pneumonic  phthisis,  posterior  view :  1,  cavity  ;  2  and  3,  consolidation  ;  4,  infiltra- 
tion; the  white  spots  indicate  rales. 

Duration  of  febrile  stage  shorter.  Duration  longer. 

Physical  signs,  as  a  rule,  first  referable       First  referable  to  apex. 

to  base  of  lung. 
Usually  limited  to  one  lobe  or  the  lower      Usually  extension  from  apex  to  base. 

portion  of  one  lung. 
Signs  of  consolidation,  followed  by  reso 

lution. 


Apex  of  healthy  side  not  involved. 

Prognosis  not  hopeless. 
Tuberculous  disease  of  other  organs  does 
not  follow  as  a  rule. 


Signs  of  consolidation,  followed  by  cavity- 
formation,  with  large  gurgling  rales  at 
apex. 

Apex  of  opposite  side  generally  in- 
vaded. 

Hopeless. 

Often  does. 


152  INFECTIOUS  DISEASES. 

(h)  Typlioid  pneumonia  must  be  diagnosed  from  pneumo-typlioid,  and 
the  blood  in  the  two  conditions  may  be  of  service  in  the  discrimination. 
Leukocytosis  usually  exists  in  pneumonia,  and  there  is  hypoleukocytosis 
in  typhoid ;  but  this  fact  is  only  of  value  when  there  is  marked  increase 
or  decrease  of  the  leukocytes,  since  figures  about  normal  may  occur  in 
either  condition. 

Widal's  test  will  be  a  decided  aid.  His  assertion  that  a  drop  of  blood 
from  a  patient  with  typhoid,  added  to  a  pure  culture  of  typhoid  bacilli, 
causes  the  cessation  of  the  motion  of  the  bacilli  and  their  collection  in 
clumps,  and  that  this  does  not  occur  with  blood  from  other  diseases,  is,  I 
think,  satisfactorily  proved. 

{c)  Meningitu  is  sometimes  mistaken  for  pneumonia,  and  particularly 
Avhen  the  latter  occurs  in  children.  The  initial  symptom  of  pneumonia 
in  the  very  young  is  often  a  convulsion  ;  whereas,  though  in  meningitis 
this  symptom  is  not  uncommon,  it  is  more  apt  to  manifest  itself  later. 
When  headache  occurs  in  pneumonia  it  is  frontal.  It  is  almost  invari- 
ably complained  of  in  meningitis,  but  is  occipital,  and  is  associated  with 
rigidity  of  the  cervical  muscles.  Before  the  occurrence  of  pressure- 
symptoms  in  the  latter  disease  the  patient  is  very  restless  and  morose ; 
his  reflexes  are  exaggerated  and  there  is  marked  hyperesthesia.  The 
temperature-range  is  lower,  more  irregular,  and  there  is  no  crisis,  while 
the  pulse  is  more  variable  and  often  irregular  in  meningitis.  In  pneu- 
monia with  latent  local  symptoms  the  pulse-respiration  ratio  is  greatly 
altered  and  the  type  of  respiration  peculiar  [vide  ante).  The  important 
rule,  to  examine  for  the  physical  signs  in  doubtful  cases,  must  not  be 
neglected,  and  if  the  subject  be  young  the  apex  region  in  particular. 

The  differential  diagnosis  between  pneumonia  and  broncho-pneumonia 
and  pleurisy  with  effusion  Avill  be  found  on  pages  517  and  551. 

Prognosis. — The  mortality  from  pneumonia  in  hospitals  averages 
about  25  per  cent.  It  is  less  in  private  practice — about  15  per  cent. 
The  death-rate,  however,  is  greatly  modified  by  the  type  of  the  indi- 
vidual epidemic,  and  by  so  many  conditions  and  incidents  that  a  pre- 
cise statement  as  to  the  percentage  of  fatal  cases  cannot  be  ventured. 
The  above  mortality-rates  have  been  based  upon  all  of  the  accessible 
statistics  at  my  command.  Wells  collected  223,730  cases,  which  gave 
a-  mortality  of  18.1  per  cent. 

The  elements  that  enter  into  a  correct  prognosis  are  in  the  main 
identical  with  those  in  other  acute  infectious  diseases,  and  concern  (1) 
the  severity  of  the  type  of  infection,  (2)  the  presence  or  absence  of 
complications,  and  (3)  circumstances  peculiar  to  the  individual. 

(1)  Severity  of  the  Type  of  Infection. — In  sthenic  cases  this  is  shown 
by  {a)  the  temperature-range,  (/')  the  degree  of  heart-power,  [e)  the  in- 
tensity of  the  nervous  symptoms,  and  to  some  extent  by  {d)  the  size  of 
the  area  of  lung-induration.  It  has  been  demonstrated,  experimentally, 
that  the  absence  of  leukocytosis  is  indicative  of  a  grave  type.'  In  case 
the  diplococcus  be  found  in  the  blood,  the  prognosis  must  be  considered 
very  grave,  as  it  has  never  been  found  there  during  life,  except  in  cases 
that  are  in  themselves  very  grave  or  seriously  complicated.  A  continu- 
ance of  marked  leukoc3^tosis  with  a  drop  in  temperature  would  point  to 
a  pseudo-crisis,     (a)  The  Temperature-range. — A  continued  high  tem- 

^  Von  Jaksch  and  Tcliistowitsch,  Annual  of  the  Universal  Med.  Sciences,  vol.  i.,  1893. 


LOBAR  PNEUMONIA.  153 

perature,  as,  for  example,  105°  F.  (40.5°  C),  on  two  or  three  consecu- 
tive days  without  material  remissions,  is  ominous,  {h)  The  Degree  of 
Heart-power. — A  steadily  rising  pulse-rate  after  the  fifth  day  indicates 
real  danger,  since  it  points  indisputably  to  gradual  cardiac  failure.  The 
same  thing  is  shown  by  a  diminution  in  the  intensity  of  the  second  pul- 
monary sound,  particularly  the  giving  out  of  the  right  ventricle,  (c-) 
The  Intensity  of  the  Nervous  Symptoms. — Active  delirium  is  not  favor- 
able at  any  stage,  and  is  particularly  unfavorable  if  it  develop  early. 
When  it  assumes  the  form  of  delirium  tremens  the  case  has  usually 
passed  beyond  the  hope  of  recovery,  {d)  The  Size  of  the  Area  of  Lung- 
induration. — I  have  observed  that  extension  of  the  consolidation  at  an 
advanced  stage  belongs  to  serious  types.  The  same  may  be  said  of 
double  basic  pneumonias. 

Typhoid  pneumonia,  being  of  asthenic  type,  gives  an  unfavorable 
prognosis,  notwithstanding  an  absence  of  high  temperature  and  of  exten- 
sive inflammation  of  the  lung-tissue. 

(2)  Presence  or  Absence  of  Complications. — Cases  in  which  there  is 
involvement  of  a  single  lobe  or  two  lobes,  if  it  occur  on  the  right  side 
and  without  complications,  generally  terminate  in  recovery.  In  nearly 
one-half  of  the  instances  complications  occur,  and  these  greatly  increase 
the  death-rate.  Among  the  most  common  is  pleurisy,  which,  unless 
accompanied  by  considerable  effusion,  does  not  add  fresh  danger ;  when 
pleurisy  attacks  the  unaffected  side,  however,  it  does.  Empyema,  fol- 
lowing pneumonia,  generally  terminates  in  recovery  unless  secondary 
septic  phenomena  appear.  Extensive  bronchitis  is  a  most  perilous  com- 
plication in  my  judgment.  Pericarditis  decreases  the  chances  for  re- 
covery, but  by  no  means  to  the  same  extent  as  endocarditis.  ■  Qardiac 
clots  may  form,  but  usually  the  patient  is  already  moribund.  Abscess 
of  the  lung  and  gangrene  form  highly  unfavorable  complications.  Con- 
gestion and  edema  of  the  uninvaded  portions  of  the  lungs  render  the 
outlook  bad,  and  these,  together  with  cyanosis,  are  apt  to  be  dependent 
upon  failure  of  the  right  heart.  Acute  meningitis  is  exceedingly  grave. 
Fenwick,  as  the  result  of  an  analysis  of  10,000  cases,  found  that  the 
quantity  of  albumin  in  the  urine  is  of  considerable  prognostic  value. 
(xastro-intestinal  complications  occurring  at  the  outset  are  unpropitious. 

(3)  Circumstances  connected  with  the  Individual. — Of  these  age  heads 
the  list,  and  after  the  twentieth  year  the  mortality  increases  progres- 
sively until  the  seventh  decade.  It  has  been  claimed  that  nine-tenths 
of  the  deaths  after  the  seventy-fifth  year  are  from  lobar  pneumonia. 
Under  the  twentieth  year,  according  to  the  analvsis  of  708  cases  at  St. 
Thomas's  Hospital  by  Hadden,  H.  W.  G.  Mackenzie,  and  W.  W.  Ord, 
the  mortality  is  3.7  per  cent. 

Sex  has  little  influence,  though  the  disease  is  believed  by  some  to  be 
more  fatal  in  females  than  in  males.     The  alcoholic  rarely  escapes  death. 

Course. — In  common  with  other  clinicians,  I  have  been  impressed  with 
the  increased  proportion  of  cases  showing  an  irregular  course,  and  I  ascribe 
this  change,  in  part  at  least,  to  influenza. 

Modes  of  Death. — Death  is  commonly  due  to  heart-failure,  which 
results  from  two  causes:  (1)  overwork,  as  when  an  extensive  area  of 
lung-tissue  is  involved  ;  and  (2)  the  direct  effect  of  the  pneumotoxin  upon 
the  heart.     The  complications  mentioned  may  prove  fatal,  however,  and 


154  INFECTIOUS  DISEASES. 

in  one  of  my  own  cases  thrombosis  of  the  coronary  artery  killed  the 
patient.      This  may  be  a  not  uncommon  terminal  condition. 

Treatment.— General  Management. — The  patient  should  occupy  a 
well-aired  apartment,  which  should  be  maintained  at  a  temperature  of 
65°  F.  (18.3°  C),  except  in  pneumonias  occurring  in  the  very  young, 
when  it  should  be  several  degrees  higher.  The  patient  should  not  be 
allowed  to  leave  his  bed  for  at  least  one  week  after  the  occurrence  of  the 
crisis ;  and  as  pneumonia  is  a  self-limited  affection,  the  principal  object  is 
to  support  the  powers  of  life  until  the  crisis  is  passed.  To  this  end  notldng 
contributes  so  much  as  proper  feeding. 

The  diet  should  be  light,  chiefly  liquid,  but  of  the  most  nutritious  sort. 
Alimentation  should  be  especially  vigorous  when  there  is  the  slightest 
tendency  to  increasing  debility.  Milk  should  constitute  the  chief  article 
of  diet;  meat-broths  or  meat-juices,  egg-white,  and  light  farinaceous  sub- 
stances may  also  be  allowed.  The  food,  particularly  the  milk,  is  to  be 
administered  at  stated  brief  intervals  and  in  definite  quantities.  When 
resolution  is  delayed  stronger  forms  of  nourishment  (scraped  meat,  etc.) 
may  be  given.  After  the  crisis  a  gradual  return  may  be  made  to  the 
usual  forms  of  solid  foods.  Alcohol  has  considerable  food- value,  it  lessens 
waste  and  improves  the  appetite  and  digestion.  T.o  accomplish  this  ob- 
ject, it  should  be  given  in  small  amounts,  two  to  three  ounces  daily. 

Cardiac  stimulants  are  often  indicated.  It  is  well  to  begin  their  use 
as  soon  as  the  slightest  tendency  to  carrliac  failure  is  shown.  The  evi- 
dences of  the  latter  conditions  are  to  be  found  in  the  state  of  the  pulse, 
the  first  sound  of  the  heart,  and  the  pulmonic  second  sound.  When  the 
pulse  becomes  more  accelerated  and  feeble,  the  first  sound  of  the  heart 
less  distinct,  and  the  pulmonic  second  sound  loses  its  accentuated  char- 
acter, or  marked  nervous  symptoms  a))pear,  then  alcoholics  must  be  used. 
At  first  they  are  to  be  employed  in  moderate  doses  (^  ounce — 16.0 — of 
whiskey  or  brandy  every  three  hours),  to  be  increased  if  the  favorable 
effect  be  proportionate  to  the  urgency  of  the  indication.  There  is  a 
great  tolerance  of  alcohol  in  this  disease.  In  the  pneumonia  of  drunk- 
ards its  early  and  free  use  is  to  be  recommended. 

If  the  alcoholic  stimulants  fiiil,  other  cardiants  must  be  administered 
simultaneously.  Of  these,  strychnin  has  been  the  most  serviceable  in  my 
own  hands,  its  mode  of  administration  following  the  same  rules  as  have 
been  mentioned  for  alcohol — at  first  in  moderate-sized  doses,  to  be  in- 
creased as  occasion  demands.  Should  urgent  need  of  stimulation  arise, 
however,  either  suddenly  or  more  gradually,  strychnin  should  be  exhibited 
hypodermically.  It  is  my  custom  in  desperate  cases  to  use  subcutaneously 
as  much  as  gr.  J^  (0.0043)  every  two  or  three  hours.  So  soon  as  the 
condition  of  the  heart  denotes  restoration  of  cardiac  power  the  size  of  the 
dose  is  to  be  reduced,  but  the  agent  is  not  to  be  withdrawn  until  the  dis- 
ease has  run  its  course.  In  no  other  disease  does  strychnin  possess  greater 
potency  for  good  than  in  pneumonia,  if  wisely  employed.  For  sudden 
heart-failure  ether,  administered  hypodermically,  is  also  very  efficacious, 
and  digitals  may  be  combined  with  the  strychnin  or  given  separately.  I 
would  advise  against  the  use  of  digitalis  unless  cardiac  weakness  (as  shown 
by  a  rapid,  feeble,  irregular  pulse)  supervene,  when  it  should  be  freely 
given.  Ten  minims  (0.666)  of  the  tincture  may  be  given  every  three 
hours  internally  or  hypodermically  if  needful,  and  I  have  found  that  the 


LOBAR  PNEUMONIA.  155 

association  of  a  small  dose  of  nitroglycerin  (Ttl^;  0.033,  every  three  or 
four  hours)  considerably  aids  the  action  of  the  digitalis.  Nitroglycerin 
is  especially  indicated  when  the  renal  secretion  is  scanty  and  the  urine 
contains  more  than  the  usual  trace  of  albumin.  Ammonium,  in  the  form 
of  the  aromatic  spirits  or  the  carbonate,  is  an  excellent  stimulant  to  the 
feeble  heart  of  pneumonia. 

Saline  injections,  given  either  intravenously  or  subcutaneously, 
increase  the  blood-pressure,  and  hence  are  valuable  in  overcoming  cir- 
culatory depression,  which  is  often  threatening  to  life.  The  hypodermic 
method  is  preferable.  From  1  to  2  pints  (strength  0.7)  may  be  injected, 
and  allowed  to  flow  under  the  skin  from  a  rubber  bag  ;  and  this  may  be 
repeated  at  intervals  of  eight  to  twelve  hours  if  necessary. 

Respiratory  Stimulants. — Beginning  cyanosis  is  the  signal  for  the  use 
of  respiratory  stimulants,  of  which  the  best  are  strychnin  and  atropin, 
and  they  should  be  given  hypodermically.  Oxygen,  if  given  freely,  often 
serves  to  tide  over  periods  of  marked  cyanosis.  The  gas  should  be 
inhaled  directly  from  the  cylinder  until  relief  is  aiforded,  when  it  may 
be  allowed  to  escape  close  to  the  patient's  nose,  or  it  may  be  taken  from 
the  nozzle  every  alternate  ten  minutes. 

Hydrotlierapy. — In  meeting  high  temperature,  marked  nervous  symp- 
toms, dyspnea,  cardiac  weakness,  etc.  baths  offer  many  superior  advan- 
tages, and  in  pneumonia  the  effect  of  gradually-cooled  baths  upon  the 
cardiac,  respiratory,  and  nervous  centers  is  especially  desirable.  It  is 
of  importance  that  the  patient  while  being  immersed  put  forth  no  mus- 
cular effort.  He  must  be  held  and  supported  while  in  the  bath,  and 
gentle  friction  to  the  skin-surface  must  be  made.  The  temperature  of 
the  baths  should  not  be  too  low  at  the  start :  at  the  beginning  it  should 
be  90°  F.  (32.2°  C),  and  then  be  lowered  according  to  the  degree  of 
sensitiveness  of  the  individual  patient.  It  is  rarely  necessary  to  go 
below  80°  F.  (26.6°  C),  and  in  the  aged,  the  very  young,  and  in  per- 
sons previously  debilitated  it  is  unwise  to  use  any  other  than  tepid  baths. 
The  duration  should  not  exceed  ten  to  fifteen  minutes  on  the  average, 
and  more  than  three — or  at  most  four — baths  daily  are  not  required.  I 
have  abandoned  the  rigid  cold-bath  method.  Cool  sponging,  combined 
with  the  ice-cap  or  the  wet  pack,  may  serve  as  a  substitute  when  full 
baths  cannot  be  employed. 

Abortive  Method  of  Treatment. — Petresco  has  found  that  large  doses  of 
digitalis  (oj-ij  ;  8-0,  of  the  digitalis-leaves  in  an  infusion  daily)  adminis- 
tered at  the  onset  will  jugulate  the  disease.  His  experience  covered  1192 
cases,  and  showed  the  surprisingly  low  mortality-range  of  1.22  to  2.66 
per  cent.  This  plan  of  treatment  is  rational,  since  it  aims  at  meeting  the 
chief  pathogenic  indication  of  pneumonia  by  passing  through  the  lung- 
tissue  an  adequate  proportion  of  leukocytes,  and  thus  re-establishing  the 
cardio-pulmonary  circulation.  In  the  few  instances  in  which  I  have 
adopted  the  plan  it  has  failed  to  cut  short  the  disease,  though  the  cases 
terminated  favorably.  After  the  full  development  of  consolidation  I 
would  urge  caution  in  the  use  of  digitalis  unless  cardiac  failure  threaten. 

Venesection. — This  is  a  good  measure  in  sthenic  cases  (which  occur 
with  relative  rarity  in  cities,  but  are  not  uncommon  in  rural  districts), 
the  temperature  falling,  the  pain,  the  dyspnea,  and  the  nervous  symptoms 
being  relieved  and  the  pulse  softened.     Later  in  the  course  of  pneumonia 


156  INFECTIOUS  DISEASES. 

venesection  may  be  resorted  to  if  cyanosis  and  the  si^ns  of  collateral 
pulmonary  edema — due  to  a  failing  right  heart — arise,  but  at  this  period 
bleedings  rarely  yield  good  results. 

Antiseptic  Method. — This  method  is  based  upon  etiologic  indications, 
and  is  most  rational.  The  best  antiseptics  are  carbolic  acid  (TTlj  ;  0.066, 
every  four  hours),  thymol  (gr.  ij-iij  ;  0.129-0.194,  every  four  hours), 
mercuric  chlorid  (gr.  y^;  0.0006,  every  four  hours). 

Ant ipneiunocoecic  Serum  and  Senim  obtained  from  Convalescents. 
— Washbourn,  Pane,  Fanoni,  and  others  have  reported  favorable  results 
from  the  use  of  antipneumococcic  serum,  but  its  practical  value  has  not 
as  yet  been  proved,  and  the  same  opinion  applies  to  the  reputed  benefits 
from  serum  obtained  from  convalescents. 

Treatment  of  Special  Symptoms. — The  initial  pain,  -which  is  of  an 
acute,  agonizing  character,  is  relieved  by  the  hypodermic  use  of  mor- 
phin  at  intervals  of  six  or  eight  hours.  This  counteracts  the  shock  pro- 
duced by  the  invasion-period,  but  it  is  to  be  omitted  if  the  bronchi  con- 
tain secretory  products,  since  morphin  dries  these  and  favors  their 
accumulation  rather  than  their  removal.  Rai-ely  is  it  necessary  to  con- 
tinue this  remedy  after  the  second  or  third  day  of  the  illness. 

Fever. — The  fever  of  pneumonia  is  a  temporary  affair,  and  instead 
of  being  hurtful  may  prove  beneficial,  since  it  furthers  tissue-metabo- 
lism, and  this  aids  in  the  destruction  of  the  specific  poison  of  the  dis- 
ease. Fortunately,  internal  antipyretics  for  the  purpose  of  combating 
high  temperature  are  not  so  largely  used  at  the  present  day  as  for- 
merly. It  is  true  that  they  possess  the  power  to  reduce  temperature, 
but  their  use  is  attended  with  danger  from  their  action  as  cardiac  depres- 
sants ;  Avhile,  if  it  be  true,  as  before  stated,  that  pneumonia  usually  kills 
through  the  heart,  it  follows  that  cardiac  power  must  primarily  be  con- 
served. Apart  from  the  above-mentioned  serious  objection  to  internal 
antipyretics,  it  is  to  be  remembered  that  they  do  not  possess  the  import- 
ant additional  advantages  to  be  derived  from  cool  baths.  In  my  opinion, 
their  use  should  be  limited  to  those  cases  in  which  cool  baths  or  their 
substitutes  (cold  pack  and  cold  spongings)  fail  to  effect  a  reduction  of 
fever.  It  must  not  be  forgotten  that  unless  the  temperature  exceed 
104°  F.  (40°  C.)  it  had  better  be  let  alone.  "When  called  for,  however, 
the  best  among  the  antipyretics  are  acetanilid  and  phenacetin.  The  dose 
of  these  should  be  small — gr.  v  (0.324)  of  the  latter  and  gr.  ij-iij  (0.129- 
0.194)  of  the  former,  to  be  repeated  at  intervals  of  four  to  six  hours  if 
required. 

Like  internal  antipyretics,  arterial  sedatives  are  to  be  used  sparingly, 
and  when  used  their  effects  must  be  carefully  noted.  In  cases  in  which 
venesection  is  indicated  the  tinctures  of  veratrum  viride  and  of  aconite 
have  been  much  vaunted  as  substitutes.  The  tincture  of  veratrum 
viride  produces  a  good  effect  upon  the  local  condition,  since  it  relaxes 
the  arterial  walls,  and  thus  bleeds  the  patient  into  his  own  vessels,  but, 
since  it  also  acts  as  a  cardiac  depressant,  it  is  questionable  whether  its 
disadvantages  do  not  outweigh  its  advantages.  The  tincture  of  aconite, 
owing  to  its  depressing  influence  upon  the  heart,  should  not  be  employed. 

The  nervous  symptoms  are  successfully  met,  as  a  rule,  by  hydrother- 
apy (including  the  ice-cap),  by  the  arterial  stimulants,  and  by  the  use 
of  morphin,  as  before  recommended. 


SECONDARY  PNEUMONIA.  157 

Cough  during  the  early  stage  is  controlled  by  the  morphin  needed  to 
combat  the  pain.  In  the  more  advanced  stages,  if  there  be  present 
numerous  moist  rales  and  a  scanty  expectoration,  stimulant  expecto- 
rants (ammonium  muriate,  terebene)  may  be  employed  with  happy 
effect ;  but  ordinarily  they  do  harm  rather  than  good.  Pilocarpin  may 
aid  resolution  when  this  is  delayed  (Reiss) ;  the  heart,  however,  must  be 
carefully  watched  over. 

Complications. — The  management  of  the  complications  does  not  differ 
from  that  which  is  appropriate  when  they  occur  as  independent  affec- 
tions, though  all  depressing  measures  must  be  positively  omitted.  I 
would  add  that  in  pleuro-pneumonia  aspiration  is  not  well  borne,  ac- 
cording to 'my  observations;  hence,  unless  urgently  needed,  I  would 
postpone  this  procedure  until  the  crisis  has  passed. 

Among  measures  to  prevent  ether-pneumonia  I  would  urge  an  appro- 
priate toilet  (a  thorough  cleansing  followed  by  the  topical  use  of  an  efficient 
antiseptic  solution)  of  the  naso-pharynx  and  mouth  as  a  routine  practice. 

Local  Measures. — When  in  doubt  as  to  whether  venesection  should  be 
employed  or  not,  it  must  be  remembered  that  early  local  bloodletting 
(cupping  and  leeching)  is  followed  by  relief  from  pain  and  dyspnea,  but 
that  these  measures  should  be  reserved  only  for  robust  persons.  Coun- 
ter-irritation by  means  of  sinapisms  is  useful  at  the  onset.  The  cotton 
jacket  has  certain  advantages  in  maintaining  the  free,  local  action  of 
the  skin,  and  may  be  employed ;  before  the  days  of  hydrotherapy  it  was 
quite  commonly  used.  The  topical  use  of  cold  in  the  form  of  ice-bags 
has  been  practiced  extensively  by  Lees  of  England  and  Mays  of  America 
with  brilliant  success,  cold  thus  applied  relieving  the  pain  and  dyspnea 
and  diminishing  pyrexia.  In  my  limited  experience  with  the  applica- 
tion of  cold  I  have  found  cases  in  Avhich  it  could  not  be  tolerated  by  the 
patient,  and  in  such,  warm  applications  (poultices,  etc.)  exerted  a  sooth- 
ing revulsive  effect.  Lepine  has  used  with  success  very  dilute  mercuric 
chlorid  injections  into  the  affected  lung-tissue.  This  mode  of  treatment 
has  not  been  followed  in  sufficient  cases  to  warrant  an  opinion  as  to  the 
extent  of  its  usefulness. 

Secondary  Pneumonia. 

Pathology. — The  lesions  are  identical  in  character  with  those  of 
primary  lobar  pneumonia,  but  the  areas  involved  have  not  always  the 
same  regular  distribution.  Congestion  surrounding  the  hepatized  lung- 
tissue  is  not  infrequently  extensive.  We  see,  post-mortem,  a  tendency 
to  commingling  with  small  areas  of  lobular  pneumonia.  Both  the  strep- 
tococcus and  the  micrococcus  lanceolatus  are  frequently  found  on  micro- 
scopic examination. 

Etiology. — Most  instances  are  secondary  to  the  acute  infectious 
diseases,  and  it  is  probable  that  the  specific  causes  of  certain  of  the 
latter  (Eberth's  bacillus,  Pfeiffer's  bacillus,  etc.)  have  the  power  to  ex- 
cite the  morbid  changes  of  acute  lobar  pneumonia.  Colon-pneumonia, 
due  to  the  bacillus  coli,  is  the  result  of  hematogenous  infection  either 
from  the  intestinal  or  from  the  urogenital  tract.  In  the  majority  of 
instances,  however,  in  which  this  disease  develops  in  the  course  of  the 
acute  infectious  diseases  the  latter  are  to  be  regarded  as  merely  furnish- 
ing the  opportunitj  for  infection  by  the  micrococcus  lanceolatus. 


158  INFECTIOUS  DISEASES. 

Symptoms. — The  rational  symptoms  are  often  absent.  Close  ob- 
servation may,  however,  detect  more  or  less  dyspnea,  cough,  and  in- 
creased fever,  and  rarely  the  attack  is  heralded  by  a  rigor,  followed  by 
fever,  the  pneumonic  type  of  breathing,  pain,  cough,  and  the  character- 
istic expectoration. 

The  physical  signs,  Avhen  carefully  observed,  usually  serve  to  enlighten 
the  physician  as  to  the  nature  of  the  affection.  Hence  it  is  a  natural 
corollary  that  repeated  ph3*sical  examination  is  demanded  in  all  cases  in 
which  there  is  danger  of  intervening  lobar  pneumonia. 

Diagnosis. — This  rests  chiefly  upon  the  physical  signs,  which  are 
the  same  as  in  primary  lobar  pneumonia.  Obviously,  when  the  local 
subjective  symptoms  and  the  characteristic  sputa  are  present  a  correct 
diagnosis  is  easily  made.  The  fact  must  be  emphasized  that  broncho- 
pneumonia arises  in  the  course  of  infectious  diseases  far  more  frequently 
than  does  lobar  pneumonia. 

Prognosis. — The  occurrence  of  lobar  pneumonia  as  an  intercurrent 
affection  adds  greatly  to  the  gravity  of  the  primary  disease.  It  is  espe- 
cially dangerous  Avhen  it  appears  as  a  sec^uel  during  convalescence  from 
acute  infectious  diseases. 

The  treatment  is  similar  to  that  of  primary  lobar  pneumonia, 
though  less  satisfactory. 


INFLUENZA. 

{La  Grippe ;  Epidemic  Catarrhal  Fever.) 

Definition. — Influenza  is  an  acute  contagious  disease,  caused  by 
the  bacillus  of  Pfeiffer.  Its  chief  symptoms  are  due  to  catarrh  of  the 
respiratory  and  digestive  tracts,  together  with  profound  muscular  and 
nervous  prostration,  and  grave  complications  (especially  pneumonia) 
often  present  themselves.  The  disease  may  be  endemic,  though  more 
•often  it  is  epidemic  or  pandemic. 

Historic  Note. — Every  (juarter  of  the  globe  has  been  the  scene  of 
visitations  of  epidemic  influenza.  More  rapidly  than  any  other  dis- 
ease belonging  to  the  same  class  does  it  traverse  a  region  of  country, 
and  hence  within  a  remarkably  brief  period  of  time  a  whole  nation  may 
suffer.  As  a  rule,  influenza  develops  into  epidemic  proportions  in  the 
East,  whence  it  spreads  with  unparalleled  rapidity  in  a  westerly  direc- 
tion. The  first  epidemic  of  the  disease  in  the  United  States  appeared 
in  1647,  and  was  subsetjuently  described ;  and,  though  it  has  since  then 
frequently  prevailed,  the  outbreaks  have  not  observed  any  regular  pe- 
riodicity. The  last  true  pandemic  of  the  affection  originated  in  Bok- 
hara in  May,  1889,  reached  St.  Petersburg  in  the  following  October, 
Paris  in  November,  and  London  in  turn  early  in  December.  In  Amer- 
ica the  cases  began  to  appear  about  the  middle  of  December,  and  rap- 
idly multiplied  into  an  explosive  epidemic,  which  reached  its  maximum 
in  January,  1890.  Influenza  reappeared  in  epidemic  form,  though  less 
extensively,  during  April  and  a  part  of  May,  1891,  and  again  in  a 
briefer  and  lighter  form  in  the  winter  of  1891-92.  During  the  winter 
of  1892-93  only  a  few  sporadic  cases  occurred.     In  the  early  part  of 


INFLUENZA.  159 

1895  the  disease  assumed  epidemic  prevalence,  and  it  again  appeared  at 
the  beginning  of  the  year  189Y. 

Pathology. — There  are  no  special  anatomic  lesions  that  charac- 
terize the  disease.  The  rare  instances  in  which  death  occurs  in  uncom- 
plicated cases  simply  show  marked  catarrhal  implication  of  the  respira- 
tory, and  usually  also  of  the  gastro-intestinal,  mucosa.  There  are 
practically  no  changes  in  the  glands  of  the  digestive  mucosa,  except  in 
the  abdominal  type  of  the  affection,  in  which  there  may  be  enlargement 
of  the  glands  of  Peyer  and  of  the  solitary  follicles.  As  will  be  seen 
hereafter,  most  of  the  fatal  cases  exhibit  lesions  which  are  to  be  ascribed 
to  the  complications.  Among  the  latter  are  pneumonia  (either  lobular 
or  lobar),  with  which  plastic  pleurisy  is  usually  associated,  sero-fibrinous 
pleurisy,  empyema,  purulent  pericarditis,  nephritis,  and  rarely  cerebro- 
spinal meningitis. 

Htiology. — That  the  disease  is  microbic  in  origin  can  no  longer  be 
doubted. 

Bacteriology. — Early  in  the  year  1892,  Pfeiffer  discovered  a  bacillus 
which  he  has  shown  to  be  the  true  cause  of  influenza — the  bacillus  of 
Pfeiffer.  It  is  of  about  the  same  breadth  as  the  bacillus  of  mouse-sep- 
ticemia,  and  only  one-half  the  length  of  the  latter.  When  stained  with 
Ziehl's  carbol-fuchsin  it  may  be  observed  as  a  small  dumb-bell,  having 
knobbed  ends  connected  by  a  rod-like  shaft.  These  bacilli  are  obtained 
from  the  sputum.  They  are  never  present  in  any  other  disease.  Pfeiffer 
has  shown  that  they  may  penetrate  the  peribronchial  tissue  and  pass 
out  to  the  pleura.  They  have  also  been  found  in  the  blood.  This 
bacillus  can  be  cultivated  in  agar  and  other  media,  but  not  in  gelatin, 
and  when  inoculated  into  rabbits  and  other  animals  it  causes  more 
or  less  typical  influenza.  The  almost  invisible  cultures  of  the  influ- 
enza bacillus  become  larger  if  inoculated  with  the  staphylococcus  aureus 
(Meunier). 

Modes  of  Conveyance. — Naturally,  a  specific  germ  that  is  propagated 
with  the  unusual  rapidity  that  marks  the  bacillus  of  Pfeiffer  must  be 
air-borne.  Even  this  view,  however,  fails  to  explain  satisfactorily  the 
coincidental  prevalence  of  the  malady  at  widely-separated  points.  Pep- 
per suggests  that  the  micro-organism  may  be  almost  universally  dis- 
tributed, but  only  capable  under  ordinary  circumstances  of  causing 
occasional  and  sporadic  cases ;  and  that  under  certain  extraordinary 
atmospheric  or  telluric  conditions  it  acquires  a  degree  of  virulence  that 
renders  all  subject  to  its  attack.  There  is  no  doubt  that  influenza  is 
communicable  by  contagion,  and  evidence  is  becoming  abundant  to  show 
that  it  may  be  transferred  hj  fomites. 

Manner  of  Invasion. — Hoav  the  contagion  enters  the  system  has  not 
been  positively  determined,  though  it  is  probably  with  the  inspired  air 
through  the  respiratory  tract.  Some  authors  contend  that  it  may  enter 
through  the  alimentary  canal,  Avhile  still  others  believe  that  the  primary 
point  of  infection  is  not  rarely  the  conjunctiva. 

Predisposing  Causes. — These  are  few  and  unimportant,  since  all  per- 
sons are  liable  to  the  contagion.  Age  has  slight  influence,  the  period 
of  greatest  susceptibility  being  from  the  twentieth  to  the  thirtieth  year. 
The  very  young  are  less  liable  than  older  subjects,  and  during  an  epi- 
demic are  apt  to  be  affected  last,  while  old  persons  (particularly  if  debil- 


160  INFECTIOUS  DISEASES. 

itated)  are  frequent  sufferers.  The  same  is  true  of  those  whose  vitality 
is  lowered  by  neuropathic  heredity  or  chronic  maladies,  these  being 
among  the  first  to  be  affected  during  an  epidemic.  On  the  other 
hand,  it  is  to  be  remembered  that  the  healthiest  are  not  exempt. 
The  affection  is  only  slightly  influenced,  if  at  all,  by  meteorologic 
conditions. 

Immunity. — A  primary  attack  of  influenza  does  not  bestow  immu- 
nity, since  relapses  are  very  common,  in  10  per  cent,  of  the  cases 
(Turney).  Many  persons,  too,  sufter  from  the  disease  with  the  reap- 
pearance of  fresh  epidemics,  so  that  two,  three,  four,  or  even  more  attacks 
may  be  observed  in  the  same  individual  {recurrences). 

Antagonism. — Recent  investigations  have  shown  that  a  decided  an- 
tagonism exists  between  influenza  and  malaria,'  and  that  during  epi- 
demic prevalence  of  the  former  the  latter  has  repeatedly  suffered  a 
great  decline. 

Clinical  History. — General  Symptomatology  and  Course. — The  in- 
cuhation  period  is  quite  brief,  rarely  exceeding  two  or  three  days.  The 
onset  is  generally  sudden,  with  either  a  severe  rigor  or  repeated  slight 
shiverings,  accompanied  by  a  rapid  elevation  of  temperature  which  may 
touch  104°  or  105°  F.  (40.5°  C),  intense  headache,  distressing  myalgic 
pains,  and  great  prostration.  The  primary  fever,  however,  varies 
greatly  in  severity,  as  does  also  the  character  of  the  symptoms — both 
local  and  general.  Profound  prostration  characterizes  the  vast  majority 
of  instances  during  the  invasicm  period.  Depression  of  spirits,  restless- 
ness, insomnia  (more  rarely  undue  somnolence),  and  frequently  delirium, 
are  among  prominent  nervous  phenomena. 

Rare  Modes  of  Invasion. — The  affection  may  set  in  («)  by  vertigo, 
(6)  by  apoplectic  features,  (c)  by  bilious  vomiting.  Nose-bleed  sometimes 
occurs. 

The  most  striking  symptom  is  pain,  which  in  many  cases  is  refer- 
able chiefly  to  the  forehead,  temples,  occiput,  eyeballs,  and  root  of 
the  nose.  General  neuro-muscular  pains,  however,  are  apt  to  be 
present.  Their  principal  seat  is  often  in  the  region  of  the  lumbar 
spine  (rachialgia),  whence  they  are  apt  to  dart  upward  to  the  neck  and 
downward  to  the  lower  extremities.  With  the  universal  myalgic  pains 
'there  is  a  general  soreness,  and  I  have  frequently  noted  cutaneous 
hyperesthesia.  The  pains  take  the  form  of  neuralgia  of  individual 
nerves  or  of  pleurodynic  stitches,  or  there  are  localized  areas  of  burn- 
ing, boring  muscular  pain.  The  temperature  may,  as  before  intimated, 
mount  quite  high  at  the  beginning,  and  if  so  it  usually  remits  during 
the  first  night.  It  subsequently  remains  at  a  comparatively  low  point, 
with  evening  exacerbations,  until  the  normal  level  is  reached,  which 
often  occurs  as  early  as  the  second  or  third  day,  but  may  be  postponed 
until  the  end  of  a  week.  The  temperature-curve  is  markedly  irregular, 
and  often  terminates  by  an  apj)arent  crisis.  The  jndse  is  small,  feeble, 
irregular,  and  even  intermittent,  and  I  have  sometimes  observed  it  to 
be  unusually  slow,  cardiac  debility  being  prominent  and  at  times  reach- 
ing a  dangerous  degree.     In  many  cases  dyspnea  is  a  rather  conspicuous 

'"A  Statistical  Study  of  Influenza;  its  Potency  to  Lessen  the  Receptivity  of  the 
Body  for  Malaria,  as  well  as  to  Increase  the  Receptivity  for  Pneumonia  and,  probably, 
Typhoid  Fever,"  by  the  author — Fhiladelphia  Hospital  Report,  1895,  vol.  iv. 


INFLUENZA.  161 

symptom,   occurring    independently   of  pulmonary    complicationis.     The 
same  is  true  of  oyanosis.     Sweating  may  be  troublesome. 

Clinical  Types. — Different  types  have  been  described  based  on  the 
differences  in  the  local  manifestations.  But  it  is  to  be  mentioned  that 
influenza  is  remarkably  protean  in  its  clinical  features,  and  that  the 
enumerated  types  quickly  and  frequently  merge  into  one  another,  [a) 
Respiratory  Type. — Local  catarrhal  symptoms  usually  develop  in  the 
course  of  one  or  two  days.  They  are,  as  a  rule,  evidenced  first  by 
a  suffusion  of  the  conjunctivae,  with  excessive  lacrymation,  frequent 
sneezing,  and  slight  pharyngitis.  A  little  later,  in  most  instances, 
hoarseness  and  cough  come  on,  the  latter  being  hard,  racking,  parox- 
ysmal in  character,  and  resembling  whooping-cough.  The  cough  and 
other  local  symptoms  are  due  to  intense,  dry  laryngo-tracheal  irritation. 
In  most  instances  the  expectoration  is  scanty,  and  in  these  the  physical 
signs  are  very  generally  negative.  In  a  smaller  proportion  of  the  cases 
there  is  considerable  expectoration,  and  the  physical  signs  of  ordinary 
bronchitis  are  manifested,  (h)  Grastro-intestinal  Type. — The  catarrhal 
symptoms  sometimes  center  in  the  digestive  system,  and  most  frequently 
in  children.  In  such,  vomiting  comes  on  early  and  is  apt  to  be  repeated 
at  longer  or  shorter  intervals.  There  is  diarrhea,  more  or  less  urgent, 
Avith  sharp  abdominal  pain,  as  a  rule,  (c)  The  cardiac  group  of  symp- 
toms that  occasionally  supervenes  comprises  heart-failure  and  distress, 
with  a  rapid,  feeble  pulse,  (d)  The  typhoid  type  presents  a  continued 
fever,  with  the  signs  of  the  typhoid  state.  Nervous  symptoms  are  very 
marked,  such  as  stupor  or  delirium,  dry,  brown  tongue,  etc.  (e)  The  rheu- 
matoid type  manifests  itself  by  violent  pains  in  the  muscles  all  over  the 
body.     There  is  no  visible  change  in  either  the  joints  or  the  nerve-trunks. 

After  the  temperature  has  become  normal  profound  prostration  is  apt 
to  continue,  and  hence  the  patient  shows  no  disposition  to  muscular  or 
mental  exertion.  In  cases  of  average  severity  convalescence  is  usually 
somewhat  protracted,  and  in  the  severer  forms  decidedly  so. 

Complications. — (1)  Pulmonary. — An  ordinary  bronchial  catarrh 
may  be  properly  regarded  as  belonging  to  the  peculiar  processes  of  the 
disease,  but  severe  bronchitis,  particularly  affecting  the  capillary  tubes 
and  leading  to  broncho-pneumonia,  is  a  common  and  very  serious  com- 
plication. As  a  secondary  result  we  are  apt  to  observe  the  development 
of  collateral  pulmonary  edema,  with  its  usual  fatal  termination ;  and, 
w^hilst  this  complication  is  prone  to  develop  in  the  so-called  thoracic 
type  of  influenza,  it  is  by  no  means  limited  to  this  class  of  cases.  In 
the  latter  it  originates  apparently  in  the  profound  prostration  of  the 
nervous  system — a  condition  Avhich  also  annuls  in  great  part  the  phago- 
cytic action  of  the  leukocytes.  In  nearly  all  instances,  however,  this 
form,  as  well  as  croupous  pneumonia,  may  be  definitely  traced  to  ex- 
posure.    The  bronchial  glands  may  become  acutely  enlarged. 

Lobar  pneumonia  is  also  a  frequent  and  very  fatal  complication.  It 
may  arise  early  and  in  rare  instances  insidiously,  but  it  is  much  more 
apt  to  manifest  itself  after  influenza  has  about  exhausted  its  force  upon 
the  vital  organs  or  during  the  early  part  of  convalescence.  The  symp- 
toms of  invasion — severe  chill,  high  temperature,  followed  by  the  usual 
physical  signs — are  sudden  in  their  onset  and  lead  rapidly  to  an  ex- 
tremely serious  condition. 
11 


162  INFECTIOUS  DISEASES. 

When  lobar  pneumonia  develops  early  in  the  course  of  influenza  (a 
rare  event),  its  symptoms  are  modified,  the  preliminary  chill  and  pain  in 
the  side  being  often  absent,  and  more  fi-equently  still  the  characteristic 
crepitant  rale.  Subcrepitant  relies,  however,  are  audible,  and  the  dys- 
pnea is  out  of  proportion  to  the  area  of  lung-tissue  involved.  Most  of 
the  peculiar  features  just  pointed  out  may  also  be  observed  in  connection 
with  the  pneumonia  that  appears  during  convalescence,  though,  accord- 
ing to  my  own  experience,  they  are  then  more  feebly  expressed. 

The  recognition  of  brcmcho-pneumonia  is  in  many  instances  quite  diffi- 
cult. Here,  as  elsewhere,  it  is  secondary  to  general  bronchitis  aftecting 
the  larger  tubes.  I  have  observed  this  condition  in  cases  in  which  the 
physical  signs  of  bronchitis  were  not  presented  prior  to  its  onset.  In 
other  instances,  however,  a  few  scattered  sibilant  and  sonorous  rales, 
intermingled  with  a  few  moist  ones — the  usual  auscultatory  signs  of 
severe  general  bronchitis — are  noted,  and  then  broncho-pneumonia 
supervenes.  Immediately  preceding  the  signs  of  consolidation  in  broncho- 
pneumonia (less  frequently  also  in  croupous  pneumonia)  the  respiratory 
murmur  becomes  exceedingly  weak,  and  later  an  abundance  of  subcrepi- 
tant rales  becomes  audible  over  the  affected  area.  Bronchial  breathing 
may  be  associated,  though  it  is  rarely  marked ;  but  when  the  spots  in- 
volved are  of  considerable  size,  they  may  give  rise  to  corresponding 
zones  of  dulness  on  percussion. 

Accordinof  to  some  authors,  the  nature  of  the  condition  is  variable, 
and  the  symptoms  that  simulate  more  or  less  closely  those  just  depicted 
are  ascribed  to  congestive  collapse  and  other  conditions,  rather  than  to  the 
ordinary  type  of  broncho-pneumonia.  Congestion  associated  with  edema 
of  the  lungs  occurs  as  a  complication  of  influenza,  as  I  have  learned  from 
personal  observation.  Acute  enlargement  of  the  bronchial  glands  may 
also  be  noted,  and  the  recognition  of  this  condition  may  be  aided  by 
careful  percussion  over  the  upper  four  dorsal  vertebne,  where  dulness 
will  be  obtained. 

Plastic  pleurisy  is  commonly  an  associated  condition,  especially  in 
cases  of  lobular  or  lobar  pneumonia.  Other  forms  of  pleurisy  also  occur, 
though  less  frequently  (sero-fibrinous  and  empyema).  Gangrene  and 
al>sces)<  of  the  lungs  may  arise  as  terminal   complications. 

Cardiac  Complications. — Heart-fiiilure  often  manifests  itself,  and  may 
prove  fatal,  though  rarely.  Purulent  pericarditis  is  a  rare  complication, 
and  is  often  secondary  to  pleurisy  or  pneumonia,  while  attacks  of  angina, 
which  usually  interchange  with  simple  weak  heart  (often  associated  with 
arrhythmia),  have  been  noted  in  certain  epidemics  (Cnrtin  and  Watson). 

G-astro-intestinal  System. — There  may  be  severe  gastro-enteritis,  with 
frequent  vomiting  and  purging  and  intense  abdominal  pains,  and,  more 
rarely,  hemorrhages  occur  from  the  stomach  and  bowel.  Catarrhal 
jaundice  may  appear,  due  to  duodenal  catarrh,  but  these  gastro-intes- 
tinal  complications  are  more  apt  to  be  met  with  in  young  children  than 
among  adults. 

Nervous  System. — The  most  frequent  symptom  is  perineuritis,  which 
probably  causes  much  of  the  patients  sufferings.  A  soporose  condition 
is  often  observed.  Delirium  of  a  most  active  form  sometimes  ap])ears. 
and  particularly  when  certain  other  complications  have  arisen,  such  as 
pneumonia,  pericarditis,  etc.      Cerebro-spinal  meningitis  occurs  as  a  rare 


INFLUENZA.  163 

complication.  I  have  observed  symptoms  identical  Avitli  those  of  menin- 
gitis appearing  suddenly,  and  in  the  course  of  a  day  or  two  disappearing 
just  as  suddenly.  The  symptoms  under  such  circumstances  must  be  due 
either  to  the  action  of  the  specific  poison  upon  the  nerve-centers  or  to 
congestion,  and  hence  a  diagnosis  of  suppurative  meningitis  is  to  be  made 
with  extreme  caution.  In  addition  to  the  symptoms,  we  should  have  the 
existence  of  suppuration  elsewhere  in  the  body  (otitis,  purulent  pericar- 
ditis, etc.)  or  the  presence  of  pneumonia.  Cerebral  abscesses  have  also 
been  noted  (Bristowe).  Kerr  has  reported  disseminated  lesions  of  the 
central  nervous  system  following  influenza. 

Genito -urinary  Tract. — Renal  congestion,  and  even  acute  nephritis, 
may  appear  as  a  complication.  A  case  of  cystitis  with  hematuria  has 
also  been  reported  (Comby  and  Le  Gendre). 

The  diagnosis  of  influenza  except  in  ill-defined,  sporadic  cases 
rarely  presents  serious  difiiculty.  In  obscure  cases  the  discharges  should 
be  studied  bacteriologically. 

(a)  Climatic  catarrhal  affections  are  sometimes  hard  to  discriminate  from 
sporadic  cases  of  influenza.  The  former  are  usually  attributed  to  sudden 
and  great  vicissitudes  of  temperature  or  exposure  to  strong  drafts  of  air, 
while  the  latter  come  on  independently  of  seasons  of  the  year  and  of 
such  agencies.  Again,  in  influenza  we  usually  observe  the  general 
features  (nervous  symptoms  and  debility)  outweighing  the  local 
(catarrhal  manifestations).  Simple  catarrhs  do  not  tend  to  traverse 
the  entire  system  Avith  the  same  remarkable  rapidity  as  influenzal 
catarrhs. 

{h)  Typhoid  Fever.,  particularly  in  its  early  stages,  is  often  closely 
simulated  by  influenza  with  intestinal  symptoms.  Danger  of  confound- 
ing these  two  aff"ections  can  be  averted  by  remembering  the  facts  that 
influenza  gives  a  difi"erent  history,  begins  suddenly,  does  not  have  the 
typical  temperature-curve  of  typhoid,  may  present  splenic  enlargement 
— but  by  no  means  to  the  same  extent  as  typhoid — and  has  no  charac- 
teristic eruption. 

(c)  Pneumonia  has  quite  frequently  been  mistaken  for  influenza,  and 
especially  when  the  thoracic  symptoms  in  the  latter  have  been  unusually 
distinct.  As  already  stated,  lobar  pneumonia  may  early  complicate  in- 
fluenza in  rare  instances ;  but  pneumonia  is  generally  unilateral,  while 
the  lung-involvement  in  influenza  is  generallv  bilateral.  In  the  former 
the  physical  signs  indicative  of  consolidation  are  clearly  marked ;  in 
the  latter  (unassociated  with  pneumonia)  Ave  often  meet  with  those  sug- 
gestive of  congestive  edema  (impaired  resonance,  stationary  crepitant 
and  subcrepitant  rales).  The  general  features  also  present  dissimilari- 
ties. Thus  the  nervous  depression  and  the  myalgic  and  neuralgic  pains 
are  more  marked  in  influenza,  while  the  pulse  and  respiration  are  apt  to 
be  less  frequent  than  in  pneumonia. 

(d)  Cerebrospinal  menijigitismsij  manifest  features  that  are  almost 
identical  with  those  characteristic  of  influenza.  Thus  during  certain 
epidemics  many  '"  grippe  "  patients  sufi"er  from  intense  headache — oc- 
cipital and  frontal — rachialgia,  fever,  prostration,  delirium,  and  stiifness 
of  the  muscles,  with  slight  retraction  of  the  head.  There  may  be  con- 
vulsions and  vomiting  at  the  outset.  Here  the  history  Avith  reference 
to  the  character  of  the  prevailing  epidemic  and  the  attendant  circum- 


164  INFECTIOUS  DISEASES. 

stances  must  be  carefully  considered,  but  an  absolute  diagnosis  is  some- 
times impossible  unless  a  bacteriologic  investigation  of  the  discharges 
be  made. 

Sequelse. — Among  the  pulmonary  sequelae  are  phthisis,  chronic 
bronchitis,  abscess  and  gangrene  of  the  lungs  (the  latter  two  being  rare), 
tachycardia,  and  angina  pectoris.  Chronic  gastro-intestinal  catarrh  is 
not  rare  as  a  remnant  of  the  acute  form  when  the  latter  arises  during 
the  influenzal  attack.  Chronic  nephritis,  and  less  frequently  cystitis, 
may  also  be  mentioned. 

Among  nervous  sequelie  which  are  both  numerous  and  important  are 
to  be  noted  especially  insomnia,  neuralgia,  migi'aine,  melancholia,  mania, 
meningitis,  acute  ascending  myelitis,  locomotor  ataxia,  peripheral  neur- 
itis, and  perineuritis.  The  organs  of  special  sense  manifest  a  great 
variety  of  sequelae,  such  as  otitis  media,  otitis  interna,  mastoid  abscess, 
conjunctivitis,  keratitis,  iritis,  irido-chorioiditis,  acute  glaucoma,  paral- 
ysis of  accommodation,  etc. 

Prognosis. — The  ])rognosis  is,  on  the  whole,  good.  Almost  all 
fatalities  are  due  to  complications,  especially  pnewiumia,  and,  less  fre- 
quently, pulmonary  congestion  and  edema,  pleurisy,  pericarditis,  cere- 
bro-spinal  meningitis,  etc. 

The  circumstances  connected  with  the  individual  case  often  affect 
the  outcome.  Thus  influenza  runs  a  more  severe  course,  and  hence 
offers  a  correspondingly  more  serious  prognosis  in  the  very  young,  the 
very  old,  and  those  enfeebled  on  account  of  previous  chronic  disease 
(phthisis,  valvular  disease  of  the  heart,  emphysema,  nephritis,  etc.)  than 
at  other  periods  of  life.  During  severe  epidemics  of  influenza  the  mor- 
tality-list in  the  latter  diseases  is  considerably  augmented.  Though 
epidemics  vary  as  regards  the  mortality,  the  general  average  death-rate 
is  a  little  under  1  per  cent.  In  some  epidemics  it  may  reach  2  per  cent., 
while  in  others  it  may  be  less  than  }y  of  1  per  cent. 

Duration. — The  duration  of  the  attack  is  brief,  though  subject  to 
variations.  In  mild  forms  it  is  from  two  to  four  days,  in  the  severe 
from  seven  to  ten  days;  but  complications  and  previous  infirmities  may 
greatly  prolong  the  attack.  The  duration  of  particular  epidemics  rarely 
exceeds  from  four  to  six  weeks. 

Treatment. — Prophylaxis. — Experience  has  shown  almost  conclu- 
sively that  tlie  various  drugs  which  have  been  counselled  for  their  pre- 
ventive effect  (quinin,  salicin,  etc.)  are  devoid  of  value.  The  strongest 
persons  are  not  immune,  and  those  who  are  at  either  extreme  of  life  or 
who  are  enfeebled  by  chronic  organic  disease  should  be  most  carefully 
protected  by  proper  Avearing-apparel,  and  should  not  be  carelessly  ex- 
posed to  unfavorable  weather  conditions.  In  this  way  we  may  lessen, 
in  a  measure  at  least,  the  totality  of  the  cases,  since  the  inmates  of  hos- 
pitals and  prisons  have  been  known  to  escape  the  disease.  Isolation 
should  therefore  be  carried  out  in  hospitals  and,  whenever  practicable, 
in  private  families,  especially  when  the  disease  appears  in  households  in 
which  there  are  young  children  and  aged  persons.  E.  W.  White  has 
reported  an  epidemic  of  influenza  that  was  successfully  aborted  by  strict 
isolation  of  the  patients.  Disinfection  of  the  catarrhal  discharges,  par- 
ticularly the  bronchial,  which,  as  a  rule,  abound  in  the  bacilli  of  Pfeiffer, 
is  necessary. 


INFLUENZA.  165 

Treatment  of  the  Attack. — In  considering  the  treatment  of  the  attack 
the  cases  may  be  grouped  under  three  heads : 

(a)  Mild  or  Rudimentary  Form. — The  cases  belonging  to  this  type  re- 
quire little  besides  careful  hygienic  management.  However  light  the 
attack,  the  patient  should  remain  in-doors  and,  if  languid  or  prostrated, 
in  bed  for  a  period  of  two  or  three  days.  The  diet  should  be  light  and 
nutritious  (milk,  eggs,  rice,  gruels,  fresh  vegetables,  stewed  fruit,  etc.), 
and  cooling  drinks  are  to  be  preferred  to  hot  ones,  among  the  former 
lemonade  or  cold  oatmeal  Avater  with  lemon,  and  effervescent  mineral 
waters  (Apollinaris,  lithia,  Seltzer)  being  the  best.  The  bowels  should 
be  moved  regularly,  avoiding,  however,  all  purgation.  Stimulants  are 
not  needful,  though  well  borne  as  a  rule,  and  the  use  of  lio-ht  wines  is 
not  objectionable  if  desired  by  the  patient.  In  all  cases  of  influenza, 
even  of  the  mildest  grade,  I  prescribe  moderate  doses  of  quinin  (  gr.  iv 
— 0.2592,  three  or  four  times  daily),  and  if  there  be  much  headache 
this  drug  may  be  combined  with  Dover's  powder  and  monobromate  of 
camphor  (of  the  first  two  gr.  iij — 0.194,  each,  and  of  the  last  gr.  j — 
0.0648,  in  capsule),  the  dose  to  be  repeated  at  intervals  of  three  or  four 
hours.  To  overcome  the  languor  and  debility,  which  are  marked,  I 
have  found  nothing  so  successful  as  strychnin. 

(6)  Cases  of  Medium  Severity. — General  Management. — This  class 
of  influenza  patients  betake  themselves  to  bed,  and  should  be  kept  there 
till  convalescence  is  Avell  advanced.  During  the  febrile  period  the  diet 
must  be  light,  liquid,  yet  nutritious,  and  the  food  should  be  given  every 
two  or f three  hours.  Although  the  patient  has  no  desire  for  food,  he 
should  be  urged  to  eat  with  regularity.  Moderate  stimulation  is  also 
useful. 

The  medicinal  treatment  is,  for  the  most  part,  simple  and  symptomatic. 
Calomel  in  moderate  doses  (gr.  j  every  third  or  fourth  hour)  should  be  a 
remedy  of  choice  for  a  day,  at  least.  The  neuralgia  and  myalgia  may  be 
relieved  by  the  use  of  quinin,  Dover's  powder,  and  camphor,  as  before 
stated ;  but  if  the  pain  be  intense,  morphin  administered  subcutaneously 
is  sometimes  required.  The  temperature  is  somewhat  reduced  by  these 
remedies,  and  especially  by  the  quinin  and  Dover's  powder,  the  latter  of 
which  acts  as  a  diaphoretic.  In  addition,  I  am  in  the  habit  of  ordering 
cool  sponge-baths  at  intervals  of  two  or  three  hours  if  the  temperature  be 
above  102°  F.  (38.8°  C),  If  not  controlled  in  this  manner,  we  may 
combine  with  quinin  some  antiseptic,  such  as  salicylic  acid  or  salol.  I 
have  found  it  necessary  to  add  to  the  foregoing  small  doses  of  phenacetin 
(gr.  ij — 0.129),  or  acetanilid  (gr.  ij — 0.129),  the  former  being  preferred, 
since  it  is  superior  to  acetanilid  in  controlling  insomnia,  which  is  so  often 
a  troublesome  symptom.  Sleeplessness  may,  however,  demand  other  and 
more  potent  hypnotics,  such  as  sulfonal,  chloralamid,  opium,  etc. 

The  local  catarrhal  conditions  (coryza,  laryngo-bronchial  irritation, 
true  bronchitis,  etc.)  must  be  treated  according  to  the  special  indications 
presented  in  individual  cases.  For  the  coryza  inunctions  of  animal  fats 
over  the  forehead  and  bridge  of  the  nose  are  useful.  A  flannel  cap  may 
be  worn  if  agreeable  to  the  patient.  Steam  inhalations  through  the 
nares  and  mouth  often  act  beneficially,  both  upon  the  coiyza  and 
laryngo-bronchial  irritation.  For  the  latter  common  condition  the  fol- 
lowing formula  will  be  found  serviceable : 


166  INFECTIOUS  DISEASES. 

^i.   Codein?e  sulph.,  gr.  iv  (0.259); 

Ammon.  chloridi,  3v         (20.0) ; 

Syr.  prun.  virgin.,  f.^ij      (60.0); 

Spts.  junip.  comp.,      q.  s.  ad  fsiv      (120.0). — M. 
Sig.   One  teaspoonful  every  two  or  three  hours. 

If  this  prescription  fail  to  mitigate  the  cough,  we  may  resort  to  morphin 
hypodermically,  but  always  in  small  doses.  In  the  later  stages,  particu- 
larly if  bronchitis  be  associated  with  free  secretions,  the  oil  of  eucalyp- 
tus (TTLiij  to  V — 0.199  to  0.333),  in  capsule,  every  four  hours,  has  in  my 
experience  proved  useful.  To  obviate  pulmonary  complications  I  have 
been  much  gratified  with  the  results  from  the  use  of  strychnin  (gr.  -^ — 
0.0021),  combined  with  vin  Mariani  (.5ss — 16.0)  at  intervals  of  three  or 
four  hours.  Chest-pains  may  be  relieved  by  the  use  of  turpentine  stupes 
and  sinapisms,  both  of  which  agents  are  also  valuable  in  averting  the 
more  serious  complications. 

(c)  Severe  Forms. —  The  general  management  is  similar  to  that  recom- 
mended in  cases  of  medium  severity,  excepting  that  freer  stimulation  is 
usually  demanded.  The  medicinal  treatment  must  also  be  more  active 
than  in  the  previous  form,  and  often  is  heroic.  Especially  must  quinin 
be  given  in  full  doses  and  continued,  since  it  not  only  serves  to  reduce 
the  temperature  somewhat,  but  also  to  sustain  the  vital  forces,  to  control 
the  nervous  symptoms  and  lessen  the  tendency  to  inflammatory  compli- 
cations. Nothing  that  exerts  a  depressing  effect  should  be  thought  of, 
since  the  cardiac  as  well  as  the  respiratory  forces  must  be  conserved. 
Should  there  be  sudden  cardiac  failure,  it  must  be  promptly  met  by  the 
various  forms  of  stimulants,  including  strychnin  and  the  cardiac  tonics. 
In  addition  to  alcoholic  stimulants,  the  aromatic  spirits  of  ammonia  is 
usually  borne  well,  and  should  be  administered.  Strychnin  must  be 
given  in  full  doses  hypodermically  every  third  or  fourth  hour.  The 
various  inflammatory  complications  that  may  arise  must  be  treated  as 
under  other  circumstances. 

The  Convalescence. — In  all  grades  of  cases  the  convalescence  from 
influenza  demands  most  rigid  supervision,  and  the  greatest  injury  to 
patients  at  this  time  comes  from  going  out  too  early.  Usually  the  tem- 
perature is  subnormal  for  several  daj's — a  circumstance  due  to  the  weak- 
ness of  the  patient — and  so  long  as  this  condition  obtains  the  patient  is 
highly  susceptible  to  a  chill.  Hence  it  is  a  good  rule  not  to  allow  ex- 
posure to  the  external  changes  of  temperature  until  the  temperature  has 
been  normal  for  several  days.  The  diet  should  now  be  more  liberal,  and 
tonics,  such  as  gentian,  iron,  and  quinin,  may  be  administered  and  con- 
tinued until  complete  restoration  of  the  patient's  health  has  taken  place. 
In  every  way  possible  exposure  to  reinfection  during  the  period  of  con- 
valescence is  to  be  avoided. 

The  treatment  of  seiiuelte  must  be  conducted  according  to  general 
rules. 


DENGUE.  167 

DENGUE. 

[Break-bone  Fever.) 

Definition. — An  acute  infectious  disease  occurring  epidemically 
in  tropical  and  subtropical  countries.  Its  chief  symptoms  are — a  double 
febrile  paroxysm  (separated  by  an  interval),  arthritic  and  muscular  pains, 
and  a  skin-eruption  in  about  one-half  the  cases. 

Historic  Note. — The  disease  was  prevalent  in  Java  as  early  as 
1779,  in  India  in  1824,  and  later  in  the  West  Indies,  Spain,  and  in 
some  of  the  southern  American  States.  Mild  epidemics  have  visited 
Philadelphia,  New  York,  and  Boston,  but,  as  a  rule,  it  has  not  traversed 
regions  beyond  32°  N.  latitude. 

Its  pathology  has  not  been  studied,  death  being  the  rarest  of  events. 

Ktiologfy. — McLaughlin  of  Texas  has  isolated  from  the  blood  and 
cultivated  a  micrococcus  which  he  claims  is  the  specific  organism. 

Preduposing  Factors. — Its  prevalence  is  favored  by  the  summer  sea- 
son, and  also  to  a  slight  extent  by  faulty  hygienic  conditions.  On  the 
other  hand,  age,  race,  sex,  and  social  status  are  all  without  effect,  most 
persons  being  susceptible,  a  fact  that  accounts  for  its  marvellously  rapid 
diffusion.  According  to  Matas,  primary  attacks  are  not  protective  in 
character,  while  other  authors  contend  that  they  even  predispose  to  subse- 
quent ones.  The  epidemics  spread  along  lines  of  travel  by  land  and  sea, 
and  most  authors  asiree  that  the  disease  is  contagious. 

Clinical  History. — There  is  a  period  of  incuhation  that  lasts 
about  four  days  and  exhibits  no  prodromes. 

Invasion  then  is  abrupt  with  a  slight  chill ;  fever  follows,  the  tempera- 
ture reaching  its  maximum — 103°  to  106°  F.  (39.4°  to  41°  C.)  or  over — 
at  the  end  of  the  first  or  on  the  second  day,  and  is  accompanied  by  head- 
ache and  by  muscular  and  arthritic  pains.  The  patient's  sufferings  are  in- 
tense, the  pains  being  described  as  "breaking" — a  peculiarity  to  which 
the  disease  owes  the  popular  name  of  '■'•  break-hone  fever.''  The  joints 
become  red,  swollen,  and  very  tender  to  the  touch.  The  respirations 
and  pulse  are  much  quickened ;  there  are  anorexia  and  sometimes  slight 
nausea.  Febrile  albuminuria  is  rare,  delirium  and  mental  torpor  also ; 
but  prostration  may  become  marked,  and  an  erythematous  eruption  com- 
monly appears.  DeBrun  ^  noted  carefully  the  symptoms  of  dengue  during 
the  epidemic  at  Beirut  (1892),  and  states  that  the  eruption  is  roseolar, 
morbilliform,  scarlatinous,  or  papular.  He  distinguished  three  groiqDS  of 
cases :  1.  With  high  fever  and  marked  associated  symptoms,  and  with 
eruption ;  2.  Fever  absent,  the  symptoms  mild,  with  eruption ;  3.  The 
eruption  the  only  symptom.  The  eruption  may  appear  early,  but  has 
no  fixed  time,  is  evanescent  in  mild  cases,  and  is  never  constant  in  cha- 
racter. It  is  attended  with  burning  and  itching,  and  DeBrun  noticed 
desquamation  of  a  varying  intensity.  Hemorrhages  from  the  various 
organs  (nose,  gums,  stomach,  bowels,  lungs,  kidneys,  etc.)  may  occur, 
and  reach  even  a  dangerous  extent.  The  lymphatic  glands  are  often 
swollen ;  the  mucosae  of  the  nose  and  throat  are  hyperemic ;  the  eyes 
are  congested  and  the  face  flushed. 

The  initial  fever  lasts  three  or  four    days,   and  ends  with  a  deep 

1  Rev.  de  Med.,  Xo.  6,  1894. 


168  INFECTIOUS  DISEASES. 

remission  accompanied  by  profuse  sweating.  All  the  symptoms  now 
vanish  save  a  slight  soreness  and  stiffness,  but  after  an  interval  of  two 
or  three  days  the  characteristic  symptoms  (including  the  eruption)  re- 
appear. This  second  febrile  paroxysm  is  usually  milder  and  shorter 
than  the  first. 

The  duration  of  the  disease  is  from  seven  to  ten  days,  the  attack 
being  followed  by  a  slow  convalescence,  Avhich  may  be  interrupted  by  a 
relapse.  The  slowness  of  the  recovery  is  due  to  persistent  mental  de- 
pression  and   marked  physical  prostration. 

Complications. — Meningitis  has  been  noted,  but  in  extremely  rare 
cases.  Convulsions  sometimes  occur  in  children,  and  severe  catarrhal 
inflammations  of  certain  mucosae  (bronchial,  gastric,  etc.)  may  develop. 
Insomnia  is  common.  Hyperpyrexia  and  pericarditis  occur  very  ex- 
ceptionally. 

Diagnosis. — The  diagnosis  of  the  usual  form  of  the  disease  (epi- 
demic) is  an  easy  one  after  observation  of  the  first  few  cases,  but  a  more 
difficult  task  is  the  discrimination  of  sporadic  cases  from  rheumatism. 
The  course  and  degree  of  the  fever,  however,  differ  in  dengue  and  in 
rheumatism,  while  the  eruption  belongs  to  the  former  alone.  Influenza 
may  resemble  dengue  closely.  In  the  former  condition  the  herpes  is 
usually  the  only  eruption  :  the  joints  are  rarely  involved  :  there  is  neither 
a  remission  nor  a  recurrence  of  the  fever ;  and  serious  complications  are 
more  frequent.  The  discovery  of  the  bacillus  of  influenza  is  of  course 
decisive,  and  the  existence  of  an  epidemic  of  either  condition  strongly 
sufTgests  the  true  nature  of  the  disease.  Scarlet  fever  has  an  erythema- 
tous eruption,  but  the  fever  is  continuous  and  the  arthritic  symptoms  are 
usually  wanting. 

Yelloiv  fever  has  often  been  mistaken  for  dengue,  and  the  two  affec- 
tions have  been  known  to  prevail  together,  as  in  the  Galveston  epidemic 
of  1897.  To  establish  a  differential  diagnosis  is  often  most  difficult,  as 
there  are  a  number  of  points  of  similarity — time  of  appearance,  geo- 
graphic distribution,  influence  of  severe  frosts,  and  the  character  of  the 
febrile  paroxvsm.  To  show  contrast,  however.  I  have  arranged  the  fol- 
lowing comparison  of  symptoms : 

Dengue.  Yei.i.oh  Fever. 

Irrefrular  rise  of  fever,  followed  by  re-       The  temperature  ri.ses  regularly.     Dura- 
mission,  then  a  second  moderate  rise.  tion  of  fever  72  hours. 
Duration  5  to  9  days. 
The  pulse  keeps  pace  with  the  rise  of       Pulse  falls  while  the  fever  is  rising. 

fever. 
Eruption  frequent.  Eruption  quite  rare. 

Vomiting  rare.  Vomiting  frequent. 

Urine  never  contains  albumin  (?).  Urine  commonly  albuminous,  often  with 

suppression. 
Jaundice  absent.  Jaundice  present  and  early  appearing. 

Hemorrhages      from      mucous     outlets,       Hemorrhages  common  and  severe.    Black 

generally  slight,  and  black  vomit  rare.  vomit  an  alarming  symptom. 

Prognosis  "favorable.  Often  Altai. 

Serum-diagnosis  valueless.  Serum-diagnosis    (Widal-reaction)    pres- 

ent in  66  per  cent,  of  cases. 
Second  attacks  common.  No  second  attacks. 

The  prognosis  is  with  rare  exceptions  favorable,  dangers  arising  only 
in  the  serious  forms,  particularly  those  showing  hemorrhages. 


THE  PLAGUE.  169 

Treatment. — The  case  presents  a  double  indication  :  (a)  to  harbor 
the  patient's  strength,  and  (h)  to  meet  certain  leading  symptoms.  The 
first  is  to  be  accomplished  by  enjoining  rest  in  bed,  by  a  generous  though 
carefully-regulated  diet,  and  by  the  timely  use  of  stimulants  and  tonics. 
Among  the  symptoms  that  demand  treatment  is  the  fever,  and  when  this 
is  high  hydrotherapy  is  indicated.  For  the  intolerable  pains  morphin  is 
to  be  administered  hypodermically.  Chloralamid  and  the  bromids  should 
be  tried. 


THE  PLAGUE. 

{Bubonic  Plague  ;  Black  DeoAh.) 

Definition. — A  specific  contagious  disease,  occurring  chiefly  in  unsan- 
itary surroundings  and  characterized  by  high  fever  and  cutaneous  symptoms 
(petechia,  etc.).     Its  course  is  severe  and  rapid,  and  it  occurs  in  epidemics. 

Historic  Summary. — An  Oriental  disease,  the  plague,  has  long 
been  endemic  in  certain  portions  of  India.  Most  European  countries  have 
in  the  past  been  visited  by  epidemics  of  the  malady,  and  among  the  most 
famous  was  the  truly  pandemic  prevalence  of  "black  death  ''  in  Europe 
during  the  fourteenth  century.  Another  virulent  outbreak  occurred  in 
London  in  1665,  destroying  more  than  70,000  persons.  In  May,  1894,  a 
severe  epidemic  prevailed  in  Canton  and  Hong-Kong,  to  which  cities  it 
had  been  imported  from  Northern  India.  The  mortality  in  the  former 
place  was  180.000.  In  September,  1896,  the  plague  appeared  in  Bom- 
bay and  the  Bombay  Presidency  ;  in  November,  the  disease,  "  which  had 
seemed  to  be  abating,  revived,  and  the  mortality  steadily  rose"'  (Wil- 
loughby).  Since  then  the  plague  has  shown  periods  of  decrease  followed 
by  others  of  decided  increase,  and  the  total  plague-statistics  for  the  Bom- 
bay Presidency  from  September,  1896,  to  January  13,  1899,  are  214,197 
cases  and  169,240  deaths.  In  Asia,  according  to  Koch,  three  endemic 
plague-foci — Mesopotamia,  Thibet,  and  Assir — are  to  be  found,  and  one 
focus  (Uganda)  in  German  East  Africa. 

!^tiology. — Bacteriolo^. — During  the  epidemic  at  Hong-Kong, 
Kitasato  and  Yersin,  working  independently  (1894),  discovered  the  special 
organism  of  the  plague  {bacillus  pestis  bubonicce).  It  stains  deeply  at 
the  ends,  giving  the  appearance  of  a  pair  of  micrococci,  but  is  really  a 
short  rod-bacillus  with  rounded  ends.  Pure  cultures  are  readily  made, 
and  when  animals  are  inoculated  with  these  the  clinical  characteristics  of 
the  disease  are  produced. 

Predisposing  Causes. — These  are  embraced  in  the  single  phrase — un- 
hvgienic  conditions.  It  is  safe  to  assert  that  without  these  fosterincf  in- 
fluences  the  plague  would  not  prevail. 

Inside  the  body  the  bacillus  has  been  found  in  the  lungs  (plague- 
pneumonia)  (where  it  is  often  combined  with  the  pneumococcus  and 
staphylococcus),  in  the  enlarged  glands,  in  the  pus  from  the  buboes,  the 
blood,  and  other  internal  organs.  Outside  the  body,  among  infected 
materials,  are  dust,  plague-infected  flies,  the  excreta,  food,  and  soil. 

Modes  of  Transmission  and  Entrance  into  tlie  Body. — According  to 
Kitasato,  the  bacillus  enters  either  through  the  digestive  or  respiratory 


170  INFECTIOUS  DISEASES. 

tract,  or  by  inoculation.  The  bubonic  pest  is  spread  by  two  principal 
factors — the  rat  and  man  (Simond).  In  almost  all  outbreaks  of  human 
plague  rats  had  the  disease  both  before  and  during  the  epidemic  (F.  G. 
Clemow).  The  rat  is  the  carrier  from  house  to  house,  and  hence  is  more 
important  in  the  transmission  of  the  disease  in  local  epidemics  than  man  ; 
but  the  latter  is  the  ordinary  agent  of  transport  for  long  distances.  Flies, 
fleas,  ants,  and  other  insects  may  act  as  carriers  of  the  contagion,  par- 
ticularly from  rat  to  man.  Nuttall's  studies  Avarrant  the  belief  that 
transmission  of  the  poison  by  stinging-insects  is  extremely  rare.  Certain 
animals  besides  rats  (mice,  dogs,  cats,  rabbits,  pigs,  horses,  etc.)  may 
become  infected  and  die  of  the  pest,  and  both  before  and  after  death 
transmit  the  disease  to  healthy  animals.  Yersin  established  contagion 
of  plague  by  keeping  inoculated  rats  and  healthy  mice  in  the  same  place 
(Payne,  in  Allbutt's  Si/stem).  The  disease,  however,  is  more  commonly 
transmitted  by  foci  of  the  infection  (houses,  ships)  and  by  fomites. 

Clinical  History. — Varieties.— Two  distinct  forms,  either  of  which 
may  prevail  alone,  are  recognized :  1.  Pestis  minor,  abortive  or  larval 
plague,  often  appearing  as  a  forerunner  of  severe  epidemics.  It  is 
characterized  by  swelling  of  the  lymphatics,  and  by  slight  general  dis- 
turbance, and  lasts  about  a  fortnight.  It  appears  only  in  the  endemic 
foci  of  the  plague.  2.  Pestis  major,  or  severe  epidemic  form.  To  rapidly 
fatal  cases  belonging  to  this  variety  the  term  pestis  siderans  or  "fulmi- 
nant" has  been  applied.  Between  the  mild  form  (pestis  minor)  and  the 
epidemic  form  transitional  cases  are  rarely  observed,  and  the  following 
description  has  reference  solely  to  the  latter.  Certain  writers  recognize  a 
third  variety — jdaf/iie-pneumotiia,  in  Avhich  the  usual  pneumonic  symp- 
toms (chill,  stabbing-pains,  cough,  rusty  expectoration,  and  signs  of  con- 
solidation) appear. 

The  Attack. — The  incubation-perxod  lasts  from  three  to  five  or  rarely 
seven  days.  Prodromal  si/mptoms  are  sometimes  observed,  and  may  last 
from  twelve  to  twenty-four  hours.  They  are  intense  headache,  vertigo, 
pallor,  and  a  gait  suggestive  of  intoxication.  The  physiognomy  is  stupid, 
and  the  patient  may  refuse  or  be  unable  to  answer  questions. 

Invasion. — This  may  be  abrupt ;  less  commonly  it  is  preceded  by  the 
above  symptoms ;  and  rarely  bilious  vomiting  or  hemateniesis  are  the 
ushering-in  symptoms.  There  occur  a  prolonged  rigor  or  recurring 
shiverings.  The  temperature  rises  rapidly  to  103°,  104°,  or  even  to 
106°  F.,  and  the  pulse  becomes  rapid  and  thread-like,  although  variable 
in  force  and  character.  Deliriiim  or  coma  tends  to  supervene.  Debility 
may  now  be  extreme,  and  the  patient  may  die  in  the  initial  period.  More 
commonly  this  threatened  collapse  is  survived,  and  then  (from  the  second 
to  the  fifth  day)  the  most  characteristic  feature  almost  always  appears — 
buboes  or  inflammation  of  the  lymph-glands.  The  latter  may  enlarge 
gradually  or  rapidly,  and  are  usually  quite  painful.  Pesolution  may 
occur,  or  they  may  remain  unchanged,  particularly  in  fatal  cases.  iSup- 
puration  may  occur,  and  rarely  gangrene,  forming  the  so-called  carbuncle. 
The  latter  may  also  appear  as  gangrenous  patches  over  the  skin  of  the 
trunk  and  legs.  Petechice  and  hemorrhagic  diathesis,  as  shown  by 
bleedings  from  the  lungs,  stomach,  and  intestines,  arise  in  the  worst 
forms.     Plague-pneumonia  is  common   in   certain  epidemics. 

The  duration  in  fatal  cases  is  usually  from  thre^e  to  five  days.     On  the 


THE  PLAGUE.  171 

other  hand,  cases  that  tend  to  recovery  may  be  prolonged,  on  account  of 
suppuration  of  the  buboes,  to  a  few  weeks  or  even  months. 

Diagnosis. — The  report  of  the  Austrian  Plague  Commission  divides 
the  disease  into  two  main  varieties,  one  affecting  the  lymphatic  glands — a 
form  easily  recognized — and  the  other  the  lungs.  It  was  found  to  be  very 
difficult  to  "  differentiate  between  an  existent  pneumonia  and  the  charac- 
teristic plague-pneumonia  in  the  initial  state. ^ 

Prognosis  and  Mortality. — The  death-rate  is  exceptionally  high, 
ranging  from  40  per  cent,  (rare)  to  80  or  even  90  per  cent.  Among 
favorable  indications  is  suppuration  of  the  buboes.  On  the  other  hand, 
a  rapid  "disappearance  of  a  group  of  swollen  glands  is  a  bad  augury. 
Additional  unfavorable  symptoms  are  plague-pneumonia,  intense  toxic 
features,  purpuric  spots  ("tokens"),  carbuncles,  and  hemorrhages. 

Treatment. — Prophylaxis. — The  precautions  to  be  taken  by  the  indi- 
vidual relate  to  the  abandoning  of  all  unsanitary  habits,  the  isolation  of 
the  sick,  and  the  avoidance  of  prolonged  contact  with  infected  patients 
or  dwellings.  It  would  seem  that  doctors  and  even  nurses  and  attendants 
in  well-ordered  and  properly-ventilated  hospitals  rarely  take  the  plague. 

The  prophylaxis  of  the  public  embraces — (a)  Isolation  of  the  sick 
and  thorough  disinfection  of  the  sick-room,  the  bed  and  bed-linen,  the 
vomitus,  and  the  stools.  Kitasato  advocates  steaming  the  bed  at  212°  F. 
(100°  C.)  for  one  hour,  or  exposure  for  a  few  hours  to  sunlight,  and  the 
burning  of  all  infected  articles.  "  After  recovery  the  patient  is  to  be 
kept  in  isolation  for  at  least  one  month."  The  infected  houses  are  to  be 
thoroughly  disinfected,  and  a  pure  water-supply  procured.  HafFkine 
suggests  a  solution  of  sulphuric  acid  (1 :  200)  for  the  disinfection  of  build- 
ings, (b)  Protective  inoculation  or  treatment  by  "  vaccination  "  of 
healthy  persons  seems  efficient.  Haffkine  reports  upon  the  epidemic  of 
plague  in  Lower  Damaun  as  follows :  24.6  per  cent,  of  over  6000  persons 
who  were  not  inoculated  died  of  the  disease,  while  but  1.6  per  cent,  of 
over  2000  inoculated  acquired  the  disease.  Immunity  seemed  to  be 
directly  in  proportion  to  the  strength  of  the  vaccine.  His  Highness  the 
Aga  Khan's   Inoculation   Station  at  Mazagon  opened  on  December  27, 

1897,  and  during  the  IGJ  weeks  between  the  latter  date  and  April  20, 

1898,  184  deaths  in  all  occurred  in  the  Khoja  community.  Of  these,  6, 
including  2  of  plague,  took  place  in  Khojas  inoculated  in  the  epidemic 
of  1896-97  and  not  reinoculated  since ;  7  deaths,  including  3  of  plague, 
occurred  in  the  5184  Khojas  inoculated  or  reinoculated  in  1898  ;  and  171 
deaths  occurred  in  the  uninoculated  Khojas. 

Treatment  of  the  Attacks. — The  diet  should  be  liquid,  concentrated,  and 
nourishing,  while  free  stimulation  is  demanded  from  the  onset.  Medicines 
do  not  exercise  any  controlling  influence,  and  hence  are  used  merely  to 
combat  symptoms  as  they  arise.  Delirium  and  pain  are  to  be  met  by 
morphin  or  hyoscin,  and  high  temperature  by  cold  or  tepid  sponging. 

Local  Treatment. — Cantlie  does  not  believe  in  local  measures  before 
suppuration  occurs,  although  he  has  observed  good  results  to  follow 
injections  of  mercuric  chlorid  and  potassium  iodid. 

Serum-therapy. — Anti-plague  serum  exercises  a  specific  action  (Yer- 
sin).      Of  26  cases  treated,  2  died — a  mortality  of  7.6  per  cent.     More 
recent  reports  by  Haffkine,  however,  show  disappointing  results. 
1  Philada.  Med.  Jour.,  Jan.  28,  1899. 


172  INFECTIOUS  DISEASES. 

ERYSIPELAS. 

{St.  Anthony's  Fire.) 

Definition. — A  specific,  acute  contagious  disease,  characterized  by 
a  special  inflammation  of  the  skin  and  subcutaneous  tissues,  with  a  ten- 
dency to  spread,  high  fever,  moderate  prostration,  a  disposition  to  mixed 
infection  (suppuration,  gangrene),  and  an  average  duration  of  fourteen 
days.      It  usually  occurs  in  endemic,  though  also  in  epidemic  form. 

Pathology. — Erysipelas  is  a  specific  inflammation  involving  the 
skin,  subcutaneous  and  mucous  surfaces,  but  the  latter  far  less  frequently. 
When  inflammation  extends  to  the  subcutaneous  connective  tissue  there 
follows,  as  a  rule,  suppuration.  The  claim,  however,  that  the  inflamma- 
tion may  penetrate  the  skull  and  attack  the  meninges  lacks  convincing 
proof.  The  specific  cocci  are  found  in  the  superficial  lymph-vessels  and 
spaces  of  the  aff'ected  skin,  being  most  abundant  in  the  ever-advancing 
elevated  margin.  Beyond  the  border  of  the  inflamed  region  they  occupy 
chiefly  the  lymph-vessels,  where  they  are  finally  overpowered  by  the 
phagocytic  action  of  the  leukocytes.  Microscopic  examination  reveals  the 
changes  of  simple  inflammation. 

Ktiology. — Bacteriology. — The  specific  cause  of  the  disease  is  the 
streptococcus  erysipelatis  of  Fehleisen,  which  is  probably  identical  with 
the  ordinary  pus-producing  streptococcus.  Frankel  and  Kirchner  have 
investigated,  experimentally,  the  streptococcus  erysipelatis.,  and  contend 
that  their  results  ofi'er  convincing  proof  of  the  separate  identity  of  the 
streptococcus  pyogenes ;  but  most  observers  hold  that  the  former  cannot 
be  distinguished  from  the  latter.  The  streptococci  of  erysipelas  assume 
the  form  of  a  serpent  or  chain  (chain-forming  coccus  of  Cohn),  and  are 
very  small,  somewhat  variable  in  size,  and  thrive  on  all  kinds  of  culture- 
media.  Their  favorite  situations  are  the  lymph-vessels  and  the  cutaneous 
connective  tissue,  where  they  are  found  in  colonies  composed  of  myriads 
of  cocci.  They  are  rarely  found  in  the  blood-vessels,  and  in  blood-serum 
they  are  caused  to  disappear  by  the  action  of  the  phagocytes ;  yet  in 
exceptional  cases  intra-uterine  infection  has  occurred.  G.  E.  Pfahler^ 
found  a  diplococcus  in  eight  cases,  and  thinks  it  may  be  the  cause  of 
the  disease. 

That  the  streptococcus  erysipelatis  is  a  saprophytic  organism  is  shown 
by  the  fact  that  the  identical  cocci  have  been  discovered  in  inanimate  and 
decomposing  animal  and  veiretable  substances. 

Predisposing  Causes. — (1 )  Season. — In  a  paper  on  "  Seasonal  Influences 
in  Erysipelas,  with  Statistics,"-  I  have  shown,  as  the  result  of  an  analysis 
of  2010  cases  collected  from  diff"erent  sources,  that  the  various  seasons  of 
the  year  exercise  a  potent  influence  upon  the  frequency  of  this  affection. 
Thus  month  by  month  the  cases  increase,  in  slightly  varying  ratio,  from 
August  to  April,  the  latter  month  giving  the  greatest  number,  and  then 
there  is  a  rapid  decrease  from  April  to  August,  when  we  find  the  smallest 
number.  Again,  one-half  of  all  the  cases  occur  during  the  months  of 
February,  March,  April,  and  May,  and  15.9  per  cent,  during  the  month 
of  April  alone.  It  was  found  that  a  low  barometer  and  mean  relative 
humidity   invariably  correspond   with   the   annual  period   in   which  the 

^  Philadtlphia  Medical  Journal,  January  13,  1900. 

*  Proceedings  of  the  American  Climaloloyical  Association,  1893. 


ERYSIPELAS.  173 

greatest  number  of  cases  occur,  and  that  the  highest  percentage  of  rela- 
tive humidity  corresponds  with  the  months  affording  the  fewest  cases. 

(2)  Age. — From  the  notes  of  1894  cases  I  found  that  in  25.8  per  cent, 
the  age  of  the  patient  was  between  twenty  and  thirty  years.  After  fifty 
years  the  cases  decrease  rapidly,  and  more  than  15  per  cent,  occur  before 
the  age  of  twenty.     The  great  liability  of  newly-born  infants  is  well  known. 

(3)  Sex. — This  factor  was  noted  in  1767  cases,  and  a  marked  prepon- 
derance of  the  male  over  the  female  sex  was  noted  (about  3  to  2). 

(4)  Previous  Attacks. — Of  450  cases,  there  had  been  previous  attacks 
in  39  (8.6  per  cent.),  in  one  instance  four,  and  in  "another  seven,  ante- 
cedent attacks  having  occurred,  Avhile  second  and  third  recurrences  were 
not  uncommon. 

(5)  Family  predisposition  exercises  a  slight  though  decided  influence. 
It  was  noted  in  4  of  the  450  cases. 

(6)  Certain  Antecedent  Affections. — Dr.  M.  Booth  Miller  examined 
the  history  of  301  cases,  and  found  that  acute  coryza  preceded  the  attack 
in  13  instances.  Slight  lesions  of  the  Schneiderian  mucous  membrane 
may  be  assumed  to  exist  in  such  instances.  Testimony  confirming  the 
now  well-known  fact  that  certain  chronic  diseases  (chronic  Bright's,  phthisis, 
organic  heart  disease,  chronic  alcoholism,  syphilis,  etc.)  augment  a  receptiv- 
ity to  the  complaint  has  also  been  brought  to  light  by  my  own  researches. 

(7)  Slight  Injuries,  Abrasions,  etc. — Erysipelas  will  not  develop  on  a 
surface  which  does  not  present  a  break,  but  with  this  present  may  do  so 
though  the  latter  be  so  trivial  as  to  escape  observation.  Slight  abrasions 
and  fissures,  either  in  the  mucous  membrane  of  the  nose  or  in  the  skin  of 
the  face  or  ear,  as  well  as  all  forms  of  slight  injuries,  are  liable  to  furnish 
a  path  of  ingress  to  the  specific  organism.  Yet  in  643  out  of*  the 
2010  cases  mentioned  above,  previous  lesions  were  noted  in  but  13. 
Women  who  have  been  recently  delivered  and  persons  subjected  to 
surgical  operations  are  peculiarly  liable,  and  any  deeply-seated  focus  of 
irritation  (necrotic  bone,  chronic  abscess,  appendicitis)  may  give  rise  to 
repeated  outbursts  of  erysipelas. 

(8)  Antihygienic  Surroundings. — These  doubtless  predispose  to  the  affec- 
tion, as  has  been  shown  by  the  prevalence  of  erysipelas  in  hospitals  and 
institutions  in  which  the  sanitary  arrangements  were  markedly  faulty. 

Modes  of  Conveyance  of  the  Contagion. — The  latter  may  be  air-borne. 
It  has  been  collected  from  the  air  of  rooms  and  wards  occupied  by  ery- 
sipelas patients  ;  but  to  what  distance  and  precisely  under  what  circum- 
stances it  can  be  conveyed  is  imperfectly  known.  It  may  also  be  trans- 
ferred for  a  longer  or  shorter  distance  by  fomites,  by  instruments,  unclean 
hands,  etc.,  the  infection  being  a  result  either  oi  contagion  or  inoculation. 

Clinical  History. — I  shall  discuss  only  the  so-called  medical  or 
idiojoathic  erysipelas,  the  traumatic  variety  falling  more  properly  within 
the  domain  of  surgical  treatises. 

Incubation. — This  is  somewhat  varied,  though  it  ranges  usually  from 
seven  to  fourteen  days.  The  prodromal  symptoms  are,  for  the  most  part, 
general  in  character,  consisting  in  headache,  restlessness,  cough  and  sore 
throat,  anorexia,  and  slight  or  moderate  pyrexia.  These  endure  for  a 
very  variable  period — from  a  few  hours  to  several  days. 

Invasion  Stage. — The  symptoms  are  (1)  local  and  (2)  general. 

(1)  At  first  the  affected  part  feels  hot,  tense,  painful,  and  is  tender  to 
the  touch.     Very  soon  a  small  circumscribed  area  becomes  red,  swollen, 


174  INFECTIOUS  DISEASES. 

firm,  and  shining,  and  simultaneously  the  subjective  symptoms  (pain, 
heat,  etc.)  become  aggravated.  The  point  of  election  is  usually  on  the 
nose,  but  it  may  be  on  the  ear,  the  face,  or  elsewhere  about  the  head,  and 
thence  the  inflamed,  swollen  zone  spreads,  chiefly  in  the  direction  of  one 
or  the  other  side  of  the  head.  Separating  the  diseased  from  the  unaffected 
skin  there  is  a  sharp  line  of  demarcation  in  the  form  of  an  elevated 
brawny  ridge,  which  can  be  seen  and  felt.  While  the  inflammation  is 
advaJicing  there  may  be  noted,  beyond  the  border  of  the  latter,  little  red 
streaks  and  spots  that  grow  in  area  till  at  last  they  become  confluent. 
The  degree  of  redness  increases  in  intensity  as  the  case  advances,  but 
any  natural  prominence  or  fold  in  the  integument  may  prevent  further 
extension  of  the  inflammation  {e.  g.  naso-labial  folds,  border  of  the  hairy 
scalp).  In  cases  of  average  severity  the  face  is  much  swollen,  the  eyes 
closed  on  account  of  tumefaction  of  the  eyelids,  the  ears  greatly  enlarged 
(far  better  marked  on  one  side  than  the  other,  as  a  rule),  the  scalp  swollen 
and  tender,  and  the  facial  lineaments  often  changed  beyond  recognition. 
In  a  minority  of  the  cases  the  inflammatory  process  extends  from  the  head 
to  the  arms,  to  the  trunk,  and  even  to  the  loAver  extremities  {erysijyelas 
migrans),  and  in  such  instances  the  face  may  be  healed  while  the  disease 
is  yet  extending  over  other  portions  of  the  body.  The  parts  first  affected 
are  pale  while  yet  the  local  inflammation  is  extending  its  boundary  lines. 
When  the  progress  of  the  inflammatory  process  is  arrested  the  peripheral 
ridge  ceases  to  extend  and  grows  pale ;  the  inflammation  then  subsides. 

The  epidermal  layer  may  become  elevated  over  circumscribed  areas, 
giving  rise  to  larger  or  smaller  vesicles  or  bullae  {erysipelas  vesiculosum). 
Suppuration  may  attack  these  large  vesicles,  Avhereupon  they  fill  Avith  pus 
(ergsipelas pustulosian).  From  intense  infiltration  the  part  or  parts  may 
become  gangrenous — erysipelas  gangrcenosum.  Enlargement  of  the 
cerebral  lymph-glands  is  common.  Desquamation  follows  erysipelas,  and 
the  face  often  presents  a  more  delicate  complexion  than  before  the  occur- 
rence of  the  attack. 

(2)  General  Symptoms. — With  the  onset  of  the  attack  the  patient  is 
seized  with  repeated  fits  of  chilliness;  less  commonly,  a  severe  rigor 
occurs.  Immediately,  and  more  rapidly  than  before,  the  temperature 
rises  to  a  height  of  104°  or  105°  F.  (40°-40.5°  C.)  on  the  evening  of 
the  first  day.  As  a  rule,  the  temperature  reaches  its  maximum  (105°  to 
1070  Y. — 40.5°  to  41.6°  C.)  on  the  third  evening.  Marked  nocturnal 
remissions  of  temperature  (2°  to  5°  F.— 1.1°  to  2.7°  C)  are  the  rule, 
but  the  evening  temperature  may  in  rare  instances  be  to  an  equal  degree 
lower  than  themorning.  At  the  end  of  a  week  the  temperature  declines 
rapidly  to  normal,  and  usually  within  twenty-four  or  thirty-six  hours; 
sometimes,  however,  the  course  of  the  fever  is  prolonged  and  deferves- 
cence may  be  less  critical.  In  erysipelas  migrans  a  long  and  decidedly 
irregular  temperature-curve  is  presented,  and  the  same  remark  applies 
when  complications  are  present.  The  pulse  is  frequent,  of  good  volume, 
and  soft.  I  have  been  able  to  confirm  the  observations  of  Da  Costa, 
Striimpell,  and  others  that  the  cutaneous  inflammation  in  ervsipelas  (par- 
ticularly erysipelas  migrans)  may  advance  to  a  slight  extent  even  after 
the  temperature  has  returned  to  the  normal  grade. 

The  toyxgue  is  furred,  the  anorexia  intensified,  and  there  are  apt  to  be 
nausea  and  fre(iuent  vomiting.  The  bou'els  are  usually  constipated, 
though  I  have  observed   a  few  instances  in  which   marked  diarrhea  de- 


ERYSIPELAS.  175 

veloped  late  in  the  attack.  The  inflammation  may  extend  to  the  mucous 
membrane  of  the  throat  and  larynx,  causing  swelling  and  edema  of  the 
parts.  It  may  also  involve  the  serous  membranes,  though  rarely.  The 
nervous  synvptoms  may  or  may  not  be  conspicuous ;  but  there  are  apt  to 
be  intense  headache  and  restlessness,  with  some  mental  aberration  at 
night.  Actual  nocturnal  delirium  appears  in  the  severer  forms,  and  in 
erysipelas  occurring  in  drunkards  delirium  tremens  may  suddenly  develop. 
The  urine  presents  the  usual  febrile  characters.  Commonly  it  contains  a 
little  albumin,  and  rarely  acute  nephritis  occurs  as  a  complication. 

There  is  a  direct  correspondence  between  the  intensity  of  the  local 
and  constitutional  disturbances  in  this  disease. 

Often  in  sevei'e  forms  (such  as  are  apt  to  arise  in  old,  much  enfeebled, 
or  intemperate  persons)  of  facial  erysipelas  the  tyflioid  (adynamic)  con- 
dition is  developed.  The  tongue  is  dry  and  brown,  the  lips  and  teeth  are 
covered  with  sordes,  the  pulse  grows  very  rapid  and  feeble,  and  the 
bowels  are  apt  to  be  loose.     Ataxic  nervous  symptoms  appear. 

Complications  and  Varieties. — An  analysis  of  1674  cases  of 
erysipelas  Avith  particular  reference  to  complications  gave  an  interesting 
series  of  results,  and  one  at  variance  with  the  notions  of  most  authors. 
Some  are  given  here  in  the  order  of  frequency  of  occurrence :  Abscess, 
105 ;  rheumatism,  20 ;  delirium  tremens,  10 ;  lobar  pneumonia,  active 
delirium,  phlebitis,  pleurisy,  each  7  ;  acute  nephritis,  6  ;  synovitis  and 
diarrhea,  each  5 ;  tonsillitis,  3  ;  catarrhal  pneumonia,  otitis  media,  phar- 
yngitis, edema  of  the  larynx,  acute  bronchitis,  each  1} 

The  fact  that  acute  articular  rheumatism  is  a  relatively  frequent  com- 
plication of  erysipelas  is  worthy  of  special  notice,  for  the  reason  that  the 
attention  of  the  profession  has  not  hitherto  been  called  to  it.  The  symp- 
toms of  rheumatism  usually  come  on  several  days  after  the  onset  of  ery- 
sipelas. In  a  few  instances  pneumonia  appeared  early,  being  due  most 
probably  to  special  localizations  of  the  specific  streptococcus.  To  such 
cases  the  term  "  pneumo-erysipelas  "  may  be  appropriately  applied.  The 
cases — 2  in  number — in  which  acute  nephritis  developed  during  the  first 
few  days  of  the  attack  should  in  like  manner  be  termed  "  nephro-erysipe- 
las."  With  few  exceptions,  however,  the  complications  enumerated  are 
secondary  affections.  Meningitis  was  present  in  a  single  instance  only,  and 
hence  active  delirium  in  this  disease  points  to  severe  infection,  but  not  to 
meningitis  as  a  rule.     Many  different  varieties  have  been  described. 

Apart  from  the  varieties  referred  to  above,  two  other  forms — namely, 
phlegmonous,  or  cellulo-cutaneous,  and  relapsing  erysipelas — should  be 
mentioned.  The  former  exhibits  an  inflammation  of  the'  subcutaneous 
connective  tissue,  which  tends  to  suppurate.  Relapsing  erysipelas,  how- 
ever, constitutes  the  chronic  form  of  the  disease,  recurnng  at  longer  or 
shorter  intervals,  and  usually  in  the  same  locality.  It  is  commonly  due 
to  some  deep-seated  focus  of  suppuration. 

Sequelae. — The  hair  often  falls,  but  it  is  usually  replaced  by  a  fresh 
crop.  Abscesses  in  various  parts  of  the  body,  particularly  the  eyelids, 
are  of  common  occurrence  (vide  Complications),  and  chronic  otitis  media 
and  chronic  nephritis  may  date  from  an  attack  of  erysipelas.  Per  contra, 
erysipelas  is  reputed  to  be  curative  of  certain  affections  (eczema,  lupus, 
carcinoma,  sarcoma,  rheumatism). 

^  "The  Complicating  Conditions,  Associated  Diseases,  and  Mortality-rate  in  Ery- 
sipelas,"  by  the  Author:   The  Int.  Med.  Mag.  for  Oct.,   1893. 


176  INFECTIOUS  DISEASES. 

Out  of  476  cases  collected  by  me  relapses  occurred  in  54  (11.3  per 
cent.),  and  in  1  of  these  instances  5  relapses  occurred ;  in  2  others,  4 ; 
and  in  3  patients.  3.* 

The  diagnosis  is  made  with  ease  after  the  eruption  has  fully  devel- 
oped, and  its  appearance,  seat,  and  behavior,  particularly  the  manner 
of  extension  of  the  brawny,  ridge-like  edge  (best  marked  on  the  forehead), 
are  the  features  that  distinguish  it  from  every  other  disease. 

J^rythema  produces  superficial  redness,  but  is  not  attended  with  heat, 
swelling,  or  fever.  Urticaria  assumes  the  form  of  pale-red  circular  wheals, 
which  cause  marked  itching  and  appear  in  successive  crops,  often  disap- 
pearing in  the  course  of  a  few  hours.  Acute  eczema  of  the  face,  when 
intense,  may  somewhat  resemble  erysipelas ;  but  it  lacks  the  peculiar  bor- 
der and  mode  of  progression  so  characteristic  of  the  latter  disease.  Again, 
eczema  produces  particularly  troublesome  itching,  and  the  swelling  is  less 
than  in  erysipelas.  Clironic  erythematous  eczema  is  met  Avith  later  in  life, 
is  without  fever,  without  any  considerable  swelling  or  pain,  and  excites 
intense  itching.  Eczema  nodosum  is  characterized  by  its  nodosities  in 
the  vicinity  of  joints. 

Course  and  Duration. — In  my  own  experience,  based  upon  1880 
cases,^  the  average  duration  (including  the  prodromal  stage  and  period 
of  convalescence)  in  persons  under  forty  years  of  age  is  fourteen  days. 
The  course  of  the  disease  is  much  lengthened  by  complications,  the  pre- 
existence  of  chronic  affections,  and  by  age  (after  the  fiftieth  year). 

The  prognosis  is  favorable,  and  it  is  rare  for  erysipelas  to  assume  a 
malignant  type.  Perhaps  the  chief  dangers  lie  in  certain  complications, 
especially  extensive  suppuration,  pneumonia,  acute  nephritis,  delirium 
tremens,  etc.  Acute  articular  rheumatism  is  comparatively  harmless ; 
but  previous  debility,  especially  if  dependent  upon  chronic  diseases,  as 
syphilis,  chronic  rheumatism,  gout,  tuberculosis,  organic  disease  of  the 
heart,  and  the  like,  increases  the  percentage  of  deaths  considerably. 
Again,  age  has  a  positive  influence  upon  the  mortality,  which  it  augments 
moderately  after  the  forty-fifth  year,  and  most  decidedly  after  the  sixtieth 
year.  Of  2663  deaths  due  to  erysipelas  (United  States  Census  Report), 
the  death-rate  per  100.000  inhabitants  was  as  follows :  under  5  years, 
31.34  ;  5  to  15  years,  0.81  ;  15  to  45  years.  2.80  ;  45  to  65  years,  8.88  ; 
Qij  and  over,  38.55  (Wm.  L.  Kodman).  When  death  occurs  it  is  due  to 
exhaustion. 

The  mortality-rate  is  low,  as  shown  by  the  results  of  my  own  collective 
investigations  into  the  subject.^  I  found  the  general  average  death-rate 
to  be  5.6  per  cent.,  while  in  cases  from  private  practice  it  was  4  per  cent. 
In  persons  over  seventy  years  it  was  46  per  cent.  The  traumatic  cases 
gave  a  mortality  of  14.5  per  cent. 

Treatment. — The  treatment  of  erysipelas  falls  naturally  into  three 
subdivisions  :  (1)  Dietetic  ;  (2)  Constitutional ;  (3)  Local. 

(1)  Dietetic. — Proper  attention  to  the  diet  is  of  the  first  importance.  It 
must  be  generous  and  composed  of  highly  nutritious  articles,  and  if  the 
temperature  be  high,  only  li(juid  forms  of  nourishment  should  be  admin- 

^  Journal  of  the  Americon  Medical  Association,  July  22,  1893. 

*"  Points  in  the  Etiologv  and   Clinical   History  of  P>rysipelas,"  by  the  Author: 
Journal  of  the  Am.  Med.  Assoc,  July  22,  1893. 
^  Loc.  cit.,  p.  3. 


ERYSIPELAS.  177 

istered  in  definite  quantities  and  at  regular,  brief  intervals.  Rectal 
alimentation  should  be  resorted  to  if  the  stomach  rejects  a  suitable  diet- 
ary, and  I  feel  confident  of  the  fact  that  liberal  feeding  is  of  greater 
service  to  the  patient  than  any  of  the  recognized  forms  of  medicinal 
treatment.  Lack  of  attention  to  the  patient's  diet  during  the  primary 
attack  tends  to  increase  the  frequency  of  relapse.  In  persons  over  fifty 
years  of  age,  and  in  those  in  whom  the  vital  processes  have  been  lowered 
on  account  of  previous  chronic  diseases,  correct  alimentation  is  of  para- 
mount importance,  often  abridging  the  otherwise  much  protracted  course 
of  the  affection. 

(2)  Constitutional  Treatment. — When,  despite  an  appropriate  diet,  the 
pulse  becomes  very  rapid  and  feeble,  the  heart's  first  sound  indistinct,  and 
the  tongue  dry  or  brown,  indications  for  the  use  of  stimulants  are  present 
and  must  be  heeded.  When  needful,  the  alcoholics  may  be  given  with  a 
comparatively  free  hand,  12  to  16  ounces  (360.0—480.0)  of  whiskey  daily 
in  divided  portions.  Strychnin  gives  prompt  results,  and  may  be  used  in 
association  with  the  alcoholics.  In  marked  gastric  irritability  champagne 
is  to  be  preferred. 

The  tincture  of  the  chlorid  of  iron  was  first  extensively  used  in  this 
disease  by  English  authorities,  and  was  formerly  regarded  by  most  clin- 
icians as  a  truly  specific  remedy.  In  74  cases  of  erysipelas  which  were 
treated  by  this  remedy  alone,  the  average  quantity  being  1  dram  (4.0)  daily 
in  divided  doses,  in  the  Pennsylvania  Hospital  by  Drs.  Lewis,  DaCosta, 
Longstreth,  Meigs,  and  others,  the  death-rate  was  4  per  cent.^  Other 
preparations  of  iron,  however,  are  equally  efficacious.  Quinin  is  a  valu- 
able remedy  in  erysipelas,  and  during  the  past  twelve  years  I  have  em- 
ployed it  in  not  less  than  30  cases,  confining  its  use  to  instances  in  which 
the  temperature  touched  103°  F.  (39.4°  C),  and,  with  a  single  exception, 
in  uncomplicated  cases  (22  in  number)  the  nocturnal  remissions  were  de- 
cidedly greater.  In  every  instance  iron  in  some  form  was  administered 
simultaneously.  J.  M.  DaCosta  first  used  pilocarpin  in  erysipelas  at  the 
Pennsylvania  Hospital.  His  experience  showed  that  when  given  hypo- 
dermically  (gr.  -|— 0.010)  in  the  very  early  stage,  and  repeated  three  or 
four  times  at  intervals  of  two  or  three  hours,  it  often  aborted  the  attack. 
If  we  except  this  use  of  the  drug,  it  is  only  in  cases  attended  with  high 
temperature  with  slight  morning  falls  that  pilocarpin  should  be  employed; 
and  the  condition  of  the  pulse  and  heart  can  be  relied  upon  as  a  guide  to 
its  administration.  Whether  or  not  the  favorable  results  from  the  use  of 
pilocarpin  are  to  be  ascribed  to  a  property  possessed  by  it  of  stimulating 
phagocytic  action  is  not  yet  clear. 

Numerous  antiseptic  remedies  have  been  recommended. 

Ajitistrejjtococcie  Serum. — Andre,  Robinson,  Cox,  and  others  have 
reported  instances  of  its  successful  use.  The  serum  is  injected  subcutane- 
ously  ;  its  influence  endures  over  several  days,  but  it  is  important  that  the 
injections  are  repeated  at  forty-eight  hour  intervals.  Marmorek's  serum 
(care  being  taken  that  it  is  not  too  old)  is  to  be  preferred,  and  it  is  prob- 
able that  it  has  immunizing  power  as  well  as  a  specific  action  as  a  prophy- 
lactic and  curative  agent. 

Certain  symptoms  demand  internal  medication.  When  the  fever,  as 
sometimes  happens,  is  alarmingly  high,  its  reduction  must  be  accom- 

^  "Tlie  Treatment  of  Erysipelas,"  by  the  Author:  Therapeutic  Gazette,  July  16,  1894. 
12 


178  INFECTIOUS  DISEASES. 

plislied,  and  the  best  method  is  by  means  of  cold  spongings  combined 
with  the  ice-cap,  or  cold  or  gradually  cooled  baths.  The  happy  effects 
of  this  agent — cold — are  manifold.  Guaiacol  has  recently  been  em- 
ployed for  the  purpose  of  reducing  the  temperature,  and  found  highly 
efficacious.  The  tendency  to  spontaneous  remission  of  fever  in  this  dis- 
ease must,  however,  be  steadily  borne  in  mind. 

For  marked  nervous  phenomena,  such  as  pain,  sleeplessness,  and 
active  delirium,  hyoscin  hydrobromate  (gr.  y^ — 0.0006)  has  been  tried 
hypodermically  in  numerous  cases  at  the  Medico-Chirurgical,  Pennsyl- 
vania, and  Philadelphia  hospitals,  and  has  given  promise  of  being  a 
valuable  remedy.  It  should  not  be  employed  when  the  heart-power  is 
found  to  be  deficient,  and  to  fulfil  the  same  indications  we  may  utilize 
the  following:  Sodium  bromid,  gr.  v  (0.324)  every  two  hours,  or  gr. 
xx-xxx  (1.296-1.944)  at  night;  morphin,  gr.  ^  (0.008),  and  chloral, 
gr.  X  (0.648),  in  combination  every  half  hour  for  three  doses;  potas- 
sium bromid,  gr.  x  (0.648),  and  tincture  of  cannabis  indica,  TTLx  (0.666), 
in  combination  at  bed-time;  atropin,  gr.  -^  (0.0008),  and  morphin,  gr. 
\  (0.0108),  hypodermicaHy. 

The  treatment  of  the  various  complications  must  be  conducted  in 
accordance  Avith  general  princi))les  applicable  to  each. 

(3)  Local  measures  have  always  held  a  prominent  place  in  the  treat- 
ment of  erysipelas.  The  list  of  agents  that  have  been  used  topically 
is  long  and  embraces  all  classes  of  therapeutic  substances.  In  the  paper 
previously  cited  it  is  stated  that  in  the  three  series  of  cases  (247)  that 
were  treated  at  the  Pennsylvania  Hospital,  together  with  a  few  collected 
from  other  sources,  no  less  than  fifty  different  remedies  and  preparations 
had  been  employed  locally.  Among  those  most  frequently  used  were 
elm  (37  cases) ;  lead-water  and  laudanum  (20  cases) ;  carbolic  acid  (1  to 
40),  injected  subcutaneously  (18  cases);  zinc  oxid  (14  cases) ;  mercuric- 
ehlorid  solution  (14  cases) ;  ichthyol  ointment  with  lanolin  (8  cases),  etc. 
Many  of  these  preparations  were  prescribed  for  their  effect  in  excluding 
the  air — a  leading  indication.  This  I  am  in  the  habit  of  meeting  by 
the  use  of  carbolized  vaselin  or  cool  carbolized  oil. 

A  knowledge  of  the  microbic  nature  of  erysipelas  has  led  to  the  local 
application  of  numerous  antiseptic  remedies,  and  it  is  along  this  line 
that  the  greatest  advances  in  the  treatment  of  the  disease  are  to  be  ex- 
pected. Mention  has  been  made  of  the  method  of  injecting  carbolic 
acid.  Here  the  aim  is  to  check  the  spread  of  the  inflammatory  process 
by  inserting  the  needle  at  numerous  points  just  beyond  the  inflamed 
border.  The  method  (introduced  by  Heuter)  has  been  much  practised 
by  Henry  at  the  Philadelphia  Hospital,  and  more  recently  by  Osier  at 
the  Johns  Hopkins  Hospital,  and  is  especially  applicable  in  erysipelas 
migrans.  In  the  statistics  befoi-e  given  a  solution  of  mercuric  chlo- 
rid  (1  :  4000)  was  used  locally  in  14  instances,  to  which  I  can  add  the 
results  of  12  others  at  the  Medico-Chirurgical  Hospital  and  in  private 
practice.  In  nearly  all  of  the  cases  it  was  employed  in  the  form  of  a 
lotion  over  the  inflamed  surface.  In  a  few  it  was  injected  beneath  the 
skin,  as  in  the  case  of  the  carbolic  acid.  More  recently  it  has  been 
recommended  to  scarify  the  affected  part  and  follow  Avith  the  application 
of  a  solution  of  mercuric  chlorid.  In  view  of  the  fact  that  the  strep- 
tococcus is  found  chiefly  in  the  more  sujDerficial  channels  of  the  corium, 


DIPHTHERIA.  179 

it  follows  that  it  may  be  attacked  directly  by  the  mercuric-chlorid 
solution  Avhen  the  latter  is  used  after  scarification ;  and  this  method 
of  treatment  is  at  once  most  promising  and  rational.  In  8  in- 
stances (3  of  which  have  been  previously  reported)  it  was  attended 
with  brilliant  results,  limiting  the  spread  and  allaying  the  severity 
of  the  local  inflammation. 


DIPHTHERIA. 

[DipMheritis ;  Angina  Maligna ;   Croup.) 

Definition. — An  acute,  contagious  disease  caused  by  the  Klebs- 
Loffler  bacillus,  and  characterized,  anatomically,  by  a  croupous-diph- 
theritic  inflammation  of  the  mucous  membrane  of  the  pharynx  and 
upper  air-passages.  Clinically,  it  is  characterized  by  irregular  fever, 
prostration,  and,  frequently,  albuminuria ;  also  by  the  secondary  devel- 
opment of  toxemia,  and  often  of  croupous  laryngitis  or  cardiac  failure. 
It  is  often  folloAved  by  peculiar  paralyses.  In  large  municipalities  it 
behaves  endemically,  and  from  time  to  time  epidemically. 

Pseudo-diplitheria. — There  are  forms  of  inflammation  occurring  most 
frequently  in  the  pharynx  and  adjacent  air-passages  (and  also  in  many 
other  parts  of  the  body)  that  are  attended  with  the  formation  of  a 
pseudo-membrane,  and  are  not  caused  by  the  Klebs-Lbjffler  bacillus. 
These  cases  have  been  studied  exhaustively  by  Prudden  and  others,  w-ho 
have  usually  found  the  streptococcus  to  be  the  specific  cause  of  infection. 
The  latter,  however,  has  been  found  occasionally  in  the  pharynx  of 
healthy  children  and  in  the  inflamed  mucous  surfaces  met  with  in  ery- 
sipelas and  measles.  "Pseudo-diphtheria,"  so  called,  is  very  common:' 
in  scarlatina. 

Pathology. — The  true  diphtheritic  inflammation  has  for  its  chief 
pathologic  peculiarity  the  production  of  a  fibrinous  exudate.  When 
the  inflammation  is  superficial  and  of  a  mild  grade,  .a  croupous  mem- 
brane is  produced  which  can  be  easily  removed  from  the  mucosa, 
which  it  covers.  Its  formation  is  accompanied  by  a  necrotic  jDrocess 
that  does  not  extend  below,  but  practically  replaces  the  epithelial 
layer  of  the  mucous  membrane.  In  the  severer  types  of  the  affection, 
however,  the  fibrinous  membrane  infiltrates  all  the  layers  of  the  mucosa, 
which  undergoes  necrosis  more  or  less  nearly  complete.  In  the  severest 
forms  the  submucous  layer  may  also  become  necrotic.  It  is  to  be  borne 
in  mind  that  the  production  of  the  fibrinous  exudate  in  croup  or  diph- 
theria is  ahvays  preceded  by  coagulation-necrosis  of  the  epithelium. 
The  mucous  membrane  surrounding  the  exudate  is  hyperemic,  more  or 
less  edematous,  and  the  seat  of  muco-purulent  secretions. 

The  Pseudo-membrane. — Its  composition  comprises  fibrin,  pus,  disin- 
tegrated leukocytes,  flakes  of  necrosed  epithelium,  bacilli,  and  some- 
times red  blood-corpuscles.  The  fibrin  has  two  main  sources :  {ci) 
"  The  fibrinogen  of  the  inflammatory  matter,"  w^hich  transudes  through 
the  capillary  walls ;  and  {h)  Disintegrated,  migratory  leukocytes,  which 
form  branching  fibrillffi.     Weigert  holds  that  the  inflammatory  exuda- 


180  INFECTIOUS  DISEASES. 

tion  is  coagulated  bj  a  ferment  derived  from  the  disintegrated  leuko- 
cytes. 

The  Klebs-Loffler  bacilli  are  found,  chiefly  and  in  varying  relative 
numbers,  in  the  meshes  of  the  fibrill^.  but  also  in  the  granular  fibrin 
and  on  the  adjacent  mucous  membrane.  Frequently  other  micro-organ- 
isms are  associated  (streptococci,  staphylococci,  etc.).  The  membrane 
presents  a  grayish-white  color,  and,  if  croupous  in  character,  can,  as  before 
mentioned,  easily  be  removed.  When  the  mucosa  is  deeply  involved  the 
membrane  is  thicker,  firmer,  and  more  adherent,  so  that  its  removal 
entire  cannot  be  effected  without  great  difficulty,  and  without,  as  a  rule, 
injury  to  the  surface,  as  shown  by  bleeding,  etc.  The  character  of  the 
pseudo-membrane  is  affected  by  the  nature  of  the  underlying  structure ; 
thus  in  the  pharynx  it  is  firmer  and  less  easily  separable  than  in  the 
larynx  and  trachea,  where  a  distinct  basement  membrane  is  found 
(Flexner).  As  the  membrane  becomes  older  its  color  is  apt  to  grow 
darker,  becoming  vellow  or  even  dark  brown.  It  sometimes  becomes 
gangrenous,  and  softens  or  disintegrates,  wirh  the  production  of  a  very 
offensive  brownish,  semi-li(iuid  excretion.  The  advancing  edge  of  the 
false  membrane  is  usually  thin.  On  the  other  hand,  when  the  process 
has  become  arrested  the  edge  is  apt  to  look  raised  or  wrinkled,  and 
later  it  may  be  distinctly  curled  up. 

The  membrane  may  extend  downward  into  the  ramifications  of  the 
bronchi.  In  such  cases  there  is  apt  to  be  a  lobular  pneumonia,  and  this 
latter  condition  may  occur  without  extension  of  the  membrane. 
Occasionally  there  is  a  lobar  pneumonia.  A  generalized  bronchitis  ex- 
tending to  the  smaller  bronchi  is  common  from  the  irritation  of  aspi- 
rated substances.  In  rare  cases  the  membrane  has  spread  into  the 
esophagus  and  even  into  the  stomach. 

After  separation  of  a  croupous  membrane  repair  consists  merely  in  a 
restoration  of  the  epithelial  layer — a  process  which  is  initiated  by  the 
fragments  of  epithelium  that  remain  along  the  edges  of  the  diseased 
area,  and  proceeds  centrally.  On  the  other  hand,  in  true  diphtheria, 
with  necrosis  more  or  less  nearly  complete  of  the  mucosa  and  even  the 
submucosa,  sloughing  occurs,  and  the  missing  structures  are  replaced  by 
cicatricial  tissues. 

The  Heart. — The  muscular  structure  and  the  nervous  mechanism 
suffer  most.  The  histologic  changes  mav  be  of  the  parenchvmatous  va- 
riety,  but  only  in  mild  instances ;  whereas  in  severer  cases  fatty  degen- 
eration is  conspicuous.  In  still  other  cases  the  chief  pathologic  charac- 
teristic is  an  interstitial  myocarditis,  and  rarely  the  lesions  of  peri- 
carditis and  endocarditis  have  been  noted.  The  heart  is  by  no  means 
always  involved. 

The  spleen  is  commonly  enlarged,  though  not  to  an  excessive  degree. 
The  blood  i.^  dark,  its  coagulability  is  greatly  diminished,  and  Canon  and 
Frosch  have  in  a  few  cases  found  the  bacilli  in  the  blood  of  those  dying 
of  diphtheria.  The  red  corpuscles  are  somewhat  decreased  in  number 
during  the  course  of  the  disease,  while  the  white  corpuscles  are  increased. 
Bouchut  and  Dulinsay  consider  the  grade  of  leukocytosis  of  prognostic 
value,  and  claim  tliat  it  varies  directly  with  the  severity.  Grawitz  has 
determined  in  numerous  ca.ses  a  higher  specific  gravity  of  the  blood 
during  diphtheria.     The  lymphatic  glands  of  the  neck  become  swollen  as 


DIPHTHERIA.  181 

a  rule,  and  are  often  greatly  enlarged,  but  they  show  little  tendency  to 
suppurate.  In  pronouncedly  septic  cases  in  which  a  mixed  infection  is 
found  by  culture  a  good  deal  of  tumefaction  of  the  neck  occurs,  this 
sometimes  even  obliterating  the  normal  contour  from  jaw  to  clavicle. 

The  Kidneys. — The  kidneys  show  degenerative  changes,  the  usual 
kidney -lesion  being  a  hyperemic  swelling  with  edema  of  the  interstitial 
tissues,  and  often  hemorrhagic  spots  in  the  cortex.  Sometimes  there  is 
a  marked  glomerulo-nephritis,  and  more  rarely  a  diffuse  granular  degen- 
eration of  the  epithelium.  Minute  areas  of  necrosis  have  been  observed 
in  the  internal  organs,  in  which  fibrin  has  been  found  deposited  (Oertel). 
Welch  and  Flexner  have  produced,  by  artificial  inoculation  upon  guinea- 
pigs,  kittens,  and  rabbits,  foci  of  cell-death  in  the  lymph-glands  through- 
out the  body,  in  the  spleen,  liver,  lungs,  heart,  and  intestinal  mucosa. 
When  the  dose  is  small  and  the  animal  lives  several  weeks,  the  paralysis 
which  belongs  to  the  disease  may  develop. 

The  nerves,  in  cases  of  paralysis,  have  shown  parenchymatous  and 
interstitial  inflammatory  lesions.  In  paralysis  of  throat-muscles  (^.  e. 
those  near  the  locality  of  the  pseudo-membranous  inflammation)  the 
latter  show  also  round-cell  infiltration  and  fatty  degeneration  of  the 
fibers. 

Etiology. — True  diphtheria  is  caused  by  the  Klebs-Lcifiier  bacillus, 
and  all  cases  of  supposed  diphtheria  in  Avhich  the  bacillus  is  absent  are 
to  be  regarded  as  non-diphtheritic.  The  etiologic  is,  therefore,  quite 
different  from  the  pathologic  significance  of  this  term.  Recent  researches 
have  removed  all  doubt  as  to  the  specific  nature  of  the  Klebs-Loffler 
bacillus. 

Bacteriology. — The  bacillus  diphtheri^e  nearly  equals  in  length  that 
of  the  bacillus  tuberculosis,  and  is  twice  the  diameter  of  the  latter.  It 
has  rounded  extremities,  ^^hich  are  also  frequently  bulbous,  giving  it  the 
appearance  of  a  dumb-bell.  At  times  one  end  only  is  clubbed,  or, 
more  rarely,  one  or  both  ends  appear  pointed.  The  bacilli  are  immobile, 
do  not  form  spores,  and  stain  readily,  the  best  agent  being  alkaline 
methyl-blue.  Their  manner  of  taking  the  stain  is  important.  The 
bacilli  show  alternating  segments  of  darker  and  lighter  stained  areas, 
and  often  minute  dots  showing  a  most  intense  and  deep  staining.  They 
grow  on  most  culture-media,  but  for  clinical  purposes  Lofiler's  blood- 
serum  is  important  (3  parts  blood-serum  and  1  part  neutral  or  slightly 
alkaline  nutritive  bouillon,  containing  1  per  cent,  of  glucose).  Inocu- 
lated on  this,  they  outgrow  all  other  organisms  that  may  be  present,  and 
within  eight  hours  or  less  show  numerous  spots,  one-half  to  one  millimeter 
in  diameter,  which  have  a  dull  surface  and  a  dense  white  or  somewhat 
yellowish  color.  There  are  usually  present  also  smaller  points  which 
have  different  appearances  and  which  are  colonies  of  other  organisms. 
The  former  are  the  colonies  of  the  bacillus  diphtherise,  and  from  these 
microscopic  preparations  and  (by  further  cultivation)  pure  cultures  can 
be  obtained.  The  bacilli  are  semi-anaerobic,  and  thrive  at  the  temper- 
ature of  the  human  body ;  a  temperature  of  122°-136.5°  F.  (50°- 
58°   C.)  causes  their  destruction  in  ten  minutes. 

Pseudo-diijJitheria  Bacillus  or  Bacillus  Xerosis. — From  many  cases, 
often  showing  no  lesions,  an  organism  may  be  obtained  that  is  identical  in 
appearance,  manner  of  culture,  growth,  etc.  with  the  bacillus  diphtheria, 


182  INFECTIOUS  DISEASES. 

but  inoculation  with  it  causes  no  lesions.  The  works  of  Abbott,  Roux, 
Yersin,  and  others  seem  to  show  that  this  is  an  attenuated  form  of  the 
true  bacillus,  and  varying  grades  of  pathogenicity  may  be  found  between 
the  two.  The  distinction  from  the  pathogenic  bacillus  can  only  be  made 
by  determining  the  hick  of  infection  after  inoculation. 

Site  of  Infection. — In  the  human  family  the  seat  of  election  of  the 
bacillus  diphtherias  is  usually  the  faucial  mucosa,  and  less  fre(iuently 
other  mucous  surfaces  and  abraded  skin.  The  bacilli  do  not  penetrate 
the  mucosa,  and  hence  do  not  find  their  way  into  the  lymphatic  or  cir- 
culatory system,  but  remain  at  or  very  near  the  site  of  the  local  changes. 

The  Toxins. — Toxins  are  absorbed  from  the  diseased  spots  by  the 
lymphatics  and  blood-vessels,  and  produce  the  general  phenomena  in  un- 
complicated cases.  They  have  been  isolated  from  artificial  cultivations 
of  the  microbe,  and  when  inoculated  the  chief  ptomain  of  tJie  Klebs- 
LbflSer  bacillus  so  modifies  the  solids  and  liquids  of  the  body  as  to  render 
the  subject  immune  (Behring).  Another,  however,  if  employed  in  like 
manner,  produces  dangerous  and  even  fatal  symptoms  (convulsions, 
paralysis,  etc.). 

It  is  certain  that  the  bacillus  can  maintain  an  existence  for  months 
outside  of  the  body,  though  its  usual  habitat  is  unknown  unless  it  be 
the  organic  constituents  of  the  superficial  soil.  The  virulence  of  its 
products  is  modified  by  many  individual  conditions,  and  chief  among 
these  is  a  healthy  and  intact  condition  of  the  mucous  membranes,  which 
greatly  reduces  tlie  susceptibility  to- the  disease. 

Associated  Microbes. — With  the  Klebs-Liiffler  bacillus  are  frequently 
found  other  microbes,  especially  streptococci  and  staphylococci.  These 
pass  beyond  the  site  of  local  infection,  reaching  the  internal  viscera  and 
other  structures,  and,  as  will  be  seen  hereafter,  give  rise  to  the  serious 
septic  element  of  the  disease.  • 

Modes  of  Infection. — When  the  bacillus  leaves  the  body  of  the  sick 
it  is  contained  in  particles  or  shreds  of  tlie  diphtheritic  membrane,  or  in 
the  expired  air.  Infection  may  then  occur  (a)  By  direct  contact  with  the 
shreds  of  membrane  thrown  off — e.g.  when  the  latter  are  ejected  by 
coughing  and  lodge  upon  the  conjunctivae  or  faucial  mucosa  of  bystand- 
ers. Under  this  category  come  the  cases  in  which  the  deadly  poison  is 
transferred  to  the  physician  and  attendants,  with  resulting  infection, 
from  the  sucking  of  tracheotomy-tubes,  (h)  Bi/  inhalhi;/  the  air  sur- 
rounding the  patient  (contagion).  Infection  by  contagion,  however, 
does  not  extend  beyond  a  radius  of  a  few  feet  from  the  patient,  (c)  A 
very  leading  manner  of  conveyance  of  the  bacillus  from  the  sick  to  the 
healthy  is  by  fomites.  The  contagion  adheres  tenaciously  to  a  great 
variety  of  objects  (toys,  clothing,  library  books,  letters,  slates  and 
drinking-cups  in  the  public  schools,  etc.),  and  in  this  way  the  germs  of 
diphtheria  have  been  transferred  over  great  distances  and  have  given 
rise  to  the  disease  long  after.  The  latter  fact  renders  it  diflBcult  to 
trace  certain  cases  to  previous  ones,  to  which  they  invariably  owe  their 
origin,  {d)  Seiver  gas.,  per  se,  is  to  be  regarded  as  non-pathogenic,  or 
at  least  so  far  as  this  affection  is  concerned  (Laws).  It  may,  however, 
become  a  carrier  of  diphtheritic  poison,  {e)  I  regard  it  as  highly 
probable  that  the  disease  may  be  communicated  by  domestic  animals 
(fowls,  cats,  etc.). 


DIPHTHERIA.  183 

As  to  the  exact  conditions  under  which  infection  occurs,  our  know- 
ledge is  as  yet  incomplete.  We  know  definitely  the  usual  point  of  local 
infection  in  man,  and  also  that  a  catarrhal  mucosa  or  an  open  lesion  of  a 
mucous  surface  invites  infection.  It  is  not  certain,  however,  that  even 
a  slight  lesion  of  the  mucous  surface  is  essential  to  infection,  though  it 
is  very  questionable  whether  the  diphtheritic  germs  ever  find  lodgement 
in  the  perfectly  healthy  mucosa.  Some  writers  claim  still  that  the 
Klebs-Lofiler  bacillus  may  enter  the  blood  through  the  respiratory 
system  and  give  rise  to  primary  constitutional  symptoms,  the  local 
manifestations  in  the  throat  being  secondary.  I  have  met  with  a 
single  instance  that  would  lend  support  to  this  view. 

Predisposing  Factors. — (1)  Age. — This  is  the  most  important  factor, 
diphtheria  being,  in  the  main,  a  disease  of  childhood.  Most  cases  occur 
between  the  second  and  seventh  years,  while  the  receptivity  diminishes 
rapidly  after  the  tenth  year.  Instances  have,  however,  been  observed 
up  to  the  fiftieth  or  even  the  sixtieth  year.  During  the  first  year  of 
life  also  it  is  rare.  (2)  Sex. — This  is  without  appreciable  influence. 
(3)  Season. — Cases  are  more  numerous  in  winter  and  spring  than  at  other 
seasons.  (4)  Climate. — Diphtheria  is  met  with  less  frequently  in  tropical 
than  in  temperate  and  cold  climates.  Humidity  favors  the  propagation 
of  the  diphtheria  germ,  and  hence  damp  cellars  also  promote  the  spread 
of  the  disease.  (5)  Unhygienic  Co7iditions. — Unfavorable  sanitary  sur- 
roundings tend  to  lower  vitality,  thus  increasing  the  susceptibility  to  the 
specific  virus.  Most  epidemic  outbreaks  have  held  more  or  less  intimate 
relationship  with  decomposing  organic  matter,  defective  drainage  and 
sewage,  cesspools,  etc.,  though  it  is  to  be  especially  remembered  that  the 
disease  often  prevails  in  sparsely-settled  rural  districts. 

Immunity. — A  single  attack  does  not  confer  perfect  immunity. 
Second  and  third  attacks  not  infrequently  occur  in  the  same  individual. 

Symptoms. — Incubation. — The  duration  of  this  period  is  from  two 
to  seven  or  ten  days,  and  in  a  small  percentage  of  the  cases  it  may  be 
longer.  In  virulent  epidemics  and  when  the  disease  is  produced  experi- 
mentally the  incubation-stage  is  short — from  twelve  hours  to  two  or 
three  days.  The  prodromal  iyidications  oi  diphtheria  are  not  strikingly 
characteristic.  They  may  either  be  acute  in  character  or  very  mild ; 
but  usually  the  child  will  complain  of  feeling  weary  and  indisposed  to 
play,  of  being  chilly  and  cold,  and  of  pain  in  the  head,  back,  and  limbs. 
In  young  children  the  onset  of  diphtheria,  as  in  other  infectious  diseases, 
may  be  marked  by  convulsions.  There  is  nothing  in  this  early  stage  of 
the  disease  to  distinguish  it  from  many  of  the  other  affections  of  children, 
such  as  simple  pharyngitis  or  tonsillitis.  There  may  be  some  fever,  not 
very  high — an  elevation  of  one  or  two  degrees  at  most.  The  child  may 
often  complain  of  discomfort  in  swallowing,  and  on  examination  the  fauces 
will  be  found  to  be  reddened,  and  in  a  short  time  the  exudate  will  be 
found  on  the  tonsils  or  soft  palate.  This  is  the  usual  type  of  simple  ton- 
sillar diphtheria. 

Pharyngeal  Diphtheria. — The  symptoms  are  usually  shiver  of  develop- 
ment than  in  tonsillitis.  The  child  is  sluggish,  looks  heavy-eyed,  languid, 
and  pale  for  several  days.  The  fever  may  not  rise  above  101°  or  102° 
F.  (38.8°  C).  On  examining  the  throat,  however,  it  is  found  to  be 
swollen  and  red,  and  if  lividity  is  more  pronounced  than  the  swelling, 


184  INFECTIOUS  DISEASES. 

it  suggests  the  true  nature  of  the  disease.  The  membrane  begins  on 
the  tonsils  in  the  form  of  small  patches  of  yellow  exudate,  scarcely 
distinguishable  from  the  thick,  cheesy  plugs  of  inspissated  dead  epi- 
thelium and  secretion  which  issue  from  the  mouths  of  the  follicles  of 
the  tonsils  during  the  course  of  acute  or  chronic  tonsillitis.  The  mem- 
brane spreads  from  the  tonsils  to  the  soft  palate  and  half  arches  within 
a  few  days,  and  it  may  also  appear  on  the  pharyngeal  wall.  During 
this  stage  the  throat  may  become  much  swollen  and  the  tonsils  greatly 
enlarged,  frequently  meeting  in  the  median  line.  The  glands  immedi- 
ately beneath  the  angle  of  the  lower  jaw  on  one  or  usually  both  sides 
become  hard,  painful,  and  slightly  enlarged ;  the  swelling  of  these 
glands  is  not  usually  great  in  mild  forms,  although  their  presence,  in 
association  with  the  foregoing  symptoms,  is  an  infallible  indication  of 
the  disease.  The  child,  as  a  rule,  shows  grave  constitutional  symptoms 
for  a  few  days,  and  loses  its  appetite.  The  temperature  is  not  charac- 
teristic, as  a  rule  not  being  high,  and  the  pulse  is  rapid  and  weak,  being 
out  of  proportion  to  the  general  indications  of  the  disease.  In  mild 
cases  the  symptoms  abate  by  the  end  of  the  first  week,  and  the  pseudo- 
membrane  separates,  leaving  a  red,  inflamed  surface  behind.  The  child 
is  prostrated  for  a  number  of  weeks,  and  in  about  20  per  cent,  of  all 
mild  cases  the  toxic  eff"ects  of  the  disease  may  show  themselves  in  the 
form  of  a  neuritis,  with  its  accompanying  paralysis. 

Variations  in  Manifestation. — Diphtheria  may  exhibit  a  number  of 
variations  as  regards  the  seat  of  attack  and  the  severity  of  the  poison- 
ing. In  some  epidemics  the  Klebs-Loffler  bacillus  seems  to  be  more 
active  and  more  numerous,  or  perhaps  more  virulent,  than  in  others. 
The  severity  of  the  attack  does  not  seem  to  depend  on  the  amount  of 
the  pseudo-membrane,  but  rather,  according  to  Rotch,  upon  three  fac- 
tors :  (1)  the  virulence  of  the  bacteria ;  1 2)  the  local  resistance ;  and  (3) 
the  general  resistance.  "While  false  membrane  is  most  frequently  seen  on 
the  tonsils,  spreading  gradually  to  the  soft  palate  and  uvula,  the  mucous 
membrane  of  any  part  of  the  body  (lips,  tongue,  conjunctivae,  vulva,  or 
glans  penis)  may  be  the  seat  of  the  growth. 

3Ialignant  ^Diphtheria. — The  symptoms  are  severe  from  the  com- 
mencement. There  are  one  or  at  most  two  days  of  slight  illness,  and 
then  alarming  symptoms  manifest  themselves,  cardiac  failure  possibly 
setting  in  without  a  specially  severe  local  lesion.  Vomiting  and  high 
fever,  resembling  the  onset  of  scarlet  fever,  may  initiate  the  attack ; 
and  within  a  few  hours  we  may  find  extensive  swelling  at  the  angles  of 
the  jaws,  with  a  feeling  of  stony  hardness,  a  very  offensive,  bloody  dis- 
charc^e  coming  from  the  nostrils,  accompanied  with  difficulty  in  opening 
the  mouth.  If  the  throat  is  examined,  there  will  be  found  extensive 
swelling  of  the  tonsils,  even  to  meeting,  the  uvula  and  soft  palate  being 
edematous  and  covered  with  much  sloughy-looking  membrane.  The 
temperature  in  severe  cases  soon  reaches  a  point  between  103°  and 
104°  F.  (40°  C),  while  the  heart-heats  become  exceedingly  feeble.  In  a 
day  or  two  the  cellulitis  extends,  the  face  becomes  edematous,  the  skin 
pits  all  over  the  face,  neck,  sternum,  and  chest-walls.  The  patient 
soon  becomes  drowsy,  cyanotic,  and  occasionally  an  erythematous  rash 
appears  about  the  face,  neck,  and  chest,  while  a  purpuric  rash  is  not  in- 
frequent  in   malignant   cases.     Death   occurs  in  such  cases  within  one 


DIPHTHERIA.  185 

week  from  toxic  poisoning.  Malignant  cases  of  diphtheria  resemble 
very  closely  malignant  scarlet  fever,  though  the  pulse  in  scarlet  fever 
will  be  of  assistance  in  the  absence  of  the  characteristic  rash. 

Nasal  Diphtheria. — In  all  severe  cases  of  pharyngeal  diphtheria  the 
inflammatory  process  is  likely  to  extend  to  the  nasal  mucous  membrane. 
In  some  cases  the  nasal  mucous  membrane  is  found  to  be  the  first  in- 
volved, and  it  may  spread  to  the  tonsils,  but  in  these  cases  the  exudate 
will  be  found  to  involve  the  back  of  the  soft  palate  and  pharynx  as  well. 
In  many  cases  of  nasal  diphtheria  no  membrane  may  be  found  during 
life ;  there  may  be  only  a  purulent  discharge  with  blood,  the  presence  of 
which  in  the  nasal  passage  obstructs  breathing,  giving  rise  to  a  bubbling 
sound,  and  rendering  sleep  troublesome  and  noisy.  Many  cases  have 
also  been  reported  of  formation  of  pseudo-membrane  in  the  nose  with 
mild  general  symptoms  (often  insignificant),  and  from  which  bacilli 
identical  with  diphtheria  bacilli  were  obtained  by  culture,  the  bacilli  often 
persisting  for  months.  Sometimes  the  cases  have  recurring  mild  attacks 
of  pseudo-membranous  inflammation  of  the  nose,  while  the  bacilli  may  be 
constantly  present.  It  is  probable  that  these  cases  may  give  rise  to  in- 
fections of  like  nature,  and  even  of  true  diphtheria.  In  nasal  diph- 
theria the  symptoms  are  quite  as  severe  as  in  faucial  diphtheria,  and  in 
cases  in  which  the  soft  palate,  tonsils,  and  nasal  mucous  membrane  are 
involved  the  general  symptoms,  the  depression,  and  also  the  albuminuria, 
are  well  marked.  In  all  cases  of  coryza  with  fever  we  should  be  guarded 
as  to  opinion,  especially  if  an  epidemic  of  diphtheria  is  prevalent  at  the 
time.  The  diphtheritic  inflammation  may  spread  from  the  nose  to  the 
conjunctivae,  with  the  formation  of  a  false  membrane,  and  much  purulent 
discharge  may  escape  from  the  eyes,  the  lids  of  which  may  be  greatly 
swollen.  In  this  place  it  is  well  to  remember  that  in  measles  we  some- 
times have  a  form  of  membranous  exudation  occurring  on  the  nasal 
mucous  membrane  and  as  a  primary  disease — "  rhinitis  fibrinosis  " — which 
is  not  always  diphtheria.  This  disorder  runs  a  favorable  course,  the 
membrane  being  less  adherent  than  in  diphtheria.  Ravenel  has  collected 
77  cases,  and  in  33  out  of  41  cases  examined  bacteriologically  the  Klebs- 
Lofiler  bacillus  was  found.  Constitutional  symptoms  were  either  slight 
or  wanting. 

Wound-diphtheria. — The  bacillus  will  not  live  on  normal  skin,  but 
when  the  skin  is  cut  or  bruised,  as  after  blistering  or  an  eczematous 
condition,  and  when  a  moist,  raw  surface  is  present,  the  bacillus  freely 
flourishes.  Granulations  also  form  a  favorable  soil.  The  diphtheritic 
germs  may  be  introduced  into  the  system  during  an  operation,  such  as  an 
excision  of  the  tonsils,  or  even  a  vaginal  examination ;  and  in  new-born 
infants  the  granulating  surface  left  after  sloughing  of  the  cord  may  be- 
come the  seat  of  diphtheritic  inflammation. 

Laryngeal  Diphtheria  or  Membranous  Croup. — In  many  cases  the 
Klebs-Loffler  bacillus  produces  its  influence  first  on  the  mucous  mem- 
brane of  the  larynx,  and  in  these  cases  the  mucous  membrane  of  the 
nose  and  pharynx  may  never  give  evidence  of  a  false  membrane.  In 
laryngeal  cases  the  first  symptom  is  a  cough  of  a  harsh,  metallic,  riyiging 
character,  and  never  to  be  forgotten  when  once  heard.  The  temperature 
may  be  slightly  above  normal,  or  even,  in  many  cases,  normal.  The 
toxic  absorption  is  slight,  on  account  of  the  locality  afiFected,  and  the 


186  INFECTIOUS  DISEASES. 

constitutional  symptoms  are  usually  mild.  The  local  symptoms,  however, 
are  very  alarming,  as  they  are  the  results  of  laryngeal  obstruction,  there 
being  marked  dynpnea  with  retraction  of  the  intercostal  and  supraclavic- 
ular spaces,  and  later  of  the  epigastrium  and  lower  chest.  These  are 
associated  with  an  increasing  cyanosis.  The  child  is  soon  very  restless. 
is  forced  to  sit  up  to  breathe,  and  for  the  same  reason  bends  forward  with 
its  head  thrown  back.  In  these  extreme  cases,  unless  relief  is  soon  gained, 
the  child  dies  of  suflFocation.  In  many  instancesa  slower  form  of  suffoca- 
tion may  result  from  the  extension  of  the  membrane  downward  to  the 
bronchi. 

Complications. — Local  complications  may  be  mentioned,  as  when 
we  have  hemurrhayc  from  the  nose  and  throat  in  the  more  severe  ulcera- 
tive cases.  Skin-rashes  are  not  unusual,  especially  the  diffuse  erythema. 
Sometimes  urticaria  will  be  noticed,  and  in  severe  forms  purpwa  will 
mark  the  skin. 

Broncho-pneumonia  is  the  most  serious  pulmonary  complication  of 
diphtheria.  It  is  not  produced  by  the  Klebs-Lciffler  bacillus,  but  by 
pyogenic  cocci  which  have  been  taken  in  during  respiration.  Broncho- 
pneumonia is  frequent,  and  most  usually  terminates  laryngeal  cases  that 
have  been  operated  upon. 

Albuminuria  is  really  a  part  of  the  disease,  and  can  scarcely  be  re- 
garded as  a  complication.  It  is  the  most  constant  symptom,  and  is 
almost  as  certain  in  establishing  a  diagnosis  of  true  diphtheria  as  a  bac- 
teriolo^ic  examination.  It  is  met  with  in  both  mild  and  severe  cases, 
and  the  greater  the  amount  of  albumin  the  more  severe  the  case.  When 
acute  nephritis  complicates  diphtheria  it  is  usually  not  accompanied  by 
edema  or  anasarca. 

Dysphaqia  may,  by  its  constant  existence  throughout  the  disease,  pro- 
duce a  profound  impression  on  the  general  nutrition.  Involvement  of  the 
conjunctivce  is  a  rare  but  grave  complication. 

Otitis  media  occurs  frequently,  and  may  be  a  troublesome  complica- 
tion as  well  as  a  sequel. 

The  most  frequent  sequelae  are  anemia,  chronic  naso-pharyngeal 
catarrh,   peripheral  neuritis  and  its   associated   paralysis. 

Anemia  may  so  prolong  convalescence  that  the  child  will  frequently 
be  exposed  to  some  intercurrent  disorder.  The  chronic  naso-pharynyeal 
catarrh  may  be  so  marked  as  to  offer  a  favorable  ground  for  new  diph- 
theritic invasion.  Xeuritis  and  paralysis  will  not  be  noticed  until  the 
third  or  fourth  week,  the  pai-alysis  usually  being  first  seen  when  the  child 
attempts  to  swallow,  and  the  food,  especially  if  li((uid,  is  regurgitated 
through  the  nose.  This  is  due  to  a  paralysis  of  the  muscles  of  the  soft 
palate,  Avhich  will  also  be  noticeable  OAving  to  a  peculiar  alteration  of  the 
voice.  The  paralysis  may  take  a  general  form,  such  as  is  seen  in  mul- 
tiple neuritis,  the  lower  extremities  being  affected  and  the  knee-jerk 
absent.  It  is  frequently  quite  extensive ;  it  may  extend  to  the  external 
ocular  muscles  and  cause  squint,  to  the  ciliary  muscles  and  cause  dimness 
of  vision  from  unequal  accommodation,  or  to  the  muscles  of  the  trunk  in 
general,  producing  widespread  paralysis.  Tiie  child,  unable  to  hold  any- 
thing, may  stagger  about  as  if  intoxicated,  so  much  so  as  to  suggest  the 
existence  of  a  cerebral  tumor.  The  disturbance  of  vision  and  the  ab- 
sence of  the  patellar  tendon  reflex  has  in  adults  led  to  a  mistaken  diag- 


DIPHTHERIA.  187 

nosis  of  locomotor  ataxia.  Loss  of  taste,  deafness,  and  a  disturbance  of 
sensation  are  not  infrequent.  Thus,  paralysis  is  to  diphtheria  what 
dropsy  is  to  scarlet  fever — a  proof  positive  of  the  disease.  To  make  one 
step  more,  in  many  sudden  deaths  occurring  in  early  diphtheria  we  must 
recognize  parali/sis  of  the  heart  outside  of  all  toxic  influence,  and  the 
fact  that  in  cases  of  sudden  death,  which  are  by  no  means  uncommon 
during  the  disease,  we  have  some  sudden  disturbance  of  the  vagus  brought 
about  by  means  of  its  cardiac  branches. 

The  prognosis  in  all  cases  of  post-diphtheritic  paralysis  is  quite  favor- 
able. Myocardial  weakness  tends  to  supervene  as  a  sequel.  It  is  evi- 
denced by  the  sudden  accession  of  pallor,  nausea,  sometimes  by  vomit- 
ing, and  also  by  weak  heart-sounds  and  a  feeble,  broken,  irregular 
pulse,  etc. 

Diagnosis. — The  diagnosis  of  a  pharyngeal  diphtheria  (the  usual 
typical  form)  is  not  difficult  if  an  epidemic  be  prevailing.  The  false 
membrane  on  the  fauces  and  the  presence  of  albumin  in  the  urine  give 
us  a  practically  certain  diagnosis.  From  follicular  tonsillitis  we  differ- 
entiate diphtheria  by  the  seat  of  the  membrane,  that  of  the  former  being 
in  the  tonsils,  while  diphtheritic  membrane  is  over  the  tonsils  and  over  the 
soft  palate.  Moreover,  in  follicular  tonsillitis  the  fever  is  high,  the  onset 
is  sudden,  and  it  is  most  usually  associated  with  gastric  disturbance. 
Albuminuria  is  generally  present  in  diphtheria,  while  it  is  present  in  fol- 
licular tonsillitis  in  exceptional  cases  only.  The  histories  of  the  two  cases 
are  quite  different.  A  mild  case  of  diphtheria  in  a  house  may  be  fol- 
lowed by  a  malignant  one.  Moreover,  mild  cases  may  not  present  albu- 
minuria, and  fail  to  show  the  presence  of  albumin  until  later  in  the 
disease.  In  many  cases  clinical  distinctions  will  entirely  fail  us,  it 
being  uncertain  whether  or  not  the  case  is  one  of  mild  diphtheria. 
The  only  unequivocal  evidence  of  the  disease  is  the  finding  of  the 
Klebs-Loffler  bacillus  in  the  membrane.  In  many  instances  of  so- 
called  diphtheroid  lesions  the  membrane  is  only  formed  by  strepto- 
coccus pyogenes  (^membranous  angina),  and  these  cases  are  sometimes 
of  an  intense  grade. 

Grou'pous  or  membranous  angina  may  offer  some  difficulty ;  yet  in 
this  disease  there  is  no  tendency  to  spread  to  the  nasal  mucous  membrane 
or  to  the  larynx  ;  there  is  a  diminished  glandular  enlargement ;  there  is 
no  albumin,  and  the  onset  is  more  sudden. 

Diphtheria  frequently  is  associated  with  a  rash,  rendering  it  difficult 
to  distinguish  the  condition  from  scarlet  fever ;  but  in  diphtheria  the 
rash  is  more  truly  an  erythema,  while  in  scarlet  fever  it  consists  of  slightly 
raised  points  between  which  there  may  be  an  erythematous  condition. 
The  glandular  swelling  and  sloughy  condition  of  the  throat,  however, 
closely  resemble  diphtheria,  and  a  positive  diagnosis  without  a  bacteri- 
ologic  examination  is  often  impossible.  An  immediate  recognition  of  the 
disease  is  often  possible  from  a  smear-preparation  of  the  exudate  from  the 
throat  (see  Fig.  19),  the  Klebs-Loffler  bacilli  being  present  in  sufficient 
numbers  to  be  readily  distinguished  by  the  microscopist.  Park,  who  has 
had  a  rare  experience  with  this  affection,  makes  the  following  statement : 
"■  The  examination  by  a  competent  bacteriologist  of  the  bacterial  growth 
in  the  blood-serum  tube,  which  has  been  properly  inoculated  and  kept 
fourteen  hours  at  the  body-temperature,  can  be  thoroughly  relied  upon  in 


188  .  INFECTIOUS  DISEASES. 

cases  in  which  there  is  a  visible  membrane  in  the  tnroat  if  the  culture  is 
made  during  the  period  in  which  the  membrane  is  forming,  and  no  anti- 
septic, especially  no  mercurial  solution,  has  lately  been  applied.  In  cases 
in  which  the  disease  is  confined  to  the  larynx  or  bronchi,  surprisingly 
accurate  results  can  be  obtained  from  cultures,  and  although,  in  a  certain 


Fig.  19.— 1,  A  tube  of  blood-serum  ;  2,  a  sterilized  cottou  swab  in  test-tube. 
Rub  the  swab  gently  but  freely  against  the  visible  exudate,  aud  without  laying  it  down,  after 
withdrawing  the  cotton  plug  from  the  culture-tube,  insert  it  into  the  latter,  and  rub  that  portion 
which  has  touched  the  exudate  gently  but  thoroughly  over  the  surface  of  the  blood-serum  with- 
out breaking  its  surface.  Now  replace  the  swab  in  its  own  tube,  plug  both  tubes,  and  place  them 
in  the  box  provided  by  the  liealth  officials.  This  is  to  be  sent  to  the  bacteriologic  expert.  In 
laryngeal  diphtheria  the  swab  is  to  be  passed  far  back  and  rubbed  freely  against  the  mucous 
membrane  of  the  pharynx  and  tonsils. 

proportion  of  cases,  no  diphtheria  bacilli  will  be  found  in  the  first,  yet 
they  Avill  be  abundantly  present  in  later  cultures.  We  believe,  therefore, 
that  absolute  reliance  for  a  diagnosis  carnot  be  placed  upon  a  single  cul- 
ture from  the  pharynx  in  purely  laryngeal  cases. "  When  a  bacteriologic 
examination  cannot  be  made  the  practitioner  must  regard  as  suspicious 
all  forms  of  throat-affections  in  children,  and  carry  out  measures  of  isola- 
tion and  disinfection.  In  this  way  alone  can  serious  errors  be  avoided. . 
Mistakes  do  not  usually  occur  in  a  more  pronounced  membranous  sore 
throat,  but  in  the  lighter  types,  many  of  which  are  in  reality  due  to  the 
Klebs-L()ffler  bacillus  (Osier). 

Prognosis. — Diphtheria  is  at  the  same  time  the  most  prevalent  and 
most  fatal  of  all  the  diseases  with  Avhich  the  general  practitioner  has  to 
deal.  The  mortality  is  enormous  (30  to  40  per  cent.),  though  it  differs 
widely  in  different  epidemics,  and  the  most  fatal  variety  is  un(iuestion- 
ably  the  laryngeal.  In  laryngeal  diphtheria  the  mortality  may  be  as 
high  as  75  per  cent.,  and  the  younger  the  child  the  more  unfavorable 
the  prognosis,  the  strong  and  healthy  seeming  to  share  the  same  fjj.te  as 
the  weakly.  Of  especially  unfavorable  prognosis  are  those  cases  that 
show  large  quantities  of  albumin  in  the  urine,  general  adenitis,  cervical 
glandular  enlargement,  excessive  nasal  discharge,  a  necrotic  state  of  tlie 
throat,  vomiting,  and  partial  or  complete  suppression  of  the  urine.  Al- 
though the  temperature  in  diphtheria  is  never  very  high,  yet  a  sudden 
fall  of  temperature  to  subnormal  and  an  irregular  pulse,  or  bradycardia, 
are  also  a  bad  augury.  Recovery  from  a  severe  attack  in  which  there 
are  extreme  depression  and  much  albumin  is  unusual,  especially  in  a 
child  under  six  years  of  age,  though  recovery  takes  place  frequently  in 
what  would  be  regarded  as  hopeless  cases.  The  results  of  Morse's  ex- 
tensive observations  are  opposed  to  those  of  Bouchut  and  Dulinsay,  who 
claim  that  the  degree  of  leukocytosis  is  of  prognostic  value  (see  p.  180). 
The  cases  of  neuritis  invariably  recover.     A  child  who  has  had  diph- 


DIPHTHERIA.  189 

theria  once  is  most  likely  to  contract  it  again,  and  if  he  recovers  is 
liable  to  suffer  from  its  effects  for  years. 

The  causes  of  death  in  diphtheria.,  in  their  order,  are  as  follows : 
membranous  croup  or  laryngeal  diphtheria ;  septic  infection,  which 
may  be  a  slow  death  ;  sudden  heart-failure — paralysis  of  the  heart ; 
broncho-pneumonia,  following  tracheotomy  or  occilrring  during  con- 
valescence. 

Treatment. — Prophylaxis. — The  best  preventive  measures  against 
diphtheria  are  a  clean  nose  and  mouth.  Insist  upon  a  careful  toilet  of 
the  nose  in  all  children.  The  slightest  appearance  of  a  coryza  must  be 
overcome  at  once  by  the  use  of  a  mild  antiseptic  wash ;  all  accumulations 
of  crusts,  dust,  dried  blood,  etc.  should  be  removed  from  the  nose  twice 
daily,  especially  in  children  attending  school  or  during  the  prevalence  of 
an  epidemic.  The  child  should  be  early  taught  to  employ  a  small  anti- 
septic gargle  as  a  daily  routine,  using  a  weak  solution  of  hydrogen  dioxid, 
listerin,  or  even  a  mild  dilution  of  alcohol.  The  teeth  should  be  care- 
fully cleaned  daily,  and  all  decaying  teeth  should  be  filled  or  removed. 
If  it  is  true,  as  one  authority  claims,  that  over  two  hundred  different  spe- 
cies of  bacteria  find  a  happy  home  in  the  oral  cavity,  this  fact  should 
make  all  parents  attentive  to  the  proper  physiologic  condition  of  the 
mouths  of  their  children. 

All  cases  of  sore  throat  should  be  examined  for  the  Klebs-Lbfiier  bacil- 
lus, and,  if  it  is  found,  the  individual  should  be  isolated ;  and  all  cases 
of  diphtheria  should  be  kept  isolated  until  the  membrane  has  disap- 
peared from  the  nose  and  throat.  This  is  especially  true  in  schools  and 
asylums.  Moreover,  the  throats  of  all  persons  exposed  to  this  disease, 
and  of  those  caring  for  diphtheritic  patients,  should  be  frequently  ex- 
amined for  the  Klebs-Loffler  bacillus,  and  if  it  be  found  the  person  should 
receive  immunizing  doses  of  antitoxin.  The  fact  that  the  Klebs-Loffler 
bacilli  when  found  in  healthy  throats  may  not  be  active  is  no  argument 
against  isolation,  because  it  is  well  known  that  if  the  same  germs  were  to 
find  such  favorable  soil  as  a  broken  or  catarrhal  membrane  they  would 
rapidly  develop.  The  seed  being  there,  the  soil  only  requires  prepara- 
tion for  its  reception. 

An  unrecognized  feature  in  the  prophylactic  treatment  of  the  disease 
is  seen  in  the  uncertain  period  of  convalescence.  It  frequently  hap- 
pens that  long  after  all  membrane  has  disappeared  active  bacilli  may 
still  cling  to  the  throat.  This  condition  may  continue  from  two  to  six 
months,  and  even  longer  in  deeply  fissured  tonsils  ;  and  the  disease  may 
be  communicated  by  such  throats  in  the  act  of  kissing  young  children  or 
adults  with  sensitive  throats  or  with  a  broken  mucous  membrane  of  the 
mouth.  For  this  reason  the  indiscriminate  kissing  of  youngs  children  on 
the  lips  should  be  interdicted  by  the  physician. 

Sufficient  importance  has  not  been  been  given  to  the  milder  cases  of 
diphtheria  as  to  their  isolation  and  disinfection,  and  this  fact  explains  the 
occurrence  of  many  house-epidemics. 

Treatment  of  the  Attack. — The  treatment  falls  very  naturally  under  sev- 
eral departments :  (a)  the  hygienic  measures  to  limit  the  diffusion  of  the  dis- 
ease ;  (h)  the  local  management  of  the  throat  to  destroy  early  the  toxic 
germs ;  (c)  medication  to  antagonize  the  effect  of  the  toxins,  and  event- 
ually to  overcome  the  complications  and  sequelae. 


190  INFECTIOUS  DISEASES. 

(a)  Hygienic  Treatment. — The  patient  should  be  in  a  room  well  ex- 
posed to  sunlight  and  fresh  air,  as  diphtheritic  germs  grow  well  in  poorly- 
liorhted  and  damp  chambers.  No  stationary  Avashstand  should  be  allowed 
in  the  room,  and  Goodhart  well  says  that  many  cases  seem  to  have  their 
origin  in  the  proximity  to  foul-smelling  drains.  The  physician  should 
never  consent  to  be  responsible  for  the  recovery  of  a  patient  in  a  room  in 
which  there  is  a  washstand  with  its  uncertain  connection  with  the  main 
sewer.  If  possible,  the  patient  should  use  two  connecting  rooms,  one 
durincr  the  day  and  the  other  at  night,  so  that  one  while  not  in  use  may 
be  thoroughly  aired  and  disinfected.  Even  in  mild  cases  the  patient 
should  be  kept  in  bed  throughout  the  attack,  and  in  more  severe  cases 
also  for  some  time  during  convalescence.  This  is  especially  important 
when  there  have  been  symptoms  of  cardiac  depression  during  the  acute 
staf^e.  The  general  comfort  of  the  patient  is  enhanced  by  two  daily 
sponge  baths  of  tepid  salt-water  or  of  alcohol  and  water. 

Feeding. — Nursing  infants  may  be  fed  on  breast-milk  obtained  by  a 
breast-pump,  but  should  not  be  placed  at  the  mother's  breast  (Holt). 
The  feedings  should  be  regular,  yet  lighter  in  quality  and  quantity  than 
in  health,  remembering  the  tendency  to  vomit  in  all  acute  febrile  affec- 
tions, and  the  fact  that  gastric  disturbance  is  closely  associated  with  diph- 
theria. The  rule  must  be,  less  solids  and  more  fluids  than  in  health. 
Milk  in  some  form  being  our  main  dependence,  it  should  usually  be 
diluted,  and  for  young  children  partially  if  not  wholly  peptonized.  The 
greatest  difficulty  comes  in  the  latter  part  of  the  disease,  when  the  child 
is  septic  and  most  likely  has  a  strong  objection  to  be  disturbed.  At  this 
time  vomiting  is  most  easily  provoked,  and  swallowing  is  rendered  very 
difficult  on  account  of  the  swelling  and  pain.  We  must  not  neglect  the 
feedinw  even  if  it  does  cause  discomfort,  and  here  forced  feeding  by 
means  of  ravage  is  most  valuable.  Gavage  is  more  desirable  and  likely 
to  be  more  successful  with  children  under  three  years  than  rectal  alimen- 
tation. In  older  children,  who  object  to  the  tube  through  the  mouth,  it 
may  be  passed  through  the  nose  with  very  little  difficulty,  and  gavage  by 
this  route,  even  in  intubated  cases,  will  be  extremely  satisfactory.  Con- 
centrated broths,  meat-juice,  and  even  milk-punch  or  raw  eggs,  may  be 
given  in  this  way. 

(/')  Medicinal.' — Alcohol  no  longer  holds  a  debatable  ground  in  the  treat- 
ment of  diphtheria  :  it  is  the  most  powerful  drug  in  our  possession  to  off- 
set the  ravages  of  the  disease  on  the  nervous  centers  and  for  the  control 
of  the  circulation.  Stimulation  should  be  commenced  as  soon  as  there  is 
a  reasonable  certainty  as  to  the  correctness  of  the  diagnosis,  and  by  com- 
mencing early  with  whiskey  or  brandy  we  may  prevent  the  depressing 
effects  of  the  jpoison  of  diphtheria  as  seen  in  the  pulse  and  general  con- 
dition of  the  child.  The  indications  for  alcohol  are  marked  prostration, 
feeble  pulse,  and  a  weak  first  sound  of  the  heart.  The  quantity  must  be 
adjusted  to  the  age  and  gastric  condition  of  the  child,  and  usually  one 
ounce  (32.0)  of  good  whiskey  or  brandy,  well  diluted,  in  twenty-four 
hours  is  sufficient  for  a  child  four  years  old.  In  very  bad  cases  five  or 
six  times  this  quantity  may  be  given,  the  only  limit  being  the  tolerance 
of  the  stomach.  As  n  rule,  the  stimulant  should  be  mingled  with  the 
food,  as  the  child  may  rebel  against  taking  both  food  and  stimulant. 

Strychnin  stands  next  to  alcohol  in   importance  in  the  treatment  of 


DIPHTHERIA.  191 

diphtheria,  and  usually  it  is  given  in  too  small  doses.  For  a  child  four 
years  old  gr.  ^  (0.0021)  may  be  given  every  six  to  eight  hours,  and 
may  be  administered  in  little  tablets  by  the  mouth  or  hypodermically. 

Digitalis  does  not  hold  an  important  place  in  the  heart-weakness  of 
diphtheria,  and  yet  it  is  strongly  indicated  on  theoretic  grounds.  Clinic- 
ally, it  has  been  found  to  have  an  unfavorable  action  on  the  stomach 
before  its  good  influence  can  be  had  on  the  heart  itself.  The  same  may 
be  said  of  camphor  and  ammonium  carbonate.  The  aromatic  spirits  of 
ammonia  is  valuable  for  rapid  effects  in  syncopal  attacks.  In  cases  of 
threatened  heart-paralysis  occurring  late  in  the  disease  Holt  has  found 
nothing  so  valuable  as  morphm  employed  hypodermically,  the  drug  being 
given  in  full  doses  and  repeated  every  two  hours,  keeping  the  child  under 
its  influence  for  some  days. 

Internal  medication  should  be  avoided  until  absolutely  necessary,  and 
such  symptoms  as  vomiting  or  diarrhea  are  to  be  met  with  sufficient  treat- 
ment only  for  their  control. 

{c)  Local  Treatment. — For  the  direct  attack  upon  the  membrane  in  the 
throat  nearly  all  the  remedies  of  the  Pharmacopeia  have  been  used.  Garg- 
ling, swabbing,  painting,  spraying,  and  washing  the  throat  out,  all  have 
their  advocates,  and  every  physician  has  his  fevorite  remedy  or  combi- 
nation. And,  as  all  adult  pharyngeal  diphtheria  tends  to  recovery,  it 
would  seem  reasonable  that  this  form  of  treatment  should  not  be  neglected  ; 
yet  since  the  acceptance  of  the  antitoxin  treatment  medical  opinion  has 
suffered  a  decided  change,  especially  as  to  the  importance  of  local  meas- 
ures. The  very  best  local  application  for  pharyngeal  or  nasal  diphtheria 
consists  of  hydrogen  dioxid,  diluted  one-sixth,  and  used  both  as  a  gargle 
and  spray  as  most  convenient ;  this  is  usually  sufficient  in  the  early  stage. 
The  tincture  of  iron  and  glycerin  is  a  valuable  local  remedy  applied  by 
means  of-  a  swab.  The  object  of  local  treatment  is  a  more  thorough 
cleanliness — the  prevention  of  systemic  absorption  of  the  ptomains. 
Hence  a  careful  toilet  of  the  nose  and  throat  is  important  in  pre- 
venting the  spread  of  the  disease.  This  part  of  the  work  is  more 
easily  directed  than  accomplished,  especially  in  rebellious  children, 
and  we  have  frequently  felt  that  new  lesions  were  created  in  the  mucous 
membrane  of  the  nose  and  throat  by  an  undue  ardor  in  making  applica- 
tions. To  avoid  new  lesions  the  spray  alone  should  be  used,  and  for  the 
nose  boric-acid  solutions  or  hydrogen  dioxid,  1 :  10,  will  be  most  service- 
able. In  this  work  the  utmost  tact  and  kindness  must  be  maintained,  for 
it  is  truly  pitiable  to  force  a  struggling  child,  endangering  the  strength 
to  accomplish  so  little.  Warm,  weak  solutions,  most  thoroughly  applied 
by  means  of  the  fountain  syringe,  will  be  better  than  the  more  frequent 
use  of  the  hand-syringe.  In  older  children  who  will  use  it  a  gargle  of 
boric  acid,  listerin,  or  Dobell's  solution,  well  diluted,  may  be  used  to  keep 
the  nose  and  mouth  clean. 

In  laryngeal  diphtheria  the  child  should  inhale  an  atmosphere  laden 
with  the  vapor  of  slaking  lime,  or,  whenever  practicable,  an  atmosphere 
saturated  with  Loffler's  solution  (m.enthol  10  grams,  dissolved  in  sufficient 
toluol  to  make  36  c.c,  liq.  ferri  sesquichlorid,  4  c.c,  absolute  alcohol, 
60  c.c).  J.  Cordin  warmly  recommends  mercurial  fumigation  for  the 
relief  of  laryngeal  stenosis.  The  development  of  the  signs  of  actual 
stenosis,  as  shown  by  stridulous  breathing,  cyanosis,  etc.,  furnishes  an 


192 


INFECTIOUS  DISEASES. 


indication  for  either  intubation  or  tracheotomy.  According  to  my 
observations,  the  results  of  intubation  have  been  quite  favorable,  and 
I  would  strongly  recommend  a  trial  of  this  procedure  before  resorting 
to  tracheotomy  (see  temperature-chart.   Fig.   20). 


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[d)  External  Applications. — External  applications  to  the  throat  have  no 
effect  on  the  course  of  the  disease.  They  are  useful,  however,  in  relieving 
the  pain  and  the  swelling  in  the  lymph-glands.  Careful  massage  of  the 
neck  with  camphorated  oil,  as  hot  as  the  skin  will  tolerate,  is  very  sooth- 
ing ;  and  soap  liniment  may  be  used  in  the  same  way,  or  if  much  pain 
exists  chloroform  liniment  may  be  substituted.  Poulticing  for  the  relief 
of  pain  is  not  desirable,  as  it  seems  to  favor  suppuration.  In  older  chil- 
dren the  ice-bag  has  be.cn  used  with  good  effect,  and  it  soon  brings  grate- 
ful relief  from  the  tension  and  subdues  inflammation.  All  manipulations 
about  the  child,  however,  should  be  carried  on  as  gently  as  possible,  so 
that  its  rest  may  not  be  disturbed. 

Serum-therapy ;  the  Antitoxin  Treatment. — This  has  now  passed  be- 
yond the  stage  of  uncertainty  and  experimentation,  and  must  be  regarded 
as  one  of  the  most  positive  advances  made  in  practical  medicine.  Its 
utility  rests  upon  the  discovery  that  animals  may  be  rendered  immune  to 
diphtheria,  and  that  the  blood  of  an  animal  so  treated,  when  introduced 
into  another  animal,  protects  the  latter  from  infection  by  the  diphtheria 
bacilli.  The  studies  of  Behring,  Roux,  Kitasato,  and  others  have  demon- 
strated that  the  use  of  the  blood-serum  of  the  lower  animals,  artificially 
rendered  immune  against  diphtheria,  has  a  powerful  healing  influence 
upon  diphtheria  that  has  been  contagiously  or  spontaneously  acquired  by 
man.  These  experiments  were  first  published  in  December,  1890.  The 
principle  was  first  shown  to  be  true  of  tetanus,  and,  late  in  1892,  Behring 
further  showed  that  the  blood  of  an  immunized  animal  had  the  power 


DIPHTHERIA.  193 

both  of  protecting  and  of  curing  susceptible  animals  which  had  been  in- 
oculated either  with  the  toxins  or  the  bacilli  of  diphtheria.  In  preparing 
the  blood-serum  it  is  very  desirable,  of  course,  to  have  a  uniform  strength 
or  standard.  One-tenth  of  one  cubic  centimeter  of  what  Behring  calls 
his  normal  serum  will  counteract  ten  times  the  minimum  of  diphtheria 
poison,  fatal  for  a  guinea-pig  weighing  three  hundred  grams.  One  cu- 
bic centimeter  of  this  normal  serum  he  calls  an  antitoxin  unit.  The 
serum  prepared  by  his  method  is  labelled  in  three  strengths.  No.  I.  is 
sixty  times  the  strength  of  the  normal  serum  ;  No.  II.  is  one  hundred 
times  as  strong ;  and  No.  III.  is  one  hundred  and  forty  titoes  as  strong. 
To  a  child  of  two  years  or  over  not  less  than  800  or  1000  units  should 
be  administered  at  the  first  dose  ;  hence  solution  No.  I.  is  rarely  employed 
at  the  present  day.  Should  a  favorable  result  not  be  attained,  then,  on 
the  following  day,  1500  to  2000  units  should  be  administered,  and  a  third 
dose  after  a  similar  interval  if  necessary.  The  latter  dose  should  be  em- 
ployed at  the  outset  in  very  severe  cases  and  in  those  not  seen  until  they 
are  far  advanced.  The  sites  to  be  selected  for  injection  are  various.  In 
very  young  children  either  the  buttock  or  thigh  is  to  be  preferred,  while 
in  older  children  the  flanks  or  subscapular  spaces  may  be  chosen  as  well. 
The  injections  should  be  made  deeply  into  the  subcutaneous  cellular 
tissue. 

In  fortunate  cases  the  influence  of  the  serum  soon  becomes  apparent. 
Within  twenty-fouji^hours  the  faucial  swelling  diminishes,  the  membrane 
exfoliates,  the  temperature  falls,  the  pulse  becomes  slower  and  stronger, 
and  the  general  condition  of  the  patient  quickly  improves.  In  cases  of 
moderate  severity  and  when  injections  are  employed  early  the  improve- 
ment in  the  throat  and  the  constitutional  symptoms  is  very  decided ;  and 
the  earlier  the  case  comes  under  treatment  the  better  are  the  results. 
There  are,  however,  many  cases  of  great  severity  in  which  the  antitoxin 
has  been  used  early,  and  yet  has  not  shown  any  benefit. 

A  danger  in  serum-therapy  may  be  the  development  of  local  abscesses, 
which,  if  full  antiseptic  precautions  be  taken,  must  be  rare  indeed.  I 
have  escaped  them  altogether.  Certain  skin-eruptions  have  been  observed 
after  injections,  mostly  urticarial,  though  sometimes  scarlatiniform.  The 
latter  form  has  given  rise  to  apprehensions  of  scarlatina.  Widerhofer 
had  one  case  which  was  isolated  as  measles,  but  never  developed  any 
symptoms  other  than  the  suggestive  eruption.  Rarely,  joint-pains  and 
swellings,  with  general  prostration,  supervene.  Two  fatal  cases  have 
been  reported — one^  that  of  a  healthy  boy  five  years  old,  the  result  of  an 
injection  of  Behring's  fresh  serum  as  a  preventive,  dying  within  five 
minutes ;  the  other  occurred  in  Berlin.^ 

For  establishing  immunity  in  subjects  exposed  to  infection  the  injec- 
tion of  60  units  (1  cubic  centimeter  of  the  No.  I.  serum)  afi'ords  pro- 
tection. In  order  to  arrest  the  development  of  the  disease  during  the 
period  of  incubation  100  units  (1  cubic  centimeter  of  No.  11.  serum)  is 
probably  sufficient. 

A  large  number  of  preparations  are  on  the  market,  many  of  which 
are  good,  yet  great  caution  must  be  exercised  in  their  selection. 

The  use  and  value  of  antitoxin  in  private  practice  are  best  shown  in 


*  Journal  of  the  American  Medical  Association,  April  4,  1896. 
2  Medical  News,  April  18,  1896. 


13 


194  INFECTIOUS  DISEASES. 

the  following  summary  of  the  report  of  the  American  Pediatric  Society's 
investigation  of  the  subject: 

1.  The  report  includes  returns  from  615  physicians.  Of  this  number 
more  than  600  have  pronounced  themselves  as  strongly  in  favor  of  the 
serum-treatment,  the  great  majority  being  enthusiastic  in  their  advo- 
cacy. 

2.  The  cases  included  have  been  drawn  from  localities  widely  sepa- 
rated from  each  other,  so  that  any  peculiarity  of  local  conditions  to  which 
the  favorable  reports  might  be  ascribed  must  be  excluded. 

3.  The  report  includes  the  record  of  every  case  returned,  except  those 
in  which  the  evidence  of  diphtheria  was  clearly  questionable.  It  will 
be  noted  that  doubtful  cases  that  recovered  have  been  excluded,  while 
doubtful  cases  that  were  fatal  have  been  included. 

4.  No  new  cases  of  sudden  death  immediately  after  injection  have 
been  returned. 

5.  The  number  of  cases  injected  reasonably  early,  and  in  which  the 
serum  appeared  not  to  influence  the  progress  of  the  disease,  Avas  but  19, 
these  being  made  up  of  9  cases  of  somewhat  doubtful  diagnosis,  4  cases 
of  diphtheria  complicating  measles,  and  3  malignant  cases  in  which  the 
progress  was  so  rapid  that  they  had  passed  beyond  any  reasonable  pros- 
pect of  recovery  before  the  serum  was  used.  In  2  of  these  the  serum 
was  of  uncertain  strength  and  of  doubtful  value. 

6.  The  number  of  cases  in  which  the  patients  app(>ared  to  have  been 
made  worse  by  serum  was  3,  and  among  these  there  is  only  1  case  in 
which  the  result  may  be  fairly  attributed  to  the  injection. 

7.  The  general  mortality  in  the  5794  cases  reported  Avas  12.3  per 
cent.,  and,  excluding  all  cases  moribund  at  the  time  of  the  injection  or 
dying  within  twenty-four  hours,  it  Avas  8.8  per  cent. 

8.  The  most  striking  improvement  Avas  seen  in  cases  that  Avere  injected 
during  the  first  three  days.  Of  4120  such  cases  the  mortality  Avas  7.3 
per  cent.,  and,  excluding  cases  moribund  at  the  time  of  the  injection  or 
dying  within  twenty-four  hours,  it  was  4.8  per  cent. 

9.  The  mortality  in  1448  cases  injected  on  or  after  the  fourth  day 
was  27   per  cent. 

10.  The  most  convincing  argument,  and,  to  the  minds  of  the  com- 
mittee, an  absolutely  unanswerable  one,  in  favor  of  serum-therapy  is 
found  in  the  results  obtained  in  the  1256  laryngeal  cases  (membranous 
croup).  In  one-half  of  these,  in  a  large  proportion  of  which  the  symp- 
toms Avere  severe,  recovery  took  place  Avithout  operation.  Among  the 
533  in  which  intubation  Avas  performed  the  mortality  was  25.9  per  cent., 
or  less  than  half  as  great  as  has  ever  been  reported  by  any  other  form  of 
treatment. 

11.  The  proportion  of  cases  of  broncho-pneumonia  (5.9  per  cent.)  is 
very  small,  and  in  striking  contrast  to  results  published  from  hospital 
sources. 

12.  As  against  the  tAvo  or  three  instances  in  Avhich  the  serum  is  be- 
lieved to  have  acted  unfavorably  upon  the  heart  might  be  cited  a  large 
number  in  which  there  Avas  a  distinct  improvement  in  the  heart's  action 
after  the   serum  was  injected. 

13.  There  is  very  little,  if  any,  evidence  to  show  that  nephritis  Avas 
caused  in  any  case  by  the  injection  of  serum.     The  number  of  cases  of 


SEPTICEMIA.  195 

genuine  nephritis  is  remarkably  small,  the  deaths  from  that  source  num- 
bering but  15. 

14.  The  effect  of  the  serum  on  the  nervous  system  is  less  marked 
than  Upon  any  other  part  of  the  body  ;  paralytic  sequelae  being  recorded 
in  9.7  per  cent,  of  the  cases,  the  reports  going  to  show  that  the 
protection  offered  by  the  serum  is  not  great  unless  injections  are  made 
early. 


SEPTICEMIA. 


Definition. — A  disease  due  to  an  introduction  into  the  system  of 
the  products  of  putrefaction  (sapremia)  or  to  a  microbic  invasion  of  the 
blood  and  tissues  (true  septicemia),  with  or  without  the  presence  of  a 
local  seat  of  infection. 

Pathology. — After  death  the  body  putrefies  early.  The  macro- 
scopic changes  in  the  viscera  are  sometimes  few  and  often  wanting.  The 
muscles  present  a  brownish  color-tint.  The  pia  mater  is  generally  con- 
gested, and,  together  with  the  nerve-centers,  may  be  the  seat  of  ecchy- 
moses.  The  blood  is  dark  ("  tar-like  ") ;  its  coagulability  is  diminished, 
and,  microscopically,  it  shows  an  abundance  of  micrococci  and  bacilli. 
The  spleen  is  somewhat  softened  and  its  lymphoid  elements  more  dis- 
tinct, and  almost  invariably  ecchymoses  are  found  in  the, serous  mem- 
branes, especially  the  pericardium  and  peritoneum. 

In  protracted  septicemia  more  marked  alterations  exist,  and  among 
them  may  be  briefly  enumerated  the  following :  endocarditis  (rarely 
ulcerative) ;  gastro-intestinal  catarrh  (of  the  duodenum  and  rectum  in 
particular)  Avith  punctiform  extravasations ;  enlargement  of  the  lym- 
phatics and  spleen,  with  softening  of  the  latter ;  cloudy  swelling  of  the 
liver  (rarely  the  so-called  emphysema  of  the  organ  due  to  putrefaction) ; 
edema  and  catarrhal  inflammation  of  the  uriniferous  tubules ;  conges- 
tion, sometimes  associated  with  edema  of  the  lungs ;  and  inflamma- 
tion of  the  pleura,  pericardium,  and  peritoneum,  with  ecchymoses  and 
trivial  effusions. 

Microscopically,  the  internal  organs  shoAV  numerous  small  foci  of  in- 
flammation, some  of  which  may  be  the  seat  of  "coagulation-necrosis." 
Bacteria  are  found  in  abundance  in  various  situations,  such  as  the  exu- 
dations, the  capillaries  of  the  inflammatory  foci,  and  especially  in  the 
renal  glomeruli.  o 

Btiology. —Bacteriology. — Septicemia  is  due  to  micrococci  which 
Koch  has  shown  to  be  considerably  smaller  than  pus-cocci,  though  no 
one  form  of  bacterium  has  been  found  constantly  present  to  the  exclu- 
sion of  all  others.  Besser,  as  the  result  of  careful  experiments,  con- 
cludes that  septicemia  is  caused  solely  by  streptococci,  while  Rosenbach 
and  others  have  found  both  staphylococci  and  streptococci.  Doubtless 
in  many  instances  of  human  septicemia  the  clinical  manifestations  are 
due  partly  to  bacterial  poisoning  and  partly  to  septic  intoxication  with 
the  poisons  (ptomains)  developed  by  the  organisms,  and  the  ptomains 
probably  kill  the  patient  before  the  bacteria  can  propagate  themselves 
throughout  the  system.     Laboratory  experiments  teach  us  that  in  the 


196  INFECTIOUS  DISEASES. 

lower  animals  septicemia  can  be  produced  both  by  chemical  poisons  and 
by  bacterial  infection,  and  these  two  types  are  observed  in  human  beings. 
With  reference  to  the  bacterial  form  Warren  ^  states :  '-Whether  this 
process  is  caused  solely  by  the  multiplication  of  bacteria,  or  is  depend- 
ent in  part  upon  the  liberation  of  intensely  powerful  poisons,  or  is  due 
to  some  ferment-like  substance  capable  of  reproducing  itself  like  the 
poison  of  the  serpent,  as  are  diphtheria  and  tetanus,  much  more  ex- 
tensive studies  upon  the  human  subject  will  be  necessar}'  to  enable  us 
to  say." 

Modes  of  Infection  and  Introduction  of  the  Poison  into  the  System. — (1) 
Wounds,  either  surgical  or  the  result  of  injury,  with  which  we  have 
nothing  further  to  do  in  this  work.  Since  the  days  of  rigid  anti- 
septic precautions  this  mode  of  entrance  is,  comparatively  speaking, 
uncommon. 

(2)  Through  the  uterus,  following  labor,  miscarriage,  or  abortion. 
Generally  in  these  cases  there  are  accompanying  local  changes,  but  in  a 
few  the  poison  appears  to  pass  the  unguarded  portals  of  the  organ,  while 
the  latter  exhibits  nothing  abnormal. 

(3)  The  cases  in  which  the  poison  gains  entrance  into  the  body 
without  obvious  wounds  or  raw  surfaces  are  relatively  more  common. 
When  the  skin  is  quite  natural,  septic  infection  or  intoxication  can- 
not occur,  but  the  slightest  abrasion  or  cut,  bed-sore,  etc.  may  serve 
as  a  gate  of  admission.  These  slight  lesions  "  may  be  almost  com- 
pletely healed  by  the  time  the  severe  symptoms  of  the  disease  are 
developed  "  (Strlimpell). 

(4)  Mucous  membranes  often  admit  the  virus,  being  less  protective  in 
nature  than  the  skin.  The  numerous  bacteria — benign  and  pathogenic 
— that  are  constantlv  present  in  the  intestinal  canal  may  also  find  in 
local  lesions  (as  in  typhoid  fever,  dysentery,  etc.),  or  catarrhal  inflam- 
mation even,  points  of  lodgement  and  cause  a  systemic  infection.  To 
this  category  belongs  that  form  of  septic  infection  which  follows  gonor- 
rhea. The  so-called  cases  of  "spontaneous  septicemia"  are  also  usu- 
ally occasioned  by  absorption  from  the  mucous  surfaces. 

Rheumatic  or  septic  manifestations  often  follow  attacks  of  tonsillitis, 
and  it  is  probable  that  the  tonsils  are  more  frequently  points  of  en- 
trance for  the  organism  than  has  hitherto  been  supposed  (Wade,  Ban- 
natyne). 

(5)  "  Sepsis  Intestinalis." — ^^This  special  form  of  poisoning  is  caused 
by  canned  meats,  ice  cream,  sausages,  and  cheese.  Vaughan,  to  whom 
we  are  indebted  for  the  first  cVescription  of  ''sepsis  intestinalis,"  found 
in  cheese  a  ptomain  Avhich  he  named  tf/rotoxicon,  and  which  he  regarded 
as  the  active  agent  in  this  group  of  poisoning  cases.  The  symptoms  are 
due,  according  to  his  statement,  to  poisoning  by  chemical  substances, 
being  instances  of  sapremia  :  but  it  may  yet  be  found  that  the  intes- 
tinal micro-organisms  play  a  more  or  less  prominent  part  in  the 
process. 

(6)  Ogston^  recognizes  as  one  of  the  mildest  forms  of  sapremia  the 
sickness  and  nausea  produced  by  a  bad  smell,  which,  he  claims,  is  but 
a  ptomain  of  putridity  that  may,  under  certain  contingencies,  produce 
serious  symptoms.      On  the  other  hand,  persons  who  are  habitually  ex- 

^  Surgical  Pathology  and  Therapeutics,  p.  340.  ^  Warren,  loc.  cit,  p.  342. 


SEPTICEMIA.  ]  97 

posed  to  bad  odors  (workers  in  sewers,  in  the  dissecting-room,  etc.)  may 
acquire  a  considerable  degree  of  immunity  against  poisoning  of  this 
sort.  The  fever  in  these  cases  corresponds  in  severity  to  the  dose  of 
the  poison. 

(7)  Septicemia  may  be  associated  with  or  follow  osteomyelitis. 

Clinical  History. — (1)  Symptoms  of  Sapremia. — The  fact  that  this 
form  may  occur  without  bacterial  infection,  either  local  or  general,  must 
be  emphasized,. but  niore  frequently  there  will  be  either  local  infection  or 
putrefactive  changes,  with  the  production  of  a  grave  general  condition 
due  to  the  absorption  of  the  poisonous  chemical  products.  In  certain 
other  acute  infectious  diseases  (diphtheria,  tetanus,  typhoid  fever,  ery- 
sipelas, etc.)  the  general  symptoms  are  similarly  engendered.  Perhaps 
the  most  typical  examples  of  sapremia  seen  by  the  physician'  are  those 
due  to  tyrotoxicon  and  to  the  unaccustomed  inhalation  of  foul  odors. 
At  the  beginning  a  chill  may  occur,  but  this  is  more  generally  wanting. 
In  ^''sepsis  mtestinalis  "  marked  local  symptoms  may  initiate  the  attack, 
as  nausea,  vomiting,  colicky  pains,  diarrhea,  etc.,  and  in  all  forms  there 
\^  fever,  the  temperature  often  rising  rapidly  to  101°  or  103°  F.  (38.3°— 
39.4°  C.)  and  sometimes  higher.  Prostration  and  anemia,  particularly 
the  latter,  may  be  prominent  symptoms.  Microscopic  examination  of 
the  blood  generally  shoAvs  leukocytosis,  and  always  a  marked  reduction 
in  the  number  of  red  corpuscles. 

Sapremia  following  childbirth  is  a  most  typical  sub-variety,  and, 
apart  from  the  special  history,  the  symptoms  are  much  the  same  as  those 
above  detailed.  It  is  the  form  most  amenable  to  treatment,  the  removal 
of  the  cause  being  followed  by  a  rapid  disappearance  of  all  alarming 
symptoms. 

(2)  Symptoms  of  True  Septicemia. — There  is  an  incuhatio7i-^eY\o^  which 
is  of  variable  duration,  though  usually  averaging  several  days.  The 
onset  is  more  gradual  than  in  the  previous  variety,  and  is  rarely  marked 
by  a  chill.  Accession  o^ fever  following  surgical  procedures,  with  head- 
ache, anorexia,  prostration,  sometimes  vomiting  and  diarrhea,  and  espe- 
cially dulness  occasionally  amounting  to  mild  stupor,  announce  the 
affection  :  these  symptoms  should  also  excite  suspicion  in  the  absence 
of  obvious  causal  factors.  They  become  intensified,  and  now  the  attack 
may  closely  simulate  certain  other  infectious  diseases  (typhoid  fever, 
acute  miliary  tuberculosis,  ulcerative  endocarditis,  etc.),  the  clinical 
picture  as  outlined  presenting  nothing  characteristic.  There  are,  how- 
ever, more  or  less  distinctive  features,  which  will  be  considered  seriatim. 

(a)  The  Fever. — This  is  usually  of  the ' continued  tyj^e,  and  tends  to 
increase  in  degree,  fatal  cases  often  terminating  in  hyperpyrexia.  At 
the  beginning  the  temperature  may  rise  quite  rapidly,  and  in  some  cases 
it  may  even  be  subnormal.     Deep  morning  remissions  may  be  observed. 

{h)  The  Circulatory  System. — The  pulse  is  frequent,  and  near  the  end 
becomes  very  Aveak.  In  subacute  cases  characteristic  lesions  (endocar- 
ditis in  particular)  may  develop,  but  are  difficult  of  recognition,  since 
they  do  not,  as  a  rule,  give  rise  to  audible  murmurs  or  other  physical 
signs.  In  other  instances  soft  murmurs  may  be  heard,  but  it  is  indeed 
hard  to  discriminate  these  from  functional  sounds.  Moderate  leukocy- 
tosis is  sometimes  observed,  and  the  presence  of  micrococci  in  the  blood 
during  life  has  been  demonstrated. 


198  INFECTIOUS  DISEASES. 

{c)  Gastro-intestinal  System. — The  spleen  may  become  perceptibly 
enlarged,  and  gastro-enteritis  is  usually  present,  either  in  an  acute  form 
with  vomiting  and  fre([uent  serous  discharges  or  more  often  merely  with 
a  diarrhea  of  moderate  intensity  (septic  diarrhea). 

(d)  Cutaneous  Symptoms. — Punctiform  hemorrhages  into  the  skin  are 
of  prime  importance  in  the  diagnosis.  Occasionally  more  extensive 
ecchymoses  appear,  scarlatinal  eruptions  also  showing  themselves,  but 
these  are  less  characteristic.  Among  rare  appearances  herpes,  ,i'oseola, 
edematous  inflammations,  and  feint  jaundice  (aflFecting  the  skin  and 
conjunctivfe)  may  be  observed.  The  icterus  is  probably  due  to  disinte- 
gration of  the  red  blood-corpuscles  in  the  liver. 

[e)  Renal  Symptoms. — The  lesions  constitute  the  so-called  "■  septic 
nephritis,"  the  urine  often  containing  a  fair  amount  of  albumin,  epi- 
thelium,  tube-casts,   and  red  and  white  corpuscles. 

Diagnosis. — {a)  Sapremia  can  be  distinguished  by  the  history,  the 
immediate  appearance  of  the  symptoms,  their  character,  and  by  the 
prompt  effect  of  the  removal  of  the  exciting  cause.  The  diagnosis  often 
requires  a  most  careful  search  for  the  known  etiologic  factors,  though 
even  without  the  latter  we  can  sometimes  arrive  at  a  correct  conclusion 
by  a  careful  process  of  exclusion. 

(5)  True  Septicemia. — Here  the  existence  of  an  incubation  period,  the 
contiued  fever,  mental  apathy,  faint  jaundice,  splenic  enlargement, 
and  the  characteristics  of  septic  nephritis,  all  combine  to  form  a  well- 
defined  group  of  symptoms.  A  careful  blood-examination  should  be 
made  for  micrococci,  etc.,  and  cultures  should  be  undertaken  in  spon- 
taneous septicemia  and  associated  forms  {e.  g.  septico-pyemia).  The 
surgeon  should  look  to  the  condition  of  the  wound  if  one  is  present. 

Course  and  Prog:nosis. — The  course  may  be  brief,  virulent  at- 
tacks sometimes  terminating  fiitally  within  forty-eight  hours,  this  being 
especially  true  of  sapremia  when  the  dose  of  the  poison  is  large.  The 
gravity  of  the  case  in  the  latter  form  is  in  direct  proportion  to  the 
amount  of  virus  that  enters  the  system,  the  outlook  being  good  when 
the  cause  is  removable.  On  the  other  hand,  in  true  septicemia  this 
avails  nothing,  the  progression  tending  steadily  to  the  end.  The 
mildest  types  may,  in  rare  instances,  reach  a  favorable  end,  but  the 
effects  are  not  dependent  upon  the  dose,  and  the  minutest  quantity  may 
lead  to  specific  results  in  their  fullest  intensity.  It  must  not  be  for- 
gotten that  septicemia  may  pursue  a  chronic  course  in  which  the  symp- 
toms are  milder,  though  the  termination  is  very  generally  unfavorable, 
as  in  the  acute  variety. 

Treatment. — Of  first  importance  is  the  removal  of  the  cause  when- 
ever practicable,  this  part  of  the  treatment  often  falling  within  the 
domain  of  surgery.  The  physician  must  support  the  patient's  strength 
by  a  suitable  dietary  and  by  the  judicious  use  of  cardiac  stimulants ; 
the  former  should  consist  mainly  of  liquids  (milk,  egg-white,  meat-juice, 
etc.),  and  the  latter  of  alcoholics,  together  with  strychnin  and  am- 
monia. Of  medicines,  internal  antiseptics  (mercuric  chlorid,  creasote, 
etc.)  richly  deserve  a  trial,  though  striking  results  have  not  been 
obtained  from  their  employment.  The  fever  calls  for  antipyretics,  such 
as  quinin,  phenacetin,  acetanilid,  together  with  hydrotherapy.  Cardiac 
depressants,  as  acetanilid  and  phenacetin,  should  not  be  resorted  to, 


PYEMIA.  199 

however,  when  great  cardiac  asthenia  exists.  To  meet  the  renal  condi- 
tion the  free  use  of  water,  together  with  the  least  irritating  of  the  diu- 
retics, is  to  be  advised  and  encouraged.  The  other  internal  organs 
should  also  receive  careful  attention. 


PYEMIA. 

Definition. — A  disease  of  the  blood  invariably  associated  with  sup- 
puration, and  due  to  an  absorption  of  pyogenic  organisms. 

Pathology. — The  cadaver  does  not  undergo  putrefaction  as  early  as 
in  septicemia.  Briefly  considered,  the  pathologic  lesions  that  fall  within 
the  physician's  province  arrange  themselves  under  the  following  heads : 

(1)  Thrombosis  and  Embolism. — At  first  the  veins  leading  to  and  from 
the  seat  of  the  local  changes  from  which  pyemia  arises  contain  thrombi 
which  may  soften  into  a  puriform  material.  Thrombi  are  also  found 
frequently  in  the  lungs,  a  circulating  embolus  first  finding  lodgement  in 
the  pulmonary  artery  and  its  branches ;  they  may  be  present  in  the 
liver,  kidneys,  spleen,  cortical  substance  of  the  brain,  and  in  other 
localities. 

(2)  Abscesses. — These  so-called  metastatic  abscesses  are  set  up  by 
septic  emboli  or  result  from  the  thrombi  (chiefly  pulmonary  and  portal), 
and  are  found  in  the  various  internal  organs,  mainly,  perhaps,  in  the 
lungs,  liver,  spleen,  and  kidneys.  They  are  not  large,  but  may  coalesce 
and  form  cavities  of  the  size  of  an  apple.  The  kidneys  are  the  chief 
organs  of  elimination  in  this  disease,  and  hence  it  happens  that  numer- 
ous clumps  of  micrococci,  producing  miliary  abscesses,  are  frequently 
seen  in  the  regions  of  the  Malpighian  bodies.  Infarction  may  be  ob- 
served also.  There  are  many  other,  though  rarer,  seats  of  abscesses,  as 
the  muscles,  submucous  and  subcutaneous  tissues,  bones,  the  parotid 
gland,  brain  (cortical  portion),  ovaries,  and  testicles. 

(3)  Lesions  of  the  Skin  and  of  Mucous  and  Serous  Membranes. — At 
the  post-mortem  examination  hemorrhagic  extravasations  and  pustules 
are  often  visible  in  the  skin.  The  mucous  membrane  of  the  alimentary 
tract  is  rarely  afi"ected,  difi"ering  in  this  point  from  septicemia,  though 
occasionally  ulcers  may  be  noted,  and  most  commonly  in  the  stomach 
near  the  pyloric  orifice  (in  puerperal  cases)  and  in  the  large  bowel.  Prob- 
ably they  are  always  secondary  to  the  submucous  miliary  abscesses.  The 
serous  membranes  (pleura,  pericardium,  meninges  of  the  brain,  synovial 
membranes)  may  be  the  seat  of  purulent  inflammation  and  of  hemor- 
rhagic extravasations. 

(4)  Cardiac  Lesions. — Ulcerative  endocarditis  forms  the  chief  morbid 
lesion.  It  begins  in  the  form  of  small  nodular  vegetations  upon  the 
valves  (most  frequently  the  mitral),  which  disintegrate  and  leave  ulcers 
behind  [vide  Ulcerative  Endocarditis). 

Ktiology. — Bacteriology. — Experimental  investigations  have  shown 
conclusively  that  the  organisms  usually  responsible  for  this  condition  are 
the  staphylococcus  and  the  streptococcus.  Whether  the  former  or  the 
latter    be    the    agent    of    infection    in    the   given    case    depends    chiefly 


200  INFECTIOUS  DISEASES. 

upon  the  condition  of  the  tissues  at  the  starting-point,  especially  with 
reference  to  the  character  of  the  local  defensive  processes ;  also,  though 
to  a  lesser  extent,  the  degree  of  virulence  of  the  micrococci. 

Other  important  pyogenic  micro-organisms  are  the  gonococcus,  pneu- 
mococcus,  bacillus  pyocyaneus,  bacterium  coli  communis,  bacillus  tetra- 
genus,   and  many  of  the  specific  micro-organisms. 

Paths  of  Infection  of  the  Body. — (a)  Almost  always  the  entrance  is  by 
the  blood-vessels,  the  special  varieties  of  micrococci  that  cause  pyemia, 
reaching  the  veins  and  producing  thrombo-pblebitis.  Less  frequently  they 
reach  the  arteries  and  produce  thrombo-arteritis.  From  the  former  con- 
dition emboli  may  be  disseminated  throughout  the  system,  while  from 
the  latter  the  emboli  are  arrested  in  the  neighboring  capillaries  to  which 
the  tributaries  of  the  vessel  lead.  Micrococci  independently  of  emboli 
may  be  found  wandering  in  the  blood-stream. 

{b)  Another  path  of  entrance  is  the  lymphatic  system,  but  here  the 
cocci  meet  with  greater  forces  opposing  their  attempts  to  spread  than 
in  the  blood-vessels,  and  hence  it  is  a  much  rarer  mode  of  propaga- 
tion. 

[c]  In  spontaneous  lyyemia,  in  which  there  is  no  wound  to  act  as  a 
point  of  departure,  we  must  presuppose  the  existence  of  either  a  trivial 
lesion,  as  in  "  spontaneous  septicemia,"  or  an  area  of  lessened  resistance. 
The  latter  may  be  produced  by  inflammation,  by  a  contusion,  and  in 
other  ways,  and  all  that  seems  necessary  is  a  lowering  of  the  tone  of 
the  general  system  (Warren).  I  am  certain  that  ulcerative  endocarditis 
is  not  frequently  the  starting-point,  but  is  usually  secondary  to  foci  of 
inflammation  elsewhere,  as  claimed  by  Osier.  The  appendix  is  often 
the  primary  or  original  focus  in  this  category  of  cases,  micrococci  local- 
izing themselves  here  in  consequence  of  a  preceding  disturbance  of  the 
circulation  or  catarrhal  inflammation.  I  recollect  one  case  in  which  no 
original  abscess  was  found  at  the  post-mortem. 

Predisposing  Causes. — (a)  Epidemic  Injluence. — It  has  been  proved 
by  abundant  experience  that  certain  seasons  are  characterized  by  epi- 
demic outbreaks  of  the  disease. 

{}))  Cases  have  sometimes  been  noticeably  more  frequent  in  the  early 
months  of  the  year  (February  and  jNIarch)  than  in  other  seasons. 

(c)  Age  and  Sex. — Males  are  more  fre([ucntly  aifected  than  females, 
and  most  cases  occur  about  the  middle  period  of  life  or  at  the  time  of 
greatest  danger  from  traumatism. 

Clinical  History. — Incubation. — Tlie  disease  sets  in  from  a  week 
to  ten  days  after  the  reception  of  the  wound  or  even  earlier,  and  always 
develops  secondarily  to  suppuration  somewhere  in  the  body. 

A  most  conspicuous  symptom,  and  usually  the  first,  is  the  chill:  it 
may,  however,  be  preceded  for  a  variable  time  hy  fever  of  a  continued 
or  intermittent  type.  The  fever  of  pyemia  is  of  the  suppurative  type. 
Profound  prost7'ation  develops  early ;  the  skin  presents  an  icteroid 
appearance ;  and  gastro-intestinal  symptoms  may  appear,  but  are  not 
prominent.  The  signs  of  abscess  of  the  lung,  liver,  and  other  oi-gans 
may  develop  in  some  cases,  while  in  others  the  whole  clinical  picture 
is  colored  by  the  ill-defined   characters   of  ulcerative   endocarditis. 

(a)  The  Chill. — This  may  be  mild,  though  oftener  it  is  quite  severe. 
It  is  repeated  at  somewhat  irregular  intervals,  and  rarely  it  may  recur 


PYEMIA.  201 

several  times  on  the  same  day.  Chills  are  most  apt  to  occur  during  the 
daytime. 

(6)  The  Fever. — A  rapid  rise  of  temperature  accompanies  the  chill. 
The  fever-curve  is  of  the  irregularly  intermittent  or  profoundly  remit- 
tent type,  with  intervening  periods,  showing  slight  or  marked  variations, 
and  as  decided  deviations  may  occur  within  a  short  space  of  time,  a 
two-hour  record  should  be  kept.  The  temperature  rarely  falls  to  the 
normal  level ;  it  may  do  so,  however,  and  remain  there  for  one  or  two 
days.  To  explain  the  peculiarities  of  the  curve  in  this  disease  we  need 
only  recall  the  great  variety  of  pathologic  processes  before  noted. 
With  the  sharp  fall  of  temperature  siveating  occurs,  and  leaves  the 
patient  more  or  less  exhausted,  though  only  temporarily  so  as  a  rule. 

(c)  Respiratory  System. — Symptoms  referable  to  the  organs  of  respi- 
ration appear  early.  The  pulmonary  abscesses  are  usually  latent,  but 
may  give  rise  to  dyspnea,  cough,  and  occasionally  a  purulent  expectora- 
tion. Pain  is  present  if  they  are  superficially  located,  and  under  such 
circumstances  the  physical  signs  of  cavity  or  of  pleural  eifusion  may  be 
noted.  The  signs  of  'pneumonia  at  one  or  both  bases  may  also  develop, 
the  expectoration  now  becoming  rusty. 

{d)  Splenic  and  Hepatic  Symptoms. — The  foci  of  suppuration  in  the 
liver  are  difficult  of  recognition  unless  they  become  large  as  the  result 
of  coalescence  and  are  superficially  located  (see  article  Hepatic  Abscess). 
Splenic  infarction  may  also  be  safely  diagnosed  if  there  are  pain  and 
great  tenderness  (due  to  localized  peritonitis)  in  the  left  hypochondrium, 
with  progressive  enlargement  of  the  organ.  In  one  case  I  detected 
distinctly  crepitant  sounds  over  the  site  of  the  spleen  during  life. 

(e)  Cardio-vascular  Symptoms. — The  pulse  at  first  is  accelerated,  but 
moderately  full  and  regular;  later  it  becomes  exceedingly  rapid  and 
feeble.  Frequently  cases  in  which  ulcerative  endocarditis  develops  are 
apparently  of  spontaneous  origin.  (For  a  discussion  of  this  grave  con- 
dition the  reader  is  referred  to  the  description  of  endocarditis  in  the  sec- 
tion on  Diseases  of  the  Heart.)  Among  the  blood-appearances  during 
life  are  leuTcocytosis  and  a  rather  marked  reduction  in  the  red  corpus- 
cles, with  moderate  poikilocytosis.     The  blood-plaques  are  increased. 

(/)  Cutaneous  Symptoms. — The  most  prominent  is  a  mild  yet  decided 
grade  of  jaundice,  that  is  hepatogenous  (?)  in  nature.  Sweating  has 
already  been  alluded  to  as  a  symptom,  both  during  and  after  the  febrile 
paroxysms.  The  skin  finally  shrinks  from  emaciation.  Skin-eruptions 
are  common,  particularly  erythema,  purpura,  and  pustules,  and  the  gen- 
eral surface  is  often  decidedly  hyper  esthetic. 

{cf)  G-enito-urinary  Symptoms. — The  urine  is  concentrated  and  urates 
are  copiously  deposited.  There  is  albuminuria,  which  may  be  due  to 
the  pathologic  changes  or  may  be  ascribable  to  the  fever.  The  micro- 
scope discloses  the  presence  of  tube-casts,  micrococci,  pus-  and  (more 
rarely)  blood-corpuscles.     Albumose  has  been  found  in  the  urine. 

(A)  Nervous  Symptoms. — The  mind  generally  remains  unclouded  until 
an  advanced  stage  is  reached ;  then  delirium  sets  in,  and  is  followed  by 
a  terminal  coma.  '  Metastatic  purulent  meningitis,  with  its  usual 
symptoms  (hemiplegia,  strabismus,  ptosis,  deafness,  etc.),  may  appear  at 
any  period  of  the  disease. 

{%)  Symptoms  may  be  presented  by  the  joints  and  bones.     Metastatic 


202  INFECTIOUS  DISEASES. 

arthritis,  usually  suppurative,  is  a  not  unusual  concomitant,  and  in  some 
cases  it  is  combined  with  similar  involvement  of  the  long  bones.  An 
acute  osteomyelitis  may  be  the  only  ascertainable  source  of  the  pyemia. 

Septico-jyyewia — By  this  term  is  meant  the  combined  presence  of 
suppuration  and  a  general  intoxication  (septicemia).  The  symptoms  of 
pyemia  (recurrent  chills,  copious  sweats,  metastatic  abscesses,  and  early 
nervous  symptoms)  dominate  the  scene  in  the  majority  of  the  cases. 
Some  of  these  instances  pursue  a  comparatively  mild,  chronic  course. 

Differential  Diagnosis. — The  disease  is  often  confounded  with  malarial 
intermittent  fever,  the  distinctive  features  of  which  have  been  given 
under  the  differential  diagnosis  of  the  latter  disease,  but  a  diagnosis 
may  always  be  made  from  the  effect  of  quinin  upon  the  fever.  A  few 
points  of  contrast,  by  means  of  Avhich  septicemia  and  pyemia  may  be 
differentiated,  are  tabulated  below  : 

Pyemia.  Septicemia. 

Always  associated  with  suppuration.  Suppuration  may  be  absent,  but   there 

may  be  a  sloughing  wound. 

Multiple  chills.  ,  A  single  chill. 

Irregularly  intermittent  fever-curve.  Continued  type  of  curve. 

Profuse     sweats     accompanying    febrile  Absent. 

attacks. 

Rapid  emaciation  and  profound  prostra-  Less  marked. 

tion. 

Nervous    symptoms    usually    come     on  Earlier. 

late. 

Hyperesthesia.  Absent. 

Slight  jaundice.  Less  marked  (very  faint). 

Metastatic  abscesses.  Absent. 

Prognosis. — Pyemia  may  kill  after  an  illness  lasting  but  a  few 
days.  Un  the  other  hand,  it  may  become  more  or  less  protracted,  so 
that. a  chronic  form  has  been  distinguished.  In  this  variety  the  symp- 
toms are  milder  in  character,  and  the  tendency  to  the  formation  of 
metastatic  abscesses  is  not  as  great  in  the  acute  form.  Not  a  few  of  the 
more  chronic  cases  terminate  in  recovery. 

Treatment. — So  far  as  the  physician's  province  extends,  the  treat- 
ment is  identical  with  that  of  septicemia — i.  e.  to  maintain  the  strength. 
For  the  sweating  the  best  agents  are  aromatic  sulphuric  acid  and  atropin  ; 
the  latter  may  be  given  with  agaricin  (atropin,  gr.  y^ — 0.0005;  agaricin, 
gr.  I  to  i — 0.008  to  0.016).  at  bedtime.  Prompt  surgical  interference 
must  be  resorted  to.  not  only  with  a  view  to  asepsis  of  the  primary  wound, 
but  also  to  evacuating  the  primary  and  all  secondary  foci  of  su])puration. 
The  use  of  antistreptococcic  serum  has  led  to  immediate  improvement. 


ACUTE  ARTICULAR  RHEUMATISM. 

[Rheumatic  Fever.) 

Definition. — An  acute  febrile  disease,  the  exact  nature  of  which  is 
unknown,  though  it  is  probably  infectious.  The  chief  local  manifesta- 
tion is  a  multiple  arthritis,  and  its  chief  complications  are  cardiac  (endo- 
and  pericarditis).    Hueter  first  advanced  the  germ-theory  to  account  for 


ACUTE  ARTICULAR  RHEUMATISM.  203 

the  disease,  and,  although  the  specific  causal  agent  has  not  as  yet  been 
discovered,  this  view  is  the  only  one  that  ofi"ers  a  satisfactory  explana- 
tion for  the  production  of  the  lesions,  the  acute  onset,  the  clinical 
course,  and  the  complications  of  the  disease.  Kheumatic  fever  is  sub- 
ject to,  and  apparently  obeys,  the  laws  of  infectious  maladies  in  general, 
and  the  frequent  involvement  of  the  joints  in  many  diseases  belonging  to 
this  class  may  properly  be  regarded  as  supporting  this  theory.  The 
disease  is,  in  certain  localities,  endemic,  and,  according  to  some  writers, 
at  times  also  epidemic.  On  the  other  hand,  in  not  a  few  regions 
(especially  European)  it  is  practically  unknown.  Striimpell  points 
out  the  fact  that  in  Leipsic,  where  articular  rheumatism  is  one  of  the 
most  frequent  of  acute  diseases,  it  has  been  observed  for  years  that 
at  certain  times  there  are  only  a  few  cases,  while  at  others  there  is  a 
striking  increase  in  the  number. 

Pathology. — The  disease  does  not  show  peculiar  lesions,  and,  al- 
though the  joints  are  the  chief  seats  of  invasion,  still  in  many  instances, 
and  even  in  aggravated  cases,  the  changes  presented  are  slight  or  alto- 
gether wanting.  Usually  the  synovial  membranes  of  the  affected  joints 
are  injected  and  swollen,  and  their  surfaces  may  be  more  or  less  coated 
with  fibrin.  The  effusion  is  mainly  serous,  but  contains  fibrin  and  often 
leukocytes,  and  occupies  the  joints.  A  similar  exudate  infiltrates  the 
periarticular  tissues.  The  tendinous  sheaths  may  also  be  inflamed; 
the  cartilages  in  protracted  cases  may  become  eroded ;  and  rarely  a 
purulent  exudate  may  be  seen. 

Fatal  cases,  except  when  death  is  due  to  hyperpyrexia,  usually  show 
the  changes  peculiar  to  endocarditis,  pericarditis,  or  myocarditis,  and 
less  frequently  those  of  pneumonia  or  pleurisy.  The  fibrin-factors  of 
the  blood  are  augmented. 

Ktiology. — Bacteriology. — Guttmann,  Collin,  and  Sahli  have  found 
the  staphylococcus  in  the  articular  exudate  of  patients  suffering  from 
complicated  or  recurrent  cases  of  acute  articular  rheumatism,  and  Sahli 
is  inclined  to  include  the  disease  in  the  group  caused  by  this  organism. 
Netter,  however,  has  found  the  streptococcus,  and  Lang  a  peculiar 
bacillus.  Sino;er  has  examined  92  cases  bacteriolocficallv  and  discovered 
staphylococci  or  streptococci  in  the  majority  of  these  cases,  and  also 
post-mortem.  Pierre  Achalme^  has  described  an  organism  which  he 
found  in  the  blood  {Thiroloix  Achalrnii)  of  cases  of  rheumatism  with 
cerebral  complications.  It  is  a  bacillus  somewhat  resembling  that  of 
anthrax  ;  it  is  readily  stained  with  anilin-dyes  and  by  Grram's  method, 
and  is  anaerobic.  When  inoculated  into  guinea-pigs,  it  causes  inflamma- 
tions of  the  serous  membranes  characteristic  of  rheumatism.  Treboulet 
and  Covon^  suo-o-est  that  Achalme's  bacillus  is  associated  with  onlv  the 
severe  forms  of  rheumatism,  and  they  have  found  it  in  some  other  cases 
associated  with  a  diploeoccus,  which  latter  Avas  found  in  all  other  cases 
of  rheumatism  examined.  The  diplococcus  was  facultative,  anaerobic 
and  stained  by  Gram's  method.  They  believe  this  to  be  the  special 
organism  of  the  common  forms  of  the  disease.  While  important  recent 
studies  have  been  made,  we  are  scarcely  justified  in  ascribing  the  afi'ec- 
tion  to  any  special  micro-organism.  A  number  of  cases  have  been 
reported  in  which  there  is  some  evidence  of  direct  contagion. 

^  Ann.  Pasteur  Inst.,  Nov.,  1897.  ^  Bull,  de  la  Soc.  med.  des  Hop.,  Dec.  24,  1897. 


204  INFECTIOUS  DISEASES. 

Predisposing  Causes. — (])  An  infective  lesion  (septic  wound,  attacks 
of  angina,  etc.)  that  has  preceded  for  some  time  the  appearance  of  the 
pain  and  articular  manifestations  may  often  be  found,  and  this  may  be 
conceived  to  form  a  portal  of  entry  for  micro-organisms  (Sacaze).  The 
frequency  with  Avhich  an  attack  of  tonsillitis  precedes  the  development 
of  acute  articular  rheumatism  almost  indicates  a  pathological  relation 
betAveen  the  two  diseases  (Cheadle.  Wade,  Gei'hardt).  (2)  Seasons. — 
The  months  of  February,  March,  and  April  furnish  the  largest  percent- 
age of  cases,  though  the  disease  is  also  quite  prevalent  in  the  remaining 
cold  months ;  on  the  other  hand,  the  disease  may  sometimes  be  espe- 
cially frequent  in  summer.  (3)-  "  Catching  cold"  was  formerly  classed 
among  exciting  causes,  but  while  this  affection  often  follows  exposure  to 
abrupt  changes  of  temperature,  it  merely  predisposes  to  the  disease.  (4) 
Climate. — The  disease  is  most  prevalent  in  temperate  latitudes,  being 
rare  both  in  the  cold  and  tropical  zones.  (5)  Occupation  is  of  primary 
importance,  especially  if  it  entail  oft-repeated  or  prolonged  exposure  to 
the  influence  of  wet  and  cold  or  to  severe  changes  of  temperature.  Hence 
those  who  follow  certain  avocations  are  attacked  with  great  relative  fre- 
quency— e.  q.  coachmen,  laborers,  sailors,  and  servant-girls.  (6)  Age. — 
Primary  attacks  are  most  common  from  fifteen  to  thirty-five  years  of 
age.  Out  of  Q55  cases,  80  per  cent,  occurred  between  the  twentieth  and 
fortieth  years  (Whipham).  Cases  are  also  rather  numerous  between  ten 
and  fifteen  years,  and  I  have  met  with  4  under  the  former  age.  Suck- 
lings rarely  suffer.  (7)  Sex. — Acute  articular  rheumatism  is  somewhat 
more  common  in  men  than  in  women,  and  possibly  owing  to  the  fact 
that  the  former  sex  more  often  follows  predisposing  occupations.  (8) 
Hereditary  influence  plays  an  important  role.  (9)  Conditions  of  ill  health, 
particularly  digestive  and  hepatic  disturbances,  seem  to  exert  a  slight  yet 
decisive  effect.  (10)  Chronic  endocarditis  renders  its  victims  very  prone  to 
attacks  of  acute  articular  rheumatism,  and  some  contend  that  the  two  dis- 
eases are  etiologically  one  and  the  same.  (11)  Choreic  children  often  de- 
velop rheumatism.  Batton  analyzed  115  cases;  he  found  that  within  3 
years  11.3  per  cent,  of  the  children,  without  previous  rheumatism,  devel- 
oped the  disease,  and  after  5  years  this  total  was  increased  to  20  per  cent. 

An  attack  of  acute  articular  rheumatismis  not  protective  in  charac- 
ter, and  rather  renders  the  individual  more  susceptible  than  before.  In 
this  respect  the  disease  resembles  certain  other  infectious  diseases  (pneu- 
monia, erysipelas,  etc.). 

Clinical  History. — Of  the  incubation  period  nothing  is  known, 
though  prodromata,  both  local  and  general,  may  be  observed.  There 
may  be  malaise,  slight  fever,  angina,  laryngitis,  etc.,  and  last  from  a  few 
hours  to  a  dav  or  two.  The  invasion  is  usually  abrupt,  with  fever  and 
synovitis,  affecting  one  or  oftener  several  joints,  and  a  chill  or  a  series 
of  chilly  sensations  may  accompany  or  precede  the  rise  of  temperature. 
The  involved  joints  are  tender,  often  red  and  swollen,  and  exhibit  the 
local  signs  of  a  rapidly  developed  inflammation.  Pain  is  a  most  promi- 
nent symptom.  The  medium-sized  or  larger  joints  (knee,  ankle,  and 
wrist)  are  first  involved,  and  especially  those  of  the  inferior  extremities; 
next  the  shoulder-,  elbow-,  and  hip-joints ;  and  lastly  the  fingers,  toes, 
and  intervei'tebral  articulations.  Quite  unusual  articulations  may  become 
implicated  (vide  infra).     One  of  the  chief  peculiarities  of  the  disease  is 


ACUTE  ARTICULAR  RHEUMATISM.  205 

in  the  fact  that  the  joints  that  are  affected  are  not  all  the  seat  of  anatomic 
changes  simultaneously,  but  that  the  process  migrates  from  one  joint  to 
another  from  da}^  to  day,  and  often  crosses  from  one  side  of  the  body  to 
the  other.  Sometimes  this  occurs  at  longer  intervals.  Hence  the  number 
of  joints  involved  at  one  and  the  same  time  may  be  either  few  or  many. 

In  cases  of  average  severity  the  general  features  are  subordinate  to 
the  local  symptoms.  The  fever  is  usually  moderate,  the  temperature 
not  exceeding  103°  F.  (39.4°  C),  and  the  temperature-curve  is  of  the 
irregularly  remittent  type,  corresponding  in  severity  with  the  joint- 
symptoms.  Defervescence  is  by  lysis.  The  skin  is  bathed  in  a  copi- 
ous perspiration  which  is  not  dependent  upon  a  previous  fall  of  temper- 
ature.    Nervous  symptoms  are  rarely  observed. 

The  general  course  of  the  disease  exhibits  wide  variations,  both  as  to 
duration  and  intensity  of  symptoms.  It  may  not  outlast  several  days,  ap- 
pearing with  mild  symptoms;  on  the  other  hand,  cases  sometimes  persist 
for  six  to  eight  weeks.  The  latter  instances,  and  even  typical  cases,  are 
apt  to  show  brief  non-febrile  periods,  alternating  with  marked  paroxysms, 
and  similar  cycles  may  be  repeated.  Cases  in  which  the  symptoms  are  dis- 
tinct from  the  start  may  terminate  in  recovery  within  a  shorter  time  than 
those  in  which  the  features  are  of  mild  character.  As  will  be  seen  here- 
after, the  disease  frequently  manifests  complications,  especially  cardiac. 

Leading  Symptoms  and  Complications  in  Detail. — (1)  Joints  and  Sur- 
rounding Structures. — As  I  have  stated,  pain  is  much  complained  of, 
and  is  greatly  augmented  by  motion  and  by  pressure  of  any  sort.  It 
may  be  out  of  all  proportion  to  the  degree  of  the  anatomic  changes. 
The  joints  affected  are  generally  swollen  (most  markedly  in  the  knees), 
and  the  swelling  is  due  partly  to  effusion  into  the  joint  and  partly  to 
inflammatory  edema  of  the  periarticular  structures.  The  sheaths  of  the 
tendons,  the  bursae,  and  often  the  adjacent  muscles  and  fascioe  exhibit 
inflammatory  changes ;  hence  it  is  usual  to  see  an  extension  of  the  swell- 
ing for  a  variable  distance  from  the  joint,  the  backs  of  the  hands  often 
showing  this  to  a  marked  extent.  The  skin  may  present  a  pink  or  rose- 
colored  blush  over  circumscribed  areas  or  taking  the  form  of  streaks. 

In  even  mild  cases  there  are  usually  two,  three,  or  more  joints  in- 
volved, though  it  often  happens  that  one  bears  the  brunt  of  the  disease, 
little  complaint  being  made  of  others  less  severely  implicated.  Hence 
it  should  be  a  golden  rule  to  examine  carefully  all  the  joints  at  each 
visit.  Involvement  of  a  single  articulation  {monarticular  rheumatism) 
does  sometimes  occur,  but  the  diagnosis  of  these  cases  offers  great  difii- 
culties.  On  the  other  hand,  an  existing  polyarticular  rheumatism  may 
become  centered  in  a  single  joint  and  there  linger  with  great  obstinacy. 

In  severe  eases  numerous  joints  may  be  invaded,  with  an  involve- 
ment of  the  joints  of  the  symphyses,  of  the  jaw,  of  the  ribs,  and  the 
sterno-clavicular  articulations.  Under  these  circumstances  the  patient 
assumes  a  dorsal  decubitus,  and  seeks  to  relieve  his  excruciating  pain 
by  holding  his  limbs  in  a  semiflexed  position  and  absolutely  motionless. 
If  now  an  attempt  be  made  to  change  his  posture,  he  complains  pit- 
eously  of  darting  pains  in  the  affected  joints.  The  fug  a  c  it  t/  of  rheumatic 
arthritis  has  already  been  alluded  to. 

The  inflammation,  however  intense,  may  quickly  subside  in  one  joint, 
while  at  the  same  time  an  acute  disturbance  appears  in  another.      Usu- 


206  INFECTIOUS  DISEASES. 

ally  resolution  is  complete,  no  trace  being  left  of  former  inflammation, 
though  the  disease  may  recur  in  the  joints  primarily  involved.  Suppu- 
rative arthritis  may  supervene,  though  rarely,  and  its  occurrence  points 
indisputably  to  mixed  infection.  This  complication  may  lead  to  anky- 
losis— a  sequela  which  does  not  belong  to  pure  rheumatism. 

(2)  The  Cardio-vascular  Symptoms. — The  jjulse  is  quickened  to  100 
beats  per  minute  or  over,  but  is  soft  and  full,  and  Avheu  cardiac  or  other 
complications  arise  it  shows  special  characteristics  which  are  described 
in  appropriate  sections  of  this  work.  In  rare  instances  it  is  very  rapid, 
feeble,  and  irregular,  apart  from  the  influence  of  the  cardiac  involve- 
ment. The  results  of  a  careful  blood-count  show  a  high  grade  of  symp- 
tomatic anemia,  which  may  develop  with  marvellous  suddenness.  Leu- 
kocytosis  is  also  present. 

Great  importance  attaches  to  the  cardiac  affections  that  so  frequently 
complicate  this  disease.  They  may  arise  in  any  case,  even  the  mildest, 
or  at  any  stage  of  the  disease,  and  hence  the  conscientious  physician 
cannot  afford  to  neglect  the  matter  of  closely  and  regularly  examining 
the  heart.  It  must  be  recollected  that  the  symptoms  announcing  the 
development  of  cardiac  disease  are  neither  constant  nor  characteristic. 
At  first  we  may  note  an  increase  in  the  febrile  movement,  more  or  less 
palpitation,  sometimes  dyspnea,  and  precordial  pains,  which  often  do  not 
amount  to  more  than  a  sense  of  soreness.  There  may  also  be  attacks 
of  angina  pectoris  of  apparently  purely  nervous-  origin  (Striimpell). 

(a)  The  most  frequent  cardiac  complication  is  acute  endocarditis, 
which  is  present  in  25  to  30  per  cent,  of  the  cases.  We  are,  however, 
sadly  in  need  of  reliable  statistics  upon  this  point.  It  usually  takes  the 
form  of  simple  (verrucose)  endocarditis,  and  affects  most  frequently  the 
mitral  valves.  But,  though  usually  indicated  by  an  apical  systolic  mur- 
mur, it  is  hard  indeed  to  eliminate  the  functional  murmurs  that  may 
also  develop  in  the  course  of  this  disease.  Unless  combined  with  the 
symptoms  detailed  above,  the  presence  of  a  blowing  systolic  murmur 
does  not  afford  trustworthy  evidence  of  the  existence  of  acute  endo- 
carditis. While  it  rarely  endangers  life  and  may  leave  no  trace,  in  the 
majority  of  instances  the  acute  endocarditis  does  not  undergo  complete 
resolution,  but  leads  to  sclerotic  changes  and  terminates  in  incurable 
chronic  valvular  disease. 

(h)  Next  in  the  order  of  frequency  is  pericarditis,  which  may 
or  may  not  be  combined  with  the  former.  Its  nature  may  be  sero- 
fibrinous or  plastic  (less  frequently),  and  in  children  the  exudate  is 
sometimes  purulent ;  it  is  distinguished  chiefly  by  its  pathognomonic 
friction-sound,  though  also  by  other  characteristic  signs  (vide  Pericar- 
ditis. It  is  of  graver  import  than  endocarditis,  so  far  as  immediate 
danger  to  life  is  concerned,  though  it  rarely  proves  fatal.  I  have  wit- 
nessed two  instances  in  which  endocarditis  preceded  the  arthritic  mani- 
festations, and  the  same  observation  has  been  made  by  others  Avith 
reference  to  this  complication  as  well  as  to  pericarditis. 

(c)  Ilyocarditis  is  often  present  to  a  slight  extent  in  rheumatic  endo- 
carditis and  pericarditis  when  these  occur  independently  of  each  other, 
but  more  often  and  to  a  more  marked  degree  when  endo-pericarditis  ex- 
ists. Hence  it  is  far  less  common  than  either  endocarditis  or  pericar- 
ditis.    The   changes   and   symptoms  occasioned  will  be  discussed  under 


ACUTE  ARTICULAR  RHEUMATISM.  207 

Myocarditis.  In  this  connection  it  should  be  pointed  out  that  the  con- 
dition weakens  the  cardiac  walls  and  leads  to  dilatation  of  the  ventri- 
cles (usually  the  left). 

If  we  consider  rheumatism  an  infectious  malady,  we  can  readily  un- 
derstand why  the  local  manifestations  should  appear  not  only  at  the  dif- 
ferent articulations,  but  also  in  the  cardiac  structures,  and,  as  we  shall 
see,  in  other  viscera. 

(3)  The  Skin. — Rheumatism  produces  copious  perspiration.  The 
sweat  emits  a  sour  odor  and  gives  at  first  an  acid  reaction,  though 
later  it  may  be  neutral,  and  rarely  alkaline.  The  temperature-curve  in 
most  cases  is  not  materially  influenced  by  the  sweats.  Occasionally  the 
drops  in  temperature  and  the  free  sweats  are  concurrent,  but  the  latter 
symptom  is  apt  to  persist  despite  the  oscillations  in  the  temperature. 
Sudamina  appear,  often  in  extensive  crops.  Among  other  skin  erup- 
tions less  frequently  observed  are  forms  of  erythema  (especially  E. 
nodosum)  and  urticaria,  which  latter  may  be  associated  with  purpura 
{urticaria  Jimmorrhagica).  The  association  of  the  latter  condition  with 
polyarthritis  is  known  as  peliosis  rheumatica,  though,  according  to  some 
writers,  this  is  not  rheumatic  in  nature.  Cutaneous  ecchymoses,  and 
even  extensive  hemorrhages  into  the  skin  and  from  the  mucous  mem- 
branes— a  general  hemorrhagic  diathesis — may  also  be  encountered. 

Subcutaneous  Rheumatic  Nodules. — In  1881,  Barlow  and  Warner 
called  attention  to  the  fact  that  during  and  after  acute  articular  rheu- 
matism, particularly  in  children  and  young  adults,  small  subcutaneous 
nodosities  attached  to  the  tendons  and  fasciae  may  in  exceptional  in- 
stances be  observed.  These  nodules  are  rather  firm,  somewhat  mova- 
ble, and  usually  painless.  The  skin  over  them  is  simply  elevated,  with 
no  traces  of  inflammatory  action.  They  are  most  frequently  found  at 
certain  points  of  election  (fingers,  wrists,  edge  of  the  patella,  malleoli, 
and  over  the  back  of  the  elbow),  though  also  seen  less  frequently  else- 
where ;  they  may  disappear,  and  after  a  brief  interval  reappear.  On 
microscopic  examination  it  is  seen  that  round  and  spindle-shaped  cells 
enter  into  their  composition.  I  met  with  one  case  of  the  sort  which 
occurred  in  a  male  aged  forty-two  years,  in  which  acute  articular  rheu- 
matism was  also  complicated  with  endo-pericarditis  and  pneumonia. 
Most  of  the  nodosities  were  of  the  size  of  a  bitter  almond,  a  few  being 
even  larger,  and  the  crop  was  extensive.     The  case  proved  fatal. 

(4)  The  Fever. — The  fact  that  the  fever  fluctuates  materially  in  this 
affection  has  already  been  noted.  It  remains  to  be  pointed  out  that  if 
suppuration  occur  as  a  complication,  the  fever  may  be  of  the  hectic 
variety ;  also  that  rarely  hyperpyrexia  is  suddenly  developed,  and 
with  it  marked  cerebral  symptoms  (restlessness,  delirium,  and  sometimes 
convulsions,  finally  merging  into  stupor)  are  usually,  though  not  neces- 
sarily, associated.  This  serious  condition  usually  develops  after  several 
days  of  illness.  Delirium  may  be  present  from  the  time  of  onset, 
though  more  often  it  comes  on  either  shortly  before  or  after  the  acute 
development  of  the  hyperpyrexia.  The  pulse  becomes  excessively  rapid 
and  feeble  and  physical  prostration  extreme.  The  temperature  may  rise 
rapidly  with  slight  interruptions  until  it  touches  108°  or  109°  F.  (42.7^ 
C),  and  as  the  fever  reaches  its  maximum  death  usually  ensues.  The 
temperature  may  continue  to  rise  after  death.     The  cause  of  "  hyper- 


208  INFECTIOUS  DISEASES. 

pyretic  rheumatism  "  is  not  definitely  known.  It  has  been  claimed  that 
the  intemperate  are  most  apt  to  be  attacked,  but  this  belief  is  not  cor- 
roborated by  many  clinicians.  In  a  case  of  my  own,  however,  of  acute 
articular  rheumatism,  in  which  pericarditis  with  hyperpyrexia  occurred, 
the  patient  was  an  ''  alcoholic."  It  is  reasonably  certain  that  the  symp- 
toms are  due  to  an  intense  infection,  with  concentration  of  the  poison 
upon  the  nerve-,  and  especially  upon  the  thermal,  centers. 

(5)  The  Muscular  and  Nervous  Symptoms. — It  has  been  stated  that 
the  adjacent  muscles  and  fascite  may  exhibit  inflammatory  changes. 
They  may  also  show  more  or  less  swelling,  and  are  often  very  tender  to 
the  touch,  while  in  long-continued  cases  muscular  atrophy  ensues.  The 
cause  of  this  change  is  not  clear,  but  the  most  likely  view  is  that  it  re- 
sults not  so  much  from  disuse  of  the  muscles  (the  old  theory),  as  from 
some  trophic  disturbance  due  either  to  the  arthritis,  or  peripheral  neur- 
itis, or,  to  some  extent  at  least,  from  extension  of  the  rheumatic  inflam- 
mation from  the  nearest  articulation.  Other  theories  have  been  advanced, 
but  are  scarcely  tenable. 

Mention  has  been  made  of  the  grave  nervous  symptoms  that  are  at- 
tendant upon  hyperpyrexia,  but,  independently  of  the  latter  condition, 
nervous  phenomena  may  be  present.  There  may  be  restlessness,  sleepless- 
ness, and  active  delirium,  the  latter  being  usually  associated  Avith  a  tem- 
perature of  104°  F.  (40°  C.)  or  higher.  In  adynamic  types,  which  are 
rare,  low  muttering  delirium  merging  into  stupor,  and  even  coma,  may 
be  observed.  Active  mental  symptoms  are  sometimes  due  to  cerebral 
embolism  secondary  to  acute  endocarditis.  When  pericarditis  is  a  com- 
plication, wild  delirium,  with  or  without  hyperpyrexia,  or  the  low  mut- 
tering variety  with  stupor,  is  not  unusual.  The  drunkard  may  develop 
delirium  tremens.  Coma,  leading  quickly  to  a  fatal  result,  may  develop 
without  other  previous  or  associated  nervous  symptoms,  and  DaCosta 
has  reported  cases  in  which  a  fatal  coma  was  of  renal  origin,  and  hence 
uremic.  Rarely  coma  develops  during  the  period  of  convalescence. 
Convulsions  may  be  noted,  generally  preceding  the  coma,  though  rarely 
as  an  independent  symptom.  Melanclwlia  may  arise  in  the  course  of  the 
disease,  but  more  frequently  at  its  close.  Meningitis  must  be  numbered 
among  the  rarest  of  complications. 

Chorea  is  a  not  infrequent  sequel  of  this  disease  in  children,  and 
more  rarely  is  associated  with  it.  Of  554  cases  analyzed  by  Osier,  in 
only  88  were  chorea  and  rheumatism  associated.  These  in.stances  may 
or  may  not  be  accompanied  by  acute  endocarditis. 

(6)  Pulmonary  Symptoms. — Pleurisi/  occurs,  and  is  generally  excited 
by  an  extension  of  iutiammation  from  the  pericardium,  and  from  the 
pleura  the  inflammatory  process  may  be  propagated  through  the  dia- 
phragm to  the  peritoneum.  Bronchitis  is  sometimes  present,  but  is 
rarely  a  part  of  the  rheumatic  morbid  process  ;  it  is  secondary,  and  in 
most  instances  is  occasioned  by  the  co-operation  of  the  factors  that  are 
at  work  in  every  disease  in  which  enforced  recumbency  and  great  pros- 
tration coexist.  In  like  manner,  broneho-pnewnonia  may  be  produced. 
Lobar  pneumonia  rarely  occurs,  and  is  confined  to  aggravated  cases,  but 
pulmonary  congestion  is  occasionally  seen,  and  may  prove  fatal.  Pul- 
monary complications  are  also  prone  to  develop  secondarily  to  pericar- 
ditis, and  especially  to  endo-pericarditis. 


ACUTE  ARTICULAR  RHEUMATISM.  209 

(7)  The  Renal  Symptoms. — The  urine  is  diminished  in  amount,  is 
high-colored,  and  of  high  acidity  and  density.  The  standing  specimen 
deposits  urates.  As  in  other  infectious  diseases,  there  is  commonly 
present  a  slight  febrile  albuminuria,  but  acute  nephritis  is  extremely  rare. 
The  chlorids  are  sometimes  diminished,  but  rarely  absent. 

(8)  The  spleen  is  slightly  enlarged  in  some  cases.  The  saliva  has 
sometimes  an  acid  reaction,  and,  according  to  certain  writers,  the  sul- 
focyanids  are  in  excess. 

Clinical  Peculiarities  of  Acute  Articular  Rheumatism  in  Children. — The 
arthritic  symptoms  in  children  are  in  abeyance  while  endocarditis  and 
pericarditis  are  predominant,  and  these  cardiac  conditions  may  appear 
before  the  joint-lesions  are  observed,  but  it  is  quite  probable  that  endo- 
carditis follows  the  joint-lesions  twice  as  frequently  in  children  as  in 
adults.  Parsons  lays  stress  upon  reduplication  of  the  cardiac  second 
sound,  audible  at  the  apex  only,  as  an  indication  of  the  development  of 
endocarditis.  This  sign  is  to  be  distinguished  from  reduplication  heard 
at  the  base,  sometimes  as  the  result  of  Bright's  disease  and  sometimes  as 
the  consequence  of  pulmonary  obstruction.  Acid  sweats  are  slight  in 
children.  Rheumatic  tonsillitis  is  quite  common,  and  may  precede, 
accompany,  or  follow  attacks  of  rheumatism  in  children.  Erythema  is 
a  frequent  concomitant,  and  is  often  mistaken  for  scarlatina.  The  fe- 
brile movement  lasts  usually  but  a  few  days. 

Diagnosis. — The  acute  development  as  a  primary  affection  of  poly- 
arthritis with  fever  is  a  symptom-complex  on  which  an  assured  diag- 
nosis can  be  usually  based. 

Differential  Diagnosis. — Pyemia  must  be  carefully  separated.  In 
pyemia,  however,  the  general  condition  is  graver,  fever  precedes  the 
local  manifestations,  and  the  fever-curve  is  irregularly  intermittent. 
Rigors  also  occur  in  pyemia  at  varying  intervals,  accompanied  by  a 
steep  elevation  of  temperature — symptoms  that  are  absent  in  rheuma- 
tism. Again,  suppurative  processes  in  the  various  viscera  and  skin  and 
slight  jaundice  appear  in  pyemia.  Rheumatic  symptoms  fluctuate 
greatly,  while  the  pyemic  do  not. 

The  multiple  swelling  of  the  joints  Avhich  develops  after  childbirth  is 
to  be  regarded  as  septic  in  nature.  In  these  cases  arthritis  leads  rapidly 
to  suppuration,  Avith  more  or  less  destruction  of  the  joints.  Crout  will 
be  distinguished  from  rheumatism  in  connection  with  the  consideration 
of  the  former  disease  {vide  p.  398). 

Monarticular  rheumatism  is  with  difficulty  differentiated  from  a 
group  of  affections  which  simulate  it  closely.  (1)  The  so-called  gonor- 
rheal rheumatism  often  affects  a  single  joint,  especially  the  knee ;  but 
in  this  disease  there  is  usually  a  definite  history  of  recent  infection,  and 
the  local  features  (pain,  swelling,  etc.),  unlike  true  rheumatism,  are  far 
more  pronounced  than  the  general.  The  course  of  gonorrheal  arthritis 
is  longer  in  duration,  and  is  generally  connected  only  with  a  single 
joint  from  the  start ;  while  acute  articular  rheumatism  almost  always 
begins  as  a  polyarthritis,  with  subsequent  fixation  in  one  articulation. 
Cardiac  complications  are  rare  in  the  former  disease. 

(2)  Acute  osteomyelitis  is  generally  single,  and  is  sometimes  mistaken 
for  rheumatism,  from  which  it  differs,  however,  in  the  localization  of  the 

14 


210  INFECTIOUS  DISEASES. 

lesions  in  a  single  joint  from  the  start,  the  greater  prominence  of  the 
local  symptoms,  and  in  the  implication  of  the  epiphyses  and  the  shaft 
of  the  affected  bone  rather  than  the  joint,  and  in  the  graver  general 
symptoms  from  the  time  of  onset. 

(3)  There  is  a  liability  to  mistake  the  acute  arthritis  of  infants  for 
rheumatism.  This  attacks  by  preference  the  hip  or  knee,  and  is  a  puru- 
lent inflammation  due  to  pyemia  (Townsend),  hence  having  no  relation 
to  the  disease  under  consideration. 

(4)  Scrofulous  arthritis,  particularly  in  children,  has  been  confounded 
with  rheumatic  monarthritis.  The  former  is  less  indurating,  the  swell- 
ing presented  is  less  symmetric,  and  the  course  is  far  less  acute  than 
that  of  the  latter. 

(5)  In  the  course  of  the  hemorrhagic  diseases,  scurvy,  purpura,  and 
hemophilia,  eff"usion  into  the  joints,  either  hemorrhagic  or  serous  in 
nature,  occurs  with  great  frequency  and  is  associated  with  rheumatic 
pains.  The  diff"erential  diagnosis  is  to  be  made  from  the  tendency  to 
hemorrhage,  and  in  scurvy  by  the  lesions  of  the  gums.  The  absence  of 
fever  is  usually  decisive :  unfortunately,  it  is  frequently  present  in  these 
joint-aff'ections. 

Prognosis. — Recovery  is  the  general  rule.  As  in  other  infectious 
diseases,  so  in  rheumatism,  the  chief  immediate  danger  springs  from  the 
great  intensity  of  the  type  of  infection,  as  manifested  in  hyperpyrexia 
with  grave  nervous  symptoms,  the  development  of  the  general  hemor- 
rhagic diathesis,  etc. — happily  rare  occurrences  in  this  disease.  Certain 
complications,  such  as  pericarditis,  endo-pericarditis,  pneumonia,  etc., 
may  render  rheumatism  grave  or  even  hopeless,  and  rarely  the  endocar- 
ditis that  complicates  the  disease  is  of  the  ulcerative  variety  and  leads 
to  fatal  pyemia.  Pulmonary  embolism  may  occur  during  the  course  of 
acute  articular  rheumatism,  causing  speedy  death. 

The  influence  of  personal  factors  may  impede  recovery,  such  as  in- 
temperate habits,  great  obesity,  the  existence  of  previous  organic  dis- 
ease of  the  heart  or  Bright's  disease,  etc. 

Treatment. — (1)  Sanitary  Environment,  Diet,  and  Stimulants. — The 
sick-room  should  be  well  ventilated,  and  its  temperature  maintained  at 
65°  to  70°  F.  (18.3°-21.1°  C),  but  draughts  should  be  avoided.  The 
patient  should  be  lightly  dressed  in  flannels  and  covered  with  a  sheet  of 
the  same  material.  The  diet  should  be  li(iuid  and  nourishing,  milk  be- 
ing the  best  food-article.  Faiinaceous  matter,  skimmed  milk,  milk  and 
Seltzer  water,  buttermilk,  egg-white,  may  all  be  employed  if  whole  milk 
cannot  be  taken  in  adequate  amount.  I  begin  the  use  of  easily-digested 
forms  of  animal  food  soon  after  defervescence  has  occurred,  but  have 
immediate  recourse  to  the  earlier,  lifjuid  or  soft  diet  upon  the  return  of 
pain  and  fever.  An  ordinary  dietary  is  to  be  gradually  resumed.  Stim- 
ulants may  be  employed  if  indications  for  their  use  are  present,  and  the 
customary  mode  of  administration  may  be  followed. 

(2)  Internal  Therapeutics. — There  has  been  of  late  a  surprising 
unanimity  among  clinicians  in  commending  the  use  of  the  salicylates 
in  the  treatment  of  this  disease — more  so  than  at  any  previous 
time  since  their  introduction.  They  are  employed  in  most  of  the 
larger  hospitals  both  in  Europe  and  America.  Differences,  however, 
relating  to  the  mode  of  administration  and  the  particular  salt  to   be 


ACUTE  ARTICULAR  RHEUMATISM.  211 

selected  still  exist.  Wood  ^  favors  ammonium  salicylate,  for  the  reasons 
that  it  is  freely  soluble,  is  rapidly  absorbed,  and  when  given  in  sufficient 
amount  quickly  produces  the  symptoms  that  mark  salicylic  action,  while, 
in  addition,  it  is  less  depressing  than  the  other  salts  of  salicylic  acid. 
It  is  best  given  in  milk  and  is  usually  well  borne.  My  experience  Avith 
this  salt  in  acute  articular  rheumatism,  though  as  yet  somewhat  limited, 
has  been  satisfactory.  Until  the  present  time  sodium  salicylate  has 
met  with  more  general  favor  than  any  other  single  salt  of  salicylic  acid. 
The  pure  acid  is  also  used,  though  not  to  any  great  extent  at  the  present 
day.  As  regards  the  mode  of  administration,  the  total  daily  amount 
taken  is  of  higher  importance  than  the  size  and  frequency  of  the  dose. 
The  amount  given  in  twenty-four  hours  should  not  exceed  2  drams 
(8.0),  while  often  1^  drams  (6.0)  of  the  sodium  or  ammonium  salicylate  is 
sufficient.  My  method  is  to  give  gr.  x  (0.648)  every  two  hours  during 
the  first  day,  or  until  the  pain  and  other  local  features  have  largely  dis- 
appeared ;  then  the  remedy  is  given  at  longer  intervals,  but  not  omitted 
entirely.  In  this  manner  fresh  exacerbations  are  most  probably  averted. 
If  the  latter  occur,  however,  larger  doses  must  be  instituted,  so  as  to 
cut  them  short.  Some  recommend  that  the  medicine  be  stopped  as  soon 
as  the  pain  has  been  controlled.  Lassere  recommends  methyl  salicylate, 
and  in  40  cases  found  it  effective  in  relieving  the  pain.  Some  prefer 
salol  to  either  the  pure  acid  or  the  salicylates :  in  my  experience,  how- 
ever, the  use  of  this  drug  has  not  been  followed  by  good  results  in  the 
severe  acute  forms  of  the  disease.  Doubtless  the  reason  for  this  lies  in 
the  fact  that  salicylic  acid  can  neither  be  introduced  into  the  system  in 
sufficient  amount  nor  rapidly  enough  in  the  form  of  salol. 

Kinnicut  has  recommended  the  employment  of  the  oil  of  winter- 
green,  a  salicylic  compound  which  does  not  generally  produce  the  un- 
pleasant toxic  symptoms  so  apt  to  be  excited  by  the  salicylates  or  sali- 
cylic acid.  The  dose  is  TTLx-xx  (0.60-1.25),  given  in  capsules  or  in 
milk,  to  be  repeated  every  two  hours.  Salicin  (gr.  x — 0.648,  every 
hour,  increased  to  gr.  xv — 0.972)  is  sometimes  efficacious  and  invariably 
agrees.  Salophen,  in  daily  doses  of  1  dram  (gr.  xv — 0.972,  every  four 
hours),  may  be  substituted  for  sodium  salicylate  if  the  latter  produces 
gastric  disturbances  after  a  few  days'  treatment ;  it  is  almost  specific  in 
its  effects.  Salophen  passes  through  the  stomach  unchanged,  to  split 
into  salicylic  acid  and  acetylparalidophenol  in  the  intestines.  Sodium 
salicylate  enemata  (oj — 1-0 — of  the  salicylate  and  TTLx — 0.60 — of  the 
tincture  of  opium  in  each  injection)  may  be  of  advantage  in  certain 
cases.  The  remedy  is  absorbed  from  the  rectal  mucosa,  though  more 
slowly  than  from  the  stomach. 

The  treatment  with  the  salicylates  or  salicylic  acid  mitigates  the 
fever,  relieves  the  pain,  and  shortens  the  stay  in  bed  by  a  few  days,  but 
does  not  curtail  convalescence.  The  statistics  of  Williams  go  to  show 
that  the  salicylate  treatment  also  tends  to  protect  against  the  develop- 
ment of  cardiac  complications,  though  it  does  not  seem  to  influence  the 
course  of  the  complications  once  they  are  established.  In  my  experi- 
ence the  alkaline  treatment  operates  potently  to  obviate  the  occurrence 
of  the  heart-complications  and  shortens  the  period  of  convalescence,  but 
exerts  slight,  if  any,  influence  upon  the  fever-curve  and  pain.      These 

^  University  3Iedical  Magazine,  Jan.,  1895, 


212  INFECTIOUS  DISEASES. 

facts  led  me  long  since  to  use  the  specific  and  alkaline  treatment  in  com- 
bination, giving,  in  addition  to  salicylates  or  other  salicylic  compounds, 
as  above  indicated,  an  alkaline  remedy,  such  as  sodium  bicarbonate, 
potassium  citrate,  etc.,  in  sufficient  doses  to  render,  and  then  maintain, 
the  urine  of  slightly  alkaline  reaction. 

There  are  a  feAv  other  remedies  that  should  be  referred  to,  and, 
although  more  or  less  serviceable,  they  are  without  specific  influence. 
The  foremost  among  these  is  antipyrin.  but  I  have  come  to  believe  that 
safer  and  equally  efiicacious  remedies  have  replaced  this  drug.  Potas- 
sium iodid  and  the  preparations  of  colchicum  belong  to  this  category, 
and  should  be  tried.  Their  effects  are  most  beneficial  in  cases  that 
drag  on  after  the  acute  stage  is  over.  Lactophenin  is  used  by  Roth 
as  a  most  useful  remedy  in  acute  rheumatism,  but  it  does  not  rival  the 
salicylates. 

(3j  Local  Measures. — These  occupy  a  subordinate  place  in  the  man- 
agement of  acute  articular  rheumatism.  Their  number  is  legion,  but 
only  a  few  of  the  more  valuable  can  be  adduced  here.  In  mild  cases 
the  affected  joints  should  be  wrapped  in  cotton  batting  or  in  flannel.  If 
the  pain  is  severe  despite  the  use  of  the  salicylates  internally,  fomen- 
tations as  hot  as  can  be  borne  or  hot  cloths  lightly  wrung  out  of  Fuller's 
lotion  (sodium  carbonate,  3vj — 24.0  ;  laudanum,  sj — 30.0  ;  glycerin, 
|ij — 60.0  ;  and  water,  six — 270.0)  are  beneficial.  As  salicylic  acid  is 
absorbed  through  the  skin,  it  has  been  combined  with  other  agents  for 
local  use  in  the  following  formula : 

I|f.  Acid,  salicyl., 

Lanolini,  da.  siij  (11.65); 

01.  terebinthinae,  oiij  (11-25); 

Adipis,  oiij  (11.65). 

M.  et  ft.  ung. 

Sig.  Rub  freely  over  the  affected  joints  and  folloAv  by  wrapping  in 

cotton. 

Methyl  salicylate,  by  local  application,  is  of  service.  It  is  put  on 
the  skin  over  the  affected  joints  drop  by  drop,  and  the  joint  then 
enveloped  in  gutta-percha  tissue  and  a  flannel  bandage  applied  to  it. 
Cold  compresses  and  the  ice-bag  to  the  joints  have  been  strongly  ad- 
vised, particularly  by  German  authors.  The  affected  joints  should  be 
kept  at  perfect  rest,  and  this  is  best  accomplished  by  padded  splints  and 
a  roller  bandage.  Blisters  near  to  the  joints  involved  and  the  light 
application  of  the  Paquelin  thermo-cautery  are  sometimes  serviceable. 
Taylor^  has  successfully  employed  currents  of  hot  air,  applied  by  means 
of  an  instrument  (electro-thermogen). 

The  treatment  of  the  complications  will  be  considered  under  their 
appropriate  headings.  Should,  however,  hyperpyrexia  occur  during  the 
progress  of  the  affection,  it  is  to  be  relieved  by  cold  baths,  since  large 
doses  of  internal  antipyretics  are  of  themselves  dangerous.  It  may  also 
be  stated  that  the  cardiac  complications — endocarditis,  pericarditis,  and 
endo-pcricarditis — rarely  require  special  remedies.  If  marked  cardiac 
asthenia  appears,  as  indicated  by  the  feeble  first  sound,  the  salicylates 

'  Lancet,  Nor.  26,  1898. 


OONOBBHEAL  ARTHRITIS.  213 

may  be  replaced  by  salicin,  Avhich  is  less  depressing  in  its  effect  upon 
the  heart.  Cardiac  stimulants  may  be  required.  A  copious  pericardial 
effusion  calls  for  paracentesis  {vide  Sero-fibrinous  Pericarditis). 

During  convalescence  the  patient  should  not  be  allowed  to  get  out  of 
bed  too  early.  My  own  rule  has  been  to  keep  him  in  bed  for  a  Aveek 
after  the  temperature  has  returned  to  the  normal  and  after  the  pain  has 
disappeared,  except  it  be  during  the  hot  season.  These  precautions  are 
taken  to  avoid  the  occurrence  of  relapses.  After  the  patient  goes  into 
the  open  air  he  should  be  told  to  avoid  cold,  and  wet  in  particular. 
During  this  period  iron  is  to  be  employed  until  the  blood-examination 
fails  to  show  anything  abnormal.  For  the  stiffness  and  swelliiTg  that 
sometimes  persist,  or  disappear  very  slowly  after  the  acute  attack, 
massage  and  the  application  of  hot  water  or  warm  baths  seem  to  yield 
the  best  results. 


SUBACUTE  ARTICULAR  RHEUMATISM. 

This  is,  as  a  rule,  a  sequela  of  acute  rheumatism,  and  may  occur, 
though  rarely,  in  persons  who  have  not  had  a  previous  acute  attack.  Both 
the  local  and  general  features  are  of  a  mild  type,  but  the  course  is  apt 
to  be  prolonged  into  two,  three,  or  more  months.  Usually  the  local 
symptoms  are  confined  to  one  or  two  of  the  larger  joints,  Avith  little 
swelling  or  redness,  and  the  pain  is  slight  except  on  movement.  The 
temperature  rarely  exceeds  101°  F.  (38.3°  C),  and  at  times  may  be 
practically  normal.  Though  the  course  is  prolonged,  the  joints  usually 
return  to  their  normal  state ;  occasionally,  however,  the  disease  becomes 
chronic.  As  in  the  acute  form,  so  in  the  subacute,  anemia  becomes  well 
marked  and  cardiac  complications  are  not  uncommon,  particularly  when 
the  disease  occurs  in  children. 

The  treatment  embraces,  in  addition  to  the  usual  antirheumatics, 
the  use  of  iron,  quinin,  cod-liver  oil,  and,  when  practicable,  a  change  to 
a  warm  climate.  The  affected  joints  demand  hot  applications  and 
massage. 


GONORRHEAL  ARTHRITIS. 

Definition. — A  septic  synovitis  caused  by  the  gonococcus,  and 
hence  having  no  connection  with  true  rheumatism.  It  usually  manifests 
itself  toward  the  close  of  an  attack  of  gonorrhea,  but  it  may  develop 
during  the  active  stage  of  the  disease  or  at  any  period  during  the  course 
of  gleet. 

Patliology. — The  signs  of  ordinary  synovitis  are  generally  found 
in  the  affected  joints,  though,  not  rarely,  the  inflammatory  process  is 
periarticular  {gonorrhceal  tenosynovitis).  In  these  cases  the  inflamma- 
tion may  travel  along  the  sheaths  of  the  tendons  for  a  considerable 
distance.  Synovial  effusion  may  occur,  and  rarely  may  be  purulent, 
this  being  most  frequent  in  gonorrheal  inflammations  affecting  the  wrist 


214  INFECTIOUS  DISEASES. 

and  band.  Gonococci  have  been  found  in  tbe  effusion,  though  this  is 
not  generally  the  case,  and  it  is  now  thought  by  many  Avriters  (Finger, 
Councilman,  and  others)  that  the  gonococcus  may  be  the  only  infective 
agent  concerned  in  the  morbid  process.  Others  contend  that  the  meta- 
static inflammation  of  the  joints  is  due  to  the  presence  of  pyogenic  cocci, 
since  they  have  been  found  to  be  frequent  companions  of  the  gonococcus. 
In  this  and  other  forms  of  secondary  inflammation  it  must  not  be  for- 
gotten, however,  that  gonorrheal  arthritis  may  be  due  in  great  part  to 
the  absorption  of  ptomains  from  the  urethra.  The  disease  is  present  in 
2  per  cent,  of  all  cases  of  gonorrhoea  in  males  and  rarely  occurs  in 
females  (Gaither) ;  it  may  follow  any  urethral  discharge  or  may  be  asso- 
ciated Avith  menstruation  or  leukorrhea. 

Clinical  Symptoms. — Two  leading  varieties,  acute  and  chronic, 
are  encountered.  (1)  Acute  Cronorrheal  Arthritis. — This  may  be  very 
mild,  amounting  merely  to  slight  fugitive  pains  and  some  stifl'ness  of 
one  or  more  joints,  without  noticeable  swelling  or  redness.  The  typi- 
cal, acute  form,  however,  presents  the  symptoms  of  a  severe  fibrinous  or 
sero-fibrinous  inflammation  of  a  single  joint,  developing  quickly.  The 
pain  is  often  violent ;  there  is  swelling  of  the  joint  Avith  extension 
along  the  course  of  the  tendons,  and  the  condition  is  obstinate.  Unless 
pus  be  present  (a  rare  event)  the  constitutional  features  do  not  corre- 
spond in  severity  with  the  local,  there  being  little  fever  and  slight  im- 
pairment of  the  general  health.  There  are  many  instances  in  Avhich 
the  complaint  begins  as  a  polyarthritis,  with  subsequent  concentration 
upon  one  or  two  of  the  larger  articulations,  especially  the  knees  or 
ankles.     Fibrinous  ankylosis  usually  remains  as  the  resulting  condition. 

Acute  endocarditis  may  be  of  gonorrheal  origin.  In  the  inflamma- 
tory products  of  this  condition  Hering  has  found  the  gonococci,  as  has 
also  Councilman,  in  the  heart-muscles  (gonorrheal  myocarditis).  Rarely, 
gonorrheal  endocarditis  assumes  the  ulcerative  or  malignant  form.  As 
the  result  of  invasion  of  the  blood  by  the  gonococci  suppurative  arthritis 
may  also  be  occasioned,  and  now  the  clinical  picture  is  that  of  general 
septico-pyemia.  I  observed  one  case  in  which  pJeurisii  Avas  associated, 
and  among  the  numerous  widespread  complications  iritis  deserves  special 
mention. 

(2)  Chronic  Gonorrheal  Arthritic. — This  occurs  {a)  as  a  serous  effu- 
sion (hi/drarthrosis),  and  (b)  as  a  chronic  inflammation  of  the  articular 
and  periarticular  structures  (synovial  membranes,  bursEC,  periosteum, 
and  tendons  with  their  sheaths).  The  former  is  usually  monarticular, 
settling  with  especial  frequency  in  the  knees,  and  may  be  Avholly  pain- 
less. The  latter  is  more  or  less  painful — causes  dense  swelling  of  the 
joint,  and  frequently  of  the  structures  for  some  little  distance  above 
and  below  the  latter.     Both  forms  lead  to  great  restriction  of  motion. 

The  diagnosis  cannot  be  determined  positively  apart  from  the  his- 
tory of  urethral  infection.  The  acute  form  is  distinguished  chiefly  from 
acute  articidar  rheumatisin  by  the  intense  pain,  the  extent  to  which  the 
periarticular  tissues  are  involved,  and  the  negative  character  of  the 
general  symptoms.  The  chronic  variety  must  be  discriminated  from 
chronic  synovitis  due  to  other  causes,  and  this  often  proves  a  diflScult 
task. 

Treatment. — I  have  never  seen  the  slightest  benefit  from  internal 


VARIOLA.  215 

medication  in  gonorrheal  arthritis,  except  possibly  from  the  use  of  mer- 
cury. Maragliano  advises  quinin  hypodermically  and  internally. 
Local  measures,  however,  are  of  paramount  importance.  Absolute  rest 
to  the  part  is  indicated,  and  the  limb  should  be  placed  upon  a  splint; 
then,  after  making  an  appropriate  anodyne  application  (ungt.  ichthyol. 
or  ungt.  belladonnte),  it  should  be  bandaged  as  firmly  as  possible.  In 
other  instances  complete  immobilization  in  plaster-of-Paris  dressing 
gives  good  results.  Before  doing  this  in  acute  cases  the  patient  should 
be  anesthetized,  and  after  the  procedure,  if  pain  be  great,  a  hypodermic 
injection  of  morphin  may  be  given.  In  chronic  forms  the  aim  should 
be  to  remove  the  eifusion  (if  present)  and  the  s-welling,  and  to  restore 
the  natural  motility  so  far  as  possible.  For  the  latter  tAvo  indications 
massage  and  passive  movements  are  best.  S"n'elling  may  also  be  di- 
minished by  the  use  of  the  thermo-cautery  at  intervals,  and  blisters  are 
highly  serviceable  in  causing  a  disappearance  of  the  effusion.  Careful 
surgical  attention  should  be  bestowed  upon  the  urethral  or  the  vaginal 
condition. 


VARIOLA. 

(Small-pox.) 


Definition. — Variola  is  an  acute  contagious  disease,  characterized 
by  its  sudden  onset  and  severe  period  of  invasion,  followed  by  a  remis- 
sion of  the  fever  and  an  eruption  of  papules,  which  pass  through  the 
stages  of  vesicle,  pustule,  and  scab.  The  stage  of  pustulation  is  accom- 
panied by  secondary  fever. 

Historic  Note. — Small-pox  has  existed  from  the  earliest  anti- 
quity in  India,  Africa,  China,  and  other  Eastern  countries.  During 
the  thirteenth  century  (1241)  it  entered  England,  in  the  early  part  of 
the  fourteenth  Ireland,  and  in  the  latter  part  of  the  fifteenth  Grermany. 
In  1507  it  Avas  imported  to  America,  and  first  appeared  in  the  West 
Indies ;  a  little  later  (1520)  the  Spanish  troops  conveyed  the  disease  to 
Mexico,  where  it  destroyed  not  less  than  three  and  a  half  millions  of 
people  in  its  pestilential  march.  It  was  brought  to  the  United  States 
from  Europe  in  1649,  and  gained  its  first  foothold  in  Boston,  whence  it 
progressed  at  intervals  in  a  westerly  direction  till  it  finally  reached  the 
western  coast-line  nearly  a  century  after  its  first  introduction. 

At  the  present  day  there  is  a  very  limited  opportunity  to  observe  the 
affection  except  in  its  modified  form  (varioloid),  since  small-pox  certainly 
does  not  prevail  in  an  epidemic  form  where  vaccination  is  practised  with 
fidelity,  and  only  among  uncivilized  peoples  Avho  are  ignorant  of  or  in- 
different to  this  certain  prophylactic  power. 

Pathology. — The  eruption  of  small-pox  consists  in  an  inflammatory 
cellular  infiltration  of  the  rete  mucosum  and  has  four  successive  stages — 
(1)  Papular,  (2)  Vesicular,  (3)  Pustular,  and  (4)  Scah. 

(1)  The  Papule. — At  first  there  is  a  hyperemia  of  the  papillae  of  the 
skin  appearing  as  small  red  spots.  These  soon  become  round,  discrete 
patches  that  may  be  rolled  like  shot  under  the  skin,  and  then,  becoming 
elevated,  owing  to  the  increase  in  the  cells  in  the  rete  mucosum,  they 
form  the  typical  pap>ule. 


216  INFECTIOUS  DISEASES. 

(2)  The  vesicle  appears  at  the  apex  of  the  papule,  and  results  from  a 
circumscribed  elevation  of  the  superficial  layer  of  the  epidermis  in  con- 
sequence of  the  mechanical  pressure  exerted  by  the  fluid  exudate,  which 
is  excited  by  active  peripheral  inflammation.  The  vesicle  is  not  uni- 
cellular, but  is  loculated  (by  fibrinous  reticuli),  and  contains  serum, 
leukocytes,  fibrin-filaments,  etc.  If  a  section  of  a  vesicle  in  the  very 
early  stage  be  made  through  the  deeper  layers  of  the  rete  mucosuni,  an 
area  of  coagulation-necrosis  is  observed,  which  is  due  to  the  presence  of 
micrococci  (Weigert).  The  vesicle  shows  central  umbilication,  Avhich 
corresponds  with  the  necrotic  area,  and  is  well  marked  just  before  the 
pustules  are  formed. 

(3)  The  pustule  is  formed  by  the  filling  of  the  reticuli  with  leuko- 
cytes. Cellular  infiltration  and  swelling  of  the  true  skin  beneath  the 
pustule  occurs,  ^s  a  rule,  as  the  result  of  diapedesis.  Moreover,  sup- 
puration may  involve  the  cutis  vera,  and  as  a  consequence  scarring  re- 
sults. When  the  suppuration  is  limited  to  the  rete  mucosum  pitting  does 
not  take  place.  In  hemorrhagic  small-pox  the  reticuli  are  occupied  by 
an  abundance  of  red  corpuscles  which  have  passed  in  from  the  adjacent 
blood-vessels,  and  may  infiltrate  the  upper  as  well  as  the  deeper  layers 
of  the  epidermis  surrounding  the  vesicles  or  pustules.  The  pustules 
may  dry  up,  but  commonly  rupture,  and  in  either  case  the  result  is  (4) 
scabbing. 

The  mucosa  of  the  mouth,  pharynx,  and,  rarely,  the  esophagus  and 
the  rectum  may  be  the  seat  of  a  variolous  eruption,  and  the  plaques  of 
Peyer  may  be  somewhat  swollen.  The  eruption  also  appears  in  the 
larynx,  the  trachea,  and  bronchi,  where  ulcers  rather  than  true  pustules 
are  seen,  and  the  conjunctiva  and  nasal  mucosa  frequently  show  the 
specific  lesions. 

Hemorrhagic  small-pox  presents  extravasations  occurring  in  the 
serous  and  mucous  membranes,  the  connective  tissue,  the  parenchyma 
of  the  various  viscera,  and  also,  though  much  less  frequently,  in  the 
nerve-sheaths,  bone-marrow,  blood-vessel  walls,  and  the  muscles.  In 
this  form  the  spleen  is  firm  (Ponfick,  Osier),  and  the  liver  is  sometimes 
enlarged  and  the  subject  of  f\itty  degeneration.  Hemorrhagic  infarction 
of  the  lung  occurred  in  5  out  of  7  cases  examined  by  Osier.  "In  4 
instances  the  pelves  of  the  kidney  were  blocked  with  dark  clots,  Avhich 
extended  into  the  calyces  and  down  the  ureters,"  and  in  a  proportion- 
ate number  of  cases  Peyer's  glands  were  swollen. 

Secondary  Lesions. — The  catarrhal  inflammation  of  the  larynx  may 
extend  in  depth  till  it  touches  the  perichondrium  of  the  cartilages  (peri- 
chondritis), and  a  croupous  exudate  in  the  larynx  may  often  coexist 
with  edema.  Lesions  are  present  in  the  lungs,  some  of  them  frequently 
(general  bronchitis,  broncho-pneumonia),  and  others  rarely  (hypostatic 
congestion,  lobar  pneumonia),  and  a  low  type  of  inflammation  of  the 
pleura  may  be  observed.  Cloudy  swelling,  diffuse  inflammation,  and 
sometimes  fatty  degeneration  of  the  liver,  have  been  noted,  the  spleen 
being  enlarged  and  l)ulpy  as  a  rule.  The  heart  may  show  myocardial 
alterations — chiefly  parenchymatous  and  fatty — and  rarely  endocarditis 
and  pericarditis  occur  in  the  nature  of  true  complications.  The  kidneys 
show  cloudy  swelling,  and  occasionally  nephritis  develops,  although  not 
until  quite  late.     Attention  should  be  called  to  the  observation  of  Wei- 


VARIOLA.  217 

gert,  who  found  that  at  the  commencement  of  the  stage  of  suppuration 
the  microscope  revealed  "small-pox  cylindric  masses"  in  the  various 
organs  (liver,  spleen,  kidneys,  and  lymphatic  glands).  The  cylindric 
masses  are  in  reality  capillaries  filled  Avith  micrococci,  which  are  derived 
from  the  eruption,  and  probably  find  their  way  into  the  circulation 
through  the  lymphatics.  These  small  areas  of  coagulation-necrosis  may 
be  the  seat  of  leukocytic  infiltration,  which  in  turn  may  result  in  a  cir- 
cumscribed miliary  abscess  if  septic  material  be  also  absorbed  from  the 
pustules.  No  special  microscopic  appearances  are  presented  by  the 
blood. 

Btiology. — Bacteriology. — Loeb  and  Pfeiflfer  ^  have  described  certain 
protozoa  found  in  the  blood  or  in  local  lesions,  to  which  they  attribute 
an  etiologic  significance.  J.  Christian  Bay  ^  has  isolated  from  small- 
pox lymph  and  vaccine  points  an  organism  [dispora  varioloe)  which  he 
believes  to  be  the  causa  morhi  of  small-pox  and  vaccinia.  The  long 
diameter  of  the  bacterium  measures  0.6^a-l//,  and  the  short  diameter 
from  0.2//-0.3//.  The  organisms  contained  two  spores,  one  at  either 
end,  and  when  reared  on  artificial  media  developed  in  colonies,  and  were 
readily  stained  with  anilin  blue  or  violet.  The  exact  role  played  by  this 
organism  in  the  causation  of  variola  has  not  as  yet  been  definitely  deter- 
mined. Haushalter  and  Etienne  consider  the  hemorrhagic  symptoms 
in  small-pox  due  to  secondary  infection  with  the  streptococcus,  since 
they  have  found  this  organism  in  the  blood  of  those  dead  of  hemorrhagic 
variola  (Saunders'  Year-Book  for  1899).  Widal  and  Sabrazes  have 
also  noted  the  streptococcus  in  autopsies  upon  small-pox  cases. 

Predisposing  Causes. — The  receptivity  for  variola  is  wellnigh  universal, 
and  among  the  few  who  have  enjoyed  immunity  were  three  distinguished 
physicians — Diemerbroeck  Boerhaave,  and  Morgagni.  It  may  be  said 
that  one  attack  confers  permanent  immunity,  but  exceptionally  a  second 
or  even  a  third  may  occur.  Vaccination,  also,  if  successful,  aifords  future 
protection  against  variola,  but  to  this  rule  exceptions  are  not  infrequent. 

Age. — All  periods  of  life  are  liable  to  the  disease,  but  the  very  young 
are  affected  in  a  relatively  larger  proportion  than  older  persons.  During 
the  entire  puerperal  stage  there  is  an  increased  liability  to  the  disease. 
It  rarely  affects  the  fetus  in  utero,  and  most  babes  even,  who  are  ex- 
posed to  the  virus  at  the  time  of  birth,  will  not  take  the  disease  if 
immediately  and  successfully  vaccinated. 

Sex  is  without  influence. 

Race. — Among  uncivilized  peoples  variola  spreads  with  frightful 
rapidity,  the  negro  and  other  very  dark  races  being  affected  in  larger 
numbers  and  more  severely  than  whites.  A  dread  of  the  infection  pre- 
disposes to  its  occurrence. 

The  Contagion ;  where  Found ;  Modes  of  Conveyance  and  of  Infection. — 
One  case  of  variola  i?,  prima  facie  evidence  of  the  existence  of  another, 
and  that  the  poison  from  the  latter  was  somehow  transferred  to  the 
former.  The  specific  poison  exists  in  the  blood  and  in  the  secretions 
and  excretions  (most  probably),  but  mainly  in  the  pustules  and  dry 
scabs  and  in  exhalations  from  the  lungs  and  skin.  Its  conveyance  from 
the  sick  to  the  healthy  or  from  one  person  to  another  is  not  a  difficult 

^  Loeb,  Oentralbl.  fiir  Bacteriologie  und  Parasitenkunde,  ii.  353,  1887 ;  Pfeiffer,  ibid., 
ii.  126,  1887.  ^  Medical  News,  January  26,  1895,  vol.  Ixvi.  p.  94. 


218  INFECTIOUS  DISEASES. 

matter,  and  may  take  place  in  one  or  other  of  the  several  following 
ways :  (a)  Inoculation  with  either  the  blood  or  the  contents  of  the  erup- 
tion or  the  dissolved  dry  scabs  is  followed  by  variola,  (b)  Contact  with, 
or  proximity  to,  a  patient  suffering  from  small-pox  is  very  apt  to  convey 
the  poison,  with  resulting  variola  in  the  person  thus  exposed.  To  what 
distance  the  contagion  can  be  conveyed  through  the  air  is  not  known, 
but  it  is  probably  considerable ;  and  all  authors  are  agreed  that  it  is 
one  of  the  most  infective  diseases  with  which  we  are  acquainted.  It  is 
contagious  from  the  earliest  active  stage  to  the  end  of  convalescence, 
and,  according  to  some  observers,  even  during  the  stage  of  incubation. 
{<;)  Transmission  by  fomites  is  common,  the  poison  adhering  to  clothes, 
body-  or  bed-linen,  etc.,  and  evidence  is  not  wanting  to  show  that  the 
poison  is  highly  tenacious  of  pathogenic  power.  Its  vitality  is  retained 
after  death,  and  ihe  room  occupied  by  a  patient,  the  bedding,  and  the 
articles  of  furniture  all  serve  to  convey  the  disease  unless  thorough  dis- 
infection be  enforced.  The  avenue  of  entrance  for  the  poison  into  the 
system  is  not  known,  but  it  is  most  probably  the  respiratory  tract,  the 
poison   being   inhaled   and  thence  taken   into   the   general   circulation. 

Clinical  History. — Incubation. — This  stage  varies  with  the  mode 
of  communication  of  the  poison.  If  following  inoculation,  the  symp- 
toms appear  in  six  or  seven  days ;  when  originating  in  infection,  usually 
in  twelve  days,  though  this  stage  may  be  either  lengthened  by  a  day  or 
two  or  shortened  to  an  etjual  extent.  During  a  portion  of  this  period 
complaint  may  be  made  of  certain  ill-defined  symptoms,  but  these  are 
usually  absent,  and  the  onset  is  sudden  and  accompanied  by  character- 
istic signs.  These  are — a  severe  rigor,  high  fever,  headache,  and  intense 
lumbar  pains.  Instead  of  the  usual  severe  rigor,  repeated  chills,  ex- 
tending over  twelve  to  tAventy-four  hours,  may  occur,  the  headache, 
intense  pain  in  the  loins,  and  the  fever  continuing  for  several  days  unless 
relieved.  During  the  same  period  the  respirations  are  accelerated,  the 
pulse  becoming  decidedly  more  rapid,  and  there  may  be  general  bron- 
chitis. The  tongue  is  coated  and  the  patient  may  make  complaint  of 
slight  pharyngitis.  There  is  anorexia,  generally  vomiting,  and  consti- 
pation or  rarely  diarrhea.  Restlessness,  wakefulness,  delirium,  and 
stupor  are  the  principal  nervous  symptoms  observed.  Infective  albu- 
minuria is  common  ;  of  400  cases  of  variola,  Arnaud  noted  albuminuria 
in  95.      In  the  female  menstruation  is  apt  to  occur. 

The  physical  signs  are  few,  and  consist  of  a  few  dry  and,  later, 
moist  rales,  heard  on  auscultation.  Palpation  detects  splenic  enlarge- 
ment. From  the  second  day  the  so-called  initial  rashes  may  appear: 
{a)  the  diffuse  scarlatinous  eruption,  which  in  no  way  differs  from  ordi- 
nary scarlatina ;  [h)  the  measly  eruption,  which  may  be  diffuse  and 
identical  with  that  of  true  measles.  Either  associated  with  these  or 
occurring  independently  there  may  be  a  hemorrhagic  eruption  (usually 
purpura),  tlie  petechice  coming  out  by  natural  selection,  mainly  upon 
the  hypogastric  region  or  the  inner  surfaces  of  the  thighs  and  in  the 
axillae  (Simon).  Rarely  the  knees,  elbows,  and  extensor  surfaces  pre- 
sent this  eruption.  The  initial  rashes  occur  in  a  considerable  propor- 
tion of  cases  (10-15  per  cent.)  and  of  these  the  petechife  outlast  the 
other  pre-variolous  eruptions.  The  stage  of  invasion  ^ust  depicted  lasts 
three  days  as  a  rule,  and  the  intensity  of  the  symptoms  is  generally  in 


VABIOLA.  219 

direct  proportion  to  that  of  the  stages  that  follow.  At  the  end  of  the 
third  day  or  on  the  fourth  the  temperature  declines  rapidly,  while  at 
the  same  time  the  true  variolous  eruption  appears  upon  the  skin  and 
mucous  surfaces.  Now  begins  the  stage  of  eruption,  which  develops 
first  upon  the  face,  particularly  upon  the  forehead  and  the  hairy  scalp, 
and  spreads  in  a  downward  direction  till  it  reaches  the  legs,  where  it 
last  appears.  The  skin  in  the  femoral  triangle  rarely  shows  the  true 
variolous  eruption.  Each  pock  passes  through  the  various  stages  noted 
in  the  pathologic  description — viz.  papule,  vesicle,  pustule,  and  scab ; 
and  when  the  stage  of  pustulation  has  been  reached  a  secondary  fever 
develops.  During  the  following  remission  of  fever  the  headache,  lumbar 
pains,  etc.  subside.  The  fever  of  suppuration  Avhich  then  succeeds  is 
accompanied  once  more  by  marked  constitutional  disturbances,  particu- 
larly nervous  derangements  (wild  delirium,  etc.),  and  at  this  time  com- 
plications are  also  apt  to  develop.  On  the  eighth  or  ninth  day  of  the 
eruption  (the  twelfth  or  thirteenth  day  of  the  disease)  the  pustules  begin 
to  dry  up,  forming  yellow  crusts ;  the  redness  and  swelling  of  the  skin 
subside ;  and  two  or  three  days  later  the  scabs  loosen  and  are  thrown 
off.  During  this  stage  the  fever  again  declines  in  company  with  the  con- 
stitutional symptoms,  and  convalescence  ensues.  As  previously  stated, 
when  suppuration  involves  the  true  skin  scars  are  the  inevitable  result, 
and  these  remain  to  the  end  of  life.  The  hair  drops  off  sometimes^  even 
to  the  extent  of  total  alopecia,  but  is  generally  renewed. 

Leading  Symptoms  and  Complications. — («)  Eruption. — As  before 
stated,  the  eruption  makes  its  appearance  at  the  end  of  the  third 
or  on  the  fourth  day,  coming  out  first  upon  the  forehead,  particularly 
along  the  border  of  the  hairy  scalp,  and  spreading  in  a  downward  direc- 
tion in  regular  progression.  It  appears  in  the  form  of  slightly  elevated 
maculae,  which  are  at  first  of  a  pale-red  color,  and  later  assume  a  darker 
red  hue,  resembling  small  fleabites.  These  increase  in  size  during  the 
next  forty-eight  hours,  at  the  end  of  which  period  they  are  developed 
into  (1)  papules.  The  change  of  character  is  accompanied  by  itching 
and  burning  of  the  skin-surface.  To  the  feel  they  are  papular — like 
shot  under  the  skin — and  if  the  finger-tips  be  rubbed  over  them  lightly 
they  are  distinctly  satin-like.  The  eruption  is  always  most  abundant 
upon  the  face  and  scalp,  while  the  hands  and  fingers  are  the  next  most 
favored  seats.  At  the  end  of  the  third  day  (the  sixth  day  of  the  disease) 
the  conical  apices  of  the  papules  contain  liquid,  forming  thus  (2)  vesicles. 
The  latter  increase  in  size  till  the  entire  papule  is  converted,  at  the  same 
time  acquiring  more  and  more  decidedly  a  central  umbilication.  Punc- 
turing a  vesicle  does  not  cause  it  to  collapse,  but  allows  only  a  small  por- 
tion of  its  liquid  contents  to  escape,  owing  to  its  reticulated  character. 
As  the  vesicle  increases  in  size  its  contents  become  opaque,  and  in  three 
days  more,  or  about  the  sixth  of  the  eruption,  the  vesicles  become  (3) 
pustules.  Umbilication  now  disappears,  and  the  pustule  looks  full  and 
well  rounded,  and  is  surrounded  by  a  red  border  or  "halo."  If  the 
pocks  be  close  set,  as  on  the  face,  wrists,  and  fingers,  the  intervening 
skin  is  inflamed  and  sAvollen  and  the  itching  and  burning  become  almost 
intolerable.  The  pustules  may  coalesce  along  their  edges,  and  thus  the 
eruption  becomes  confluent.  The  eyes  are  closed  as  the  result  of  swell- 
ing and  tumefaction  of  the  face,  and  the  hands  and  feet  assume  a  rounded, 


220 


INFECTIOUS  DISEASES. 


ball-like  appearance.  The  face,  as  a  whole,  is  markedly  misshapen  and 
is  ultimately  disfigured.  When  the  pus  is  not  liberated  (a  comparatively 
rare  event),  its  desiccation  begins  on  the  ninth  day  (the  twelfth  day  of 
the  aifection) :  if  the  pustule  is  ruptured  earlier  (as  when  confluence 
occurs),  it  begins  at  an  earlier  day.  (4)  The  scabs  now  form,  and  remain 
until  about  the  twelfth  day  of  the  eruption,  and  when  pits  or  scars  result 
thev  are  at  first  distinctly  hyperemic,  but  gradually  fade  until  at  last  they 
remain  as  permanent  whitish  spots. 

The  eruption  upon  the  mucous  membrane  develops  simultaneously  with 
that  of  the  skin,  and  among  favorite  surfaces  for  its  appearance  are  (as 
pointed  out  under  Etiology)  the  mouth,  tongue,  soft  palate,  and  pharynx 
(causing  dysphagia),  the  nasal  chambers  (causing  coryza),  the  larynx 
(causing  hoarseness),  the  trachea  and  bronchi  (causing  bronchitis).  This 
mucous  efflorescence  does  not  proceed  to  the  development  of  pustules,  but 
forms  ordinary  ulcers  as  a  consequence  of  early  maceration  of  the  super- 
ficial lavers  of  the  mucosa,  and  these  ulcers  also  may  become  confluent. 

The  skm  also  presents  certain  complications  that  ai-e  always  secondary 
and  are  deserving  of  mere  mention  (erysipelas,  abscess,  gangrene,  bed- 
sores, etc.). 

{b)  The  Fever. — The  temperature  at  the  onset  rises  rapidly,  and  may 
touch  103°  or  104°  F.  (40°  C.)  on  the  first  day,  its  range  being  high 
and  of  the  continued  type  during  the  invasion  period.  Evening  tem- 
peratures of  105°  F.  (40.5°  C.)  or  higher  may  be  observed,  and  in  three 
days  (or  with  the  first  appearance  of  the  papules)  the  temperature  remits, 
but  does  not  intermit  in  true  variola.  It  remains  at  a  low  elevation  till 
the  stage  of  suppuration  is  reached,  when  a  fresh  rise,  sometimes  to  its 


Fig.  21.— Temperature-chart  of  a  case  of  variola,  from  a  patient  iu  the  Municipal  Hospital,  Phila- 
delphia.   A.  F ,  aged  three  years;  not  vaccinated. 

original  height,  occurs.  This  secondary  fever-curve  is  apt  to  show  a 
decided  irregularity,  with  exaggerated  points  of  elevation  and  deep  re- 
missions. The  latter  may  be  due  to  complications,  but  are  most  gener- 
ally the  result  of  septic  absorption  (the  fever  of  suppuration).  This 
period  lasts  from  one  to  three  or  four  days  in  typical  cases.  AYhen  desic- 
cation of  the  pustules  begins  defervescence  also  commences,  and  proceeds 
in  a  gradual  manner  by  lysis.  There  may  be  a  post-variolous  rise,  and 
if  so  its  presence  is  to  be  attributed  to  some  sequel  or  other. 


VARIOLA.  221 

(c)  The  Circulatory  System. — The  pulse  is  soft  and  much  accelerated 
(100  to  130)  and  of  good  volume  during  the  invasion  stage.  It  is  slower 
during  the  period  of  remission,  only  to  be  greatly  increased  in  frequency 
during  the  second  stage  of  fever.  During  the  latter  period  it  may,  owing 
to  cardiac  failure,  become  very  rapid,  much  enfeebled,  and  finally  irregu- 
lar or  even  intermittent.  The  pulse-rate  will  vary  according  to  differ- 
ences in  the  previous  general  condition  of  the  individual.  Simple  endo- 
carditis rarely,  and  pericarditis  somewhat  more  frequently,  occur  as 
complications. 

(d)  Respiratory  Tract. — The  laryngitis  and  pharyngitis  Avhich  are  due 
to  the  presence  of  pocks  in  the  mucosa  of  the  respiratory  passages  have 
already  been  mentioned.  The  most  serious  events,  however,  connected 
with  the  respiratory  system  originate  in  secondary  infections,  if  we  except 
laryngeal  jjerichondritis  with  edema  of  the  glottis,  the  latter  perhaps 
being  the  result  of  a  direct  extension  of  the  pock-ulcers  to  the  perichon- 
drium. Chief  among  the  secondary  complications  is  broncho-pneumonia 
(inhalation  pneumonia),  and  lobar  pneumonia  also  occurs,  though  rarely. 
Pleurisy,  however,  is  not  infrequent,  particularly  as  an  associated  condition 
in  broncho-pneumonia. 

(e)  The  Digestive  System. — A  frequent  seat  of  the  variolous  efflorescence 
is  in  the  buccal  and  pharyngeal  mucosae,  where  it  causes  exceedingly  un- 
pleasant symptoms  {vide  ante).  It  may  also  be  an  agency  in  predisposing 
to  a  secondary  inflammation  in  adjacent  organs — e.g.  suppurative  otitis 
media,  suppurative  parotitis,  pseudo-diphtheria,  etc.  Palpation  almost 
always  shows  an  enlarged  spleen,  and  not  infrequently  an  enlarged  liver. 
The  vomiting  which  is  usual  at  the  onset  is  not  due  to  the  presence  of 
pocks  in  the  stomach,  but  to  a  catarrhal  condition  of  the  organ.  Consti- 
pation is  common,  but  diarrhea  is  also  sometimes  met  with,  being  excited 
by  a  catarrh  of  the  large  intestine,  and  is  especially  common  in  children. 
The  pocks  may,  however,  be  found  in  the  rectum,  where  they  sometimes 
excite  dysenteric  symptoms. 

(/)  The  Nervous  Symptoms. — The  chief  of  these  have  been  already 
pointed  out,  as  well  as  the  fact  that  complications  and  sequelae  are  by  no 
means  rare.  Violent  delirium  (previously  referred  to)  may  be  followed 
by  fatal  coma,  and  in  children  convulsions  may  be  seen.  Yery  rarely 
paraplegia  has  been  observed  during  the  attack,  though  it  is  more  com- 
mon during  the  convalescence,  and  is  then  due  to  different  causes,  such  as 
peripheral  neuritis  and  disseminated  myelitis  (Westphal).  Multiple  neur- 
itis may  be  a  sequel  or  the  phai'yngeal  nerve  may  alone  be  affected. 
Among  other  conditions  rarely  arising  during  convalescence  are  insanity, 
epilepsy,  and  hemiplegia. 

(^)  The  joints  may  be  swollen  and  painful  after  small-pox,  the  con- 
dition being  secondary  and  rheumatic  in  nature,  and  in  rare  cases  peri- 
ostitis may  be  observed. 

(A)  Renal  Symptoms. — Apart  from  the  febrile  albuminuria  already  re- 
ferred to,  renal  complications  are  of  great  rarity,  and,  with  one  exception 
(hemorrhagic  nephritis),  are  of  little  practical  import.  Hemorrhagic 
nephritis  may  occur,  and  is  always  of  a  serious  character,  though,  for- 
tunately, it  is  very  rare. 

{%)  The  Special  Senses. — The  pustules  may  form  upon  the  conjunctivae 
and  eyelids,  and  several  important  conditions  result  from  this  variolous 


222  INFECTIOUS  DISEASES. 

involvement  of  the  eye — viz.  conjunctivitis,  keratitis,  choroiditis,  and 
panophthalmitis.  Hebra  met  with  ocular  complications  in  1  per  cent,  of 
5000  cases  of  small-pox.     Otitis  media  has  already  been  mentioned. 

Special  Clinical  Forms. — There  are  two  unusual  types  of  variola 
that  are  important  in  being  severer  than  the  moderate  (discrete)  form 
already  described. 

(a)  The  Confluent  Form. — This  is  the  result  of  an  abnormally  severe 
infection,  but  cannot  be  said  truly  to  be  atypical.  The  ushering-in 
symptoms  are  very  severe,  and  the  eruption  may  appear  as  early  as,  or 
even  before,  the  third  day,  when  the  temperature  remits,  though  not  to 
any  great  degree.  The  separate  papules  are,  perhaps,  somewhat  smaller 
than  in  the  discrete  variety,  and  vastly  more  abundant  and  close-set ;  and 
after  the  stage  of  pustule  is  reached  the  face  and  hands  present  an  unin- 
terrupted area  of  suppui'ation.  The  deformity  of  the  countenance  is 
correspondingly  pronounced.  Naturally,  the  local  symptoms  are  intense 
and  the  fever  and  its  concomitants  are  in  exact  proportion.  The  nervous 
STjmptoms  often  predominate.  Salivation  is  frequent,  and  vomiting  is 
excessive  in  adults,  while  diarrhea  is  equally  so  in  children.  The  erup- 
tion may  also  entirely  cover  the  mucous  snrfices.  The  lymphatics  of  the 
neck  may  be  greatly  swollen — a  circumstance  that  contributes  to  the 
patient's  unparalleled  disfigurement.  The  various  complications  previously 
adduced  are  of  comparatively  frequent  occurrence,  and  following  these  a 
general  pyemic  process  may  then  develop.  When  death  occurs  it  is 
usually  preceded  by  the  development  of  the  symptoms  that  belong  to  the 
typhoid  state  (typhomania,  tremors,  subsultus  tcndinum,  a  rapid,  feeble 
pulse,  dry,  brown  tongue,  and  diarrhea).  On  the  other  hand,  if  recovery 
ensues,  it  is  tardy  and  often  interrupted  by  complications  and  sequelae. 

(b)  Black  Small-pox. — In  this  form  the  blood  is  much  changed,  so  that 
hemorrhages  into  the  skin,  mucous  membranes,  and  various  viscera  occur. 
It  is  important  to  distinguish  several  sub-varieties,  as  follows :  (1)  A 
benign  form,  in  which  blood  is  infused  into  the  pustules  Avhen  patients  are 
allowed  to  leave  their  bed  too  early  in  convalescence.  Here  the  condition 
is  due  to  the  eifect  of  gravitation,  and  hence  is  confined  almost  solely  to 
the  lower  extremities.  (2)  Doubtless  the  ordinary  variolous  eruption  may 
become  slightly  hemorrhagic  without  aggravating  the  constitutional  con- 
dition. Often  this  is  seen  in  debilitated  and  intemperate  subjects.  (3) 
In  the  same  class  of  subjects  a  dangerous  hemorrhagic  tendency  may  be 
manifested.  During  any  of  the  eruptive  stages — papular,  vesicular,  or 
pustular — hemorrhages  may  occur  into  the  eruption,  and,  moreover,  free 
bleedings  may  take  place  from  the  various  mucous  surfaces  (hematuria, 
epistaxis,  hematemesis,  entei'orrhagia,  etc.).  The  initial  symptoms  are 
usually  intense,  the  eruption  abundant,  and  in  consequence  of  the  hemor- 
rhages collapse  often  occurs.  The  most  serious  complications,  pneumonia, 
diphtheria,  and  nephritis  (followed  by  uremia),  are  also  apt  to  develop 
and  terminate  life,  and  even  should  recovery  ensue  it  is  very  tedious. 
This  and  the  subsequent  sub-variety  are  truly  anomalous.  (4)  A  not 
uncommon  form  of  hemorrhagic  variola  is  met  with  in  which  the  acute 
hemorrhagic  diathesis  develops  during  the  period  of  invasion.  Its  onset 
is  characterized  by  the  usual  symptoms  intensified,  and  as  early  as  the 
second  day  ecchymotic  patches  appear  upon  the  skin-surface  and  grow 
rapidly  by  peripheral  extension,  the  mucous  surfaces  also  showing  more 


VAEIOLA.  223 

or  less  extensive  ecchymoses.  The  regular  variolous  eruption  rarely  ap- 
pears, though  occasionally  shot-like  papules  may  be  detected  here  and 
there.  The  temperature  may  be  slightly  elevated,  but  is  rarely  high, 
and  not  infrequently  it  may  remain  normal  or  subnormal.  Death  often 
occurs  before  the  time  for  the  appearance  of  the  characteristic  eruption, 
and  very  rarely  does  the  patient  survive  the  fourth  or  fifth  day. 

There  are  also  varieties  of  small-pox  that  pursue  an  abnormally  mild 
course.  Of  these  (c)  varioloid  deserves  first  place.  By  this  term  is  usually 
meant  small-pox  occurring  in  individuals  who  have  been  protected  by  a 
successful  vaccination,  but  it  may  also  be  the  result  of  natural  insuscepti- 
bility. Hence  variola  and  varioloid  are  one  and  the  same  affection,  the 
latter  name,  however,  representing  a  milder  form  of  the  disease  than  the 
former.  The  initial  symptoms  of  varioloid  do  not  differ  either  in  charac- 
ter or  severity  from  those  of  true  variola,  but  the  general  course  of  the 
attack  is  peculiarly  prone  to  manifest  irregularities.  In  the  pre-eruptive 
stage  an  erythematous  rash  is  very  common,  and  its  appearance  is  regarded 
by  many  as  being  of  value  in  discriminating  varioloid  from  variola. 

When  the  regular  eruption  appears  the  fever  falls  to  normal  and  re- 
mains there.  The  rash  comes  out  by  the  end  of  the  first  or  on  the  second 
day,  the  papules  being  scanty,  and  quite  as  liable  to  appear  first  upon  the 
trunk  as  upon  the  face.  They  are  identical  with  the  papules  of  variola,  as 
is  true  also  of  the  vesicles ;  but  pustulation  rarely  develops,  for  the  reason 
that  resolution  takes  place,  as  a  rule,  before  the  latter  stage  is  reached. 

The  secondary  fever  is  either  very  slight  or  entirely  wanting.  The 
mucous  surfaces  are  affected  but  to  a  correspondingly  slight  degree,  and 
thus  the  general  course  of  the  disease  is  characterized  by  irregularity. 
Papules  and  vesicles  may  be  found  in  close  proximity ;  not  so  in  variola. 
Desiccation  begins  between  the  fifth  and  seventh  days  of  the  eruption 
(the  eighth  and  tenth  of  the  disease),  and  hence,  as  compared  with  variola, 
the  course  is  cut  short  and  serious  complications  almost  never  occur. 

{d)  An  abortive  form  is  occasionally  observed.  It  is  characterized  by 
the  great  intensity  of  the  invasion  symptoms,  but  these  promptly  subside, 
and  the  patient  enters  at  once  upon  a  stage  of  speedy  recovery. 

An  exceedingly  mild  type  may  arise  during  seasons  of  epidemic  preva- 
lence of  the  disease,  either  with  or  without  a  scanty  and  undeveloped  erup- 
tion, when  the  diagnosis  is  made  entirely  from  the  etiologic  circumstances. 

Diagnosis. — With  a  clear  history  and  the  presence  of  the  character- 
istic features  a  positive  diagnosis  is  a  simple  problem.  But  at  any  period 
before  the  papules  are  fully  developed  it  may  be  confounded  with  certain 
other  acute  infectious  diseases,  notably  cerebro-spinal  meningitis,  pneu- 
monia, typhus  fever,  scarlatina,  and  measles. 

Differential  Diagnosis. — In  typhus  fever  the  onset  is  very  like  that  of 
small-pox.  The  former  may,  however,  be  distinguished  by  its  peculiar 
etiologic  factors,  especially  its  origin  by  importation  or  its  non-prevalence 
in  the  vicinity  ;  the  appearance  of  the  eruption,  first  upon  the  trunk  (chest 
and  abdomen)  in  the  form  of  maculae,  and  later  becoming  petechial ;  and 
by  the  fact  that  it  is  neither  papular,  vesicular,  nor  pustular,  as  in  small- 
pox. Moreover,  in  typhus  the  temperature  does  not  remit  with  the  appear- 
ance of  the  eruption,  but  persists,  and  may  even  rise  higher. 

From  hemorrhagic  small-pox  typhus  is  sometimes  distinguished  with 
great  difiiculty.     In' the  most  virulent  type  of  the  former  death  often 


224  INFECTIOUS  DISEASES. 

occurs  before  the  eruptive  stage  is  reached.  When  it  does  not,  the  causal 
data  are  most  important  factors  in  making  a  discrimination.  In  typhus 
shot-like  papules  are  never  detected  upon  the  skin-surface  of  the  hands 
and  head,  whereas  they  are  sometimes  found  in  hemorrhagic  small-pox. 

The  diagnosis  from  scarlatina  may  early  be  made  from  the  erythema- 
tous (scarlatinous)  rash  Avhich  often  precedes  the  appearance  of  the  vario- 
lous eruption.  This  is,  as  a  rule,  neither  so  intense  nor  so  uniformly  dis- 
tributed over  the  skin-surface  of  the  body  as  in  true  scarlatina. 

Lobar  jjneumonia  begins  with  many  of  the  symptoms  that  character- 
ize the  initial  stage  of  small-pox,  but  in  addition  there  are  sharp  pain  in 
the  side,  cough  with  rusty  sputum,  acceleration  of  the  respirations  out  of 
proportion  to  the  temperature  and  pulse,  and  the  cheeks  are  bedecked 
with  the  typical  mahogany  flush. 

Meniiu/itis  may  be  eliminated  if  the  patient  has  been  exposed  to  small- 
pox, and  if,  being  unprotected  by  vaccination,  he  suddenly  develops  the 
symptoms  of  the  initial  stage  of  this  disease — severe  rigor  with  high  fever 
and  intense  pain  in  the  loins.  To  confirm  the  discrimination  from  men- 
ingitis we  may  note  the  absence  of  involvement  of  the  ankles  and  other 
joints,  the  irregular  temperature-curve,  the  herpes  and  opisthotonos,  and 
marked  hyperesthesia. 

The  macular  stage  of  the  eruption  may  be  confounded  with  measles. 
The  absence  of  the  characteristic  prodromes  and  symptoms  of  invasion 
belonging  to  the  latter  disease,  the  redness  and  swelling  of  the  conjunctivae, 
the  photophobia  and  marked  coryza,  the  stubborn  cough,  and  increased 
fever  after  the  eruption  appears,  make  the  separation  easy.  In  measles 
the  maculae  do  not  develop  into  hard,  shot-like,  conical  papules  as  in 
variola. 

Nothing,  however,  could  be  more  difiicult  than  to  differentiate  certain 
mild  cases  of  discrete  small-pox  (in  the  non-vaccinated)  and  varioloid 
from  varicella.  In  the  table  below,  however,  may  be  found  a  few  con- 
ti-asted  points  of  distinction,  which,  I  trust,  may  prove  helpful : 

Variola.  Varicella. 

History. 
Absence  of  previous  attack.  Same. 

Previous  or  present  case  in  the  vicinity.         Traceable  to  previous  or  present  case  of 

varicella. 
Not  successfully  vaccinated.  Negative. 

Occurs  at  any  age.  Almost  always  in  childhood. 

Characteristic  pre-eruptive  stage  —  rash      Eruption  not  preceded  by  prodromes, 
on  the  third  day. 

Eruption. 
Appears  first  upon  the  forehead,  extend-      Appears  first  upon  the  neck  and  trunk — 

ing  downward.  no  regular  progression  over  the  body. 

Vesicles  uniform  in  size,  umbilicated,  and       Vesicles  vary   much  in  size,  are   rarely 
deeper  seated.  umbilicated,  and  are  more  superficial. 

Eruption  contains  serum,  later  pus.  Only  serum. 

Most  abundant  on  face  and  fingers.  Most  abundant  upon  back  and  lower  ex- 

tremities. 
Various  stages  of  eruption  observed  at      Various  stages  side  by  side. 

points  removed  from  each  other. 
Pin-prick  does  not  cause  collapse  of  ves-      Does  cause  collapse,  being  unicellular, 
icles,  being  multicellular. 

Secondary  Fever. 

Usually  present.  Absent. 


VARIOLA.  225 

Prognosis. — The  prognosis  depends  upon  (a)  the  degree  of  severity 
of  the  type,  whether  mild  or  intense,  the  severer  forms  (confluent  and 
certain  of  the  hemorrhagic)  being  grave.  The  hemorrhagic  variety,  in 
which  large  cutaneous  ecchymoses  suddenly  develop,  is  almost  invariably 
fatal,  and  often  before  the  cases  have  advanced  to  the  eruptive  stage.  The 
aggregate  number  of  pocks  that  appear  and  the  gravity  of  the  infection 
are,  as  a  rule,  proportionate. 

(b)  The  prognosis  is  modified  by  individual  peculiarities  (age,  race,  in- 
temperance, etc.).  Thus  it  is  much  more  fatal  in  the  very  young  than  in 
older  subjects,  much  more  fatal  in  dark-  than  light-complexioned  races, 
more  fatal  in  the  intemperate  than  in  the  temperate,  and  so  on. 

(c)  Complications  increase  the  death-rate  considerably.  Of  these, 
broncho-pneumonia,  lobar  pneumonia,  acute  nephritis  with  uremia,  septico- 
pyemic conditions,  pseudo-diphtheritic  angina,  and  pericarditis  are  most 
potent  for  evil.  Among  the  foremost  serious  symptoms  may  be  mentioned 
excessive  vomiting,  wild  delirium,  coma,  a  temperature  of  106°  F.  (41.1° 
C.)  or  over,  urgent  diarrhea,  and  dysentery. 

The  death-rate  has  been  computed  to  be  between  15  and  30  per  cent., 
varying,  however,  with  each  epidemic,  and  thus  rendering  an  exact  esti- 
mate out  of  the  question. 

Treatment. — The  varied  indications  in  the  treatment  of  small-pox 
will  be  considered  separately  : 

(1)  Prophylaxis. — The  rules  that  have  been  laid  down  elsewhere 
(vide  Treatment  of  Typhoid  Fever)  for  disinfection  in  infectious  diseases 
must  be  rigidly  enforced  in  this  affection.  Quarantine  (public  and  pri- 
vate) must  be  secured  if  the  deadly  progress  of  small-pox- is  to  be  averted, 
and  it  would  seem  altogether  unnecessary  to  adduce  arguments  to  show  the 
correctness  of  this  dictum.  In  the  homes  of  the  poorer  classes,  however, 
and  even  in  those  of  the  higher,  absolute  isolation  cannot  be  carried  out 
successfully,  and  in  view  of  this  fact  special,  well-equipped  hospitals 
should  be  provided  for  the  reception  of  the  disease.  Without  a  rigid  en- 
forcement of  these  hygienic  rules  the  spread  of  small-pox  cannot  be  pre- 
vented. It  is  important  also  to  remember  that  persons  who  have  been 
afflicted  with  the  disease  cannot,  with  safety  to  others,  resume  their  former 
places,  either  in  the  family  or  in  society  at  large,  before  they  are  completely 
convalescent.  The  best  means  of  prevention,  however,  is  vaccination, 
and  this  subject  will  receive  separate  consideration  (vide  p.  229). 

(2)  G-eneral  Management. — Apart  from  perfect  isolation  and  thorough 
disinfection,  there  are  other  hygienic  requirements  that  must  be  complied 
with.  The  room  occupied  by  the  patient  should  be  large  and  freely  ven- 
tilated (an  essential  matter,  though  strong  drafts  are  to  be  avoided),  and 
all  carpets,  curtains,  and  articles  of  furniture  not  absolutely  needful 
should  be  removed. 

The  diet  is  an  element  of  treatment  that  demands  most  careful  atten- 
tion, and  should  be  varied  according  to  the  stage  of  the  affection.  During 
the  initial  stage  it  must  be  restricted  to  liquid  nourishment  (milk,  animal 
broths,  etc.),  and  in  addition  cooling  drinks,  including  ice,  lemonade,  and 
other  of  the  various  fruit-juices  (diluted).  During  the  stage  of  remission 
of  fever  we  may  add  soups,  jellies,  eggs,  toast,  etc.,  and  with  the  onset  of 
the  stage  of  suppuration  a  supportive  diet,  reinforced  by  the  judicious  use 
of  stimulants,  is  a  highly  essential  part  of  the  treatment.     Light  forms 

15 


226  INFECTIOUS  DISEASES. 

of  nourishment  must  now  be  given  in  definite  quantities  at  short  inter- 
vals. When  little  nutriment  can  be  taken  there  exists  a  clinical  indica- 
tion for  the  free  use  of  alcohol. 

(8)  The  fever  and  associated  symptoms  during  the  invasion  stage  are 
best  controlled  by  the  cold  or  gradually  cooled  baths,  which  possess  all 
the  advantages  in  this  disease  that  they  command  in  typhoid  fever.  Their 
eflfectiveness,  together  with  the  fact  that  in  some  of  the  various  forms  of 
variola  the  temperature-chart  registers  a  normal  or  even  a  subnormal 
grade  of  body-heat,  shows  the  fallacy  of  regarding  temperature  as  the 
sole,  or  even  the  chief,  indication  for  the  use  of  the  Brand  method.  Cold 
sponge-baths,  the  ice-cap,  or  the  cold  pack  may  be  resorted  to  if  cold 
immersion  baths  are  not  accessible  to  the  patient.  The  internal  antipy- 
retics must  be  given  with  a  sparing  hand,  if  at  all,  and  should  be  em- 
ployed as  antiseptic  agents  rather  than  as  direct  antipyretics,  on  account 
of  their  depressing  effect. 

The  therapy  of  this  stage  also  embraces  the  treatment  of  certain 
symptoms.  The  vomiting  may  be  incessant  and  exhausting,  and  chipped 
ice,  champagne,  dilute  hydrocyanic  acid,  and  cocain  hydrochlorate  should 
be  tried  in  the  order  mentioned.  If  diarrhea  be  severe,  it  should  be 
checked  (though  neither  wholly  nor  suddenly)  by  the  use  of  arsenite  of 
copper,  the  acetate  of  lead  (gr.  ij — 0.1296)  and  opium  (extr.,  gr.  i — 
0.0162),  in  combination,  or  by  bismuth  salicylate  (gr.  v — 0.324)  and 
/9-naphtol  (gr.  iij — 0.1944).  The  nervous  symptoms  are  usually  re- 
strained by  the  cold-bath  treatment,  but  occasionally  a  wild  delirium 
may  necessitate  further  therapeutic  interference,  and  at  such  times  a  com- 
bination of  sodium  bromid  (gr.  x-xv — 0.648-0.972)  with  the  deodor- 
ized tincture  of  opium  (TtLv — 0.333),  given  every  two  or  three  hours,  is 
of  signal  value.  Very  often  the  wise  administration  of  stimulants  re- 
moves all  necessity  for  the  use  of  further  means  of  overcoming  the  ner- 
vous symptoms,  and  in  maniacal  delirium  ether  may  be  cautiously  admin- 
istered with  great  benefit.  The  catheter  must  be  used  if  retention  of 
urine  should  occur.  For  the  intense  pains  that  belong  to  this  stage  no 
other  remedy  can  be  compared  with  morphin  sulphate  (gr.  ^  to  I — 0.008 
to  0.016),  to  be  administered  hypodermically,  and  repeated  if  neces- 
sary ;  this  measure  also  ensuring  good  sleep,  which  would  be  otherwise 
impossible. 

(4)  As  previously  stated,  the  eruption  appears  with  the  termination  of 
the  initial  febrile  period,  and  deserves  the  closest  attention.  The  indica- 
tions are  twofold :  (a)  to  limit  the  eruption  as  far  as  is  possible,  and  (b) 
to  modify  its  course,  so  that  extensive  suppuration  and  consequent  dis- 
figurement may  be  prevented.  Ablutions  with  lukewarm  water,  to  which 
may  be  added  some  antiseptic  (carbolic  acid  and  glycerin,  or,  better,  a 
mercuric-chlorid  solution — 1  :  5000  or  1  :  10,000)  Avill  be  found  of  great 
use.  To  prevent  pitting  many  local  applications  have  been  used.  For- 
merly, a  common  mode  of  treatment  was  to  open  the  pustules  as  early 
as  possible  and  touch  them  with  silver  nitrate — either  in  the  solid  stick 
or  brushed  over  in  a  strong  aqueous  solution.  Painting  the  skin  with 
the  tincture  of  iodin  was  a  practice  frequently  followed  in  the  past.  The 
formula  of  Schwimmer,  herewith  given,  gave  excellent  results  in  a  case 
of  my  own  : 


VARIOLA.  '  227 

^.  Acid,  carbolici,  4.0-10.0; 
01.  olivse,  40.0 ; 

Cretse  prseparat.,  60.0. 

M.  et  ft.  pastamollis. 

It  has  been  recommended  to  touch  each  pustule  with  carbolic  acid,  and 
then  to  apply  this  agent  in  equal  parts  with  the  oil  of  thyme  (San- 
som).  It  is  important  that  only  a  certain  proportion  of  the  pustules 
be  touched  at  once ;  this  to  be  followed  by  an  equal  number  on  suc- 
cessive occasions.  The  parts  must  be  kept  aseptic  and  clean,  while 
irritation  from  scratching,  etc.  must  be  carefully  avoided.  Moore  and 
Fingen  have  recommended  the  use  of  red  curtains  or  shades  to  cut 
out  certain  chemical  rays.  J.  Moir,^  from  an  experience  with  4000 
cases,  increases  the  elasticity  of  the  skin  by  rubbing  it  with  oil  early 
in  the  disease. 

During  convalescence,  or  as  soon  as  the  general  condition  of  the 
patient  will  admit  of  it,  warm  baths,  with  the  free  use  of  carbolic  soap, 
are  to  be  given  at  intervals  of  two  days  until  several  baths  have  followed 
the  separation  of  the  crusts.  Any  cutaneous  sequelge  that  may  present 
tTiemselves  must  be  attacked  in  accordance  with  ordinary  principles. 

(5)  The  Period  of  Remission  of  Fever. — There  are  very  rarely  any 
symptomatic  indications  apart  from  those  presented  by  the  eruption.  It 
is  of  first  importance,  however,  to  thoroughly  support  the  powers  of  the 
system  by  means  of  tonics,  and  especially  by  quinin,  in  addition  to  an 
appropriate  diet  and  the  moderate  use  of  stimulants. 

(6)  The  Suppurative  Stage. — All  measures  tending  to  support  the 
strength  of  the  patient  are  needed — the  mineral  acids,  with  the  elixir  of 
calisaya,  quinin,  strychnin,  etc.  Stimulants  are  often  required,  and  it 
may  become  necessary  to  give  them  unsparingly,  the  character  of  the 
pulse  and  of  the  first  sound  of  the  heart,  as  well  as  the  nervous  symp- 
toms, being  the  physician's  guides.  Gradually  cooled  baths  of  the  usual 
duration  or  warm  baths  somewhat  more  prolonged  give  excellent  results. 
In  this  stage  certain  symptoms  may  require  special  treatment.  The 
ulcers  in  the  mouth  and  throat  are  best  relieved  by  the  use  of  a  saturated 
solution  of  chlorate  of  potash  in  water  as  a  gargle  or  in  the  form  of  an 
atomizer  spray.  Ice  allowed  to  melt  in  the  mouth  is  also  valuable. 
Hemorrhages  demand  prompt  interference,  and  full  doses  of  ergot  must 
be  given  subcutaneously.  Internally,  large  doses  of  the  tincture  of  the 
chlorid  of  iron,  gallic  acid,  the  mineral  acids,  or  turpentine  may  be 
administered. 

The  complications,  as  before  intimated,  are  not  numerous,  and  are  for 
the  most  part  secondary  in  nature.  Those  connected  with  the  respiratory 
passages  should  be  prevented  if  possible,  and,  owing  to  the  fact  that  they 
indicate  danger,  should  receive  active  treatment  if  they  occur.  By  fre- 
quently changing  the  position  of  the  patient  when  bronchitis  is  present, 
and  by  encouraging  him  to  cough  frequently,  as  well  as  by  the  timely 
use  of  stimulants  and  the  proper  care  of  the  mouth,  pulmonary  complica- 
tions can  often  be  obviated.  Should  lobular  pneumonia  occur,  the  plan 
of  treatment  which  is  likely  to  meet  with  most  success  may  be  briefly  put 
thus :  Free  stimulation,  the  assiduous  use  of  cold  sponges  or  gradually 
'  Edinburgh  Medical  Journal,  June,  1898. 


228  INFECTIOUS  DISEASES. 

cooled  baths,  and  nourishing  foods.  Laryrigeal  perichondritis  with  ede- 
ma of  the  glottis  may  suddenly  demand  tracheotomy.  To  avoid  the  de- 
velopment of  bed-sores  an  air-cushion  or  a  water-bed  should  be  provided, 
if  needful.  Care  should  also  be  exercised  to  prevent  ocular  complications, 
and  their  occurrence  demands  a  vigorous  form  of  supportive  treatment. 
I  have  much  confidence  in  the  use  of  cold  compresses,  instilling  into  the 
eyes  at  the  same  time  a  solution  of  boric  acid  (gr.  x  to  xv — 0.648  to 
0.972— to  f5j  (30.0). 

(7)  Special  Modes  of  Treatment. — These  would  be  found  to  be  numer- 
ous were  we  to  enumerate  all  of  them,  but  only  those  based  on  the  prin- 
ciple of  antisepsis  are  worthy  of  notice.  According  to  one  plan,  which 
has  many  advocates,  antiseptic  agents  are  administered  internally.  The 
remedies  that  have  been  most  frequently  employed  in  this  mannei',  and 
with  perhaps  the  most  promising  results,  are  the  sulphocarbolates,  salol, 
sodium  salicylate,  carbolic  acid,  creasote,  mercuric  chlorid,  and  the  sul- 
phites. Zuelzer  states  that  xylol  given  internally  is  potent  in  coagu- 
lating the  contents  of  the  pustules,  but  experience  does  not  corroborate 
this  opinion. 

Kinyoun,  Lundmann,  and  Bdclere  have  used  the  serum  from  vacci- 
nated subjects  (human  beings  and  the  lower  animals)  or  from  variolous 
patients  in  advanced  stages  of  the  disease  in  the  treatment  of  small-pox. 
The  cases,  however,  are  insufficient  to  warrant  deductions. 

Special  Methods  of  External  Medication. — Dr.  Galewouski^  reports 
brilliant  results  in  the  treatment  of  variola  with  baths  of  potassium  per- 
manganate. The  salt  is  added  till  the  water  is  of  a  rose-red  color,  and 
Galewouski  claims  that  by  its  application  the  temperature  is  lowered,  the 
pustules  disappear,  and  recovery  speedily  ensues.  Talamon^  recommends 
a  special  plan  of  external  medication  in  the  form  of  a  mercuric-chlorid 
spray  for  small-pox  vesicles  and  pustules,  his  object  being  to  keep  the 
surface  under  the  influence  of  an  antiseptic.  The  mercuric-chlorid  solu- 
tion is  prepared  after  the  following  formula  : 

I^.  Mercuric  chlorid,  gr.  xv  (1.0) ; 

Tartaric  acid,  gr.  xv  (1.0); 

Alcohol  (90  per  cent.),  fejss     (6.0) ; 

Ether  to  make  fijss     (45.0). 

Sig.  To  be  applied  as  a  spray  three  or  four  times  daily  for  one 
minute. 

It  is  essential  to  exercise  the  precaution  to  protect  the  eyes,  which  may  be 
covered  by  layers  of  cotton  dipped  into  a  saturated  solution  of  boric  acid. 
Talamon  advises  the  commencement  of  his  method  on  the  first  day  of  the 
eruption,  the  application  to  be  preceded  with  a  vigorous  washing  of  the 
face  with  soap,  which  may  be  rinsed  off  with  boric  acid  and  then  dried 
with  absorbent  cotton.  After  the  spray  has  been  used  the  face  should 
be  covered  Avith  a  layer  of  a  50  per  cent,  glycerolate  of  mercuric  chlorid 
in  order  to  keep  the  skin  continuously  aseptic.  After  the  fourth  day  the 
number  of  sprayings  per  diem  is  gradually  lessened,  so  that  by  the  seventh 
day  they  may  be  discontinued ;  but  the  application  of  the  glycerolate 
should  be  continued. 

1  Med.  Pre.'^s  and  Circular,  1890. 

^  Journal  of  Culaneous  and  Venereal  Diseases,  February,  1891. 


VACCINATION.  229 

Talamon  added,  in  the  confluent  and  other  grave  forms  of  the  disease, 
general  mercuric-chlorid  baths,  lasting  for  three-quarters  of  an  hour  to 
an  hour.  The  buccal  and  pharyngeal  eruption  is  to  be  treated  by  gargles 
and  lotions  of  boric  acid.  Internally,  the  therapy  is  limited  to  sustaining 
the  strength  of  the  patient  by  means  of  alcohol  (siij-iv  ;  90.0-120.0 
daily),  according  to  the  gravity  of  the  case. 


VACCINATION. 


Historic  Note. — One  of  the  first  steps  in  preventive  medicine 
was  the  practice  of  inoculation  as  a  method  of  protection  against  the  in- 
fection of  small-pox.  It  had  been  practised  in  China  and  other  Asiatic 
countries  for  centuries,  and  Lady  Montague,  the  \vife  of  an  English  am- 
bassador to  Turkey,  early  in  the  eighteenth  century  introduced  it  into 
England,  after  Tvhich  time  and  until  vaccination  was  known,  it  was  very 
extensively  practised  there. 

Pus  taken  directly  from  a  small-pox  pustule  was  introduced  beneath 
the  epidermis,  and  the  person  inoculated  developed  variola,  though  in  a 
milder  form  than  when  arising  from  ordinary  infection.  The  attack  ran 
a  more  rapid  course,  having  fewer  pustules,  rarely  terminating  fatally, 
and  protected  the  individual  from  subsequent  attacks. 

The  objections  to  this  method  were  that  it  did  not  always  produce  a 
mild  form  of  variola,  a  small  percentage  of  cases  having  a  fatal  termina- 
tion, and  that,  however  mild  the  attack,  other  unprotected  persons  brought 
in  contact  with  it  were  as  liable  to  contract  small-pox  in  as  virulent  a  form 
as  if  contracted  in  the  usual  way. 

In  a  paper  published  in  1798.  Edward  Jenner,  a  physician  of  Glouces- 
tershire, England,  and  a  pupil  of  John  Hunter,  first  made  known  to  the 
world  the  value  of  vaccination.  Twenty  years  previous  he  had  observed 
that  persons  employed  in  dairies,  who  were  accidentally  inoculated  with 
cow-pox.  were  insusceptible  to  the  contagion  of  small-pox,  and,  after  ex- 
perimenting all  these  years,  he  became  satisfied  that  inoculation  with  the 
vaccine  lymph  was  a  preventive  against  small-pox.  After  the  publication 
of  his  paper  he  was  subjected  to  ridicule  and  abuse  by  the  profession, 
but  through  his  persistence  he  was  finally  allowed  to  practise  his  method 
of  vaccination  in  the  wards  of  a  hospital,  and  in  the  course  of  a  few  years 
it  became  generally  recognized  and  was  practised  in  France  and  America, 
as  well  as  in  England.  Later,  the  method  fell  into  disrepute  for  a  time, 
owing  to  the  fact  that  certain  persons  who  had  been  vaccinated  subse- 
quently contracted  the  disease,  it  not  being  known  then  that  a  revaccina- 
tion  was  necessary  from  time  to  time.  Strange  to  say,  however,  in  the 
century  that  has  passed  since  the  first  vaccination  by  Jenner  there  has 
practically  been  no  change  or  improvement  either  in  the  method  or  the 
vaccine  used. 

Vaccinia,  or  co-w-pox,  is  a  mild  eruptive  disease  that  occasionally 
occurs  among  cattle,  a  similar  disease  being  produced  in  them  by  inocu- 
lation with  the  small-pox  virus  from  man.  It  is  communicable  by  con- 
tact onlv.  and  is  usually  carried  from  one  cow  to  another  by  the  hands  of 
the  milkers ;  hence  being  usually  found  on  the  udder  or  teats  of  milch 


230  INFECTIOUS  DISEASES. 

cows.  Since  Jenner's  time  many  theories  have  been  advanced  as  to  the 
exact  nature  of  this  disease  in  cattle,  and  at  the  present  day  the  subject 
is  still  in  dispute.  It  is  now,  however,  generally  conceded  that  if  cow- 
pox  is  a  distinct  disease,  originating  only  ^Yith  the  cow,  the  eruptive  dis- 
ease produced  in  this  animal  either  by  inoculation  of  small-pox  virus  from 
man  or  of  "grease  "  from  the  horse  is,  at  least  in  all  essential  respects, 
a  disease  not  to  be  distinguished  from  primar}'^  or  idiopathic  vaccinia. 
Guarnieri  has  described  certain  parasitic  organisms,  the  Ci/torectes  Guar- 
nieri,  found  in  corneal  lesions  produced  by  the  injection  of  vaccine  lymph. 
This  observation  has  been  confirmed  by  Pfeiffer  and  others,  but  the 
pathogenic  nature  of  these  protozoa  has  not  been  determined. 

The  vaccine  virus  consists  either  of  the  liquid  contained  in  the  ves- 
icle or  of  the  scab  resulting  from  the  desiccation  of  the  pustule.  The 
former  is  furnished  from  vaccine  farms,  of  which  there  are  several  in  this 
country,  is  then  dried  on  ivory  points,  and,  if  kept  in  a  cool  place,  re- 
tains its  virtue  for  a  week  or  ten  days,  or,  possibly,  longer,  but  should 
be  used  as  fresh  as  possible  to  ensure  a  successful  result.  It  is  also  some- 
times pi'eserved  in  capillary  glass  tubes,  sealed  at  both  ends,  or  between 
glasses,  and  kept  in  this  way  it  is  less  liable  to  infection  through  unclean- 

liness  in  handlino-.     The  scab  from  the  cow  is  not  used. 

•       •       •  1 

The  Site. — The  point  usually  chosen  for  vaccination  is  on  the  arm 

over  the  insertion  of  the  deltoid  muscle  ;  but  in  girls,  for  cosmetic  reasons, 

it  is  sometimes  preferred  on  the  leg,  and  the  most  common  site  is  over  the 

junction  of  the  two  heads  of  the  gastrocnemius  muscle. 

Technique  in  Vaccination. — After  the  part  selected  has  been  rendered 
surgically  clean,  gently  scrape  the  skin  with  an  aseptic  lancet  or  other 
instrument  until  serum  begins  to  exude.  If  by  too  vigorous  scraping 
blood  should  be  drawn,  it  must  be  carefully  dried  with  a  piece  of  sterile 
cotton  before  the  lymph  is  applied.  Hutchins  has  recommended  a  method 
in  vaccination  of  denuding  the  surface  of  the  skin  with  a  caustic  in  place 
of  the  lancet.  A  piece  of  cotton,  as  large  as  the  spot  to  be  denuded,  is 
wet  with  liquor  potassae  and  laid  on  the  skin  for  two  or  three  minutes, 
after  which  the  spot  is  wiped  dry  and  the  softened  epidermis  rubbed 
aAvay  with  an  ink-eraser,  a  piece  of  soft  wool,  or  preferably  a  piece  of 
sterile  gauze  cotton,  when  the  vaccine  is  applied  in  the  usual  way.  The 
advantages  of  this  method  are  its  painlessness  and  the  absence  of  ter- 
rifying instruments  and  bleeding. 

The  charged  end  of  a  point,  which  has  been  previously  dipped  in 
tepid  water,  is  now  gently  rubbed  over  the  abraded  spot  and  the  limb  left 
exposed  to  the  air  until  the  lymph  has  been  dried  upon  it.  It  may  then 
be  protected  by  a  piece  of  gauze  strapped  on  it  or  by  a  shield. 

Humanized  ly)np]i  is  still  preferred  by  some,  and  when  this  is  used  the 
"arm-to-arm"  vaccination  is  best.  The  lymph  is  taken  from  a  character- 
istic vaccine  vesicle  (from  the  fifth  to  the  seventh  day  of  its  development) 
of  a  healthy  child  and  applied  directly  to  the  arm  of  another.  The  virus 
may  be  dried  and  preserved  for  use  as  in  the  case  of  bovine  virus. 

The  scab  resulting  from  a  vaccine  vesicle  on  a  healthy  child  was  for- 
merly quite  generally  used,  and  it  could  be  kept  a  long  time  without 
losing  its  virtue.  It  was  sure  in  its  action,  and  offered  the  advantage  to 
the  physician  of  being  easily  preserved  ;  but  it  was  more  liable  to  become 
infected  than  the  lymph  Avhen  i3reserved  in  the  usual  way,  and,  since  the 


VARICELLA.  231 

vaccine  farms  are  so  conveniently  located,  Ivmph  may  be  obtained  from 
them  at  any  time  without  delay. 

The  possible  danger  of  conveying  syphilis  or  other  constitutional  dis- 
ease from  one  person  to  another  by  means  of  humanized  lymph  should 
lead  to  its  abandonment  in  favor  of  the  bovine  lymph. 

Period  of  Life  for  Vaccination. — It  is  usually  advised  to  vaccinate 
infants  -within  a  few  weeks  or  months  after  birth,  but,  unless  small-pox  is 
prevalent,  it  is  best  to  wait  until  the  latter  part  of  the  second  or  the 
beginning  of  its  third  year,  as  the  child  has  then  passed  through  its 
teething  period  and  will  be  better  able  to  resist  the  effects  (slight  though 
they  may  be)  consequent  upon  vaccination. 

Tiine  for  Revaccination. — To  ensure  the  individual  against  infection 
he  should  be  revaccinated  at  puberty  and  every  few  years  afterward,  or 
at  any  time  when  small-pox  is  epidemic  or  liable  to  become  so. 

Sjrtnptoms. — After  vaccination  no  local  or  constitutional  effects — 
except  the  slight  irritation  due  to  scarification — are  noticed  until  the 
third  day,  when  a  small  red  jKijnile  appears.  By  the  fifth  or  sixth  day 
a  vesicle  appears.  By  the  ninth  day  it  is  fully  developed,  and,  like  the 
vesicle  of  variola,  is  filled  with  colorless  lymph,  is  umbilicated,  multi- 
locular,  and  has  a  distinctly  inflamed  areola  of  deep  red  color,  accom- 
panied by  heat,  itching,  and  tenderness.  By  the  tenth  day  this  may  ex- 
tend an  inch  or  two  from  the  vesicle.  Quite  frequently  the  axillar}'-  or 
inguinal  glands  (depending  upon  the  location  of  vaccination)  are  swollen 
and  tender,  and  in  a  tubercular  child  they  may  go  on  to  suppuration. 
After  the  tenth  day  all  these  symptoms  gradually  decline ;  the  ^^uMide 
dries  up,  and  then  forms  a  brown  scab  which  is  usually  detached  in  the 
third  or  fourth  week,  leaving  a  permanent  cicatrix. 

Complications. — Occasionally  one  or  more  additional  vesicles  are 
formed  at  a  little  distance  from  the  point  of  inoculation,  and,  rarely, 
there  is  a  general  vesicular  eruption,  due  to  absorption  of  the  lymph. 
An  erythematous  rash  is  not  uncommon,  and  appears,  if  at  all,  about  the 
sixth  day.  JErysipelas  may  occur  as  a  complication,  and,  if  it  is  preva- 
lent in  the  house,  vaccination  should,  as  a  rule,  not  be  performed ;  if 
deemed  necessary,  great  care  should  be  taken  to  ensure  cleanliness. 

An  ulcer  may  form  which  may  be  weeks  in  healing.  Eczema  and 
other  skin-aifections  are  usually  aggravated  during  the  cou^rse  of  vaccin- 
ation, and  it  is  possible  for  syphilis  to  be  inoculated  with  the  vaccine 
virus.     Any  of  these  complications  call  for  the  usual  treatment. 


VARICELLA. 

(  Chicken-pox. ) 


Definition. — An  acute,  contagious  disease,  characterized  by  a  cutane- 
ous eruption  of  papules,  passing  into  vesicles  and  pustules ;  also  by  slight 
fever  and  mild  constitutional  symptoms.  For  a  long  time  it  was  con- 
founded with  varioloid,  but  its  distinct  character  has  now  been  recognized 
for  many  years.      Complications  and  sequelse  are  infrequent, 

Ktiologfy. — It  is  well  established  that  the  contagium  of  varicella  is 
found  in  the  vesicles,  as  the  disease  has  been  communicated  by  actual 


232  INFECTIOUS  DISEASES. 

inoculation  with  their  contents.  The  specific  poison  has  not  been  satis- 
factorily isolated,  although  it  is  suspected  that  certain  protozoa  are  the 
direct  cause,  but,  as  in  the  case  of  vaccinia  and  small-pox,  positive  proof 
is  wanting.  Varicella  may  be  transmitted  by  exposure  to  another  case 
or  possibly  through  the  medium  of  a  third  person,  the  school  and  asylum 
being  the  most  frequent  points  of  its  origin.  It  aifects  children  of  all 
ages,  and  usually  one  attack  is  protective.  It  closely  resembles  measles 
in  its  contagiousness. 

Symptoms. — The  incubation  period  is  uniformly  from  fourteen  to 
sixteen  days.  If  there  be  a  prodromal  stage  of  the  disease,  certainly  in 
the  vast  majority  of  cases  it  cannot  be  recognized,  though  a  slight  ferer 
and  general  indisposition  may  be  noticed  for  twenty-four  hours  before  the 
appearance  of  the  eruption.  In  many  cases  the  eruption  is  the  first 
symptom.  This  occurs  in  the  form  of  small  reddish  puncta,  from  which 
rapidly  develop  rosy-colored  maculations,  and  these  become  tensely  dis- 
tended, transparent,  or  slightly  yellowish  vesicles  of  the  average  size  of 
a  split  pea.  The  eruption  appears  first  upon  the  upper  part  of  the  body, 
the  chest  and  back,  neck,  scalp,  and  face  (on  the  latter  quite  sparingly), 
and  always  upon  the  hairy  scalp.  Frequently  the  vesicles  form  on  the 
mucous  surface  of  the  lips,  inside  the  cheeks,  on  the  tongue,  palate,  con- 
junctivae, and  in  the  progenital  regions  of  both  sexes.  At  times  the 
glands  of  the  throat  become  slightly  enlarged  and  painful,  the  vesicles 
are  superficial,  the  child  has  the  appearance  of  having  received  a  shower 
of  boiling  water,  and  the  firm  papule  which  precedes  the  variolous  rash 
is  altogether  wanting.  The  vesicles  are  at  first  transparent,  and  their 
contents  plainly  show  through  their  translucent  roof-wall  which  is  com- 
posed only  of  the  stratum  corneum  of  the  e))idermis.  Umhilication  rap- 
idly occurs  at  the  apex,  and  the  contents  of  the  vesicles  become  lactescent, 
and  gradually  sero-purulcnt.  The  areola  is  most  distinct  when  the  vesicle 
is  fully  formed  and  fades  as  the  latter  dries.  Crusts  form,  which  drop  off 
in  from  five  to  twenty  days,  depending  upon  the  depth  to  which  the  skin 
has  been  involved.  On  the  trunk,  as  a  rule,  no  mark  is  left,  but  after 
the  more  severe  attacks,  when  the  true  skin  has  been  involved,  scars 
remain,  and  frequently  there  is  quite  deep  pitting.  The  marks  are  usu- 
ally on  the  face  when  the  skin  has  been  unprotected.  On  the  hands  and 
feet  the  vesicles  appear  without  having  been  preceded  by  a  papule,  and 
sometimes  there  is  no  areola,  each  vesicle  resembling  a  drop  of  water 
upon  a  healthy  skin.  Pustules  may  develop  in  consequence  of  irritation 
or  infection,  as  the  result  of  scratching,  or  in  feeble  or  poorly-nourished 
children  and  in  unhealthy  children  deep  ulceration  may  occur,  lasting 
for  weeks.  In  rare  cases  there  may  be  necrotic  inflammation  about  the 
site  of  the  pox  (^varicella  gangrcenosa). 

In  7nild  cases  only  ten,  twenty,  or  thirty  spots  may  be  found  on  the 
body,  but  in  severe  cases  the  skin  may  be  almost  covered  in  certain 
regions.  The  eruption,  however,  is  never  confluent.  The  temperature 
is  highest  on  the  second  or  third  day,  when  the  eruption  is  appearing.  In 
mild,  uncomplicated  cases  the  thermometer  registers  101°  or  102°  F. 
(38.8°  C.)  for  two  or  three  days  at  most,  but  in  severe  cases  the  tempera- 
ture may  be  as  high  as  104°  F.  (40°  C).  This  is  usually  due  to  broken 
health  prior  to  the  acute  illness.  The  temperature  fiills  gradually  as  the 
rash  fades,  and  presents  a  temperature-curve  similar  to  that  of  measles. 


VARICELLA.  233 

There  is  usually  neither  coryza,  vomiting,  cough,  nor  diarrhea,  and  in 
their  place  is  onl}^  the  general  indisposition  which  is  associated  with  any 
febrile  disease. 

Complications. — Erysipelas  occasionally  acts  as  a  serious  compli- 
cation in  delicate  children.  It  may  develop  about  the  pocks,  particularly 
when  they  are  deep  and  associated  with  some  ulceration,  and  scratching 
with  unclean  fingers  is  its  prime  causal  factor. 

Adenitis,  mild  and  isolated,  and  suppuration  with  abscesses  in  the 
deeper  cellular  tissue  are  occasionally  seen. 

Nephritis  is  infrequent,  but  may  occur  in  unhygienic  surroundings  or 
in  carelessly  managed  cases,  just  as  it  may  follow  scarlet  fever  or  measles. 

Varicella  is  also  quite  frequently  complicated  with  other  infectious 
diseases,  and  varicella,  scarlet  fever,  and  measles  have  been  seen  curiously 
blended  in  epidemic  form.  Varicella  and  measles,  however,  are  most 
frequently  associated. 

The  diagnosis  of  varicella  oflFers  no  special  difficulties.  The  erup- 
tion comes  out  slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts 
may  be  seen  upon  the  skin  in  close  proximity.  Again,  it  should  be  noted 
that  the  umbilication  is  due  only  to  the  fact  that  the  drying  up  of  the 
vesicle  begins  at  the  center,  and  that  the  pocks  may  appear  on  the  mucous 
membrane.  Varicella  is  distinguished  from  urticaria  by  the  presence  of 
fever,  and  from  eczema  pustulosum  by  the  mild  febrile  symptoms  of  the 
latter,  the  discreteness  of  its  pustular  lesions,  the  absence  of  itching  and 
of  infiltration  of  the  skin  in  patches,  and  by  its  tendenc}^  to  symmetric 
development. 

Variola  and  varioloid  of  infants  are  to  be  distinguished  from  varicella 
by  the  prodromal  symptoms,  and  by  the  greater  rise  of  temperature, 
though  the  distinction  between  mild  varioloid  and  severe  varicella  in 
infancy  and  childhood  will  always  tax  to  the  utmost  the  skill  of  the 
keenest  diagnostician.  The  sooner  it  is  understood  that  intermediate 
forms  are  likely  to  occur,  which  cannot  be  positively  assigned  to  one  or  the 
other  category,  the  better  it  will  be  for  both  the  profession  and  the  laity. 

The  prognosis  in  private  practice  is  always  favorable.  Only  in  the 
slums  or  in  hospital  cases  complicated  by  erysipelas,  adenitis,  or  nephritis 
may  grave  results  be  anticipated.  The  milder  cases  may,  however,  leave 
slight  monuments  of  their  existence  in  the  form  of  one  or  more  depressed 
cicatrices  which  may  mar  an  otherwise  beautiful  face. 

Treatment. — Isolation  should  be  enforced  in  schools  and  in  all  in- 
stitutions containing  many  young  children.  In  private  houses,  unless  the 
younger  children  are  delicate,  quarantine  is  unnecessary.  The  disease 
may  be  transmitted  to  others  as  long  as  the  crusts  are  present,  and  hence 
isolation  should  be  maintained  until  they  have  fallen  ofi".  In  most  cases 
constitutional  symptoms  of  the  disease  are  so  mild  as  to  require  no  treat- 
ment. It  is  best  at  the  outset  to  place  the  child  in  bed  for  a  few  days, 
and  sponge  daily  with  warm  carbolized  water ;  the  local  itching  may 
be  allayed  by  sj^onging  with  a  weak  solution  of  carbolic  acid  or  by  the 
use  of  carbolized  vaselin.  When  the  crusts  have  formed,  especially  on 
the  face,  an  ointment  of  zinc  oxid  containing  ichthyol  (2  per  cent.)  should 
be  applied,  and  care  should  be  exercised  to  keep  the  skin  clean  and  to 
prevent  scratching.  In  all  cases  the  urine  should  invariably  be  examined 
several  times  during  and  following  the  attack. 


234  INFECTIOUS  DISEASES. 

SCARLET  FEVER. 

{Scarlet  Bash;  Scarlatina.) 

Definition. — Scarlet  fever,  or  scarlatina,  is  a  self-limiting,  acute,  con- 
tagious disease,  characterized  by  vomiting,  fever  (more  or  less  typical), 
angina,  and  in  twelve  or  twenty-four  hours  by  a  diffuse,  punctiform,  scar- 
let eruption,  followed  by  membranous  desquamation  and,  frequently,  by 
nephritis.     It  is  a  disease  of  childhood,  but  may  occur  at  any  time  of  life. 

Scarlatina  is  a  widespread  disease,  though  perhaps  less  universal  than 
measles.  It  is  endemic  in  all  the  large  cities  of  the  globe,  and  at  inter- 
vals the  cases  multiply  into  more  or  less  extensive  epidemics.  Smaller 
towns  and  rural  districts  are  visited,  and  the  epidemics  are  usually  trace- 
able to  importation  of  scarlatinal  poison,  so  that  it  may  be  stated  that 
they  never  originate  de  novo. 

Pathology. — There  are  no  pathognomonic  changes.  When  death 
occurs  early  the  chief  lesions  are  presented  by  the  throat,  while  in  addi- 
tion engorgement  of  the  viscera  is  noted,  especially  of  the  brain.  The 
exanthem  is  rarely  visible.  In  malignant  types,  however,  in  which  the 
eruption  is  not  seen  during  life,  it  makes  its  appearance  rarely  after  death, 
and  this  aids  in  establishing  the  nature  of  the  affection. 

When  death  occurs  at  an  advanced  stage  the  lesions  are  those  either 
of  nephritis  (with  dropsy),  or  of  septico-pyemia,  or  of  inflammation  of  one 
or  more  of  the  serous  surfaces  (pleurisy,  pericarditis,  endocarditis,  menin- 
gitis, etc.).  Additional  changes  in  the  various  viscera  are,  for  the  most 
part,  identical  with  those  met  with  in  other  acute  infective  diseases,  and 
hence  need  not  be  described  here.  The  blood,  it  should  be  pointed  out, 
is  dark,  fluid,  and  coagulates  feebly,  owing  to  a  decrease  in  its  fibrin  fac- 
tors. The  process  of  descjuamation  may  be  observed,  together  with  more 
or  less  emaciation  in  protracted  cases. 

Among  other  lesions  which  are  more  or  less  peculiar  to  the  disease  are 
(a)  The  eruption,  which  is  a  dermatitis  of  very  mild  grade,  (b)  Scarlatinal 
angina,  which  in  its  mildest  form  presents  hyperemia  and  a  slight  swell- 
ing of  the  mucosa  of  the  tonsils,  soft  {)alate,  and  pharynx.  In  the  severer 
grades  the  inflammation  is  phlegmonous  (scarlatina  anginosa),  and  some- 
times terminates  in  ulceration.  There  is  great  SAvelling  (especially  of  the 
tonsils),  and  the  formation  of  abscesses,  due  to  secondary  infection,  is  com- 
mon. Extension  of  the  purulent  inflammation  to  the  connective  tissue 
of  the  neck  produces  marked  induration,  and  more  or  less  extensive  ab- 
scesses may  take  ])lace.  Gangrene  sometimes  supervenes,  (c)  In  certain 
epidemics  a  membranous  exudate  accompanies  the  scarlatinal  angina,  and 
this  may  or  may  not  be  truly  diphtheritic.  When  it  appears  early  it  is 
non-diphtheritic,  as  a  rule,  and  often  due  to  the  streptococcus ;  on  the 
other  hand,  when  it  comes  on  late  it  often  shows  the  presence  of  the 
Liifller  bacillus.  There  is  also  a  malignant  form  of  membranous  scarla- 
tinal angina,  occasioned  by  a  secondary  streptococcic  infection  (Hirsch- 
feld).  Other  secondary  inflammatory  processes  occur;  but  these  will  be 
considered  later  at  sufficient  length  {vide  Clinical  History),  {d)  The 
Nepliritis. — The  renal  lesions,  so  prominent  and  so  common  in  scarla- 
tina, are  included  in  the  description  of  "Acute  Bright's  Disease." 

Etiology. — The  bacteriology  of  the  affection  is  imperfectly  known,  al- 
though the  fact  that  it  depends  upon  a  special  poison  cannot  be  doubted. 


SCARLET  FEVER.  235 

As  early  as  1892,  Doehle  described  a  peculiar  variety  of  protozoa  which 
he  found  in  the  blood  of  patients  suffering  from  some  of  the  eruptive 
fevers,  and  among  them  scarlet  fever.  He  found  a  ciliated  and  a  con- 
tractile form,  occurring  both  within  the  red  blood-cells  and  free  in  the 
plasma,  and  staining  well  with  methylene-blue.  This  observation,  how- 
ever, has  not  been  confirmed,  and  as  the  streptococcus  pyogenes  has  been 
found  in  nearly  all  the  inflammatory  complications  of  the  disease,  espe- 
cially scarlatinal  pneumonia  and  angina,  some  pathologists  (Bab^s,  Berge, 
Klein)  have  held  it  to  be  the  cause.  Mai-morek,  Raskin,  and  Mosny, 
however,  believe  that  it  is  an  example  of  mixed  infection,  the  streptococ- 
cus being  merely  a  secondary  factor,  and  Marmorek  has  been  confirmed 
in  this  view  by  the  results  of  his  experiments  with  antistreptococcus  serum. 

The  general  receptivity  for  scarlet  fever  is  not  so  great  as  in  certain 
other  exanthemata  {e.  g.  small-pox,  measles) ;  hence  in  a  household  in 
which  there  are  several  children  some  are  apt  to  escape  the  disease,  even 
though  all  have  been  equally  exposed. 

The  virus  is  probably  contained  in  the  excretions  from  the  throat,  nose, 
or  ear,  and  in  the  epidermal  scales  thrown  off  from  the  surface  of  the 
body.     It  is  also  present  in  the  blood  of  scarlatina  patients. 

Modes  of  Conveyance. — The  majority  of  the  cases  are  produced  by  con- 
tagion, and  I  have  observed  that  a  single  contact  of  a  healthy  child  with 
a  scarlet-fever  patient  suffices  to  convey  the  disease.  It  is  also  com- 
municated hj  fomites,  and  the  poison  of  scarlatina  contained  in  clothing 
retains  its  infective  power  for  months.  The  patient  himself  is  a  center 
of  infection  until  the  end  of  the  period  of  desquamation.  Again,  any 
objects  (furniture,  utensils,  library  books,  toys)  which  the  patient  has 
touched  or  handled  may  serve  to  communicate  the  poison.  The  disease 
may  also  be  transferred  by  persons  who  have  been  in  the  sick-room, 
while  they  themselves  escape.  Infected  dairies  have  been  known  to 
disseminate  the  poison  and  give  rise  to  epidemics.  The  infection  may 
also  be  air-borne,  though  not  for  any  great  distance.  Behle  reports  an 
outbreak  of  human  scarlatina  in  swine,  and  it  is  fairly  well  proven  that 
kine  are  susceptible  to  the  disease,  though  in  a  modified  form,  and  are 
potent  to  transmit  it  to  man. 

Mode  of  Infection. — Most  probably  the  poison  is  inhaled  into  the 
throat,  where  infection  usually  occurs ;  but  it  may  gain  entrance  to  the 
body  through  the  alimentary  tract.  Infection  may  also  take  place 
through  the  blood,  as  is  shown  by  the  fact  that  children  have  been  born 
in  all  stages  of  the  disease.  Artificial  inoculation  with  the  blood  of  scar- 
latina patients  has  resulted  in  more  or  less  typical  forms  of  the  com- 
plaint. Open  lesions  predispose,  but  Avhether  they  are  essential  to  in- 
fection is  not  knowm.  Seitz  believes  there  is  strong  evidence  of  Sbfamily 
predisposition  to  the  disease,  as  371  out  of  800  cases  occurred  in  152 
families. 

Predisposing  Causes. — (1)  Age. — The  period  of  chief  liability  is  from 
the  second  to  the  tenth  year,  after  which  it  diminishes.  It  is  rare  under 
the  age  of  one  year,  and  especially  so  under  six  months.  (2)  Recent 
wounds — accidental  or  surgical — increase  the  susceptibility  to  the  pecu- 
liar poison.  (3)  Women  in  childbed,  for  the  same  reason  as  (2);  but  care 
must  be  exercised,  lest  this  class  be  confounded  with  septic  affections.  (4) 
Season. — The  autum  and  winter  months  furnish  the  most  cases. 


236  INFECTIOUS  DISEASES. 

Immunity. — Single  attacks  during  the  life  of  a  person  form  a  rule  to 
which  there  are  rather  frequent  exceptions. 

Clinical  History. — The  incubation  period  is  extremely  brief,  lasting 
usually  from  two  to  three  or  four  days.  It  may  rarely,  however,  be 
longer — five  to  eight  days — or  more  rarely  still  shorter — less  than 
twenty-four  hours. 

The  invasion  of  scarlet  fever  is  generally  quite  sudden  and,  as  a  rule, 
active.  The  child  feels  uncomfortable,  looks  stupid,  complains  of  sore 
throat  and  decided  nausea,  and  in  the  great  majority  of  the  cases  vomits. 
The  tongue  is  furred.  If  he  be  very  young,  nervous  symptoms  are  prom- 
inent, and  he  may  exhibit  convulsions.  The  pulse,  which  is  a  strong 
diagnostic  factor,  is  rapid  and  hard,  reaching  140  to  160  at  the  very 
onset.  The  temperature  rises  quickly  to  104°  or  105°  F.  (40.5°  C), 
and  remains  high. 

Eruption. — Within  the  first  twenty-four  or  thirty-six  hours  the  charac- 
teristic rash  appears,  and  is,  as  a  rule,  first  seen  on  the  neck  ;  there  is  no 
certainty  about  this,  however,  as  it  may  first  come  out  on  the  abdomen  or 
back  of  the  hands  or  on  the  thighs,  and  not  be  seen  on  any  other  part  of 
the  body.  Frequently  it  is  found  on  the  dependent  portions  of  the  trunk. 
At  first  it  is  slight,  but  perfectly  characteristic,  and  usually  takes  two 
days  to  mature.  In  mild  cases  it  disappears  within  thirty-six  to  forty- 
eight  hours,  and  at  no  time  is  more  than  a  very  fine  rash,  but  when 
typical  it  cannot  be  mistaken,  especially  if  accompanied  by  the  premoni- 
tory symptoms.  When  seen  from  a  short  distance  at  the  end  of  the  first 
twenty-four  hours  of  its  appearance  the  whole  body  (except  the  face)  is 
of  a  uniform  bright  scarlet  color.  If  we  examine  more  closely,  we  find 
that  the  eruption  consists  of  a  multitude  of  red  points  that  correspond 
to  the  hair-follicles.  These  points  are  surrounded  by  zones  of  erythem- 
atous redness,  which,  joining  Avith  one  another,  give  a  generally  diffuse 
red  appearance  to  the  whole  skin.  Frequently,  however,  the  rash  con- 
sists of  points  representing  the  hair-follicles  without  the  erythema,  and 
in  rough  skins  the  rash  may  be  more  punctiform — that  is,  more  strictly  a 
condition  of  "goose  skin."  Sudamina  are  quite  frequent.  Pressure  by 
the  finger  causes  a  pallor  which  at  once  disappears  when  the  finger  is 
removed.  The  patient's  lips  and  chin  are  pale  and  in  striking  contrast 
with  the  vividly  scarlet  cheeks.  In  some  cases  the  rash  is  patchy,  espe- 
cially on  the  limbs,  and  in  these  cases  it  may  suggest  measles,  the  patches 
consisting  of  clusters  of  fine  papules  or  points  with  much  surrounding 
erythema,  while  normal  skin  is  present  between  the  patches.  In  severe 
cases  the  rash  may  be  hemorrhagic  in  character,  minute  extravasations  of 
blood  taking  place  in  the  skin ;  this  may  occur  even  in  mild  attacks,  and 
not  be  seen  until  after  death,  but  more  frequently  it  is  seen  in  malignant 
cases.  Purpuric  patches  are  frequently  found  after  death  Avhen  even  in 
life  they  did  not  appear.  There  is  itching,  which  may  be  either  mod- 
erate or  intense  throughout  the  eruptive  stage. 

The  rash  is  succeeded  by  a  desquamation  that  will  be  extensive  or 
slight  according  to  the  intensity  of  the  fever.  In  7mld  cases  the  tonsils, 
palate,  uvula,  and  pharynx  are  deeply  congested,  and  the  mucosa  of  the 
cheeks,  palate,  and  tonsils  may  show  the  eruption.  In  severer  forms 
the  tonsils  are  red  and  inflamed,  and  covered  with  tenacious  secretions, 


SCARLET  FEVER. 


237 


while  minute  yellow  points  corresponding  to  the  tonsillar  crypts  are 
usually  prominent.  (  Vide  Malignant  Scarlatina.)  The  nasal  chambers 
are  swollen,  producing  a  free  discharge,  and  the  deeper  cervical  glands 
at  the  angle  of  the  jaw  are  frequently  enlarged.  The  tongue  is  coated 
with  a  thick,  dense  white  fur  (dead  epithelium),  and  frequently  shows  a 
dry,  glazed  central  band.  In  a  few  days  the  dead  epithelium  is  cast  off, 
clearing  the  tongue,  when  we  have  a  red,  clean,  glazed  tongue  with 
greatly  enlarged  fungiform  papillge,  giving  us  the  strawberry  tongue  of 
classical  history.  The  eyes  are  frequently  swollen  and  the  conjunc- 
tivae injected. 

Sleeplessness  and  mild  delirium  often  mark  a  typical  case,  suggest- 
ing a  congested  state  of  the  meninges,  but  it  is  neither  usual  for  the 
child  to  be  violent  nor  for  the  delirium  to  continue  long. 

The  pulse  is  usually  a  strong  diagnostic  feature,  and  is  always  hard, 
quick,  and  wiry,  varying  from  140  to  160 ;  it  is  out  of  proportion  to 
the  temperature  and  the  general  condition  of  the  child.  Leuhocytosis 
is  commonly  noted.     The  temperat^ire  in  average  cases  reaches  104°  or 


•36° 


Fig.  22.— Temperature-curve  of  a  case  of  scarlatina  with  favorable  course— William  C , 

seven  years. 


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105°  F.  (40.5°  C),  and  in  severe  forms  it  may  touch  106°  F.  (41.1°  C), 
the  nocturnal  remissions  being  slight  and  defervescence  gradual  {vide 
Fig.  22).  The  urine  is  scanty,  thick,  and  contains  urates,  with  a  small 
quantity  of  albumin. 

Within  one  week,  if  no  complications  have  occurred,  the  attack  will 
have  reached  its  height  and  the  symptoms  have  begun  to  decline.      The 


238  INFECTIOUS  DISEASES. 

rash  gradually  fades,  temperature  falls,  the  tongue  is  less  red,  the  throat 
less  injected,  and  the  child  seems  more  natural.  If  at  the  end  of  one  week 
the  fever  continues,  it  suggests  the  many  possible  complications,  the 
most  frequent  of  which  is  a  throat  or  tonsillar  ulceration,  inflammation 
of  the  cervical  glands,  otitis,  or,  most  probably,  acute  nephritis.  It 
must  be  well  understood  that  no  two  cases  of  scarlet  fever  are  alike. 

Clinical  Types. — Mild  Scarlet  Fever. — In  very  many  cases  of  scar- 
let fever  all  the  premonitory  symptoms  are  absent,  and  the  rash  is  the 
only  indication  of  the  trouble.  There  is  neither  vomiting  nor  fever  to 
be  recognized,  and  no  tonsillar  trouble  of  any  importance,  while  the 
rash  is  neither  uniform  nor  well  marked.  In  these  cases  we  must  be 
very  careful  not  to  confound  the  eruption  with  urticaria  or  some  of  the 
many  medicinal  rashes.  The  most  difficult  cases  of  all  to  diagnose  are 
those  in  which  sore  throat  is  present  Avithout  a  rash,  inasmuch  as  there  is 
nothing  characteristic  about  a  scarlatinal  tonsillitis. 

During  house  epidemics  when  several  children  are  affected  it  fre- 
quently happens  that  a  child  has  sore  throat  and  the  "  strawberry 
tongue  "  Avithout  a  development  of  the  rash.  This  may  also  occur  in 
adults,  and  is  the  so-called  scarlatina  sine  eruptione.  These  very  slight 
cases  of  the  fever  are  the  most  to  be  dreaded,  as  they  may  be  folloAved 
by  the  most  severe  attacks  of  nephritis. 

Malignant  Scarlet  Fever. — Death  occurs  usually  by  the  end  of  the  first 
Aveek  in  severe  cases,  Drs.  Ashby  and  Wright  reporting  a  death  within 
the  first  twenty-four  hours  {atactic  form).  In  malignant  cases,  such  as 
usually  occur  among  the  unhygienic  and  delicate,  the  tonsils  may  be 
covered  by  a  membranous  exudate,  and  the  system  quickly  receive  an 
overwhelming  dose  of  the  poison  ;  death  then  results  from  septic  causes 
{anginose  form).  In  cases  in  Avhich  death  occurs  early  a  child  soon  be- 
comes cyanotic,  restless,  or  more  frequently  somnolent.  In  all  these 
cases  the  temperature  remains  high — 105°  to  106°  F.  (41.1°  C),  and 
very  frequently  107°  F.  (41.6°  C).  Diarrhea  is  frequently  a  trouble- 
some factor  in  severe  cases ;  coryza  is  very  abundant :  there  is  much 
glandular  swelling  and  cellulitis,  the  neck  becoming  enormously  enlarged 
and  hard,  the  skin  dull  and  livid  in  color;  the  extremities  groAv  cold; 
the  heart  gradually  becomes  irregular,  losing  a  beat,  and  finally  fails. 

If  life  is  sustained  thi-ough  such  an  ordeal,  the  tonsils  slough  and 
the  lungs  may  eventually  become  the  seat  of  a  septic  pneumonia.  In 
many  desperate  cases  Avhen  life  is  prolonged  to  the  end  of  the  second  or 
even  third  Aveek  general  septicemia  is  most  likely  to  occur.  In  this 
condition  the  tonsils  ulcerate,  sloughing  patches  appear  on  the  fauces, 
the  glands  about  the  neck  become  enlarged  and  doughy,  and  the  nasal 
mucous  membrane  gives  out  a  purulent  secretion  in  abundance.  The 
temperature  may  remit,  but  continues  high  ;  the  urine  is  albuminous ; 
pus  Avells  from  both  eai*s ;  and  thus  the  child  is  gradually  consumed  and 
perishes.  In  all  these  cases  pleuro-pneumonia  Avill  be  found,  together 
Avith  hemorrhagic  kidneys,  and  most  probably  small  abscesses  Avill  be 
found  in  the  latter  at  the  post-mortem. 

A  third  variety  ijiemorrhagic)  shoAvs  at  first  cutaneous  petechise, 
Avhich  grow  rapidly  into  large  ecchymotic  patches.  Hemorrhages  also 
take  place  from  the  mucous  surfaces,  epistaxis  and  hematuria  being  very 
common.     Death,  as  a  rule,  folloAvs  in  two  or  three  days. 


SCARLET  FEVER.  239 

Desquamation. — By  the  end  of  the  first  week  the  rash  commences  to 
disappear,  the  skin  is  (or  soon  becomes)  mottled,  dry,  and  rough,  and 
gradually  the  scarf  skin  begins  to  separate.  This  process  usually 
begins  about  the  neck  and  trunk,  and  frequently  large  flakes  are  de- 
tached, the  whole  cuticle  of  the  hand  or  foot  sometimes  coming  off  in 
one  mass  like  a  glove.  The  degree  and  character  of  the  desquamation 
bear  some  relation  to  the  severity  of  the  eruption.  In  some  cases  the 
hair  and  nails  have  been  cast  off.  In  many  cases  desquamation  is  pro- 
longed to  the  eighth  week ;  it  is  usually  longest  on  the  hands  and  feet. 

Complications. — Otitis. — The  inflammation  may  extend  from  the 
throat  along  the  Eustachian  tubes  to  the  middle  ear,  and  pus  be  formed 
in  the  tympanic  cavity,  making  its  exit  by  perforating  the  membrane. 
This  complication  may  occur  either  during  the  fever  or  at  some  time 
during  convalescence.  Suppuration  in  the  middle  ear  is  one  of  the 
common  causes  of  a  continued  high  temperature  after  the  disappear- 
ance of  the  rash.  Pain  in  the  ear  may  not  attract  our  attention  to 
this  unfortunate  complication  ;  most  frequently,  however,  the  child  Avill 
place  its  hand  on  the  ear  and  shake  its  head,  as  if  to  get  rid  of  some 
source  of  irritation. 

Pyemia. — Pyemia  and  abscess  of  the  lungs  may  follow,  and  throm- 
bosis of  the  lateral  sinus  may  occur.  The  tonsils  may  be  the  seat  of 
deep  ulceration,  and  the  soft  palate  may  slough  and  show  cicatrization 
of  the  soft  parts  of  the  throat  in  cases  which  may  yet  recover.  The 
cervical  glands  may  become  enlarged  and  suppurate,  either  during  the 
fever  or  while  the  child  is  convalescent.  In  debilitated  or  strumous 
children  this  complication  may  be  very  troublesome,  with  the  formation 
of  deep  ragged  ulcers,  slow  to  heal,  and  in  rare  cases  exposing  the 
larger  blood-vessels.  Broncho-  or  lobar  'pneumonia  may  occur,  and  is 
most  usual  during  the  second  week,  being  due  to  extension  downward 
of  the  lesion  from  the  throat.  Pneumonia  followed  by  empyema  may 
also  occur  during  convalescence. 

Joint-affections. — {a)  Scarlatinal  syyiovitis^  which  occurs  in  7  per  cent. 
of  cases,  nearly  always  appearing  from  the  fourth  to  the  tenth  day  ;  in 
72  per  cent,  of  cases  affecting  the  wrists  (Marsden).  Less  commonly 
the  small  joints  of  the  fingers,  the  elbows,  the  ankles,  the  knees,  and 
soles  of  the  feet  may  be  affected.  The  trouble  is  fugitive,  and  seldom 
returns  to  the  same  joint,  and  is  caused  by  the  scarlatinal  poison,  (b) 
Septic  arthritis,  met  with  in  severe  or  fatal  cases,  is  often  associated  Avith 
grave  throat  symptoms.  In  these  cases  the  knees  may  be  most  severely 
affected,  remaining  swollen  for  weeks,  and  in  unusual  cases  suppuration 
may  take  place  and  be  followed  by  pyemia,  (c)  Rheumatic  synovitis, 
which  usually  develops  during  convalescence.  Two  cases  have  occurred 
in  my  practice,  complicated  with  simple  acute  endocarditis.  Rarely 
tuberculous  invasion  of  the  joints  occurs  as  a  sequel.  Here  the  scar- 
latina merely  affords  a  predisposition  to  tuberculosis. 

Nephritis. — No  other  complication  of  scarlet  fever  can  equal  nephritis 
in  importance  or  interest,  this  condition  always  giving  rise  to  anxiety  in 
otherwise  mild  and  hopeful  cases.  During  the  height  of  the  fever,  as  is 
the  case  in  all  exanthemata,  there  is  a  trace  of  albumin  in  the  urine 
that  has  no  special  significance,  and  it  is  possible  for  the  kidneys  to 
escape  without  greater  damage  than  occurs  in  other  acute  febrile  affec- 


240  INFECTIOUS  DISEASES. 

tions.  Independently  of  this  febrile  albuminuria,  there  are  two  forms 
of  nephritis  which  it  is  important  to  bear  in  mind,  though  they  have 
been  frequently  confounded : 

(a)  Septic  Nephritis. — In  severe  forms  of  scarlet  fever,  when  the 
throat  symptoms  include  sloughing  tonsils,  involvement  of  the  soft 
palate,  and  general  adenitis,  the  urine  quickly  becomes  loaded  with 
albumin,  but  shows  scarcely  any  blood  and  but  few  casts.  No  renal 
symptoms  will  be  recognized,  and  if  present  they  may  be  masked  by  the 
general  condition  of  septicemia.  There  may  be  neither  dropsy  nor  uremic 
phenomena,  but  the  patient  usually  dies  by  the  end  of  the  second  week, 
Auhen  a  typical  pyemic  kidney  is  found  containing  minute  abscesses. 
This  condition  of  the  kidney  is  only  one  part  of  the  general  pyemia, 
and  merely  illustrates  the  fact  that  this  organ  suffers  during  the  course 
of  the  general  inflammation. 

(b)  Post-scarlatinal  nephritis  is  the  form  most  likely  to  occur  about 
the  third  or  fourth  week,  and  is  the  one  generally  known  as  scarlatinal 
nephritis.  The  kidneys  are  undoubtedly  involved  in  an  active  sympa- 
thetic inflammation,  and  at  the  end  of  the  fever,  more  than  at  the  be- 
ginning, are  engaged  in  carrying  off"  waste  products  of  the  fever  itself. 
From  the  nature  of  the  disease  they  are  in  an  irritable  condition  and 
prone  to  take  on  inflammatory  changes,  just  as  the  bronchial  tubes  and 
the  lungs  are  left  in  a  very  susceptible  condition  following  measles  and 
whooping-cough.  In  this  way  the  uriniferous  tubules  become  choked 
up  by  the  des(iuamation  that  is  going  on  inside.  The  numbev  of  cases 
that  suff'er  from  post-scarlatinal  nephritis  varies  according  to  social  con- 
ditions, the  nature  of  the  epidemic,  the  season  of  the  year,  the  nature  of 
the  treatment  received  during  the  disease,  and  especially  the  care  received 
throughout  convalescence.  Ashby  and  Wright  fix  the  rate  of  those 
who  suff'er  at  6  per  cent,  of  hospital  cases,  but  this  is,  undoubtedly,  too 
high,  since  hospital  cases  receive  better  care  during  convalescence  than 
private  cases.  The  usual  time  for  this  form  of  nephritis  to  occur  is 
from  the  end  of  the  second  up  to  the  fourth  week,  but  it  usually  begins 
very  insidiously.  Traces  of  albumin  may  be  found  for  a  few  days  be- 
fore the  blood  and  larger  quantities  of  albumin  occur,  but  it  is  often  im- 
possible to  date  the  commencement  of  an  attack.  Usually  after  the  fever 
has  subsided  the  patient  for  a  few  days  feels  well,  but  very  suddenly 
grows  restless,  is  feverish  at  night,  is  thirsty,  has  a  quick,  hard  pulse, 
and  passes  a  small  quantity  of  dark-colored  urine.  If  care  has  been 
exercised,  it  will  be  found  that  the  urine  has  been  gradually  diminishin,g 
for  several  days,  and  a  slight  puffiness  about  the  face  frequently  an- 
nounces the  beginning  of  the  trouble.  Later  the  face  becomes  pale  and 
puffy,  while  there  may  be  edema  of  the  feet  and  scrotum,  and  some 
vomiting.  Under  favorable  treatment  improvement  may  take  place, 
large  quantities  of  urine  may  be  passed,  and  the  child  resume  convales- 
cence. The  nephritic  symptoms  may,  however,  deepen  until  uremia 
appears,  the  pulse  becoming  slow,  the  temperature  subnormal,  and  the 
tongue  dry  and  brown.  Vomiting  is  now  a  frequent  occurrence ;  diar- 
rhea is  not  unusual ;  nose-bleed  and  hemorrhages  from  the  various  mu- 
cous surfaces,  and  muscular  twitchings  may  be  noted,  and  most  likely 
the  end  may  be  reached  in  a  general  convulsion.  In  all  cases  of  nephri- 
tis great  care  must  be  taken  to  recognize  heart-changes,  and  fatal  results 


SCARLET  FEVER.  241 

are  more  frequent  from  cardiac  failure  than  from  the  uremic  convulsions. 
The  constant  effect  of  nephritis  is  to  raise  the  blood-tension,  and  this 
continued  tension  in  the  blood-vessels  is  followed  by  dilatation  of  the 
heart.  Another  not  unusual  result  is  endocarditis  or  pericarditis,  "^ith 
possible  embolism. 

Sudden  death  frequently  occurs  during  the  course  of  nephritis.  The 
child  may  be  doing  well,  possibly  sitting  up  in  bed  and  playing  with  its 
toys,  when  an  attack  of  dyspnea  occurs ;  the  face  becomes  livid,  the 
pulse  disappears,  and  death  quickly  takes  place.  Death  in  such  cases 
is  usually  said  to  be  due  to  edema  of  the  lungs :  the  dilated  heart,  how- 
ever, has  been  overlooked,  and,  while  edema  of  the  lungs  is  present,  it 
is  only  secondary  to  the  cardiac  failure. 

It  is  not  unusual  for  a  false  membrane  to  form  ujDon  the  larynx. 
This  is  not  infrequently  due  to  the  streptococcus  pyogenes,  but  the 
Klebs-Loffler  bacillus  is  oftener  found  (Ranke  found  it  in  more  than 
half  of  92  cases).  A  bacterial  examination  should  always  be  made 
early  in  the  disease,  and  if  the  diphtliericd  nature  of  the  infection  has 
been  determined  the  serum-treatment  should  be  employed  at  once. 

Diagnosis. — A  typical  form  of  scarlet  fever  offers  few  difficulties 
in  diagnosis.  The  period  of  incubation  is  short  in  comparison  with 
that  of  any  of  the  other  exanthemata,  particularly  variola,  measles,  and 
varicella.  The  vomiting,  which  is  almost  a  constant  factor  in  the  early 
stage,  associated  with  high  fever,  would  also  exclude  the  other  eruptive 
diseases.  The  pulse  in  itself  is  most  strongly  diagnostic,  being  quick, 
hard,  and  Aviry,  striking  the  finger  at  the  rate  of  140  to  180  per  minute; 
no  other  disease  has  a  similar  pulse.  The  early  sore  throat  and  the  in- 
tense hyperemia  of  the  Avhole  mucous  membrane,  associated  with  severe 
constitutional  symptoms,  make  it  easy  to  differentiate  from  measles, 
varicella,  and  variola.  The  punctate  erythematous  lesions  that  appear 
during  the  stage  of  efflorescence  of  scarlet  fever  are  not  found  in  any 
of  the  other  eruptive  diseases.     {^Vide  table  on  page  247.) 

The  dliferential  diagnosis  embraces  the  discrimination  of  those  rashes 
that  follow  the  use  of  certain  drugs  (quinin,  belladonna,  potassium  bro- 
mid  and  iodid,  chloral,  etc.).  The  characteristic  invasion-symptoms 
(vomiting,  angina,  etc.)  of  scarlatina  are  absent ;  also  the  high  fever 
and  frequent,  hard  pulse  of  the  latter  disease.  Drug-rashes  are  seldom 
so  vivid  or  diffuse  as  the  eruption  of  scarlatina. 

Scarlatina.  Acute  Exfoliating  Dermatitis. 

Onset  is  sudden,  with  vomiting,  angina,  Sudden,  with  fever  only. 

fever,  and  frequent,  hard  pulse. 

Eruption  appears  first  on  neck,  face,  and  xlppears  first  on  trunk. 

chest,  soon  becoming  difi"use. 

Duration,  three  or  four  days.  Duration,  five  or  six  days. 

Desquamation  begins  after  eruption  has  Desquamation  begins  earlier,  often  before 

faded,  often  one  week  later.  eruption  has   faded,  and  involves  the 

hair  and  nails. 

Ear  and  throat  complications  common.  Absent. 

Nephritis  is  a  common  sequel.  Xot  so. 

Relapses  exceptional.  Relapses  common. 

The  prognosis  in  regular,  uncomplicated  scarlet  fever  is  in  almost 
every  case  favorable,  and,  unless  the  treatment  is  unusually  indifferent, 

16 


242  INFECTIOUS  DISEASES. 

the  patient  will  recover.  Severe  types,  however,  and  especially  malig- 
nant scarlatina,  are  very  fatal.  Complications  arise  that  will  most 
seriously   endanger  life. 

The  treatment  of  scarlet  fever  is  that  of  the  symptoms,  together 
with  an  attempt  at  arresting  the  complications. 

Prophylaxis. — The  patient  should  be  strictly  quaraiitined  in  an  upper 
room  for  at  least  eight  weeks  or  until  desquamation  has  been  completed. 
A  competent  nurse  should  be  put  in  charge,  and,  Avhether  a  member  of 
the  family  or  otherwise,  she  should  Avear  a  washable  dress,  and  should 
not  mingle  wdth  the  family,  except  her  clothing  be  changed  or  thoroughly 
disinfected.  The  room  is  to  be  stripped  of  all  superfluous  hangings  and 
furniture.  Inunctions  are  required  as  soon  as  desquamation  commences, 
with  a  view  to  preventing  the  difiusion  of  the  dried  epidermal  scales ; 
and  the  best  preparation  for  this  purpose  consists  of  cosmolin,  menthol, 
and  carbolic  acid,  ten  grains  each  of  the  latter  to  one  ounce  of  cosmo- 
lin, after  the  plan  of  J.  Lewis  Smith.  Carbolized  water,  1 :  40  (thor- 
oughly shaken),  may  be  used  to  sponge  the  surface  and  may  be  agree- 
ably followed  by  cocoa-butter. 

The  disinfection  of  the  physician  himself.  I  am  sorrj^  to  state,  is  fre- 
quently neglected.  He  should  generate  chloriu  gas  by  the  following 
simple  method,  and  allow  it  to  permeate  his  clothes  thoroughly  before 
going  into  other  families :  A  dram  of  powdered  potassium  is  placed  in 
a  saucer,  and  a  small  quantity  of  hydrochloric  acid  added.  The  dish  is 
then  placed  on  the  floor,  and  the  physician  stands  over  the  vapor  chlorid 
as  it  arises  until  it  penetrates  all  his  clothing.  This,  with  the  free  use 
of  the  whisk  and  thorough  hand-washing,  renders  him  non-contagious 
and  safe  in  entering  any  home  or  sick-room.  Perhaps  a  less  disagree- 
able method  is  to  have  in  the  patient's  house  a  linen  duster  or  surgeon's 
apron  that  has  been  dipped  in  a  bichlorid  solution  and  allowed  to  dry. 
This  is  slipped  over  the  clothing  before  entering  the  sick-room,  and  is 
removed  after  leaving. 

In  the  room,  if  the  case  be  a  severe  one  involving  the  throat,  I  keep 
the  gas  or  an  alcohol  lamp  burning  under  a  small  dish  of  water,  so  that 
steam  may  be  constantly  generated.  To  the  boiling  water  I  frequently 
add  carbolic  acid  or  oil  of  eucalyptus ;  this  saturates  the  room  very 
pleasantly,  and  at  the  same  time,  I  believe,  limits  the  extent  of  the 
contagion. 

General  Management. — The  sick-room  should  be  large  and  well  ven- 
tilated, and  should  be  kept  at  a  uniform  temperature  (68°  to  70°  F. — 
21.1°  C).  A  light  flannel  night-dress  should  be  worn  by  the  child,  and 
the  bed-clothing  should  be  light  as  well.  The  diet  should  consist  of 
milk,  broths,  egg-white,  and  fruit-juices,  and  after  the  temperature  has 
declined  soft  diet  may  be  allowed.  A  few  days  later  the  return  to  ordi- 
nary solid  foods  may  be  complete. 

The  evidences  of  heart-enfeeblement  often  arise  and  call  for  the 
judicious  use  of  stimulants.  It  is  to  be  pointed  out  that  this  class  of 
agents  is  remarkably  well  borne  in  this  aff"ection,  and  hence  may  be 
freely  administered.  To  a  child  of  four  years  I  give  one  dram  (4.0)  of 
brandy  or  whiskey  every  second  hour,  and  often  increase  the  dose  as 
required.  The  preparations  of  ammonium,  particularly  the  carbonate 
and  the  aromatic  spirits,  have  also  been  warmly  recommended  as  stim- 


SCARLET  FEVER.  243 

ulants  in  this  affection.  Thej  should  be  administered  in  milk  as  the 
vehicle  to  prevent  gastric  irritation. 

Special  Treatment. — Bathing  is  recommended  in  scarlet  fever  by  the 
best  writers,  yet  often  in  such  an  indefinite  and  uncertain  manner  as  to 
give  the  busy  practitioner  neither  any  encouragement  to  resort  to  it  nor 
any  guidance  in  the  matter  of  technique  and  mode  of  procedure.  In  the 
classical  work  of  Thomas  Watson,  now  over  fifty  years  old,  he  hints  in  his 
treatment  of  scarlet  fever  "  that,  if  the  heat  on  the  surface  be  very  great 
and  distressing,  he  should  not  recommend  the  cold  effusion,  but  cold  or 
tepid  sponging  Avould  be  very  refreshing  and  beneficial."  This  senti- 
ment finds  its  echo  in  most  works  on  practical  medicine  at  the  present 
day.  Unfortunately,  the  majority  of  medical  practitioners  do  not  give 
their  instructions  for  the  thorough  sponging  of  their  scarlet-fever  cases, 
chiefly  through  fear  of  objections  from  the  family. 

The  physician  must  quietly  but  firmly  insist  upon  the  patient  being 
most  thoroughly  sponged  three  or  four  times  daily,  according  to  the 
severity  of  the  individual  case,  using  carbolized  water  (1 :  60),  mercuric 
chlorid  (1  :  8000),  salt  water,  or  alcohol  and  water,  at  a  temperature 
of  T0°-100°  F.  (2i.l°-3T.7°  C).  Systematic  bathing  in  this  manner 
and  inunctions  as  above  described  protect  the  body  from  certain  disas- 
trous complications  and  sequelae.  The  ice-cap  may  be  combined  with 
cool  spongings.  In  extreme  cases,  with  marked  nervous  symptoms  and 
high  temperature,  the  cold  pack,  with  cold  affusions  applied  to  the  head 
and  nape  of  the  neck,  may  be  cautiously  employed,  and  a  description 
of  the  method  of  giving  a  cold  pack  may  be  found  under  the  treatment 
of  Typhoid  Fever.  The  gradually  cooled  bath  may  be  substituted  if 
open  objection  is  made  by  the  parents  to  the  cold  pack. 

In  regard  to  the  use  of  internal  antiiiyretics,  I  prefer  phenacetin  for 
older  children,  combined  with  quinin  in  capsules.  Acetanilid  is  better 
for  younger  children,  and  I  generally  give  one-third  as  many  grains  as 
there  are  years  in  the  child's  life.  When  medicine  can  be  exhibited  in  the 
form  of  capsules,  I  always  prefer  to  combine  it  with  quinin  or  strychnin 
to  overcome  the  tendency  to  depression.  Phenacetin  and  acetanilid  act 
successfully  in  controlling  the  nervous  element,  relieving  headache  and 
fever,  promoting  diaphoresis,  and  inducing  refreshing  sleep.  Acetanilid 
is  much  more  prompt  in  its  action  than  phenacetin.  but  its  effects  are 
not  so  lasting.  I  therefore  choose  it  for  young  children,  and  exhibit  it 
in  small  doses  in  the  form  of  a  powder,  and  if  the  bowels  are  torpid  I 
combine  with  the  acetanilid  small  doses  of  calomel  and  soda.  These 
agents  are  rarely  required,  and  are  not  comparable  in  their  good  effects 
to  hydrotherapy. 

Internal  Antiseptics. — Those  remedies  that  are  purely  antisejotic, 
administered  internally,  have  not  given  proof  of  their  utility  as  yet. 
The  sulphocarbolates  of  zinc  and  of  sodium,  on  account  of  their  breaking 
up  in  the  system  and  liberating  carbolic  acid,  cannot  be  used  in  a  suf- 
ficiently large  dose  to  meet  with  success.  The  syrup  of  phenic  acid  is 
used  by  many  physicians,  but  their  success  does  not  as  yet  seem  to  war- 
rant its  being;  classed  as  an  efficient  remedv.  Marmorek  has  used  his 
antistreptococcic  serum  extensively,  and,  although  it  does  not  act  as  a 
specific,  he  claims  that  it  prevents  the  serious  complications  and  invari- 
ably renders  the  attack  mild. 


244  INFECTIOUS  DISEASES. 

The  care  of  the  nose  and  throat,  and  eventually  of  the  ears,  will  re- 
quire all  the  skill  of  the  medical  attendant,  and  by  commencing  early 
in  the  case  to  give  careful  and  constant  attention  to  these  parts  we  may 
prevent  much  trouble  and  danger  later  on.  The  attendant  should  use 
a  small  atomizer  filled  with  warm  water  containing  a  solution  of  sodium 
bicarbonate  (gr.  xv-5J — 0.975-32.0).  If  decided  inflammation  should 
occur,  a  solution  of  hydrogen  peroxid  and  cold  water  or  glycerin  (1  :  5) 
may  be  used,  and  then  be  followed  by  an  oily  preparation,  such  as  liquid 
albolene  containing  menthol  (a  5  per  cent,  solution). 

If  the  patient  cannot  tolerate  an  atomizer,  an  application  of  the  anti- 
septic oil  directly  to  the  posterior  nasal  spaces,  by  means  of  an  aluminum 
applicator,  may  be  made.  Faithful  attention  to  the  removal  of  the  secre- 
tion from  the  nose  and  throat  will  prevent  accumulation,  and  thus  pre- 
vent regurgitation  up  the  Eustachian  tube  with  its  associated  ear-troubles. 
In  this  way  diphtheria  can  be  prevented  from  gaining  its  full  lodgement, 
and,  if  it  gains  ground  at  all,  little  trouble  is  experienced  with  this 
dreaded  disease.  For  the  appro])riate  treatment  of  this  complication  the 
reader  is  referred  to  the  treatment  of  Diphtheria.  If  pain  in  the  ear 
should  indicate  the  extension  of  the  trouble  up  the  Eustachian  tube,  we 
must  redouble  our  efforts,  even  though  the  desquamation  Avithin  the 
Eustachian  tube  itself  may  be  quite  beyond  the  reach  of  our  detergent 
wash. 

The  external  auditory  canal  may  also  become  blocked  by  desquamat- 
ing epithelium,  and  this  must  be  removed  by  gentle  sponging.  If  the 
tension  of  the  ear-drum  becomes  very  great,  it  must  be  punctured.  The 
crude  method  of  dropping  laudanum  and  sweet  oil  in  the  ear  is  to  be 
condemned,  as  it  serves  as  a  nidus  for  a  collection  of  dust  and  dirt,  inde- 
pendent of  the  rapid  accumulation  of  dead  epidermis. 

Scarlatinal  rheumatism  I  have  encountered  in  but  a  small  proportion 
of  cases,  and  then  it  was  of  a  transient  character,  leaving  no  damaged 
heart-valves  behind.  I  am  inclined  to  attribute  this  fortunate  result  to 
the  faithful  use  of  daily  bathing  and  inunctions,  long  continued  and  at 
least  until  after  completion  of  desquamation. 

The  most  constant  complication  of  scarlet  fever  is  nephritis.  The 
specific  poison  of  scarlet  fever  is  peculiarly  obnoxious  to  the  kidneys, 
and  is  largely  eliminated  through  them  ;  and  upon  this  fact  hinges  the 
scientific  part  of  the  treatment  of  this  disease.  The  more  active  we 
render  the  skin  the  less  likely  will  there  be  danger  to  the  kidney.  If 
the  urine  is  examined  throughout  the  whole  course  of  the  disease,  we 
will  find  in  the  earlier  stage  that  it  grows  less  in  quantity  and  becomes 
more  laden  with  the  waste  of  the  body,  at  times  being  nearly  suppressed 
by  mechanical  blocking  of  the  uriniferous  tubules.  If  now  the  skin  is 
not  invited  to  act  to  its  fullest  extent,  we  will  soon  find  our  patient  re- 
duced to  a  comatose  state.  Free  bathing  has  the  happy  effect  of  vica- 
riously eliminating  the  poison,  and  in  this  way  it  removes  the  undue 
pressure  placed  upon  the  kidneys.  (For  the  treatment  of  nephritis  the 
reader  is  referred  to  the  discussion  of  acute  Bright's  disease  under  Dis- 
eases of  the  Kidneys.) 


MEASLES.  245 


MEASLES. 


Definition. — An  acute  contagious  disease,  characterized  by  an  initial 
corjza,  general  catarrhal  symptoms,  fever  in  the  earlier  stage,  followed 
by  a  peculiar  papular  eruption  on  the  face  and  body. 

Pathology. — In  uncomplicated  measles  Tve  have  no  pathologic 
lesions.  The  only  post-mortem  changes  found,  as  a  rule,  are  those  of 
catarrhal  pneumonia  and  acute  nephritis.  All  the  internal  organs  are 
gorged  with  blood,  and  minute  hemorrhages  are  found  on  their  surfaces, 
while  occasionally  croupous  pneumonia  may  be  found  involving  a  lobe 
or  small  portions  of  a  lobe  of  the  lung. 

Ktiologfy. — Measles  occurs  in  epidemics,  yet  we  have  frequent 
sporadic  cases  in  the  larger  cities.  There  is  an  epidemic  prevalence  in 
large  centers  of  population  every  eighteen  months  or  two  years,  but  the 
different  epidemics  vary  in  their  extent  and  fatality.  It  generally 
happens  that  when  once  the  disease  enters  a  home,  street,  or  small 
court,  scarcely  any  one  escapes  who  has  not  been  protected  by  a  pre- 
vious attack,  those  who  suffer  being  for  this  reason,  in  nearly  all  cases, 
young  children.  The  adults  and  older  children  may  enjoy  immunity  in 
consequence  of  a  prior  attack,  although  this  does  not  always  follow. 
The  susceptibility  to  measles  in  children,  however,  is  very  great.  A 
most  notable  example  of  this  was  the  epidemic  that  occurred  in  the 
Fiji  Islands  in  1875,  and  raged  for  four  months,  40,000  of  the  natives 
dying  out  of  a  population  of  150,000  (Corney,  quoted  by  Callir). 
Biedert  ^  found  that  only  14  per  cent,  of  unprotected  children  escaped. 
In  the  Faroe  Islands,  under  similar  conditions,  only  1  per  cent,  escaped 
(Madsen,  Pannum).  There  is  the  same  experience  in  schools  and  hos- 
pitals :  when  a  case  incubating  the  disease  is  admitted,  the  Avhole  un- 
protected junior  population  is  attacked.  The  epidemics  occur  mostly 
in  the  fall  and  winter,  yet  the  season  seems  to  have  but  little  influence. 

Bacteriology. — Micrococci,  especially  streptococci,  have  often  been 
found  in  the  secretions  of  the  respiratory  tract,  but  they  have  not  been 
proved  to  be  specific,  as  they  are  not  always  found  and  cultures  from 
them  do  not  cause  the  disease. 

Canon  and  Pielicki  ^  found  in  the  blood  of  14  cases,  as  well  as  often 
in  the  sputum  and  nasal  and  conjunctival  secretions,  a  special  bacillus 
of  irregular  size,  which  colored  irregularly  with  methylene-blue.  It 
was  decolorized  by  Gram's  method,  did  not  grow  on  solid  media,  but 
did  occasionally  on  bouillon. 

Czajkamski^  described  motile  bacilli.  2.5  to  5  micromillimeters  in 
length,  which  did  not  color  by  Gram's  method.  They  could  not  be  cul- 
tivated on  gelatin  or  agar,  but  grew  on  glycerin-agar,  bouillon,  and 
blood-serum,  and  killed  mice  by  producing  septicemia.  Xeither  of 
these  observations  has  been  advanced  to  any  firmer  position  in  the  eti- 
ology of  the  disease. 

One  attack  of  measles  does  not  seem  always  to  exhaust  the  soil,  as 
in  the  other  exanthemata :  one,  two,  and  in  several  cases  families  of 
children,  including  the  parents,  have  had  four  attacks  in  successive  years. 

^  Jahrbuch.  filr  Kinderheilkunde,  vol.  xxiv.  p.  94. 

^  Berliner  klinische  Wochensehrift,  1892,  S.  377. 

^  Centralblatt  fiir  Bacteriologie,  vol.  xviii.  Nos.  17  and  18. 


246 


INFECTIOUS  DISEASES. 


Clinical  History. — The  period  of  incubation  is  from  seven  to  four- 
teen days,  and  in  inoculated  cases  from  seven  to  ten  days. 

Catarrhal  Stage. — The  early  symptoms  are  those  of  a  cold  with  some 
fever.  The  child  has  marked  coryza,  -watery  eyes,  sneezes,  and  has  a 
dry,  croupy  cough.  Frequently  the  symptoms  are  those  of  a  catarrhal 
laryngitis  and  bronchitis,  the  fauces  and  tonsils  being  hyperemic,  with 
abundant  secretion,  and,  in  addition,  an  examination  of  the  eyelids  re- 
veals a  conjunctivitis.  The  patient  may  be  acutely  ill,  the  temperature 
rising  several  degrees  in  the  evening,  and  falling  slightly  in  the  morn- 
ini^ ;  the  fever  continues  high  until  the  rash  is  fully  developed.  The 
rashy  consisting  of  one  or  more  distinct  papules,  may  be  seen  on  the  hard 
palate  fully  twenty-four  hours  before  it  appears  on  the  face. 

The  eruptive  stage  is  very  characteristic,  and  usually  makes  its  appear- 
ance at  the  end  of  the  fourth  day.  The  neck,  face,  forehead,  and 
trunk  receive  the  eruption  in  the  order  of  mention.  The  whole  physi- 
ognomy of  the  child  is  so  characteristically  altered  that  a  well-marked 
case  may  be  diagnosticated  at  a  glance.  The  face  is  flushed ;  the  eyes 
are  red  and  watery ;  a  short,  dry  cough,  frequently  metallic  in  ring,  is 
present ;  and  the  nose  and  cheeks  are  covered  with  crops  of  dusky-red 
papules  surrounded  by  a  zone  of  erythema  which  sharply  contrasts  with 
the  normal  skin  between  the  patches.  The  rash  on  the  face  is  both  dis- 
crete and  confluent,  or  may  be  arranged  at  times  in  small  crescents,  and 
in  the  course  of  a  day  or  two  the  whole  trunk  is  invaded,  but  in  a 
slighter  degree.  By  the  fifth,  and  seldom  the  sixth  day,  the  eruption 
has  reached  its  height,  and  commences  to  fade,  first  on  the  face  and 
neck,  then  on  the  body  and  limbs,  followed  by  a  fine  desquamation. 
By  the  seventh  or  eighth  day  the  rash  is  nearly  gone,  leaving  a  blue, 

mottled  stain  over  the  body. 
The  temperature,  which  has 
reached  103°  F.  (39.4°  C.)  or 
even  105°  F.  (40.5°  C),  falls 
when  the  rash  is  fully  estab- 
lished— i.  e.  on  the  fifth  or  sixth 
day — while  the  headache,  the 
severe  bronchial  cough,  and  the 
oreneral  features  subside  with 
the  fever.  If  the  temperature 
continues  high  after  the  rash  is 
out,  we  may  look  for  some  com- 
plication, such  as  severe  bron- 
chitis, pneumonia,  or  acute  ne- 
phritis (I'iih'  Fig.   23). 

Complications. — In  some 
epidemics  the  character  of  the 
disease  is  very  severe,  being 
marked  by  high  fever  (105°- 
106°  F. — 41.1°  C).  a  dry,  brown  tongue,  delirium  and  convulsions, 
and  feeble  heart-action,  due  to  the  intense  hyperemia  of  all  internal 
organs — lungs,  brain,  kidneys,  etc.  I  have  observed  cases  in  which  the 
eruption  was  petechial. 

The  main  complications  are  presented  by  the  lungs.      The  accompa- 


40.0 


39.0 


37.0 


36.0 


Fig.  23.— Temperature-curve  of  a  case  of  measles. 


MEASLES. 


247 


nying  bronchitis  manifests  a  strong  tendency  to  extend  to  the  bronchioles, 
with  resulting  broncho-pneumonia.  The  extent  and  seriousness  of  this 
complication  are  largely  dependent  upon  the  degree  of  the  previous  de- 
bility.    Lobar  pneumonia  is  rarely  met  with. 

Catarrhal  or  membranous  laryngitis  is  frequent  in  the  pre-eruptive 
stage  or  as  a  sequela.  Quite  rarely  edema  of  the  glottis  occurs.  Oph- 
thalmia may  occur  in  anemic  and  strumous  children  if  strict  eye-toilet 
is  not  enforced.  Glandular  involvement  may  take  place  in  the  cervical 
glands.  Otitis  is  frequent  during  desquamation,  suppuration  taking 
place  in  the  middle  ear  and  the  membrane  being  perforated.  This  may 
be  avoided,  however,  by  cleansing  the  post-nasal  spaces  frequently  dur- 
ing desquamation.  Cayicrum  oris  and  noma  pudendi  may  also  appear  as 
complications  of  the  disease.  Diarrhea  is  frequent  at  the  end  of  the 
eruptive  period  and  as  a  sequela. 

The  health  of  the  child  often  remains  impaired  for  a  long  time  after 
an  attack  of  the  measles  :  it  is  at  this  period  that  whooping-cough,  diph- 
theria, nephritis,  and,  later  on,  acute  tuberculosis,  may  arise.  Tuber- 
culosis very  frequently  gains  entrance  into  the  system  from  the  existence 
of  enlarged  and  cheesy  bronchial  and  mediastinal  glands.  Nervous 
sequelse  rarely  occur  (hemiplegia,  paraplegia). 

Diagnosis. — Epidemics  may  be  characterized  by  irregular  forms  of 
the  disease,  and  the  diagnosis  of  sporadic  cases  is  often  very  difficult. 
We  cannot  recognize  it  by  its  dermal  lesions,  but  by  the  prodromal 
symptoms,  by  the  fall  of  temperature  after  the  eruption  is  well  out  (dif- 
fering here  from  scarlet  fever),  and  by  the  character  of  the  pulse,  tongue, 
and  desquamation.  Koplik's  early  sign  is  usually  present  and  is  dis- 
tinctive. From  six  to  twenty  bluish-white,  slightly-raised  spots,  about 
the  size  of  a  linseed,  appear  on  the  mucous  membrane  of  the  lips  and 
cheeks.  A  feverish  period  of  four  days,  associated  with  catarrhal  symp- 
toms of  the  eyes,  nose,  and  upper  air-passages,  a  few  papules  on  the  hard 
palate,  followed  Avithin  twenty-four  hours  by  a  papular  efflorescence  on 
the  face,  will  differentiate  the  disease  from  variola,  varicella,  scarlet 
fever,  and  rubella. 

The  accompanying  table  from  Rotch  will  aid  the  discrimination  : 


Measles. 

Variola. 

Varicella. 

Scarlet 
Fever. 

Rubella. 

Incubation   .    .    . 

1 0  days. 

12  davs. 

17  days. 

4  days. 

21  days. 

Prodromata     .    . 

3  days. 

3  days. 

A  few  hours. 

2  davs. 

A  few  hours. 

Efflorescence    .    . 

Papules. 

Macules. 
Papules. 
Vesicles. 
Pustules. 

Vesicles. 

Erythema. 

Papules. 

Desquamation 

Purpuraceous. 

Large  crusts. 

Small  crusts. 

Lamellar. 

Complications  and 

Eye  and  lung. 

Larvnx. 

Kidney, 

sequelae     .    .    . 

Lungs. 

ear,  and 
heart. 

The  mortality  differs  according  to  the  surroundings  of  the  patient. 
In  healthy  children  under  favorable  environment  the  mortality  is  prac- 
tically nil,  while  in  tuberculous  and  Avasted  children  it  is  very  large,  this 
being  especially  due  to  complications  and  sequelse.  Infants  may  be 
born  with   the  rash  on  them.^ 

1  Hem.  Med.  Chronicle,  May,  1890;   Brit.  Med.  Journal,  vol.  i.  p.  612,  1890. 


248  INFECTIOUS  DISEASES. 

Treatment. — Measles  is  a  self-limited  disease,  and  we  are  unable 
to  shorten  its  duration,  nor  is  there  any  means  of  producing  immunity 
from  the  attack.  The  treatment  is  necessarily  symptomatic  ;  hence  our 
efforts  should  be  directed  to  protecting  the  various  organs  that  are  most 
likely  to  become  involved  by  complications,  remembering  at  the  same 
time  that  the  nose,  ears,  eyes,  and  throat  are  involved  during  the  fever- 
ish stage,  and  that  the  skin  is  in  a  very  susceptible  condition. 

The  patient  should  be  placed  in  a  large  dark,  -well-ventilated  room, 
with  a  uniform  temperature  between  68°  and  70°  F.  (21.1°  C).  He 
should  remain  in  bed  until  the  temperature  has  been  normal  for  one 
■week,  and  until  the  efflorescence  has  nearly  faded  and  the  desquamation 
is  almost  complete.  The  diet  during  the  period  of  fever  should  be  milk, 
bread,  and  light  soups.  Near  the  end  of  desijuamation,  if  all  symptoms 
are  favorable,  a  more  generous  dietary  may  be  allowed. 

The  bronchial  cough,  which  may  be  very  troublesome  during  the 
first  few  days,  can  be  readily  relieved  by  some  simple  expectorant  mix- 
ture, as — 

I^.  Potassii  citrat.,  ^ss(16.0); 

Succi  limonis,  |j  (32.0) ; 

Tr.  opii  camph.,  3ij  (8.0); 

Syr.  ipecac,  3ij  (8.0)  ; 

Syr.  tolu.,  q.  s.  ad  gij  (64.0).— M. 

Sig.  3ss-.'^j  every  two  or  three  hours,  according  to  the  age  and 
condition  of  the  patient. 

This  will  serve  as  a  fever  mixture  as  well  as  an  expectorant. 

For  the  coryza  I  have  found  that  atomizing  the  nares  with  some  oily 
vehicle  (oleum  petrolatum  album,  etc.)  is  advantageous. 

The  skin  is  in  a  state  of  great  irritation,  and  from  the  very  com- 
mencement of  the  disease  until  the  end  of  desquamation  a  daily  warm 
bath  (95°  to  100°  F.— 35°  to  37.7°  C.)  should  be  given  the  patient. 
The  body  should  be  carefully  dried  and  cocoa-butter  then  thoroughly 
rubbed  over  the  entire  surface.  The  child  should  live  in  an  equable 
temperature  for  at  least  thi-ee  weeks,  and  longer  if  desquamation  has  not 
then  ceased.  For  months  he  should  be  protected  from  sudden  atmo- 
spheric changes  in  order  to  avoid  general  respiratory  troubles.  If  he 
be  predisposed  to  tuberculosis,  cod-liver  oil  and  creasote  should  be  pre- 
scribed for  a  period  of  two  months  or  more. 


RUBELLA. 

{Entheln;  Rubeola  Notha ;    German  Measles;  French  Measles.) 

Definition. — An  acute  contagious  disease.  It  has  no  prodromal 
stage,  and  is  characterized  by  slight  fever,  coryza,  and  an  efflorescence 
upon  the  skin. 

Btiology. — Rubella  was  not  distinguished  from  measles  and  scarlet 


RUBELLA.  249 

fever  until  about  the  middle  of  the  eighteenth  century.  Since  then  con- 
siderable controversy  has  arisen  at  different  times  as  to  its  nature,  the 
theory  being  at  one  time  strongly  advanced  that  it  was  a  combination 
of  these  two  diseases,  as  many  of  the  milder  cases  have  symptoms  com- 
mon to  both.  That  there  is  a  difference,  however,  in  the  character  and 
course  of  these  diseases  has  been  proved  beyond  doubt  to  careful  ob- 
servers by  the  facts  that  rubella  occurs  independently  of  either  lAeasles 
or  scarlet  fever ;  that  contagion  from  this  disease  produces  a  similar  dis- 
ease ;  that  one  attack  affords  immunity  to  subsequent  seizures  (although 
those  who  have  had  other  eruptive  diseases  are  as  liable  as  those  that 
have  not  to  contract  this  disease  during  an  epidemic) ;  and  that  its  onset 
and  clinical  course  are  characteristic. 

Rubella  is  contagious,  and  may  occur  epidemically  or  sporadically. 
It  is  like  measles  and  the  other  exanthemata  in  its  being  of  undoubted 
microbic  origin,  although,  as  is  the  case  with  them,  the  specific  organism 
has  not  been  isolated.  When  that  is  accomplished  the  diagnosis  will  be 
more  easy  and  certain. 

In  hospitals  or  where  persons  are  crowded  and  living  under  unhy- 
gienic circumstances  the  disease  is  very  contagious  and  the  epidemic 
will  be  quite  general ;  but  in  family  practice  it  is  but  slightly  so,  and 
the  epidemics  are  limited,  often  being  confined  to  a  single  household 
and  attacking  perhaps  but  one  or  two  of  the  family.  As  stated  by 
Edwards,  it  is  spread  by  the  cutaneous  exhalations,  breath,  fomites,  and 
clothing,  and  is  probably  contagious  from  the  period  of  incubation  until 
far  into  convalescence. 

Clinical  History. — The  incubation  stage  lasts  from  ten  to  twelve 
days,  though  this  period  may  vary  and  the  disease  appear  three  or  four 
days  after  exposure.  On  the  other  hand,  cases  have  been  reported  in 
which  it  w^as  as  long  as  three  weeks.  As  a  rule,  the  period  of  incuba- 
tion is  longer  perhaps  than  in  measles.  The  stage  of  invasion  covers 
from  one  to  three  days,  but  in  mild  cases  the  rash  is  very  often  the  first 
indication  we  have  that  the  child  has  developed  an  infectious  disease. 

For  a  period  of  a  few  days  before  the  rash  appears  there  w-ill  be 
noticed  chilliness,  pains  in  different  parts  of  the  body,  a  dull,  heavy 
feeling,  perhaps  feverishness,  accompanied  by  sore  throat,  enlarged  ton- 
sils, coryza,  and  suffusion  of  the  eyes,  constriction  over  the  chest,  and  a 
dry  cough  and  bronchitis.  Enlargement  and  induration  of  the  cervical 
and  other  lymphatic  glands,  together  with  the  sore  throat,  are  common 
symptoms. 

Just  before,  or  with  the  appearance  of,  the  rash  there  is  a  rise  in 
temperature  to  99°  or  100°  F.  (37.7°  C),  or  in  severe  cases  as  high  as 
103°  F.  (39.4°  C.)  or  more.  Again,  the  invasion  symptoms  may  be 
absent  or  so  mild  as  to  escape  notice,  and  the  first  sign  of  infection  be 
the  appearance  of  a  rash  which  first  shows  itself  on  the  face  and  extends 
downward  over  the  body.  In  some  cases  the  eruption  does  not  follow 
the  regular  course,  and  is  confined  to  one  part  of  the  body,  and  cases 
have  been  reported  in  which  it  only  appeared  on  the  roof  of  the  mouth 
or  on  the  tonsils.  In  other  cases  every  part  of  the  body,  including  the 
palms  of  the  hands  and  the  soles  of  the  feet,  may  be  covered. 

The  eruption  consists  of  papules,  is  multiform,  confluent,  and  of  a 
pale  or  rosy-red  color.     The  patches  do  not  assume  any  regular  shape 


250  INFECTIOUS  DISEASES. 

or  form,  and  the  skin  between  them  may  become  hyperemic  and  cause 
itching.  The  rash  reaches  its  height  on  different  parts  of  the  body  in 
succession,  fading  in  one  part  while  appearing  in  another.  Its  duration 
is  from  two  to  five  days,  and  possibly  longer  in  some  cases. 

A  slight  desquamation  usually  occurs,  and  a  slight  pigmentation  of 
brownish  color  after  the  rash  fades  is  frequently  noticed,  disappearing 
after  a  few  days.  The  temperature-curve  is  variable,  but  as  a  rule  it 
remains  between  100°  F.  (37.7°  C.)  and  102°  F.  (38.8°  C.)  while  the 
eruption  is  present.  As  mentioned  above,  sore  throat  is  nearly  always 
present,  Avith  enlarged  tonsils,  a  dry  cough,  and  bronchitis.  The  glan- 
dular enlargement  will  also  continue  with  the  rash,  and  in  severe  cases 
the  axillary  and  inguinal  glands  may  become  involved.  The  pulse 
varies  with  the  temperature  and  respiration.  Vomiting  has  been 
noticed  as  occurring  during  the  eruption   in  severe  cases. 

After  a  period  varying  from  three  days  to  a  week,  Avith  the  disap- 
pearance of  the  rash,  convalescence  begins  and  the  child  rapidly  regains 
its  former  health,  and  the  whole  course  of  the  disease  may  be  so  mild 
that  the  patient  cannot  be  persuaded  to  remain  in  bed. 

Complications. — The  most  common  are  affections  of  the  respir- 
ator// tract  (pneumonia  or  severe  bronchitis),  and  in  some  cases  we  have 
a  gastro-intestinal  catarrh  of  a  troublesome  character.  Diphtheria  or 
other  contagious  diseases  may  occur.  A  relapse  is  not  uncommon,  and 
may  be  as  severe  as  the  initial  attack. 

Diagnosis. — Rubella  may  be  distinguished  from  measles  by  its  less 
severe  onset  and  course,  by  the  lighter  color  and  more  diffuse  character 
of  its  rash,  and  by  the  irregidar  shape  which  the  patches  assume.  The 
presence  or  absence  of  an  epidemic  is  an  important  factor  in  the  diag- 
nosis, and  in  cases  occurring  Avhen  there  is  no  epidemic  the  diagnosis 
between  this  disease  and  measles  of  a  mild  type  is  difficult  if  not  alto- 
gether impossible. 

From  a  well-marked  case  of  scarlatina  the  diagnosis  offers  no  diffi- 
culty. The  absence  of  its  initial  vomiting,  the  strawberry  tongue,  the 
character  of  the  rash  (wliich  in  scarlet  fever  is  erythematous),  and  the 
shorter  duration  and  milder  course  of  rubella,  all  help  to  render  the 
diagnosis  easy. 

Rubella.  Erythema.  Urticaria. 

Occurs  first  on  the  face.  On  the  hiinds  and  feet.  In  wheals  on  arms  and  legs. 

Marked  eorvza  present.  No  coryza.  Xo  coryza. 

At  first  no  ftching.  Burning  pain.  Intense  itching. 

Contagious.  Not  contagious.  Not  contagious. 

Microbic  origin.  Reflex  origin.  Gastric  oi-igin. 

The  prognosis  in  uncomplicated  cases  is  invariably  good,  but  when 
the  surroundings  are  unhygienic,  or  in  cases  in  which  the  child  has  been 
delicate  previously,  it  is  more  serious.  Complications,  especially  pneu- 
monia or  diphtheria,  may  prove  fatal,  and  in  some  cases  the  mortality 
reported  has  been  as  high  as  9  per  cent. 

Treatment. — The  treatment  is  simple  and  principally  symptomatic. 
A  mild  cough-mixture,  such  as  is  recommended  in  measles  for  the  bron- 
chitis, nutritious  but  easily  digested  food,  and  medicine  to  regulate  the 
bowels  when  necessary,  fulfil  all  the  indications  for  internal  medication. 


WHO  OPING-CO  UGH.  251 

As  in  measles,  cool  sponging  should  be  resorted  to  before  and  during 
the  rash ;  and,  when  the  fever  is  high,  a  cool  tub-bath,  where  practicable, 
will  be  found  to  reduce  the  temperature,  quiet  the  patient,  and  hasten 
the  appearance  of  the  eruption.  During  convalesence,  if  the  child  does 
not  rapidly  regain  his  appetite  and  strength,  tonics,  such  as  tincture 
of  nux  vomica  and  syrup  of  hydriodic  acid,  are  indicated. 

The  complications  are  to  be  treated  as  they  arise,  but  the  sponging 
should  not  be  discontinued  until  the  temperature  reaches  its  normal 
level. 


WHOOPING-COUGH. 

(Pertussis  ;    Tussis  Convulsiva  ;  Keuchhusten.) 

Definition. — Whooping-cough  is  a  highly  contagious  disease  which 
is  characterized  by  a  catarrhal  inflammation  of  the  respiratory  tract, 
associated  with  a  peculiar  spasmodic  cough,  ending  in  a  whooping 
inspiration. 

Pathology. — There  is  no  lesion  that  can  be  considered  characteris- 
tic of  whooping-cough,  and  there  is  no  distinct  causal  lesion  around 
which  all  the  symptoms  and  complicating  lesions  are  grouped.  In  the 
beginning  there  is  catarrh  of  the  naso-pharynx,  and  this  may  be  the 
only  lesion  coincident  with  the  development  of  the  characteristic  cough. 
In  advancing  cases  this  naso-pharyngeal  catarrh  becomes  generalized  by 
extension  to  the  lachrymal  ducts,  the  conjunctivae,  the  Eustachian  tube 
and  the  middle  ear,  to  the  glottis,  trachea,  large  and  small  bronchi,  and 
the  air-vesicles.  The  more  decided  pulmonary  lesions — emphysema, 
pulmonary  collapse,  pulmonary  congestion  and  edema,  and  broncho- 
pneumonia— are  advanced  pathologic  conditions  accompanying  the 
later  stages  or  more  intense  forms  of  the  disease  (W.  W,  Johnston). 

The  post-mortem  table  does  not  give  us  much  information  as  to  the 
pathology  except  as  to  the  sequences  of  the  disease.  In  the  early  stages 
swelling  and  redness  of  the  respiratory  and  digestive  tracts  will  be  found, 
together  with  a  large  quantity  of  viscid  mucus. 

Ktiology. — The  disease  occurs  in  epidemics,  yet  occasionally  may 
appear  sporadically.  Pertussis  seems  to  have  a  tendency  to  occur  in 
epidemics  every  two  years,  although  in  large  cities  the  disease  is  gener- 
ally endemic.  There  is  no  doubt  that  it  should  be  classed  with  the  spe- 
cific diseases,  yet  for  a  long  time,  like  mumps,  it  hovered  between  the 
specific  and  the  catarrhal  diseases  for  a  home.  Pertussis  is  directly 
contagious,  though  scarcely  so  in  houses  and  school-rooms  unless  it  be 
for  those  of  a  specially  susceptible  nature.  It  is  possible,  however,  for 
the  disease  to  be  propagated  in  schools,  though  not  to  the  same  extent 
as  measles  and  scarlet  fever.  It  seems  that  a  more  decided  and  pro- 
longed personal  contact  must  be  made,  as  with  members  of  a  family,  to 
ensure  transmission.  One  attack  practically  protects  the  child,  yet  ex- 
ceptions to  this  rule  may  be  found.  The  influence  of  the  seasons  does 
not  seem  to  have  any  eifect,  though  perhaps  fall  and  spring  are  the  more 
frequent  periods  ;  the  station  in  life,  whether  hygienic  or  unhygienic,  does 


252  INFECTIOUS  DISEASES. 

not  modify  the  disease.  Bad  ventilation,  however,  may  propagate  the 
disorder,  and  cause  additional  cases  by  favoring  the  increase  of  germs 
in  the  immediate  surroundings.  The  previous  condition  of  health,  espe- 
cially of  the  respiratory  mucous  membrane,  seems  to  possess  some  pre- 
disposing influence,  weak,  delicate  children  with  an  irritable  digestive 
tube  associated  with  a  catarrhal  state  of  the  respiratory  passages,  more 
readily  contracting  whooping-cough  than  those  in  robust  health. 

There  seems  to  be  an  intimate  association  between  Avhooping-cough 
and  measles,  and  it  is  a  Avell-recognized  fact  that  an  epidemic  of  measles 
will  be  followed  by  whooping-cough  in  the  same  sufferers.  This  is  pos- 
sibly due  to  the  sensitive  condition  of  the  mucous  membrane  left  by  the 
measles,  which  is  so  favorable  to  the  lodgement  of  the  germs  of  pertus- 
sis ;  and  the  association  of  the  two  diseases  must  be  more  than  acci- 
dental. There  exists  a  certain  individual  susceptibility  to  whooping- 
cough,  as  well  as  to  other  infectious  diseases,  and  yet  many  children 
never  contract  them,   though  fre([uently  exposed. 

Age  exercises  some  influence  on  the  development  of  whooping-cough, 
most  cases  occurring  before  the  tenth  year ;  after  this  time  the  frequency 
of  the  disease  rapidly  diminishes.  West  states  that  one-half  of  all 
cases  develop  under  three  years,  but  he  must  have  based  his  knowledge 
upon  an  experience  in  hospitals  and  children's  homes,  as  the  experience 
of  others  does  not  sustain  his  statement.  The  disease  occurs  in  adults 
but  rarely,  this  being  due  partly  to  the  fact  that  so  many  have  suff'ered 
from  it  while  young,  and  partly  because  of  a  lessening  of  the  suscepti- 
bility with  advancing  years.  It  occurs  frequently  before  the  first  year, 
and  when  it  does  it  is  the  most  fatal  of  all  the  diseases  of  childhood 
(Goodhart). 

The  sexes  are  about  equally  divided  as  regards  susceptibility;  many 
writers,  however,  seem  to  think  that  girls  are  most  liable.  Ofttimes 
one  close  exposure  in  a  susceptible  child  is  sufficient  to  ensure  an  attack. 
The  germs  seem  to  be  located  at  first  in  the  secretions  of  the  respiratory 
tract,  and  are  thus  disseminated  through  the  air,  the  disease  being  most 
highly  contagious,  therefore,  during  the  paroxysms  of  coughing.  Good- 
hart  reports  a  case  in  which  a  third  party  was  the  medium  in  conveying 
the  disease  from  one  child  to  another,  thus  suggesting  a  possibility  of 
the  contagion  being  ponderable. 

The  highway  of  the  contagion  of  whooping-cough  into  the  system  is 
evidently  through  the  respiratory  tract,  though  this  fact  has  not  yet 
been  definitely  settled.  Published  cases  of  pertussis  in  the  new-born 
would  even  seem  to  make  its  transmission  possible  through  the  fetal 
circulation,  yet  the  reports  are  neither  numerous  nor  satisfactory,  and 
cannot  be  depended   upon. 

Nature  and  Bacteriology. — The  true  nature  of  whooping-cough  has 
been  thoroughly  discussed,  but  is  not,  as  yet,  fully  settled.  Many 
writers  claim  it  to  be  a  simple  bronchitis  due  to  "  cold  "  associated  Avith 
a  certain  nervous  habit  or  mimicry.  The  cough  is  started  by  the  bron- 
chial irritant,  and  soon  tends  to  become  a  habit,  thus  returning  again 
and  again,  until  it  dies  out  in  the  oblivion  engendered  by  more  healthy 
and  regulated  discharges  of  nervous  energy  (Goodhart).  This  theory 
fails  to  account  for  the  nervous  element  and  the  decided  paroxysmal 
character  of  the  coush.     It  has  been  held  that  the  disease  is  a  lesion  of 


WHOOPING-COUGH.  253 

either  the  pneumogastric,  phrenic,  sympathetic,  or  recurrent  laryngeal 
nerves,  or  perhaps  even  of  the  medulla.  If  this  ground  is  valid,  it  is 
simply  a  neurosis.  Eustace  Smith  says  it  is  caused  by  the  pressure  of 
the  enlarged  tracheal  and  bronchial  glands  upon  the  terminal  filaments. 
of  the  pneumogastric  nerve.  Whatever  the  direct  cause,  the  highly 
contagious  character  of  whooping-cough,  its  appearance  in  epidemics, 
its  incubating  period,  and  the  possible  immunity  from  subsequent  at- 
tacks seem  to  prove  beyond  argument  that  it  should  be  classed  among 
purely  infectious  diseases. 

Bacteriology. — Linnaeus  (to  quote  Dr.  J.  P.  C.  Griffith,  in  the  Ameri- 
can  Text-hook  of  Diseases  of  Children)  attributes  pertussis  to  the  pres- 
ence in  the  nose  of  larvae  of  insects.  Letzerich  found  a  micrococcus  in 
the  sputum  which  he  believed  to  be  the  specific  germ,  and  claimed  to 
have  been  able  to  produce  the  disease  in  animals  by  introducing  the 
secretion  into  the  trachea.  Diechler-Kurlow  claimed  that  there  was 
always  present  in  the  sputum  an  organism  of  the  nature  of  a  protozoon 
which  possessed  ameboid  motion.  The  researches  of  Afanassieif,  in 
1887,  however,  have  attracted  the  most  attention.  This  observer  iso- 
lated a  short  bacillus,  which  he  named  the  bacillus  tussis  convulsivce,  and 
of  which  he  was  able  to  obtain  pure  cultures  upon  various  media.  Ani- 
mals inoculated  upon  the  respiratory  mucous  membrane  with  these  cult- 
ures exhibited  some  of  the  symptoms  of  the  disease  and  developed 
catarrhal  conditions  of  the  respiratory  tract,  with  a  tendency  to  broncho- 
pneumonia. These  observations  have  been  confirmed  by  others,  and  a 
toxin  has  also  been  reported  as  present  in  the  urine  of  patients  suffer- 
ing from  pertussis  w^hich  is  identical  '.vith  that  produced  by  AfanassiefiF's 
bacillus.  KuolofF  believes  that  the  parasite  of  whooping-cough  is  a  spe- 
cific micro-organism,  a  protozoon,  and  has  found  uniformly  in  the  fresh 
sputa  of  patients  ameboid  organisms  with  spheric  spores  characterized 
by  concentric  laminations.^  Czaplewski  and  Hensel  describe  a  short 
bacillus  with  distinctly-staining  rounded  ends,  and  commonly  occurring 
in  pairs.  It  is  found  in  sputum,  both  free  and  in  pus-cells,  increasing 
as  the  disease  advances.  It  can  be  obtained  in  pure  culture  ;  and  grows 
on  any  ordinary  medium  except  potato.  It  resembles  Koplik's  bacillus. 
The  latter  is  facultative-anaerobic,  and  is  not  stained  by  Gram's  method 
except  in  pure  culture.  The  organism  is  not  found  in  the  sputum  during 
the  prodromal  stage. ^  Even  though  it  be  admitted  as  most  probable 
that  some  micro-organism  is  the  cause  of  the  malady,  it  is  by  no  means 
clear  how  the  symptoms  are  produced  or  where  the  principal  seat  of  the 
infection  arises.  The  careful  investigations  of  Myer-Huni  and  of  von 
Heroff  indicate  that  the  catarrhal  inflammation  is  most  pronounced  in 
the  mucous  membrane  of  the  nose,  larynx,  and  trachea  down  to  the 
bifurcation,  but  especially  so  on  the  posterior  wall  of  the  larynx  in  the 
interarytenoid  region,  the  so-called  "cough  region."  Undoubtedly  Ave 
have  in  whooping-cough  an  infectious  catarrhal  process  Avhich  affects  the 
mucous  membrane  controlled  by  the  superior  laryngeal  nerve,  and  the 
value  in  many  cases  of  purely  local  treatment  indicates  that  the  abode 
of  the  germs  is  in  this  region,  whence  the  poisonous  products  of  their 
growth  are  absorbed. 

1  Medical  Neiv^,  Nov.  9,  1896. 

'^  Saunders'  Year-Book  for  1899,  p.  696. 


254  INFECTIOUS  DISEASES. 

The  nature  of  the  "whoop  "  has  been  frequently  discussed  to  show 
the  nervous  origin  of  the  disease,  yet  the  infantile  larynx  is  capable  of 
responding  to  purely  neutral  stimuli  owing  to  the  flexible  nature  of  the 
young  cartilage.  If  we  carry  a  young  sleeping  child  from  a  warm  room 
out  in  the  cool  air,  the  same  characteristic  whoop  may  be  produced, 
showing  that  this  reasoning  cannot  be  depended  upon. 

Clinical  History. — The  period  of  incubation  varies  from  four  to  four- 
teen days  according  to  the  extent  of  catarrhal  trouble  in  the  child  existing 
at  the  time.  Goodhart  gives  several  authenticated  cases  in  which  the  in- 
cubation ended  on  the  eighth  day.  In  the  beginning  the  symptoms  are 
those  of  a  slight  bronchial  cough,  which  has  a  tendency  to  be  more  pro- 
nounced during  the  night.  After  a  few  days  the  cough  assumes  an  in- 
fluenzal character,  and  at  the  same  time  it  gradually  grows  metallic  in 
ring  and  shows  a  laryngeal  type.  There  is  some  fever  present.  This 
catarrhal  or  feverish  stage  lasts  for  a  week  or  more,  when  it  is  followed 
by  the  paroxysmal  stage,  and  these  stages  are  divisions  of  the  symptoms 
worthy  of  recognition,  as  the  treatment  in  the  first  is  not  applicable  to 
the  second.  Many  authorities  speak  of  a  third  stage  as  one  of  decline, 
which  does  not  sharply  occur,  but  includes  the  sequence  of  the  disease. 
The  catarrhal  stage  lasts  about  one  week  or  ten  days,  during  which  the 
child  is  ill  at  ease,  is  feverish,  and  has  a  hoarse,  dry  cough.  The  symp- 
toms may  either  be  entirely  laryngeal  at  first  or  bronchial,  with  a  loss 
of  appetite  and  broken  rest  at  night.  Auscultation  at  this  time  will 
reveal  a  few  moist  or  dry  rales  in  the  larger  bronchial  tubes,  but  there 
is  very  little  secretion.  The  cough  seems  to  be  out  of  proportion  to  the 
physical  signs.  As  the  catarrhal  stage  proceeds  the  cough  commences 
to  indicate  its  character  by  becoming  more  noisy,  increasing  especially  at 
night.  The  physiognomy  of  the  child  commences  to  change,  the  face  is 
swollen,  the  eyes  suftused  and  watery,  the  under  lids  swollen  and  pink  in 
color.  This  is  one  of  the  most  decisive  indications  of  the  trouble,  and 
may  be  recognized  by  a  careful  observer  a  few  days  before  the  "  whoop  " 
begins  which  stamps  the  disease  and  ushers  in  the  second  stage.  The 
commencement  of  the  paroxysmal  stage  is  quite  diff'erent  from  the  easy 
and  more  constant  coughing  of  the  first  stage.  If  the  child  is  in  bed, 
the  onset  of  a  paroxysm  is  usually  quite  sudden,  but  if  he  is  up  and 
playing,  there  is  a  period  of  restlessness,  a  premonition  of  the  coming 
storm  similar  to  the  aura  in  epilepsy,  and  the  child  may  even  have  time 
to  run  to  his  mother  or  nurse  before  the  paroxysm  comes  on.  Usually 
the  paroxj'sms  are  induced  by  a  quick  inspiration,  as  during  drinking, 
eating,  or  crying.  The  first  (expiratory)  part  is  short,  and  followed  by 
a  short  whoop ;  this  is  very  quickly  followed  by  a  long  series  of  short 
expiratory  efforts  and  a  second  and  longer  whoop,  when  the  pai'oxysm 
may  cease.  In  some  cases  a  third  and  a  fourth  may  quickly  follow,  un- 
til the  child  is  quite  exhausted.  The  paroxysms,  whether  short  or  long, 
generally  terminate  Avith  vomiting  or  eructation  of  a  quantity  of  stringy 
mucus.  Food  is  ejected,  and  in  most  cases  a  little  blood  is  mixed  with 
the  vomited  mucus. 

At  this  stage  of  the  disease,  if  at  all  severe,  the  countenance  of  the 
child  is  characteristic,  and  so  much  so  that  a  mistake  is  no  longer  pos- 
sible :  the  features  are  swollen,  puffy,  and  dusky  in  color ;  the  eyes 
are  injected,  the  lids  swollen  and  pink  ;  the  skin  livid,  due  to  a  minute 


WHOOPING-COUGH.  255 

ecchymosis  of  th«  smaller  capillaries.  In  many  cases  there  will  be  ex- 
travasation of  blood  beneath  the  conjunctiva,  due  to  the  violence  of  the 
congestive  cough.  If  the  chest  be  examined  at  this  stage,  it  "will  tell 
but  little,  provided  we  have  no  broncho-pneumonia,  though  a  few  moist 
rales  may  be  found  scattered  through  the  larger  tubes. 

The  spasmodic  stage  of  whooping-cough  has  no  set  duration  and 
varies  frequently  in  intensity.  In  severe  cases  it  may  consist  of  twenty 
to  forty  j)aroxysms  during  the  twenty-four  hours.  Some  spasmodic 
coughs  are  not  accompanied  by  a  whoop,  and  the  absence  of  this  sign 
may  be  noted  in  very  young  children,  as  well  as  in  those  that  are  very 
ill  with  broncho-pneumonia.  Some  children  vomit  after  a  coughing 
spell  without  the  Avhoop. 

It  is  frequently  observed  that  long  after  the  spasmodic  spell  has  come 
to  an  end  the  paroxysms  return  again  and  again,  perhaps  years  after- 
ward, with  almost  characteristic  features,  evidently  acting  under  the 
stimulus  of  some  perfectly  neutral  catarrh, 

ComplicatioiiS. — In  severe  cases  the  complications  are  likely  to  be 
numerous. 

Einstaxis  often  occurs  in  children  ;  hemopti/sis  when  vomiting  is  fre- 
quent ;  ulceration  of  the  frenum  linguge  in  violent  coughing;  convulsions 
in  vigorous  children ;  and  hroncJio-jmeumonia,  i^leurisy,  ])ericarclitis, 
laryngitis,  and  hernia  in  severe,  prolonged  coughing.  Convulsions  and 
broncho-pneumonia  are  alarming ;  in  young  children  a  profound  stupor 
takes  the  place  of  the  convulsions,  and  the  latter  then  become  of  graver 
significance. 

Sequelae. — Acute  neph-itis  frequently  occurs,  and  is  as  severe  as 
that  found  in  scarlet  fever,  although  the  condition  has  not  received  the 
recognition  it  should  from  the  authorities.  In  a  series  of  over  200  cases 
I  have  found  the  kidneys  affected  in  20  per  cent.  Emaciatioyi  is  a  very 
important  sequence  of  pertussis.  All  the  viscera  are  liable  to  fatty  de- 
generation, and  nutritional  changes  open  the  door  to  cheesy,  glandular 
alterations,  and  eventually  to  a  secondary  tuberculosis.  Atelectasis,  by 
curtailing  lung-space,  frequently  brings  about  a  general  collapse,  and 
this  condition  very  frequently  explains  the  flattened  chest  found  in 
young  adults.  Emaciation  may  also  be  due  to  mucous  disease,  a  chronic 
gastro-intestinal  catarrh  of  long  standing. 

Prognosis. — Associated  Avith  its  complications,  pertussis  is  a  very 
fatal  disease,  especially  in  children  under  two  years  of  age.  Dolan  re- 
gards it  as  third  in  rank  among  the  fatal  diseases  of  England,  where 
the  death-rate  per  million  is  five  thousand  annually.  The  deaths  occur 
chiefly  among  children  of  the  poor  and  in  bottle-fed  infants. 

Goodhart  regards  Avhooping-cough  as  the  most  fatal  of  all  the  dis- 
eases in  children  under  one  year  of  age.  He  places  the  mortality  as 
high  as  12  per  cent.,  and  thinks  that  this  is  not  too  high;  his  state- 
ment, however,  is  hardly  warranted,  as  he  includes  the  deaths  from  the 
many  sequelae  which  Ave  cannot  estimate.  Ashby  and  Wright  place  the 
mortality  at  7.6  per  cent. 

Diagfnosis. — Young  infants  usually  do  not  "Avhoop,"  but  cough 
spasmodically.  Children  Avith  pleurisy  or  pneumonia  do  not  Avhoop, 
yet  Ave  diagnose  Avhooping-cough  by  the  preceding  catarrhal  fever. 
From  influenza  in  its  early  stages  it  is  most  difiicult  to  differentiate  the 


256  INFECTIOUS  DISEASES. 

affection.  The  pink  under  eyelid  has  to  me  been  the  most  certain  sign. 
When  the  whoop  appears  and  during  the  existence  of  an  epidemic,  how- 
ever, the  diagnosis  may  be  rendered  certain. 

The  diagnostic  points  prior  to  the  whooping  stage,  enunciated  by 
Eustace  Smith  (viz.  "  If  a  chikl  be  made  to  bend  back  the  head,  so  that 
his  face  becomes  almost  horizontal,  and  the  e3'es  look  straight  upward 
at  the  ceiling  above,  a  venous  hum,  varying  in  intensity  according  to 
the  size  and  position  of  the  diseased  glands,  is  heard  with  the  stetho- 
scope placed  upon  the  upper  bone  of  the  sternum.  As  the  chin  is  now 
slowly  depressed  the  hum  becomes  less  loudly  audible,  and  ceases 
shortly  before  the  head  reaches  its  ordinary  position  ")  has  not  been 
very  satisfactory.  It  is  true  that  we  do  recognize  the  hum  caused  by 
the  enlarged  bronchial  gland,  but  it  occurs  long  after  other  symptoms 
are  manifest,  and  thus  its  importance  is  much  lessened. 

I  have  for  several  years  been  able  to  place  considerable  value  on  the 
peculiar  puffiness  of  the  mucous  membrane  of  the  eyes  and  the  swollen 
or  edematous  condition  of  the  Avhole  face  and  almost  dusky  color.  This 
condition  may  exist  for  days  before  the  catarrhal  symptoms  have  ex- 
tended throughout  the  respiratory  mucous  membrane.  The  cough  at 
this  stage  may  not  be  at  all  suggestive :  it  may  be,  in  fact,  pm-ely 
bronchial. 

This  symptom  of  fulness  about  the  eyes,  which  is  quite  as  constant 
as  in  measles,  would  in  fact  suggest  that  disease,  and  must  be  differen- 
tiated from  it.  As  Ave  are  able  to  diagnose  measles  by  its  appearance 
first  on  the  hard  palate,  so  I  contend  we  may  diagnose  whooping-cough 
in  its  earliest  stage  by  the  characteristic  swollen  condition  of  the  eyes 
and  face.  I  insist  upon  this  factor  as  of  the  greatest  importance,  as 
its  recognition  will  enable  us  to  institute  specific  treatment  early, 
when  the  disease  is  yet  local  and  may  be  brought  more  speedily 
under  control. 

Treatment. — The  gravity  of  pertussis  is  scarcely  appreciated 
either  by  the  general  physician  or  the  public,  and  there  is  more  crim- 
inal neglect  in  connection  with  whooping-cough  than  with  any  other 
disease.  Medicinal  treatment  is  exceedingly  unsatisfactory,  although 
the  therapeutic  measures  are  boundless :  just  as  in  phthisis  and  diph- 
theria, they  cover  the  whole  domain  of  the  Pharmacopeia,  and  we  have 
as  yet  found  no  specific.  The  remedies  most  in  use  are  the  antispas- 
modics and  the  germicides. 

"Whooping-cough  has  a  striking  parallel  in  diphtheria,  in  that  it 
has  in  its  early  stages  a  local  manifestation  in  its  strong  tendency  to 
fasten  itself  upon  the  throat.  How  long  this  period  exists  we  know  to 
a  certainty  no  more  than  we  know  just  how  long  diphtheria  is  purely  a 
local  throat-poison ;  yet  there  is  undoubtedly  a  period  in  whooping- 
cough,  as  there  is  in  diphtheria,  long  or  short,  in  which  the  virus — if 
it  could  be  recognized — could  be  destroyed  and  the  disease  terminated. 
To  abort  cases  thus  within  two  weeks  is  not  unusual,  and  this  explains 
the  number  of  reported  cures  made  by  germicidal  remedies. 

I  have  notes  of  2  recent  cases  in  which  the  characteristic  Avhoop  com- 
menced at  once  with  the  general  catarrhal  symptoms,  and  was  cut  short 
by  a  hydrogen-peroxid  gargle.  I  think  these  2  cases  illustrate  very 
clearly  the  fact  that  the  germs  of  the  disease  will  locate  on  the  mucous 


WHOOPING-COUGH.  257 

membrane  of  the  respiratory  passages  and  bring  about  a  nerve-discharge 
which  ends  in  the  characteristic  whoop.  In  my  treatment  of  this  dis- 
ease I  find  the  greatest  necessity  of  recognizing  the  nature  of  the  trouble 
early  in  the  catarrhal  stage.  If  I  can  satisfy  myself  that  I  am  dealing 
with  a  case  of  early  pertussis,  my  methods  of  procedure  are  much  differ- 
ent from  what  they  would  be  if  the  case  were  well  advanced.  We  must 
remember  that  the  two  stages  are  not  sharply  defined,  and  that  many 
cases  entirely  lack  the  catarrhal  stage,  just  as  there  are  many  cases  that 
do  not  whoop. 

Pertussis,  as  we  all  know,  is  a  notoriously  unsatisfactory  disease  to 
manage,  and  if  we  put  our  whole  confidence  on  a  single  remedy,  we  are 
likely  to  meet  with  keen  disappointment.  The  drugs  I  have  found  most 
efiicient  in  the  catarrhal  stage  have  been  hydrogen  peroxid  in  sterilizing 
the  naso-pharynx,  and  asafetida,  occasionally  used  for  the  paroxysms. 
Belladonna  is  to  a  high  degree  beneficial  in  young  children.  I  push  this 
drug  until  I  get  the  full  toxic  efi'ects,  when  I  am  generally  rewarded 
with  a  diminution  of  the  suggestive  characteristics  of  the  cough. 

To  be  more  explicit,  I  will  detail  the  methods  of  procedure  in  a  fam- 
ily in  Avhich  I  have  instituted  my  plan  of  thorough  treatment :  A  child  of 
four  years  attending  kindergarten  was  brought  to  me  with  a  suspicious 
cough.  The  history  was  given  of  an  exposure  of  over  two  Aveeks  prior. 
The  child  had  coughed  for  a  few  days,  more  at  night  than  in  the  daytime ; 
was  feverish  during  the  evenings ;  showed  slightly  swollen  eyelids,  thus 
suggesting  the  nature  of  the  impending  trouble.  I  ordered  hydrogen 
peroxid  and  pure  glycerin  in  equal  parts,  which  Avere  well  diluted  and 
thoroughly  sprayed  through  the  naso-pharynx  every  four  hours.  The 
diet  was  light  and  digestible ;  out-door  life  was  encouraged,  except  on 
windy  days.  All  excitement  was  avoided,  so  as  to  avoid  the  precipita- 
tion of  any  additional  paroxysms.  At  night  the  child  was  placed  in  a 
large,  well-ventilated  room,  and  over  its  cot  was  erected  a  mosquito  net- 
ting, so  as  to  prevent  any  unusual  draught — a  procedure  which  I  have 
found  highly  beneficial,  as  it  materially  lessens  the  number  of  the  noc- 
turnal paroxysms.  When  the  cough  was  fully  established  and  was 
accompanied  by  eructations  of  stringy  mucus,  I  commenced  the  exhibi- 
tion of  the  mixture  of  asafetida  J  dram  (2.0)  every  two  hours.  The 
record  of  the  paroxysmal  stage  was  as  folloAvs :  The  first  week  averaged 
six  coughing  spells  per  day;  the  second  week  averaged  ten  per  day; 
the  third  week,  four  paroxysms ;  and  the  fourth  and  fifth  weeks  aver- 
aged about  two  paroxysms  during  the  twenty-four  hours.  When  the 
younger  brother,  but  eight  weeks  old,  commenced  to  show  evidences  of 
the  disease,  I  first  used  hydrogen  peroxid  as  in  the  older  brother,  and 
immediately  followed  it  Avith  asafetida.  This  case  continued  scarcely 
four  weeks  when  all  symptoms  subsided. 

Mistura  asafoetida,  however,  is  at  times  disappointing,  even  in  younger 
children.  My  second  choice  is  the  tincture  of  belladonna,  exhibited  in 
doses  of  one  drop  for  every  month  of  the  child's  life,  the  doses  being 
rapidly  increased  until  toxic  efi'ects  are  reached.  Then  I  gradually  in- 
crease the  amount  as  tolerance  of  the  drug  seems  to  be  established.  In 
very  young  children  I  have  obtained  good  results  from  the  use  of  a 
freshly-prepared  belladonna  plaster  placed  between  the  scapulge,  and 
the  physiologic  action    of  the    drug  seems  thus  to  be  more  constantly 

17 


258  INFECTIOUS  DISEASES. 

maintained.  The  plaster  may  be  changed  at  the  end  of  one  week.  In 
a  number  of  very  troublesome  cases  in  young  children  I  have  gained  a 
decided  advantage  by  an  application  of  a  2  per  cent,  cocain  solution 
directly  to  the  naso-pharynx.  This  treatment,  however,  does  not  pre- 
clude the  use  of  hydrogen  peroxid,  which  should  be  continued  through- 
out the  catarrhal  stage. 

Bromoform  was  resorted  to  in  fully  20  per  cent,  of  my  cases,  and 
was  a  keen  disappointment ;  it  seemed  merely  to  stupefy  the  patient 
and  did  not  apparently  shorten  the  progress  of  the  disease.  The  coal- 
tar  products,  pushed  to  the  toxic  limit,  modified  the  disease  but  slightly. 
Belladonna  and  antipyrin  in  combination  gave  better  results  than  either 
alone.  Quinin,  chloral,  creasote,  carbolic  acid,  I  found  to  be  of  little 
practical  use,  owing  largely  to  difficulty  in  administration.  This  out- 
line of  the  drug-treatment  in  whooping-cough  has  reference  solely  to 
the  catarrhal  and  paroxysmal  stages  of  the  disease.  As  important  ad- 
juncts to  the  management  of  the  disorder  careful  hygiene  must  be  en- 
forced, and  a  diet  of  the  simplest  character  and  a  uniformly  quiet  life 
maintained.  Throughout  the  whole  course  of  the  disease  out-door  life, 
as  far  as  possible,  should  be  encouraged,  and  if  convenient  a  sojourn  at 
the  sea-shore  Avill  shorten  the  progress  of  the  trouble  and  limit  to  a 
great  extent  the  number  of  sequelae. 


PAROTITIS. 
{Mumps ;  Parotiditis ;  Epidemic  Parotitis.) 

Definition. — An  acute  contagious  disease,  characterized  by  an  in- 
flammation and  swelling  of  the  parotid  gland,  and  occasionally  by  an 
involvement  of  the  salivary  glands,  the  testicles,  and  in  the  female  the 
mammjie. 

Pathology. — Opportunities  for  post-mortem  examinations  are  rare, 
leaving  in  some  doubt  the  pathologic  course  of  the  disease ;  but  it 
probably  begins  as  a  catarrhal  inflammation  of  the  ducts,  involving  the 
periglandular  connective  tissue.  The  inflammation  is  seldom  severe 
enough  or  of  such  a  nature  as  to  produce  suppuration. 

Ktiology. — Mumps  is  undoubtedly  a  constitutional  or  blood-disease 
with  local  manifestations.  "It  is  a  question,"  Goodhart  says,  "with 
mumps  w'hether  this  disease  shall  be  placed  with  the  specific  diseases  or 
with  those  aff'ecting  the  parts  or  organs  with  which  the  symptoms  more 
particularly  concern  themselves." 

The  disease  is  no  doubt  of  microbic  origin,  but  the  specific  organism 
has  not  yet  been  isolated,  and,  while  there  has  been  some  reason  to  be- 
lieve that  it  is  a  bacillus,  this  has  not  been  proved  and  is  still  doubtful. 
It  is  highly  contagious.,  and  at  times,  usually  during  the  spring  and 
autumn,  becomes  epidemic.  It  is  communicated  principally  by  the 
breath  and  exhalations,  the  greatest  source  of  contagion  being  the 
salivary  secretions.  It  may,  however,  be  carried  by  a  third  person  or 
by  fomites,  and  is  most  liable  to  be  communicated  during  the  begin- 


PAROTITIS.  259 

ning  of  the  attack,  although  the  contagiousness  continues  until  after  the 
subsidence  of  the  febrile  symptoms.  It  occurs  mostly  among  childreyi 
and  young  adults^  infants  and  old  persons  being  rarely  affected,  while 
males  are  more  liable  than  females.  One  attack  usually  gives  immunity 
from  a  second  attack  in  the  same  gland. 

Clinical  History. — The  average  period  of  incubation  is  fourteen 
days,  but  it  may  develop  as  early  as  ten  or  as  late  as  tAventy  days  after 
exposure.  The  invasion  is  marked  by  languor  and  a  temperature  from 
101°  to  103°  F.  (38.3°-39.4°  C),  with  possible  headache  and  vomit- 
ing ;  the  patient  complains  of  pain  at  the  angle  of  the  jaw,  and  this 
is  greatly  increased  if  an  acid  (such  as  vinegar)  is  swallowed.  With 
these  symptoms  is  noticed  a  pyriform  stvelling  of  the  parotid  glands, 
the  one  on  the  left  side  usually  appearing  first,  and  the  other  one 
soon  following.  Occasionally  cases  are  seen  in  which  but  one  gland  is 
involved,  or  the  swelling  may  begin  in  both  at  the  same  time.  This 
increases  gradually  until  some  time  between  the  third  and  sixth  days, 
involving  the  other  salivary  glands  and  causing  marked  disfigurement ; 
the  swelling  fills  the  depression  beneath  the  ear  and  extends  to  the 
cheek  and  neck,  the  most  prominent  part  being  just  below  and  pressing 
outward  the  lobe  of  the  ear.  The  salivary  secretions  are  generally 
much  increased,  though  there  may  be  the  opposite  condition  of  marked 
dryness  of  the  mouth.  When  the  swelling  has  reached  its  height,  pres- 
sure on  the  adjacent  tissues  causes  a  disagreeable  sensation  of  tension, 
and  chewing,  swallowing,  and  even  speaking,  are  at  times  painful  and 
difiicult.  The  skin  over  the  afi"ected  part  may  be  of  a  pale  or  of  a  dull- 
red  color.  Ringing  in  the  ears  and  a  dulling  of  the  hearing  is  common. 
The  nervous  system  may  be  affected,  causing  headache  and  delirium,  or 
a  low  typhoid  state  may  be  present.  The  duration  is  about  one  week 
(six  to  ten  days),  after  which  time  the  swelling  subsides,  and  by  the 
tenth  or  twelfth  day  entirely  disappears. 

Diagnosis. — The  diagnosis  is  easy,  the  nature  and  position  of  the 
swelling  and  the  course  of  the  disease  being  characteristic,  while  the 
fact  that  the  tonsils  are  seldom  involved  prevents  a  diagnosis  of  acute 
tonsillitis. 

Occasionally,  however,  in  the  course  of  se])tic  infection  or  after 
operations,  or  owing  to  the  extension  of  inflammation  along  the  duct 
from  the  mouth,  the  parotid  gland  becomes  the  seat  of  an  acute  inflam- 
mation at  first  hardly  distinguishable  from  mumps.  The  existence  of  a 
possible  source  of  infection,  and  the  fact  that  the  gland  under  these 
circumstances  usually  undergoes  suppuration,  should  lead  to  the  recog- 
nition of  the  true  nature  of  the  case. 

Complications  and  Sequelse. — Mumps,  as  a  rule,  runs  a  mild 
course  without  any  serious  symptoms,  but  occasionally  complications 
arise  that  tax  the  skill  of  the  physician  to  the  uttermost.  The  most 
common  of  these  are  orchitis  in  the  male,  which  may  be  followed  by 
atrophy  of  the  testicle ;  and  mastitis,  ovaritis,  or  vulvo-vaginitis  in  the 
female,  especially  after  puberty.  These  complications  appear  after  the 
subsidence  of  the  swelling  of  the  glands  of  the  neck,  only  occasionally 
developing  while  the  glands  are  still  affected,  though  cases  have  been 
reported  in  which  the  disease  first  manifested  itself  by  involvement  of 
the  sexual  organs.     This  complication  lengthens  the  course  of  the  attack 


260  INFECTIOUS  DISEASES. 

and  increases  the  constitutional  symptoms,  but  the  rule  is  complete  re- 
covery. Otitis  media  sometimes  occurs,  and  a  lesion  in  the  auditory 
nerve,  with  more  or  less  deafness  (which,  unfortunately,  may  be  perma- 
nent), has  been  observed.  Meningitis,  with  active  brain-symptoms, 
facial  paralysis,  convulsions,  albuminuria,  and  arthritis,  have  all  been 
noted  in  certain  cases. 

Treatment. — The  patient  should  be  kept  in  a  well-ventilated  room 
of  even  temperature,  and  in  bed  if  the  fever  is  at  all  severe,  and  should 
be  isolated  from  those  who  have  not  had  the  disease.  Either  hot  or 
cold  applications  to  the  swelling  will  often  give  relief,  and  support  to 
the  swollen  gland  by  means  of  cotton  and  a  bandage  is  very  comforting. 
Saline  laxatives  may  be  given,  and  aconite  or  some  simple  fever-mixture 
at  the  beginning  of  the  attack  is  usually  indicated.  These  simple 
measures  are  all  that  are  re(iuired  in  an  ordinary  case,  while  complica- 
tions or  unusual  conditions  must  be  treated  as  they  arise. 


TUBERCULOSIS. 


Definition. — A  chronic  (less  frequently  acute)  infectious  disease, 
caused  by  the  bacillus  tuberculosis.  This  organism  produces  specific 
lesions,  taking  the  form  either  of  separate  nodular  masses  or  diffuse 
growths,  infiltrating  the  tissues,  while  aggregations  of  these  element- 
ary tubercles  give  rise  to  large  tubercular  masses.  Tubercles  undergo 
caseation  and  sclerosis,  followed  in  turn  by  ulceration  (in  consequence 
of  secondary  pyogenic  infection),  or,  more  rarely,  calcification. 

Historic  Note. — Prior  to  the  discovery,  in  the  early  part  of  the 
nineteenth  century,  by  Bayle  and  Laennec,  of  the  tuberculous  new 
growth  as  a  distinctive  body,  this  disease  had  been  studied  chiefly  from 
a  clinical  point  of  view.  At  this  early  period  the  disease  was  believed 
to  consist  chiefly  of  a  suppurative  process,  and  in  its  observation  the 
physician  w^as  unaided  by  auscultation.  Later,  the  tubercle  was  recog- 
nized as  a  small  rounded  nodule  without  any  special  histologic  cha- 
racteristics. Villemin  in  1865  performed  his  epoch-making  experi- 
ments, and  the  tubercle  was  no  longer  distinguished  by  its  anatomic 
characters  alone.  Though  the  theory  of  the  infectious  nature  of 
tuberculosis  had  been  previously  advanced  by  Buelil  and  others,  it 
was  first  clearly  demonstrated  by  Yillemin's  beautiful  inoculation- 
experiments  upon  rabbits  and  guinea-])igs  with  particles  of  tubercular 
and  cheesy  substances,  producing  the  characteristic  lesions  of  tubercu- 
losis. It  then  remained  for  Koch  to  discover  (in  1881)  the  specific 
cause  of  the  most  important  of  all  human  ills — the  tubercle  bacillus. 
So  soon  as  the  specificity  of  the  disease  was  definitely  established  it 
became  clear  that  the  associated  inflammatory  processes,  that  were  for- 
merly believed  to  be  primary  and  to  hold  first  place,  were  secondary. 
The  important  role,  however,  played  by  the  latter,  particularly  in  the 
production  of  the  general  features  of  the  disease,  will  be  shown  here- 
after. 

Geographic    Distribution. — Tuberculosis     prevails     in     almost    every 


TUBERCULOSIS.  261 

quarter  of  the  globe,  but  is  more  prevalent  in  certain  latitudes  than  in 
others.  Thus,  in  general  terms,  it  may  be  said  to  prevail  more  exten- 
sively in  warm  than  in  cold  countries,  though  it  lessens  in  frequency  as 
Tve  approach  either  pole.  Local  conditions,  however,  exercise  a  more 
decisive  influence  in  engendering  predisposition  than  mere  geographic 
position.  It  is  of  quite  frequent  occurrence  in  all  densely  populated 
municipalities,  and  more  especially  in  the  overcrowded  sections  of  the 
latter ;  this  fact  explains  why  the  inhabitants  of  cities  of  the  North  are 
but  little  less  spared  than  those  of  the  cities  of  the  South.  On  the  other 
hand,  residents  of  mountainous  countries,  owing  to  the  purity  of  the 
atmosphere  and  the  elevation,  are  rarely  among  its  victims.  The  influ- 
ence of  race  in  predisposing  to  tuberculosis  should  also  be  mentioned 
here,  the  South  Sea  Islanders,  the  Indians,  and  the  colored  race  being 
peculiarly  liable. 

General  Pathology  of  Tubercular  I^esions.— Bistribution  of 
the  Lesions  in  the  Body. — Tuberculous  noAv  growths  elect,  most  fre- 
quently, the  lung,  and  when  the  disease  occurs  in  the  adult  this  organ 
is  almost  invariably  implicated.  Next  in  frequency  follow  the  larynx, 
intestines,  peritoneum,  urogenital  organs,  and  the  brain.  The  other 
chief  viscera  of  the  body  (spleen,  liver,  heart,  etc.,  particularly  the  lat- 
ter) are  less  frequently  the  seat  of  tuberculosis.  In  children  the  lesions 
exhibit  a  difi'erent  distribution,  the  favorite  seats  being  the  lymph-glands, 
intestines,  bones,  and  joints.  In  them  the  distribution  corresponds 
pretty  closely,  if  we  except  the  bronchial  and  mesenteric  glands,  to  that 
of  surgical  tuberculosis. 

The  Elementary  (Nodular)  Tubercle. — This  may  be  developed  in  any 
tissue  to  which  the  tubercle  bacillus  has  found  its  way,  and  the  presence 
of  the  bacillus  is  its  sole  distinguishing  feature,  since  the  self-same 
bodies  are  generated  by  other  micro-organisms — e.  g.  certain  of  the 
worms  (eggs  of  the  distoma),  actinomyces,  aspergillus  glaucus,  and  even 
as  a  result  of  irritation  by  certain  foreign  bodies  (podophyllum).  Various 
forms  of  pseudo-tuberculosis  have  been  described,  but  all  are  due  to  bac- 
teria that  difi'er  from  the  bacillus  tuberculosis.  Mallassez  and  Vignal 
described  a  form  produced  by  a  micrococcus  occurring  in  a  zooglea,  and 
this  observation  was  later  confirmed  by  Nocard,  Eberth,  and  others. 
Charrin  and  Rogers  have  described  still  another  form,  in  Avhich  they 
found  bacilli  about  Ifx  long,  actively  motile,  and  growing  freely  upon 
ordinary  media,  but  not  growing  upon  glycerin  and  agar,  and  not  lique- 
fying gelatin. 

The  various  stages  in  the  development  of  a  tubercle  are — 

(a)  Proliferation  of  the  fixed-tissue  elements  (connective  tissue,  en- 
dothelium of  the  capillaries,  etc.)  of  the  part  infected,  due  to  the  local, 
specific  irritant  action  of  the  bacilli.  These  anatomic  products  are 
transformed  into  epithelioid  and  giant  cells.  The  epithelioid  cells 
assume  various  shapes,  chiefly  rounded  and  polygonal ;  they  have  vesic- 
ular nuclei,  and  soon  show  tubercle-bacilli  in  their  interiors.  A  certain 
proportion  of  the  epithelioid  cells,  as  the  result  of  increase  in  their  size 
and  a  repeated  division  of  their  nuclei,  become  giant  cells.  The  latter 
occupy  the  center  of  the  tubercle,  and  also  contain  bacilli,  the  number 
of  giant  cells  and  of  the  bacilli  being  largely  reciprocal.  Thus,  the 
giant  cells  are  numerous  in  tubercular  lymph-glands,  joints,   etc.,  in 


262  INFECTIO  US  DISEASES. 

which  the  bacilli  are  relatively  few  ;  on  the  other  hand,  they  are  scanty 
in  miliary  tubercles,  in  which  the  bacilli  are  numerous — two  facts  sup- 
porting the  view  that  giant  cells  display  phagocytic  action.  Hektoen 
asserts  that  the  giant  cell  is  a  living  defensive  agent. 

(h)  About  the  site  of  infection  a  diapedesis  of  leukocytes  occurs  in 
the  nature  of  a  defensive  inflammatory  process.  At  first  the  leukocytes 
are  of  the  polynuclear  variety  and  are  quickly  destroyed ;  but  later 
mononuclear  leukocytes  (lymphocytes)  appear.  These  latter  resist  the 
action  of  the  bacilli,  and  I  think  their  true  function  is  a  phagocytic 
one.  The  various  forms  of  cells  described  are  connected  and  sur- 
rounded by  a  reticular  stroma  "  formed  by  the  fibrillation  and  rarefac- 
tion of  the  connective-tissue  matrix  "  (Baumgarten). 

The  fully-developed  tubercles  are  small,  nodular  bodies  whose  diam- 
eters range  from  -I-  to  2  or  3  mm.  At  first  they  are  almost  transparent, 
but  soon  lose  this  quality  in  consequence  of  the  further  changes  de- 
scribed beloAv.  They  are  non-vascular  bodies,  and  invariably  undergo 
{a)  caseation  and  {b)  sclerosis. 

{a)  Caseation. — This  implies  "coagulation-necrosis" — a  destructive 
process  proceeding  from  the  center  toward  the  periphery  of  the  tubercle, 
and  the  result  of  the  local  action  of  the  bacilli  or  their  chemical 
secretions.  The  cells  are  thus  transformed  into  a  uniformly  yellow- 
ish-gray, structureless  matter.  When  the  foci  are  numerous  and  closely 
set,  fusion  may  occur,  Avith  the  production  of  larger  or  smaller  homo- 
geneous masses  (cheesy  pneumonia).  The  latter  may  soften,  resulting 
in  the  formation  of  cavities :  this  is  due,  usually,  to  secondary  pyogenic 
infection,  causing  ulceration.  Less  frequently  the  cheesy  masses  under- 
go calcification*  or  become  encapsulated.  Such  masses  may  remain  in- 
definitely and  are  practically  harmless. 

{h)  Sclerosis. — Preceding  and  during  the  time  that  cell-destruction 
is  going  on  in  the  center  of  the  tubercles  the  protective  forces  of  nature 
are  asserting  themselves,  though  too  often  without  avail.  In  the  first 
place,  hyaline  transformation,  with  conversion  of  the  cellular  elements 
into  fibrous  tissue,  occurs.  Frequently,  now,  the  center  of  the  tubercle 
is  caseous  and  contains  bacilli,  Avhile  the  peripheral  parts  are  quite  hard 
and  do  not  contain  bacilli.  The  fibroid  change  may  pervade  the  entire 
tubercle.  Again,  the  fibroid  element  in  the  tissues  immediately  sur- 
rounding the  tubercle  may  be  greatly  increased  and  form  new  connective 
tissue,  and  this  process  be  followed  by  secondary  contraction,  convert- 
ino;  the  tubercle  into  a  firm  fibrous  nodule.  The  fibroid  change  in  its 
completest  development  is  observed  in  tuberculosis  of  serous  membranes, 
especially  of  the  peritoneum. 

Whether  in  any  given  case  the  destructive  forces,  on  the  one  hand, 
or  the  conservative,  on  the  other,  shall  come  oiF  victorious  depends  upon 
several  conditions.  Though  natural  immunity  is  probably  unknown, 
yet  under  certain  circumstances  and  at  certain  times  tissue-soils  may 
successfully  resist  bacillary  invasion.  The  bacilli  of  tubefculosis  doubt- 
less produce  special  toxins  {vide  Etiology),  and  hence  there  is  a  reason- 
able probability  that  the  tissues  and  liquids  of  the  body  manufacture  an 
antitoxin.  The  latter  agent  may  therefore  constitute  one  of  Nature's 
chief  means  of  defence.  There  are  also  soils  that  are  moderately  recep- 
tive, and  these  may  become  infected ;  but  sooner  or  later  the  destruction 


TUBERCULOSIS.  263 

of  the  invading  parasite  may  be  determined  by  altered  soil-conditions — 
changes  induced  by  Nature's  benign  and  curative  efforts.  It  is  prob- 
able that  in  such  instances  the  favorable  issue  is  sometimes  to  be  ascribed 
to  the  fact  that  relatively  few  bacilli  find  lodgement,  so  that  the  average 
phagocytic  activity  and  other  protective  processes  suffice.  But  when 
the  bacilli  fall  upon  a  soil  that  is  altogether  favorable  to  their  growth 
their  pernicious  influence  cannot  be  arrested,  since  the  means  that  usually 
turn  the  scales  in  favor  of  a  cure  are  wanting. 

We  are  now  prepared  to  understand  the  coarser  appearances  pre- 
sented by  tuberculous  lesions,  especially  of  the  lungs.  Fusion  of  mi- 
nute centers  of  infection  or  of  miliary  tubercles  results  in  the  formation 
of  larger  nodules  or  areas,  which  lead  by  a  process  of  local  extension  to 
diffuse  tuberculous  infiltration  (gray  infiltration  of  Laennec).  An  entire 
lobe  may  become  similarly  involved  (tuberculous  pneumonia),  and  "  there 
may  also  be  a  diffuse  infiltration  and  caseation  without  any  special  foci, 
a  widespread  tuberculous  pneumonia  induced  by  the  bacilli  "  (Osier). 

The  term  "  gray  infiltration  "  is  misleading  from  a  pathologic  point 
of  view,  since  the  morbid  changes  differ  in  no  essential  manner  from 
those  described  as  occurring  in  the  miliary  or  nodular  tubercle.  More- 
over, the  latter  also  presents  a  grayish  appearance.  The  apparent  dif- 
ference between  a  miliary  tubercle  and  diffuse  tubercular  infiltration  lies 
in  the  fact  that  the  latter  displays  a  greater  tendency  to  spread  by  direct 
extension. 

Associated  Inflammatory  Processes. — The  tubercle  bacilli  excite  asso- 
ciated inflammatory  processes  in  the  organs  affected,  and  if  the  tubercu- 
lous lesions  run  a  slow  course,  a  limiting  wall  of  true  fibroid  induration 
circumscribes  the  area  involved.  By  means  of  this  induration  the  nat- 
ural protective  forces,  either  temporarily  or  permanently,  check  the 
progress  of  the  local  lesions,  and  the  change  is  strictly  analogous  to  the 
sclerosis  that  takes  place  in  the  peripheral  parts  of  the  elementary 
tubercle  or  immediately  surrounding  the  latter,  as  in  tuberculosis  of 
serous  membranes.  On  the  other  hand,  when  the  tuberculous  infiltra- 
tion is  less  tardily  developed  the  secondary  inflammatory  processes  may 
show  changes  similar  to  those  of  catarrhal  or  croupous  pneumonia.  It  is 
a  noteworthy  fact  that  the  constitutional  features  in  tuberculosis  are  not 
so  much  dependent  upon  the  primary  as  upon  a  secondary  infection, 
chiefly  with  the  streptococci.  The  latter  are  responsible  for  the  seri- 
ous septic  element  in  certain  varieties  of  tuberculosis  (especially  pul- 
monary), and  some  contend  that  the  tubercle  bacilli  can  excite  suppura- 
tion directly.  The  pus,  however,  in  this  instance  does  not  contain  the 
streptococci,  and  is  sterile.  Mixed  infection  is,  I  believe,  the  rule  {vide 
Pathology  of  Pulmonary  Tuberculosis). 

etiology. — The  Specific  Cause  and  its  Physical  Characteristics. — In 
1881,  Koch  discovered  the  tubercle  bacillus,  Avhich  is  the  sole  cause  of 
the  disease.  This  bacillus  is  rod-shaped,  straight  or  someAvhat  bent,  and 
slender,  its  length  equalling  about  one-third  or  one-half  of  the  diameter 
of  a  red  blood-corpuscle  (Fig-  24).  Its  extremities  are  slightly  rounded, 
it  is  non-motile,  and  on  the  interior  of  the  bacilli  small  colorless  spots 
can  be  observed  on  microscopic  examination;  these  clear  spaces  in  the 
bacilli  represent  plasmolysis,  and  have  nothing  to  do  with  spore-forma- 
tion.     Spores  undoubtedly  do  occur,  but  have  not  yet  been  demonstrated. 


264 


INFECTIOUS  DISEASES. 


Fig.  24.— Tubercle   bacillus   in   sputum   (Frankel  and 
Pfeitter). 


When  stained  the  bacilli  have  a  somewhat  beaded  appearance,  this  being 
probably  due  to  slight  bulgings  caused  by  the  presence  of  spores.      The 

tubercle  bacillus  is  one  of  the 
few  varieties  of  bacteria  that 
retain  the  anilin  dye  after 
washings  with  acids. 

Biology. — The  bacilli  can 
be  grown  on  culture-media, 
but  not  without  difficulty,  since 
thev  demand  an  even  temper- 
ature between  98°  and  100°  F. 
(37.7°  C),  or  that  of  the  hu- 
man body.  The  best  soil  is 
blood-serum  previously  coag- 
ulated by  heating.  Over  the 
latter  may  be  gently  rubbed 
tuberculous  tissue,  which  is 
then  allowed  to  remain  on  the 
surface.  The  growth  of  the 
bacilli  requires  about  two 
weeks,  when  colonies  appear 
as  dry,  grayish-white  or  gray- 
ish-brown, thin  scales  or  masses  on  the  surface  of  the  culture-medium. 
From  such  cultures  others  may  be  grown  on  glycerin-agar  or  on  the  potato. 
Inoculations  into  the  guinea-pig  and  other  animals  are  succeeded  in 
two  or  three  weeks  by  the  appearance  of  elementary  tubercles — first, 
locally,  and  then  in  other  organs  of  the  body. 

Chemical  Products. — The  growth  of  the  bacilli  is  probably  attended 
by  the  formation  of  secretory  proilucts.  Thus  an  albuminoid  substance 
has  been  separated,  and  this  when  injected  into  the  body  of  an 
animal  produces  slight  fever.  The  albuminoid  separated  from  cultures 
of  tuljorcle  bacilli  is  a  nuclear  proteid.  and  not  a  specific  toxin.  There 
have  also  been  isolated  a  ptomain  and,  some  contend,  an  extract  which 
displays  pyogenic  properties  (Koch's  tuberculin).  The  constitutional 
features  of  the  disease  may  be  ascribed,  in  part,  to  the  circulation  of 
these  poisons  in  the  blood,  but  principally  to  the  products  of  suppuration. 
Ferran  holds  that  the  bacillus  spermoi/enes  and  the  t.  bacillus  are  identical. 
Sources  of  the  Bacilli. — The  chief  source  of  the  bacilli  is  the  sputum 
of  tuberculous  i)atients.  It  has  been  shoAvn  that  in  the  advanced  stage 
of  pulmonary  tuberculosis  several  billions  of  bacilli  are  expectorated 
daily  (Nuttall),  and  the  desiccated  sputum  is  wafted  into  the  atmosphere 
in  the  form  of  dust-like  particles  containing  innumerable  bacilli.  When 
the  facts  that  tuberculosis  is  almost  universally  prevalent,  and  that  each 
patient  throws  off  countless  millions  of  bacilli  are  remembered,  it  is 
clear  that  abundant  op])ortunity  is  everywhere  presented  for  infection, 
or,  in  other  words,  that  secondary  sources  of  infection  are  numerous 
and  varied. 

Distribution  of  the  Bacilli. — The  tubercle  bacillus  is  exceedingly 
tenacious  of  life,  this  being  its  chief  distinguishing  characteristic. 
Hence  it  is  found  in  a  viable  condition,  both  (a)  inside  and  (b)  out- 
side of  the  body. 


TUBERCULOSIS.  265 

(a)  Inside  of  the  Body. — As  before  stated,  the  number  of  bacilli 
found  in  tuberculous  growths  varies  within  wide  extremes.  In  general 
terms,  it  may  be  said  that  the  more  rapidly  the  process  advances  the 
greater  the  number  of  parasites  present.  It  must  not  be  forgotten, 
however,  that  the  activity  of  the  tuberculous  processes  is  intimately  con- 
nected with  the  degree  of  resistance  offered  by  the  tissues.  A  chronic 
tuberculous  focus  may  establish  a  fistulous  connection  with  a  vein  or  a 
lymph-vessel,  and  thus  scatter  the  bacilli  to  the  remotest  parts  of  the 
body ;  and  in  such  instances  (as  the  direct  eflFect  of  the  original  number 
of  bacilli  present)  a  chronic  is  quickly  converted  into  an  acute  form  of 
tuberculosis.  The  bacilli  may  also  be  found  in  the  bodies  of  non- 
tuberculous  persons.  Strauss  ^  demonstrated  virulent  bacilli  within  the 
nasal  cavities  of  healthy  persons  whose  positions  necessitated  their  asso- 
ciation with,  and  frequent  presence  in  rooms  occupied  by,  tuberculous 
patients. 

(h)  The  Bacilli  Outside  of  the  Body. — Tubercle  bacilli  can  maintain 
their  existence  almost  indefinitely  outside  the  body.  On  the  other  hand, 
they  probably  do  not  develop  or  multiply  under  the  usual  external  influ- 
ences, though,  as  I  have  said,  their  vitality  is  extraordinary.  Their 
destruction  cannot  be  effected  by  freezing  nor  by  desiccation,  and  they 
survive  for  months  in  water.  Their  power  to  resist  chemical  agents 
(nitric  acid,  etc.)  is  also  very  great,  but  they  may  be  destroyed  by  boil- 
ing for  four  or  five  minutes  or  by  exposure  to  the  direct  solar  rays. 
Tubercle  bacilli  are  undoubtedly  present  in  all  inhabited  places,  and  it 
is  obvious  that  they  may  be  conveyed  for  long  distances  by  means  of 
water,  milk,  and  in  many  other  ways. 

The  sputum  dries  and  flies  into  the  atmosphere  in  the  form  of  dust, 
which  not  only  floats  in  this  medium,  but  also  settles  upon  articles  of 
furniture,  the  floor,  the  walls  of  living-rooms,  hospital  wards,  draperies, 
clothing,  bed-linen,  etc.  ;  and  from  these  resting-places  it  may  be  con- 
veyed back  into  the  atmosphere.  It  has  been  shown,  experimentally, 
that  the  dust  obtained  from  the  walls  or  from  the  air  of  rooms  and  hos- 
pital wards  occupied  by  tuberculous  patients  is  frequently,  though  not 
invariably,  infected.  It  is  the  in-door  atmosphere,  laden  with  bacilli, 
that  is  especially  liable  to  excite  tuberculosis  when  breathed  more  or 
less  constantly.  In  places  only  rarely  frequented  by  consumptives  the 
dust  is  usually  free  from  virulent  bacilli. 

Modes  of  Infection. — (1)  Inhalation  of  the  Bacilli. — In  the  vast  ma- 
jority of  instances  the  bacilli  are  inhaled  with  the  inspired  air,  but  the 
exhaled  breath  of  tuberculous  patients  is  not  infectious.  It  is  the  dried 
sputa  floating  in  the  atmosphere  that  are  pathogenic.  Klebs  and  FlUgge 
claim  that  infection  may  result  from  moist  particles  thrown  off  in 
coughing.  Occasionally  the  bacilli  attack  first  the  upper  respiratory 
passages  (larynx,  nose).  Usually,  however,  primary  infection  takes 
place  in  the  smaller  bronchi,  or  less  frequently  in  the  lungs  ;  and 
that  these  are  the  points  of  election  is  shown  by  the  fact  that  healed 
tuberculous  lesions  in  the  bronchi  and  lungs  of  persons  who  died  of 
other  diseases  are  frequently  met  with  at  post-mortem 'examinations. 
Under  similar  circumstances  the  bronchial  glands  may  be  found  to 
present  tuberculous  lesions.  Thus,  in  8  out  of  30  cases  in  which  both 
-  Mimchener  medicinische  Wochenschrift. 


266  INFECTIOUS  DISEASES. 

old  and  recent  tuberculous  lesions  were  absent  H.  P.  Loomis  found  the 
bronchial  glands  infective  to  rabbits. 

It  is  obvious  that  the  bacilli  which  cause  fresh  cases  come  indirectly 
from  other  tuberculous  subjects,  and  it  has  long  been  supposed  that 
tuberculosis  is  a  contagious  affection  ;  unlike  small-pox,  scarlatina,  and 
other  acute  contagious  diseases,  however,  tuberculosis  is  not  trans- 
mitted by  a  single  contact  with  a  person  ill  of  the  disease.  On  the 
other  hand,  Flick  and  others  have  shown  that  persons  who  come  into 
contact  with,  or  who  live  in  close  proximity  to,  aflFected  persons  fre- 
quently fall  victims  to  the  same  affection.  ("  The  latter  is  as  truly  con- 
tagious as  the  former,  differing  only  in  degree.")  We  can  safely  say, 
therefore,  that,  though  less  liable  to  Idc  transferred  by  contact  than  certain 
other  affections,  yet  on  account  of  the  fact  that  tuberculosis  usually  pur- 
sues a  chronic  course  there  is  every  opportunity  for  prolonged  or  re- 
peated contact  with  resulting  infection. 

Flick's  elaborate  topographic  study  of  phthisis  in  the  Fifth  Ward 
of  the  city  of  Philadelphia,  extending  over  a  period  of  twenty-five  years, 
shows  conclusively  that  consumption  obeys  the  laws  of  infectious  and 
contagious  diseases.  His  researches  furnish  incontestable  proof  that  the 
tuberculous  virus  is  limited  to  centers,  and  that  the  latter  owe  their 
existence  to  previous  cases  in  the  same  house  or  locality ;  that  a  house 
which  has  had  a  case  of  consumption  will  probably  have  others  within  a 
few  years,  and  may  have  a  very  large  number  of  cases  in  rapid  succes- 
sion ;  and  that  approximate  houses  are  considerably  exposed  to  the  con- 
tagion. 

The  contagious  theory  of  tuberculosis  gains  support  from  the  fact 
that  husbands  have  been  frequently  observed  to  contract  the  disease 
from  their  wives,  and  the  latter,  since  they  are  more  constantly  con- 
fined in  the  house,  to  become  infected  yet  more  frequently  from  the 
former.  Weber  has  observed  the  case  of  a  tuberculous  husband  who 
lost  four  wives  in  succession,  another  who  lost  three,  and  four  others 
who  lost  two  each.  In  like  manner,  the  statistical  studies  of  Cornet, 
Niven,  Baer,  and  others  show  that  the  disease  spreads  through  factories, 
prisons,  cloisters,  and  even  among  the  physicians,  nurses,  and  attend- 
ants in  hospitals  for  the  reception  of  tuberculous  patients,  producing  a 
mortality-rate  from  this  disease  ranging  from  45  to  75  per  cent.  Sev- 
enty-three per  cent,  of  nurses  up  to  the  age  of  fifty  die  of  tuberculosis 
(Whittaker).  It  is  obvious  that  those  who  are  engaged  in  making  the 
beds,  dusting  and  sweeping  the  rooms  of  patients,  are  most  exposed ; 
and  on  the  other  hand,  better  hvofienic  livino;  amoncr  these  classes  of 
individuals,  and  improved  hygienic  arrangements  in  prisons,  institutions, 
and  hospitals,  have  been  found  to  reduce,  decidedly,  the  death-rate  from 
this  dread  affection.  This  result  is  to  be  accounted  for  by  the  following 
facts  :  ('/)  There  is  thus  established  a  greater  tissue-resistance  to  the  bacil- 
lus tuberculosis  on  the  part  of  the  persons  exposed ;  and  (A)  The  germs 
are  thus  to  a  greater  extent  disseminated.  Obviously,  then,  in  institutions 
in  which  the  proper  sanitary  precautions  are  used  there  may  be  few  if 
any  instances  of  communication  by  contagion ;  and  from  the  records  of 
the  latter,  facts  opposed  to  the  contagious  theory  of  the  disease  can 
readily  be  furnished. 

(2)  Infection  by  Swallowing. — {a)  That  the  milk  of  tuberculous  ani- 


TUBERCULOSIS.  267 

mals  contains  the  bacillus,  and  that  the  use  of  contaminated  milk  may- 
infect  the  human  subject,  are  well-established  facts. ^  Gerlach  and  Klebs 
long  since  observed  the  occurrence  of  the  disease  in  animals  fed  with  milk 
from  cows  aifected  with  the  so-called  "pearl  disease."  It  is  not  even 
necessary  that  the  animal  infected  should  have  tuberculous  mammitis 
(Ernst),  though  some  are  of  contrary  opinion  (Flick,  Sidney  Martin, 
and  others).  The  exact  frequency  of  this  mode  of  infection  is  not  known, 
but  there  is  some  little  clinical  evidence  to  support  it.  Infected  animals, 
especially  cows  and  pigs,  that  suckle  their  young  very  frequently  trans- 
mit the  disease  to  the  latter,  the  infection  usually  resulting  in  intestinal 
and  mesenteric  tuberculosis.  Hence  it  is  obvious  that  the  bacillus  of 
tuberculosis  is,  in  this  instance,  swallowed  and  finds  lodgement  in  the 
primce  vice.  Bang  has  even  shown  that  butter  made  from  the  milk  of  tuber- 
culous cow^s  may  be  infectious.  It  is  entirely  analogous  in  the  human 
race,  bovine  and  human  tuberculosis  being  one  and  the  same  affection ; 
and  hence  the  tuberculous  mother  is  likely  to  transmit  the  disease  to 
her  suckling  offspring.  This  explains,  adequately,  why  abdominal 
tuberculosis  is  frequent  in  children. 

(b)  The  meat  of  a  tuberculous  animal  may  rarely  be  infectious,  but 
the  bulk  of  experimental  evidence  would  seem  to  show  that,  unless  the 
parts  consumed  are  the  seat  of  tuberculous  deposit,  infection  does  not 
follow.  J).  H.  Bergey,^  in  discussing  the  public-health  relations  to 
tuberculosis,  holds  that  the  lower  mortality  from  this  disease  shown  by 
the  Jewish  race  is  ascribable  to  their  careful  meat-inspection.  Again, 
the  possibility  of  contamination  during  the  course  of  preparation  for 
the  market,  as  well  as  during  its  transportation,  must  also  be  recol- 
lected. The  experiments  of  Aufrecht,  Chauveau,  Klebs,  Parrot, 
Trappeiner,  and  others  show  that  tuberculosis  may  be  communicated 
by  incorporating  with  the  food  the  expectoration  from  tuberculous 
patients. 

(3)  Infection  by  Inoculation. — Tuberculosis  may  be  transferred  by 
direct  inoculation,  as  show^n  originally  by  Villemin's  beautiful  experi- 
ments upon  the  eyes  of  guinea-pigs.  Infection  may  take  place,  though 
this  is  rare,  through  slight  cutaneous  lesions  (cuts,  fissures,  excoriations, 
etc.),  but  only  as  the  result  of  accidental  inoculation  of  tuberculous 
matter.  In  this  manner  there  is  produced  a  local  tuberculosis  of  the 
skin,  as  a  rule.  Barely,  the  contagion  is  conveyed  by  the  lymphatics 
to  the  glands  in  the  vicinity  of  the  point  of  infection.  Persons  who 
follow  certain  occupations  are  more  or  less  liable  to  this  mode  of  infec- 
tion— e.  g.  butchers,  handlers  of  hides,  dissectors  of  dead  bodies,  and, 
rarely,  surgeons.  Baldwin  has  called  attention  to  the  danger  of  infec- 
tion from  the  unclean  hands  of "  tuberculous  patients.  Rare  instances 
of  transmission  by  inoculation  occur  in  divers  ways  (the  bite  of  a  con- 
sumptive, a  cut  from  the  broken  spit-glass  of  the  latter,  or  even  from  his 
pocket-knife,  as  I  have  seen  in  one  instance). 

The  handkerchiefs,  body-  and  bed-linen  of  the  patient  may  infect 
by  inoculation  those  who  handle  or  wash  them  frequently,  if  they  chance 
to  have  a  fissure  or  excoriation  upon  the  hand.     No  doubt  lupus  also 

^  See  the  elaborate  statistical  studies  of  Dr.  George  Cornet :  "  Die  Tuberkulose  in  den 
Strafanstalten,"  Zeitschrift  fur  Hygiene,  Bd.  x.,  1891. 
^  Saunders'  Year-Book  for  1899. 


268  INFECTIOUS  DISEASES. 

arises  in  the  same  way.  Czerny  has  reported  2  cases  of  infection  by 
transplantation  of  skin ;  Ceilings  and  Murray,  3  cases  by  tattooing  (?). 
The  contact  of  the  lips  of  tuberculous  operators  -nith  surgical  wounds 
(as  in  sucking  the  latter)  may  transmit  tuberculosis,  as  in  the  perform- 
ance of  the  rite  of  circumcision. 

(4)  Direct  Hereditary  Transmission. — In  exceptional  cases  the  bacillus 
is  found  in  the  fetus  in  utero.  In  such  instances  the  disease  may  re- 
main latent,  to  break  forth  during  childhood  or  later  in  life :  and  even 
though  the  fetus  itself  mav  display  no  evidence  of  tuberculosis,  the 
fetal  viscera  may  yet  be  infective  to  guinea-pigs  (Birch-Hirschfeld). 
Lehmann  ^  has  reported  an  undoubted  instance  of  intra-uterine  infec- 
tion. The  tuberculous  mother  died  of  tuberculous  meningitis  three 
days  after  the  birth  of  her  child,  an<l  the  child  lived  twenty-four  hours. 
In  its  spleen,  lungs,  and  liver  were  found  nodules  resembling  tubercles 
and  containing  tubercle  bacilli  in  large  numbers.  Galtier  has  inocu- 
lated  a  pregnant  animal  with  the  disease,  and  found  that  the  offspring 
was,  in  consequence,  tuberculous  at  birth.  The  views  of  Baumgarten 
upon  this  question  should  be  accorded  careful  consideration.  This 
author  believes  that  the  contagion  may  be  transmitted  and  become 
pathogenic  at  a  variable  period  after  birth — first,  because  the  affection 
is  very  frequent  in  young  children,  even  during  the  first  months  or 
weeks  of  life ;  and,  secondly,  because  certain  structures,  not  apt  to  be 
accidentally  infected,  are  commonly  the  seat  of  tuberculous  lesions  in 
children — the  bones  and  joints.  After  birth  the  bacillus  may  at  any 
time  either  lose  its  vitality  or  take  on  a  luxuriant  growth.  It  is  not 
known,  however,  in  what  percentage  of  these  cases  the  lungs,  intestines, 
peritoneum,  and  lymph-glands  are  free  from  tuberculous  lesions.  More- 
over, Kiiss  disputes  the  theory  of  the  latency  of  the  tubercle  bacilli, 
and  further  contends  that  these  latent  foci  do  not  exist  before  the  age 
of  three  months  ;  that  they  are  rare  before  the  first  year,  when  they 
mature  progressively. 

In  this  place  two  facts  deserve  to  be  emphasized :  First,  that  a 
child  born  of  tuberculous  parents  is  more  receptive  than  one  born  of 
healthy  stock ;  and  second,  that  it  is  more  liable  to  accidental  infec- 
tion, as  by  swallowing  the  virus  (particularly  if  breast-fed)  or  by 
inhalation. 

The  instances  of  direct  transmission  that  have  been  traced  occurred 
through  tuberculous  mothers.  The  observations  of  Csokor-  upon  hered- 
itary tuberculosis  in  cattle  also  corroborate  this  dictum  :  but  as  the 
result  of  carefully  conducted  experiments  by  A'^ignal  ^  it  is  reasonably 
certain  that  invasion  by  heredity  is  very  rare. 

(5)  Dock  and  Chadbourne  have  shown  that  mixed  modes  of  infection 
occur. 

Predisposing  Causes. — (1)  Race  and  Nationality. — The  effect  of  nation- 
ality upon  the  receptivity  to  tuberculosis  can  be  studied  advantageously 
in  America  on  account  of  the  cosmopolitan  character  of  the  population. 
The  tuberculous  tendency  on  the  part  of  Indians  of  this  continent, 
even  in  the  most  favorable  climates,  has  been  observed  repeatedly,  and 

1  Berlin,  klin.   TIocA.,  July  9,  1895. 

'^  Deumhe  medizinul  Zeitiing,  Berlin,  Jan.  29,  1892. 

'  La  Semaine  medkale,  Paris,  Aug.  1,  1892. 


.    TUBERCULOSIS.  269 

the  fact  that  the  negro  race  is  highly  receptive  to  tuberculosis  is  also 
well  known.  Osier ^  gives  the  following  corroborative  statistics:  "Of 
the  427  cases  of  pulmonary  tuberculosis  at  the  Johns  Hopkins  Hos- 
pital for  the  two  years  ending  June  1,  1891,  there  were  41  cases  in  the 
colored — i.  e.  about  1  :  10.  The  ratio  of  colored  to  white  of  all  patients 
in  the  wards  has  been  1:7."  It  is  more  than  twice  as  common  in  the 
African  as  in  the  white,  and  still  more  prevalent  with  the  Indian  (W. 
L.  Rodman).  Sears  ^  found  that  in  200  cases  of  tuberculosis  nearly 
50  per  cent,  belonged  to  the  first  and  second  generations  of  Irish 
immigrants. 

(2)  Hereditary  Predisposition. — The  percentage  of  cases  in  Avhich 
heredity  can  be  traced  has  been  variously  estimated  at  from  10  to  40. 
As  before  intimated  (vide  Direct  Hereditary  Transmission),  a  child 
reared  by  tuberculous  parents  runs  great  danger  of  being  infected  acci- 
dentally ;  and  again,  a  person  living  in  an  infected  house  (with  or  Avith- 
out  the  presence  of  a  tuberculous  patient)  is  very  liable  to  become 
infected,  whether  his  antecedents  give  a  tuberculous  history  or  not. 
It  follows  that  a  correct  estimate  of  the  number  of  cases  of  phthisis  in 
which  hereditary  influence  plays  an  etiologic  part  cannot  be  obtained. 
Too  much  importance  has  heretofore  been  attached  to  the  influence  of 
inherited  constitutional  peculiarities  to  the  exclusion  of  other  potent 
factors.  Moreover,  the  latter  may  be  acc^uired  as  the  result  of  certain 
debilitating  influences  (childbirth,  defective  food-supply,  close  living-  or 
working-roomsj.  An  inherited  tendency  to  tuberculosis  is  more  unfail- 
ingly transmitted  through  the  mother  than  the  father.  Multiple  appear- 
ance is  commoner  in  families  with  tuberculous  parents  (Dock  and  Chad- 
bourne).  Children  begotten  of  parents  who  are  drunkards,  or  who  suffer 
from  certain  chronic  incurable  diseases  (syphilis,  cancer,  etc.)  at  the 
time  of  the  birth  of  their  children,  are  liable  to  inherit  a  condition  of 
the  system  that  greatly  increases  morbidity,  unless  the  tendency  is  over- 
come by  a  proper  environment,  together  with  systematic  physical  train- 
ing during  the  first  years  of  life.  Moreover,  persons  who  have  the  so- 
called  tuberculous  diathesis  are  frequent  sufferers  from  catarrhal  affec- 
tions, especially  of  the  respiratory  organs.  The  latter  condition  forms 
a  marked  predisposing  factor  ;  yet,  on  the  other  hand,  tuberculosis  is 
met  with  in  persons  of  robust  figure. 

The  older  authors  of  medical  text-books  describe  two  types  of  con- 
formation— the  tuberculous  and  the  scrofulous.  The  latter  has  a  heavy 
figure,  thick  lips  and  hands,  large,  thick  bones,  and  an  opaque  skin ;  the 
former,  a  light  figure,  bright  eyes,  thin  skin,  oval  face,  and  long,  thin 
bones.  The  phthisical  type  of  the  chest  will  be  referred  to  in  connec- 
tion with  the  physical  signs  of  pulmonary  tuberculosis.  Here  emphasis 
should  be  given  to  Cohnheim's  view,  Avhich  is  for  the  greater  part  cor- 
rect, to  the  effect  "  that  the  so-called  phthisical  habit  is  not  an  indication 
of  a  tendency  to,  but  actually  of  the  existence  of,  tuberculosis."  Whilst 
the  recognition  of  a  pre-tubercular  condition  has  its  practical  bearing, 
it  must  be  recollected  also  that  the  term  implies  merely  a  "  delicacy  of 
constitution,  incomplete  growth,  and  imperfect  development  "  (Fagge). 
(3)  Previous  Infectious  Diseases. — That  there  is  no  tendency  to  the  tran- 

^  Text-book-  of  3fedicina,  p.  204. 

^  Boston  Medical  and  Surgiccd  Journal,  April  4,  189-5. 


270  INFECTIOUS  DISEASES. 

sition  of  other  diseases  into  tuberculosis,  as  was  formerly  supposed,  cannot 
now  be  questioned  in  view  of  the  undoubted  specific  nature  of  the  latter 
disease.  Tuberculosis  is,  however,  embraced  among  the  sequelte  of  such 
affections  as  acute  infectious  and  chronic  diseases — influenza,  measles, 
whooping-cough,  typhoid  fever,  cirrhosis  of  the  lungs,  and  diabetes 
mellitus  (the  latter  disease  involving  a  predisposition  to  the  former) — for 
the  reason  that  they  render  the  tissue-soil,  especially  that  of  the  respira- 
tory tract,  more  favorable  to  tubercular  infection.  Dock  and  Chad- 
bourne  have  analyzed  100  cases  of  adult  tuberculosis  (bacillary  phthisis) ; 
it  developed  rapidly  after  influenza  in  16,  and  followed  pneumonia  in  9. 
It  seems  proper  to  mention  here  the  fact  that  certain  other  diseases  dis- 
play an  antagonistic  eifect  (chronic  valvular  disease,  pulmonary  emphy- 
sema, etc.).  Our  knowledge  of  the  subject,  however,  is  as  yet  quite  in- 
complete. 

(4)  Age. — This  affects  predisposition  decidedly,  though  tuberculosis 
may  occur  at  any  or  all  times  ;  and  the  relation  between  age  and  the 
distribution  of  the  lesions  has  been  previously  indicated.  Certain  forms 
of  tuberculosis  are  especially  frequent  in  young  children  (meningeal, 
mesenteric,  and  lymphatic). 

Pulmonary  tuberculosis  is  most  common  between  twenty  and  thirty. 
It  is  more  rare  during  early  childhood  and  in  the  aged,  but  may  appear 
at  any  period  of  life,  and  the  cases  that  occur  in  young  children  are 
likely  to  be  rapid  in  their  progress. 

(5)  Sex. — Predisposition  has  but  slight  relation  to  sex.  Females  are, 
however,  somewhat  more  liable  than  males,  and  pregnancy  in  particular 
is  a  disposing  factor.  Again,  when  tuberculous  females  become  preg- 
nant the  progress  of  the  aftection  is  accelerated,  and  even  more  so  by 
the  period  of  lactation.  Regarding  tuberculosis  as  being  pre-eminently 
a  house-disease,  females  are  more  exposed  to  contagion  than  males, 
because  they  are  more  closely  confined  ih-doors. 

(6)  Climate  and  Soil. — Humidity  of  the  soil  and  abundant  atmospheric 
moisture  increase  the  prevalence  of  tuberculosis.  It  is  especially  com- 
mon in  regions  where  sudden  variations  of  temperature,  or  protracted 
cold  with  dampness,  prevail.  This  increase  is  most  probably  associated 
with  a  heightened  vulnerability,  due  to  an  increased  tendency  to  ca- 
tarrhal affections  of  all  kinds  (Osier).  It  has  been  shown  that  proper 
drainage  of  marshy  districts  has  diminished,  to  some  extent,  the  fre- 
quency of  this  disease  (Buchanan),  and,  on  the  other  hand,  mountainous 
districts  are  often  remarkable  for  freedom  from  the  disease. 

Local  Causes. — (1)  Occupation. — Persons  whose  employment  exposes 
them  to  different  forms  of  irritating  inhalations  are  particularly  liable. 
In  such,  however,  tliere  is  usually  first  developed  a  fibroid  induration, 
and  the  latter  in  turn  is  followed  by  pulmonary  tuberculosis.  The  con- 
tinual inhalation  of  an  atmosphere  laden  with  noxious  particles,  such  as 
is  met  with  in  ill-ventilated  and  overcrowded  working  or  living  apart- 
ments, renders  the  tissue-soil  more  vulnerable. 

(2)  Bronchial  Catarrh. — An  acute  catarrh  of  the  small  bronchi  pre- 
pares the  soil  for  tuberculous  infection.  Frequently,  liowever,  this  is 
the  first  step  in  tuberculosis,  since  the  latter  disease  almost  invaria])ly 
begins  as  a  local  catarrhal  process,  involving  the  smaller  apical  bronclii. 
Here  may  be  pointed  out  that  gastro-intestinal  catarrh  (of  somewhat 


TUBERCULOSIS  OF  THE  LYMPH-GLANDS.  271 

protracted  duration — H.  M.  King)  increases  the  receptivity  for  tuber- 
culosis. 

(3)  Tubercular  Pneumonia. — In  like  manner,  pulmonary  tuberculosis 
may  follow  an  unresolved  pneumonia,  but  such  cases  are,  as  a  rule,  in- 
stances of  tuberculous  pneumonia  primarily. 

(4)  Hemoptysis. — According  to  some  authors,  hemoptysis  is  potent  in 
producing  pulmonary  tuberculosis.  It  is,  however,  certain  that  in  most 
instances  in  Avhich  it  appears  to  precede  phthisis,  and  have  a  causal  con- 
nection with  it,  it  is  in  reality  a  symptom  of  existing  pulmonary  tuber- 
culosis. 

(5)  Pleurisy  may  be,  though  rarely,  the  starting-point  of  phthisis. 
Its  predisposing  effect  may  be  attributable  to  compression  of  the  lung, 
thus  interfering  with  the  respiratory  excursions,  or  to  the  bronchitis 
which  is  frequently  associated.  Pleurisy  sometimes  initiates  fibroid  in- 
duration, which  may  then  terminate  in  a  tuberculous  affection ;  but  the 
fact  is  to  be  emphasized  that  a  very  large  proportion  of  the  cases  of 
apparently  primary  pleurisy  are  tuberculous  in  nature. 

(6)  Intrathoracic  Tumor. — Tuberculosis  is  often  associated  with  intra- 
thoracic tumors,  and  especially  with  aneurysm.  Fehde^  has  reported 
3  interesting  cases  of  the  kind. 

(7)  Congenital  or  acquired  contraction  of  the  orifice  of  the  pulmonary 
artery  predisposes  markedly  to  tuberculosis. 

(8)  Trauma. — Injuries  to  the  chest-wall,  with  or  without  laceration 
of  the  lung,  are  frequently  followed  by  pulmonary  tuberculosis.  The 
explanation  of  this  association  is  to  be  found  in  the  fact  that  trauma 
increases  largely  the  susceptibility  of  the  parts  injured  by  diminishing 
phagocytic  activity — the  natural  power  of  resistance.  It  is  a  familiar 
observation  in  surgical  practice  that  after  injuries  to,  or  operations  on, 
joints,  tuberculosis  frequently  ensues.  Again,  operations  upon  tuberculous 
lesions  are  succeeded  by  general  tuberculosis — often  acute — in  about  8 
per  cent,  of  the  cases. 


Tuberculosis  op  the  Lymph-glands. 

{Scrofula.) 

Scrofula  implies  tuberculous  infection,  and  scrofulous  material  inocu- 
lated upon  susceptible  lower  animals,  especially  guinea-pigs  and  rabbits, 
invariably  causes  tuberculosis.  The  virus  is,  however,  less  virulent  than 
that  derived  from  other  sources,  and  this  explains  the  slow  progress  and 
often  latent  character  of  tuberculosis  of  the  glandular  system.  A  major 
predisposing  factor  is  age,  this  form  of  tuberculosis  preponderating  in 
children.  Hecker,  from  an  examination  of  the  records  of  the  Munich 
Pathological  Institute,  found  that  in  147  cases  of  tuberculosis  among 
children  the  lymphatics  Avere  affected  in  92  per  cent. ;  and  it  is  generally 
conceded  that  in  young  adults  tuberculous  adenitis  is  not  uncommon,  and 
that  it  is  rarely  met  with  during  and  after  the  middle  period  of  life. 
The  lesions  generally  remain  limited  to  the  glands  first  infected — i.  e. 
the  cervical,  mesenteric,  etc.,  as  the  case  may  be — and  this  for  the 
reason  that  the  natural  powers  of  resistance  in  the  tissues  are  often  able 

^  "  Lungentuberculose  mit  Brusthohlengeschwulste,"  Inaug.  Diss.,  Leipzig,  1S94. 


272  INFECTIOUS  DISEASES. 

to  oppose  the  march  of  the  destructive  forces.     Another  predisposing 
condition  is  an  acute  or  chronic  catarrh  of  the  mucous  membranes. 

The  cases  are  all  divisible  into  two  groups :  (1)  Local  tuberculous 
adenitis,  and  (2)  general  tuberculous  adenitis. 

(1)  Local  Tuberculous  Adenitis. — {a)  Cervical. — This  is  the  most  fre- 
quent form,  and  is  especially  common  among  children.  Of  2035  per- 
sons examined  by  Valland,  enlarged  cervical  glands  were  found  between 
the  ages  of  seven  and  nine  in  96  per  cent.  ;  between  ten  and  twelve  in 
96.1  per  cent. ;  between  thirteen  and  fifteen  in  84  per  cent.  ;  between 
sixteen  and  eighteen  in  69.7  per  cent. ;  and  between  nineteen  and 
twenty-four  in  68.3  per  cent.  Tubercle  bacilli  were  found  in  the  cer- 
vical lymph-glands  in  about  68  per  cent,  of  adults.  Negroes  are  found 
to  be  more  prone  to  the  affection  than  whites. 

Etiology. — I  have  stated  before  that  tubercle  bacilli  are  sometimes 
found  on  the  nasal  mucous  membrane  of  healthy  persons.  The  pres- 
ence of  an  acute  or  chronic  catarrh  of  the  nasopharynx  may  noAv 
lower  the  resistance  of  the  tissue-cells,  so  that  the  bacilli  may  gain 
access  to  the  lymph-current,  and  through  the  latter  to  the  neighboring 
glands,  setting  up  tubercular  adenitis.  Though  often  the  seat  of  tuber- 
cular invasion,  the  cervical  lymph-glands  do  not  furnish  a  highly  favor- 
able soil  for  the  growth  and  development  of  the  bacilli,  and  hence  the 
tendency  toward  latency  of  tuberculous  disease  of  these  organs. 

The  tonsils,  owing  to  their  free  communication  with  the  atmosphere, 
in  which  there  is  a  w^ide  diffusion  of  tubercle  bacilli,  may  be  primarily 
infected.  But  here  also,  as  in  the  case  of  other  glandular  structures, 
there  is  a  tendency  for  the  affection  to  become  latent,  for  the  reason  that 
the  tissue-soil  after  a  prolonged  contest  generally  gains  the  ascendency 
over  the  invading  bacilli.  The  latter  mav,  however,  under  certain 
favorable  conditions,  break  down  the  barriers  opposed  by  nature  and 
effect  a  lodgement  elsewhere,  or  even  become  widely  diffused  through 
the  economy.  Thus  Kinckraann  in  64  autopsies  found  25  cases  of 
tuberculosis,  in  12  of  which  the   tonsils  were  affected. 

A  third  mode  of  infection  of  the  cervical  lymph-glands  is  through 
the  medium  of  slight  injuries  and  abrasions  of  the  skin  or  certain  forms 
of  skin-eruptions  (eczema,  etc.).  These  serve  as  doors  of  entrance  for 
the  bacilli,  which  find  their  way  into  the  neighboring  lymph-glands 
through  the  lymph-channels.  Compared  with  infection  from  within, 
this  mode  is  most  probably  much  less  frequent. 

Symptoms. — The  main  feature  is  a  visible  enlargement  of  the  af- 
fected cervical  glands,  chiefly  the  submaxillary.  At  first  the  glands 
are  too  small  to  be  even  palpated  ;  later,  they  can  be  felt  as  small,  firm 
tumors  underneath  the  skin.  By  and  by  they  appear  as  visible  protuber- 
ances, ranging  in  size  from  that  of  an  English  walnut  to  that  of  a  hen's 
egg  or  even  larger.  The  slchi  over  the  enlarged  gland  is  freely  movable, 
as  a  rule ;  less  frequently  it  becomes  adherent — an  indication  of  suppu- 
ration. When  an  abscess  forms  and  is  allowed  to  open  spontaneously, 
there  remains  a  chronic  discharging  sinus.  Suppuration  is  attended 
with  fever,  anemia,  and  emaciation.  In  well-marked  cases  the  separate 
tumors  coalesce,  forming  large  and  irregular  masses.  The  affection  is 
usually  bilateral,  though  almost  invariably  it  is  more  marked  on  one 
side  tiian  on  the  other. 


TUBERCULOSIS  OF  THE  LYMPH-GLANDS.  273 

Not  infrequently,  in  addition  to  the  enlargement  of  the  submaxillary, 
post-cervical,  and  supraclavicular  glands,  there  is  also  involvement  of 
the  axillary,  as  was  the  case  in  a  fatal  instance  in  my  own  practice. 
The  patient  was  a  male  child,  eight  years  of  age,  who  developed  pul- 
monary tuberculosis.  It  may  reasonably  be  assumed  that  the  bronchial 
glands  also  become  implicated,  and  may  excite  lung  tuberculosis. 

The  diagnosis  is  based  upon  the  history  and  the  associated  evidences 
(keratitis,  conjunctivitis,  eczema  of  the  scalp  or  face,  nasopharyngeal  or 
bronchial  catarrh,  etc.),  coupled  with  the  glandular  enlargement.  Bacilli 
have  occasionally  been  found  in  the  purulent  discharge  from  abscesses. 
Otis  applies  the  tuberculin-test,  and  obtains  positive  reactions  in  62  to 
69  per  cent. 

The  course  of  this  affection  is  exceedingly  slow,  often  extending 
over  a  number  of  years.  Many  cases,  however,  recover  if  surgical  in- 
terference be  employed.  On  the  other  hand,  neglected  cases  are  a 
menace  to  the  life  of  a  patient,  since  they  may  be  followed  by  diffusion 
of  the  bacilli,  with  the  development  of  a  fatal  form  of  disease. 

(h)  Broncliial. — Tuberculosis  of  the  bronchial  glands  may  be  primary, 
or  secondary  to  infection  of  the  lungs,  and  it  is  commonly  preceded  by  or 
associated  with  bronchial  catarrh,  Avhich  is  its  chief  predisposing  cause. 
The  primary  form  is  met  with  frequently  in  young  children,  the  medias- 
tinal lymph-glands  being  affected  uniformly  in  127  cases  at  the  New 
York  Foundling  Hospital  (Xorthrup). 

The  bronchial  and  tracheal  glands  are  the  receptacles  for  all  foreign 
substances,  including  the  tubercle  bacilli  that  are  not  dealt  with  by  the 
broncho-pulmonary  phagocytes.  After  infection  with  tubercle  bacilli 
the  lymph-glands  become  swollen,  tumefied,  and  are  the  seat  of  caseous 
change  ;  later  they  may  undergo  calcification  or  proceed  to  abscess-for- 
mation. The  latter  may  rupture  either  into  the  lungs,  into  the  trachea 
or  the  bronchi,  or  into  a  pulmonary  blood-vessel. 

Symptoms. — If  a  fistulous  communication  be  established  with  the  air- 
passages,  cough  and  expectoration  of  purulent  material,  blood,  and 
caseous  matter  containing  bacilli  w'ill  be  noted. 

Secondary  infection  of  the  lung  may  occur  in  this  manner.  When 
rupture  takes  place  into  a  vessel  systemic  infection  promptly  follows. 
Tubercular  adenitis  involving  mediastinal  lymph-glands  may  also  lead 
to  infection  of  the  pericardium  and  then  proceed  to  tuberculous  peri- 
carditis. 

(e)  Mesenteric  {Tabes  Mesenterica). — This  may  be  primary  or  sec- 
ondary, the  latter  being  very  common  and  a  secondary  infection  to 
intestinal  tuberculosis. 

The  former  is  rare,  however,  and  the  intestinal  catarrh  with  which 
it  is  associated  is  doubtless  tuberculous  in  the  vast  majority  of  cases. 
The  mode  of  infection  has  already  been  pointed  out.  The  lesions  pre- 
sented are  similar  to  those  met  with  in  tuberculous  bronchial  glands. 

The  symptoms  are  not  always  distinctive,  and  may  be  entirely  nega- 
tive during  the  life  of  the  patient ;  hence  the  condition  is  often  incident- 
ally discovered  during  the  post-mortem  examination.  The  local  symp- 
toms when  marked  are  due  in  the  main  to  an  associated  peritonitis.  The 
abdomen  is  painful  and  more  or  less  swollen.  Peritoneal  effusion  is 
present,  and  sometimes  sufiicient  in  amount  to  be  detected  by  the  cus- 
18 


274  INFECTIOUS  DISEASES. 

tomaiy  physical  signs.  Large  and  small  nodules  may  sometimes  be  felt. 
Diarrhea  is  a  marked  and  obstinate  feature  and  is  usually  due  to  tubercu- 
lous intestinal  ulcers.  Fever  of  an  intermittent  type  is  almost  constantly 
present,  causing  emaciation,  and  the  objective  changes  (pallor  of  skin, 
mucous  membrane,  etc.)  due  to  anemia  become  pronounced.  This  form 
of  tuberculosis  may  persist  as  a  local  condition,  but  there  is  danger  of 
extension  to  other  organs  (pleura,  lungs,  etc.).  On  the  other  hand,  in 
the  adult  pulmonary  tuberculosis  may  be  followed  by  involvement  of  the 
mesenteric  glands  without  involvement  of  the  intestines,  and  in  such  in- 
stances there  occurs  an  extension  by  contiguity  along  the  course  of  the 
lymphatics  that  pass  through  the  diaphragm,  and  finally,  in  adults,  pri- 
mary tuberculous  new  growths  may  be  met  Avith  in  the  mesenteric  glands. 

Diagnosis. — A  probable  diagnosis  can  usually  be  made  if  careful  at- 
tention be  paid  conjointly  to  the  symptoms,  physical  signs,  and  course 
of  the  affection.  The  detection  in  a  child  of  a  tumor  which  may  be 
moderately  hard,  doughy,  or  even  fluctuating  will  aid  materially  in  the 
diagnosis,  and  will  also  afford  evidence  of  tuberculous  disease  in  other 
organs. 

(2)  General  Tuberculous  Adenitis. — This  term  implies  tuberculous  dis- 
ease of  the  lymph-glands  throughout  the  body,  with  little  if  any  involve- 
ment of  other  organs;  this  is  a  rare  condition.  The  affection  may  begin 
as  a  local  tuberculous  lymphadenitis,  nearly  all  of  the  rest  of  the  glands 
of  the  bofly  becoming  secondarily  implicated.  The  primary  seat  of  the 
trouble  is  perhaps  most  frequently  the  cervical  lymph-glands,  though  in 
one  instance  observed  by  myself  the  mesenteric  glands  first  became 
affected,  the  case  terminating  in  pleuro-pulmonary  tuberculosis. 

Symptoms  and  Diagnosis. — There  is  protracted  fever,  the  temper- 
ature being  of  the  remittent  or  intermittent  type.  Wasting  and  debility 
are  progressive  until  the  patient  presents  a  decidedly  puny  aspect, 
while  the  lymph-glands  that  are  accessible  to  inspection  and  palpa- 
tion are  more  or  less  enlarged  and  manifest  a  marked  tendency  to  sup- 
pwation.  The  affection  is  usually  chronic,  though  very  exception- 
ally it  may  exhibit  an  acute  course.  One  of  the  chief  dangers  over- 
hanging the  sufferer  in  this  affection  is  that,  owing  to  liberation  of  the 
bacilli,  the  meninges  or  the  lungs  may  become  tuberculous ;  these  cases 
may  also  terminate  unfavorably  from  asthenia.  Cases  in  which  the 
glands  are  but  little  enlarged,  -while  the  general  features  are  marked, 
are  puzzling.  On  the  other  hand,  when  the  superficial  lymph-glands 
are  greatly  enlarged  the  affection  may  bear  a  striking  resemblance  to 
Hodgkin's  disease. 

Acute  Tuberculosis. 

This  form  of  tuberculosis  is  characterized  anatomically  by  the  rapid 
development  of  miliary  tubercles  in  many  and  widely-separated  parts  of 
the  body.  In  some  instances  the  new  growths  are  pretty  evenly  distrib- 
uted through  all  the  organs  of  the  body,  manifesting  the  clinical  symp- 
toms of  an  acute  general  infection.  In  other  instances  there  is  a  tend- 
ency to  centralization  of  tuberculous  growths,  as,  for  example,  in  the 
lungs  (pulmonary  variety)  or  in  the  meninges  of  the  brain  and  spinal 
cord  (meningeal  variety). 


ACUTE  TUBERCULOSIS.  275 

Pathology. — The  fact  is  to  be  emphasized  that  somewhere  in  the 
body  there  is  an  old  tuberculous  focus.  Apart  from  this  primary  lesion, 
the  anatomic  changes  consist  in  the  widely  disseminated  miliary  tuber- 
cles. Their  most  frequent  seats  are  the  lungs,  liver,  and  spleen ;  less 
frequently,  the  marrow  of  the  bones,  the  heart,  the  choroid,  and  the 
meninges.  In  some  of  the  organs,  particularly  the  meninges,  lungs, 
etc.,  the  tubercles  may  be  readily  perceived  by  the  naked  eye,  while  in 
others  they  frequently  cannot  be  detected  without  the  aid  of  the  micro- 
scope. It  must  not  be  forgotten  that  in  some  of  the  more  protracted 
cases  the  nodular  tubercles  may  grow  into  foci  of  considerable  size, 
ranging  from  that  of  a  lentil  to  that  of  a  pea. 

Ktiology. — This  has  been,  in  the  main,  given  in  connection  with  the 
general  etiology  of  tuberculosis  (vide  supra),  though  a  few  special  points 
remain  to  be  adduced.  The  acute  forms  of  tuberculosis  are  decidedly 
more  frequent  during  infancy  and  childhood  than  during  adult  life,  and 
with  few  exceptions  the  cases  are  secondary  to  a  local  tuberculous  focus 
in  one  or  more  lymph-glands  (tracheal,  bronchial,  mesenteric,  etc.)  or  in 
the  lungs.  More  rarely  a  pre-existing  tuberculous  focus  in  the  kidneys, 
the  bones,  or  the  skin  may  give  rise  to  the  affection,  as  may  the  occur- 
rence of  certain  other  acute  infectious  diseases — such  as  measles,  whoop- 
ing-cough, and  influenza,  in  children,  and  typhoid  fever  and  lobar  pneu- 
monia, especially  with  delayed  resolution,  in  adults. 

Modes  of  Infection. — Most  frequently  there  is  established  a  fistulous 
connection  between  the  local  tuberculous  focus  and  a  vein,  especially  the 
pulmonary  vein.  Under  these  circumstances  there  may  be  large  num- 
bers of  bacilli  discharged  into  the  blood-stream  ;  but  oftener  only  small 
numbers  of  bacilli  enter  and  subsequently  multiply,  inducing  general 
infection  (Ribbert  and  Wild  ^).  A  second  mode  of  infection,  though  de- 
cidedly more  rare  than  the  above,  is  the  rupture  of  a  tuberculous  focus 
into  the  thoracic  duct,  in  which  case  the  tuberculous  material  passes 
almost  directly  into  the  subclavian  vein.  In  these  cases,  according  to 
Ponfick,  the  disease  is  less  rapid  in  its  course. 

Clinical  History. — That  miliary  tubercles  may  exist  in  many 
organs  of  the  body  (liver,  heart,  etc.)  without  giving  rise  to  symptoms 
is  a  noteworthy  fact.  Cohnheim  and  Manz  have  discovered  miliary  tu- 
berculosis of  the  choroid  when  the  condition  was  only  detectable  with 
the  aid  of  the  ophthalmoscope. 

The  following  forms  of  the  disease  may  be  distinguished : 

General  Miliary  Tuberculosis. 
(a)  typhoid  form. 

The  symptoms  are  those  of  a  general  infection  of  the  body,  there 
being  in  most  cases  a  period  of  incubation,  during  which  the  patient 
complains  of  malaise,  headache,  chilliness,  feverishness,  and  increasing 
debility.  Rarely,  the  onset  is  comparatively  sudden.  The  reaction  of 
the  nervous  system  against  the  poison,  which  is  now  scattered  to  all 
parts  of  the  body,  is  shown  by  such  symptoms  as  the  fever ^  which  rapidly 
increases,  a  rapid,  feeble  p)idse,  and  meiital  dulness  or  delirium.  The 
tongue  becomes  dry,  and  sometimes  also  brown.  The  respirations  are 
^  Deutsche  medicinische  Wochenschrift,  Dec.  30,  1897. 


276  INFECTIOUS  DISEASES. 

accelerated,  and  there  is  more  or  less  cyanosis,  with  which  symptom  is 
associated  a  peculiar  and  characteristic  pallor  of  countenance.  Coinci- 
dentlv  with  the  febrile  exacerbations  the  cheeks  may  wear  a  circum- 
scribed blush.  Among  the  rarer  early  symptoms  is  epistaxis.  The 
patient  soon  becomes  profoundly  prostrated  or  experiences  a  feeling  of 
anxiety  :  if.  as  sometimes  happens,  the  course  is  protracted,  tceakness, 
anemia,  and  especially  emaciation,  are  Avell  marked  and  assume  diag- 
nostic importance.  These  cases  sometimes  pass  into  the  pulmonary  or 
the  meninffeal  form,  the  patients  often  succumbing  speedily  to  such 
localized   developments. 

Fever. — The  temperature  usually  pursues  a  high  range,  although 
there  are  not  a  few  cases  in  which  the  entire  course  is  afebrile. 
Aorain,  it  occurs  not  infrequently  that  the  temperature  is  normal  or 
nearly  so  for  a  short  period.  The  usual  temperature-curve  ranges  at 
first  between  102°  and  104°  F.  (38.8°-40°  C),  and  then  continues 
to  rise,  with  the  development  of  the  serious  general  condition  in  a  way 
exactlv  similar  to  that  observed  in  typhoid  fever.  In  many  instances 
the  fever  is  irregularly  remittent,  at  least  at  intervals,  if  not  so  con- 
stantly. Thus,  periods  of  irregular  fever  may  alternate  with  others  of 
continued,  and  later  deeply  remittent  or  distinctly  intermittent,  fever. 

Nervous  Symptoms. — In  most  cases  the  nervous  symptoms  are  not 
prominent.  In  a  smaller  number  headache,  vertigo,  delirium,  and  often 
stupor,  become  marked  at  an  earh"  stage  and  may  persist.  They  are  due 
to  the  general  infection. 

Circulatory  System. — The  pulse  is  small,  and  its  rate  is  out  of  pro- 
portion to  the  fever,  varying  from  100  to  140  or  higher.  It  may  be- 
come irregular,  particularly  if  the  meninges  be  involved. 

Respiratory  System. — The  breath  is  somewhat  hurried  and  labored; 
there  is  a  cough,  but  it  is  not  annoying  as  a  rule:  and  there  is  a  slight 
expectoration,  which  is  not  characteristic.  If  there  be  present  simul- 
taneously in  the  lungs  an  old  tuberculous  focus,  the  expectoration  may 
be  more  profuse  and  typical.  The  bacilli  are  also  absent  from  the  spu- 
tum unless  an  old  tuberculous  lesion  exist  in  the  lungs. 

The  physical  signs  are  those  of  a  moderate,  diffuse  bronchitis,  though 
local  signs  of  consolidation  or  pleurisy  may  develop  late  in  the  course 
of  the  affection.  On  the  other  hand,  such  signs  may  be  evidences  of  an 
old  tuberculous  affection. 

Digestive  System. — As  before  noted,  there  are  anorexia  and  a  dry 
tongue  (symptoms  due  to  the  systemic  infection),  while  vomiting  may 
occur  at  the  outset  and  excessive  thirst  is  common.  The  spleen  usually 
becomes  enlarged,  though  only  to  a  moderate  extent. 

Ocular  Symptoms. — The  important  symptom  presented  by  the  eye  is 
the  presence  of  choroid  tubercles,  which  may  be  determined  by  a  care- 
ful ophthalmoscopic  examination.  Their  absence  does  not  militate 
against  the  diagnosis  of  general  miliary  tuberculosis,  since  they  may 
be  too  few  to  be  detected,  or  possibly  absent  altogether.  Their  demon- 
stration is  always  exceedingly  difficult,  and  only  possible  with  the 
skilled  ophthalmologist. 

Diagnosis. — This  form  of  tuberculosis  is  often  with  difficulty  dis- 
criminated from  typhoid  fever,  but  in  the  following  table  I  have  endeav- 
ored to  contrast  points  of  dissimilarity  : 


ACUTE  TUBERCULOSIS.  277 

Acute  General  Miliary  Tuberculosis.  Typhoid  Fever. 

Family  history  of  tuberculosis,  or  pres-  Coexistent  with  an  epidemic  or  following 

ence  of  an  old  focus.  previous  cases  of  typhoid. 

Evolution  of  the  disease  not  characteris-  Evolution  of  the  disease  is  character- 
tic,  istic. 

Epistaxis  rare.  Epistaxis  a  common  early  symptom. 

Fever-curve  of  decidedly  irregular  type.  Temperature-curve     of     the     continued 

Pulse  rapid,  out  of  proportion  to  fever.  Pulse  often  dicrotic  ;  slow  m  proportion 

to  fever. 
Respirations  rapid  and  labored.  Respiration  moderately  increased. 

Face  dusky,  with  peculiar  pallor.  No  duskiness  of  face. 

Abdominal  symptoms  are  not  suggestive.       Abdominal    symptoms  (stools,  enlarged 

spleen,  tympanites,  etc.)  suggestive. 
No  characteristic  eruption.  The  eruption    (appearing    in   successive 

crops)  is  pathognomonic. 
Widal  reaction  absent.  Present. 

Knee-jerk  may  be  absent.  Knee-jerk  never  wanting. 

Leukocytosis  present  (if  there  be    sup-      Leukocytosis  absent. 

puration). 
Choroid  tubercles  may  be  detected.  Choroid  tubercles  absent. 

Tubercle  bacilli  rarely  demonstrable  in  Cultures  from  punctured  spleen  may  show 
the  blood.  typhoid-bacilli  (dangerous  procedure). 

They  may  be  found  in  the  stools. 
Hemorrhage    from    bowels  very  excep-      Hemorrhage  from  the  bowels  common. 

tional. 
Perforative  peritonitis  absent.^  Perforative  peritonitis  often  present. 

(b)  PULMONARY    FORM. 

Though  all  gradations  between  the  typhoid  and  the  pulmonary  types 
occur,  the  latter  should  be  recognized  and  briefly  described.  It  may 
develop  sudde7ily,  the  ushering-in  symptom  being  sometimes  a  chill, 
though  more  frequently  there  is  a  'premonitory  period,  during  which 
the  general  health  fails  materially.  Some  acute  illness,  as  measles  or 
whooping-cough,  in  which  there  has  been  marked  catarrhal  bronchitis, 
often  constitutes  the  point  of  departure  for  this  variety. 

The  respiratory  symptoms  are  early  prominent,  and  later  preponder- 
ate in  the  clinical  picture.  From  the  start  there  is  dyspnea,  and  this 
gradually  increases  until  the  respirations  become  rapid  (40  to  60  per 
minute).  When  dyspnea  becomes  pronounced  the  face  assumes  a  char- 
acteristic cyanotic  pallor.  The  cough  at  first  is  moderately  severe,  but 
it  soon  becomes  troublesome,  being  frequent  and  attended  with  a  slight 
expectoration,  which,  however,  is  non-characteristic. 

The  physical  signs  are  those  of  broncho-pneumonia,  and  the  latter 
may  or  may  not  be  preceded  by  the  signs  of  generalized  bronchitis. 
With  the  onset  of  consolidation  there  appear  spots  that  yield  either 
dulness  or  a  tympanitic  resonance  on  percussion,  and  broncho-vesicular 
breathing  with  numerous  subcrepitant  rales  on  auscultation. 

The  general  symptoms  are  marked  from  the  beginning.  The  fever 
is  high— from  103°  to  105°  F.  (39.4°-40.5°  C.)  or  often  higher.  The 
pulse  ranges  from  100  to  140,  is  small,  feeble,  and  sometimes  irregular, 
and  it  may  be  more  rapid  still  during  the  advanced  stage  of  the  affec- 
tion (see  Fig.  25).     Cerebral  symptoms  rarely  appear. 

^  See  also  Differential  Diagnosis  of  Typhoid  Fever. 


278  INFECTIOUS  DISEASES. 

The  course,  as  a  rule,  is  more  prolonged  than  that  of  general  miliary 
tuberculosis,  except  in  children,  in  whom  it  often  runs  an  exceedingly 
acute  course.  As  the  end  approaches  the  signs  of  suffocation  are  gradu- 
ally intensified,  and  finally  lead  to  a  fatal  termination. 

Diagnosis. — The  diagnosis  is  difficult ;  but  a  family  history  of 
tuberculosis,  a  knowledge  of  the  pre-existence  of  a  tuberculous  focus  or 
of  an  antecedent  predisposing  affection,  will  aid  in  its  recognition. 
Tubercle  bacilli  are  perhaps  not  demonstrable  in  the  sputum  unless  an 
old  tuberculous  lesion  is  present.  In  doubtful  cases,  however,  an 
attempt  should  be  made  to  detect  the  bacilli  in  the  blood.  Occasionally 
either  tuberculous  meningitis  or  peritonitis  supervenes,  and  aids  in 
removing  the  doubt,  and  in  a  small  percentage  of  the  cases  choroid 
tubercles  are  detectable.  These  points,  together  with  the  more  marked 
general  symptoms,  will  usually  enable  the  clinician  to  distinguish  this 
variety  of  tuberculosis  from  non-tuberculous  hroncho-^^neumonia. 

{c)  CEREBRAL    OR    MENINGEAL    FORM    (TUBERCULOUS    MENINGITIS). 

This  variety  is  of  quite  frequent  occurrence,  appearing  in  not  less 
than  50  per  cent,  of  the  cases  of  miliary  tuberculosis.  When  it  devel- 
ops the  symptoms  referable  to  other  organs  than  the  meninges  are  in 
abeyance.  AVith  reference  to  the  etiology  of  this  form  one  fact  needs 
to  be  emphasized — namely,  that  most  cases  are  observed  between  the 
ages  of  two  and  seven  years ;  it  may,  however,  be  met  with  at  any  time 
of  life.  The  affection  frequently  has  its  origin  in  tuberculous  bronchial 
glands  (Jacobi),  and  the  history  of  a  fall  is  common.  A  few  cases  have 
been  found  to  be  associated  with  erythema  nodosum.  Exceptionally 
the  meninges  are  primarily  involved. 

Pathology. — The  chief  site  of  the  tubercles  in  children  is  the  pia 
mater  at  the  base  of  the  cerebrum  (basilar  meningitis),  Avhilst  in  adults 
the  pia  at  the  vertex  is  more  apt  to  be  involved.  The  membrane  sur- 
rounding the  tubercles  mav  not  be  inflamed,  there  being  a  simple  tu- 
berculous  deposit.  On  the  other  hand,  more  or  less  inflammation,  Avith 
sero-fibrinous  or  fibrino-purulent  exudation,  is  generally  present  in  the 
region  of  the  base.  This  exudate  is  usually  abundant  in  the  Sylvian 
fissures,  and  may  find  its  way  to  the  external  surface  of  the  hemispheres. 
It  is  gray  in  color,  transparent,  and  gelatinous,  and  contains  in  its 
meshes  the  tubercles,  which  appear  as  grayish-white  bodies,  and  which, 
in  cases  of  equal  severity,  may  be  either  numerous  or  scanty.  They 
may  be  scarcely  visible  to  the  naked  eye,  but  may  vary  from  the  size  of 
a  pinhead  to  that  of  a  French  pea.  The  branches  of  the  Sylvian 
artery  may  be  implicated,  either  owing  to  the  direct  pressure  of  the 
exudate  or  to  the  obliterating  arteritis  produced  by  a  tuberculous  infil- 
tration. The  pia  looks  like  wet  blotting-paper  over  the  quadrangle  at 
the  base  (Gray).  Elsewhere  it  is  thickened  and  opaque,  though  easily 
detachable.  Osier  says :  ''  The  arteries  of  the  interior  and  posterior 
perforated  spaces  should  be  carefully  withdrawn  and  searched,  as  upon 
them  nodular  tubercles  may  be  found  when  not  present  elsewhere.  In 
doubtful  cases  the  middle  cerebral  arteries  should  be  very  carefully  re- 
moved, spread  on  a  glass  plate  with  a  black  background,  and  examined 
with  a  low  objective.     The  tubercles  are  then  seen  as  nodular  enlarge- 


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280  INFECTIOUS  DISEASES. 

ments  on  the  smaller  arteries."  Involvement  of  the  chief  vessels  that 
nourish  the  walls  of  the  ventricles  and  the  ependyma,  and  stretch  from 
the  vermis  cerebelli  forward  over  the  quadrigemina,  explains  the  con- 
stant presence  of  a  turbid  fluid  in  the  ventricles,  with  softening  of  their 
walls.  As  the  result  of  undue  intraventricular  pressure  the  cerebral 
convolutions  become  more  or  less  flattened,  with  effacement  of  the  sulci. 
The  cortex,  to  a  variable  depth,  is  generally  the  seat  of  red  softening, 
and  more  rarely  of  Avhite  softening  alone.  The  tuberculous  infiltration 
involves  the  cranial  nerves. 

Histology. — The  tubercles  grow  in  the  perivascular  sheaths,  which 
are  often  distended  with  lymphoid  and  epithelioid  cells,  and  there  is 
observed  not  infrequently  a  thrombosis  of  the  arteries  and  of  the 
venules  of  the  pia,  obliterating  their  lumen.  The  pia  mater  is  gradu- 
ally thickened  through  cellular  infiltration,  and  in  a  small  proportion  of 
the  cases  the  spinal  meninges  are  similarly  involved,  chiefly  in  the  cer- 
vical portion  of  the  cord. 

Symptoms. — There  is  2i  prodromal  jscr/oc^  which  lasts  one  or  more 
■weeks,  during  Avhich  the  patient  (usually  a  child)  is  pale,  peevish,  has 
headache  and  photophobia,  and  grinds  its  teeth  during  sleep  ;  the  tongue 
is  coated,  appetite  impaired,  and  there  may  be  occasional  vomiting, 
either  propulsive  or  regurgitative.  Constipation  is  present  and  may  be 
marked.  Among  rare  premonitory  symptoms  are  slight  hyperesthesia 
of  the  abdomen  and  a  diminished  urinary  secretion.  A  tendency  to 
emaciation  is  quite  constant.  These  prodromal  symptoms  present  varia- 
tions as  to  their  number  and  combinations  in  different  cases.  In  few 
instances  only  is  the  onset  acute.  The  symptoms  usually  indicate  basic 
meningitis,  and  at  first  there  is  associated  considerable  mental  excite- 
ment ;  later  there  are  pressure-symptoms  (caused  by  the  exudate),  with 
total  loss  of  the  mental  faculties. 

(1)  Stage  of  Cerebral  Excitement. — The  invasion  is  generally  gradual, 
or  even  quite  insidious,  its  most  characteristic  phenomena  being  severe 
vomiting,  marked  headaclie.,  and  cliilh  followed  hy  fever.  Certain  other 
symptoms  now  arrest  the  attention,  such  as  extreme  irritability,  scream- 
ing, and' great  obstinacy,  and  occasionally  drowsiness  appears  early.  When 
the  onset  is  sudden  the  disease  may  be  disclosed  by  convulsions,  paral- 
ysis, Avild  delirium,  or  coma.  The  established  disease  exhibits  certain 
distinctive  features.  The  pain  is  often  most  excruciating,  causing  the 
child  to  utter  short  penetrating  screams  (hydrocephalic  cry),  and  in  rare 
instances  the  sharp  cries  may  be  continuous  and  lead  to  physical  exhaus- 
tion. The  headaclie  is  increased  by  light,  noise,  or  movement.  Vertigo 
is  common  ;  the  pupils  are  contracted  at  this  period ;  the  face  pales  and 
then  flushes ;  the  pupils  alternately  dilate  and  expand ;  and  the  expres- 
sion is  sometimes  sad,  though  more  often  stupid.  Generally  hyperes- 
thesia or  dysesthesia  may  appear,  and  there  may  be  a  slight  mind-wan- 
dering at  night,  though  active  delirium  is  rare.  Tdches  cerebrales  may 
be  obtained,  but  are  not  characteristic.  The  patient  is  intolerant  of 
every  form  of  disturbance.  All  the  symptoms  of  the  prodromal  stage 
are  now  aggravated;  slight  muscular  twitchings  and  sleep-starts  occur; 
the  vomiting  is  apparently  causeless,  and  may  be  frequently  repeated ; 
and  constipation  persists. 

Fever  is  present,  but  is  of  slow  development,  and  rarely  rises  higher 


ACUTE  TUBERCULOSIS.  281 

than  102°  or  103°  F.  (39.4°  C.)  in  the  evening.  The  skin  is  dry  and 
harsh,  as  a  rule.  The  pulse  is  slow  or  moderately  accelerated,  but 
soon  quickens  to  120  or  even  130,  and  later  it  may  be  irregular.  At 
times  the  pupils  are  unequally  contracted,  and  ptosis  may  also  be  looked 
upon  as  an  early    sign. 

(2)  Second  or  Transitional  Stage. — The  symptoms  of  cerebral  irrita- 
tion now  abate,  the  patient  becoming  more  quiet,  while  mental  dulness 
often  supervenes.  The  vomiting  and  headache  subside  gradually,  and 
the  child  cries  out  only  occasionally.  The  abdomen  is  now  distinctly 
scaphoid  and  the  head  occasionally  retracted.  Constipation  is  obstinate. 
The  evidences  of  localized  organic  foci,  such  as  slight  twitchings  of  the 
muscles  of  the  face,  folloAved  by  strabismus,  ptosis,  or  paralyses  of  the 
face  or  limbs,  may  appear.  Generalized  convulsions  may  occur,  and 
muscular  tremors  and  athetoid  movements  may  appear.  Both  pupils 
(or  one  only)  may  be  dilated  as  intracranial  pressure  develops ;  patchy 
flushing  of  the  face  is  common.  The  respiration  is  now  irregular  and 
sighing. 

(3)  The  Stage  of  Paralysis. — On  account  of  the  exudation  the  mental 
faculties  are  abolished,  so  that  the  patient  is  comatose,  though  convul- 
sions or  localized  spasms  of  the  muscles  in  different  parts  of  the  body 
(neck,  back,  limbs,  etc.)  may  be  observed.  Optic  neuritis  develops, 
while  the  paralysis  of  the  ocular  muscles  above  noted  deepens.  The 
pupils  are  dilated,  the  eyes  are  partly  closed,  and  the  eyeballs  at  inter- 
vals slowly  and  alternately  move  in  a  lateral  direction.  Hemiplegia 
sometimes  develops,  and  more  rarely  monoplegia,  affecting  the  face  or 
one  of  the  extremities.  There  may  be  paralysis  of  the  third  nerve,  with 
involvement  of  the  face,  hypoglossal  nerve,  and  limbs  on  the  opposite 
side  (a  combination  of  symptoms  first  observed  by  Weber),  consequent 
upon  a  lesion  localized  in  the  internal  inferior  portion  of  the  crus. 
Monoplegia  of  the  right  side  of  the  face  has  been  observed  in  a  few 
instances,  associated  with  aphasia.  Exceptionally  aphasia  and  brachial 
monoplegia  have  been  combined.  The  temperature  in  the  early  part  of 
this  stage  usually  rises  to  103°  F.  (39.4°  C.)  or  higher,  but  later  it  may 
drop  to  a  subnormal  level,  and  in  rare  instances  as  low  as  94°  F.  (34.4° 
C).  Immediately  preceding  the  fatal  termination  the  temperature  may 
rise  to  106°  or  107°  F.  (41.6°  C),  the  pulse  becoming  frequent,  small, 
and  irregular.     Anesthesia  comes  on  with  general  muscular  relaxation. 

Occasionally  a  typJioid  state  (great  prostration,  dry  tongue,  diarrhea, 
etc.)  may  develop,  and  Cheyne-Stokes  respiration  is  almost  invariably 
present,  preceding  the  fatal  event.     Leukocytosis  has  been  observed. 

Ophthalmoscopic  Examination. — The  ophthalmoscopic  appearances 
are — hyperemia  of  the  disk,  later  the  changes  belonging  to  neuritis 
(swelling  and  striation)  appear,  and  choroidal  tubercles  may  be  detected. 

Diagnosis. — This  is  based :  (1)  On  the  reaction  to  tuberculin  ;  (2) 
Examination  of  eyes,  which  present  the  characteristic  appearance  of  the 
choroid  coat  (Jacobi).  Post-basic  meningitis  gives  the  same  symptoms, 
and  lumbar  puncture  is  the  only  means  of  diagnosis.  In  tubercular 
meningitis  the  diplococcus  is  found. 

Clinical  Types. — {a)  Mild  Type. — The  marked  or  alarming  symp- 
toms (tetanic  rigidity  of  the  muscles,  convulsions,  and  paralysis)  develop 
at  a  late  period.     In  this  class  should  be  placed  those  cases  in  which  the 


282  INFECTIOUS  DISEASES. 

meningitis  is  but  feebly  indicated — e.  g.  when  it  is  but  a  small  factor  in 
the  condition  of  acute  general  tuberculosis. 

{h)  Malignant  or  Rapid  Form. — This  type  is  comparatively  rare,  oc- 
curring most  frequently  in  adult  life,  while  the  lesions  have  their  seat 
almost  exclusively  upon  the  convexity.  The  onset  is  marked  by  the 
most  frightful  tetanic  convulsions,  which  precipitate  a  fatal  termination 
in  a  couple  of  days. 

{c)  Clironie  Type. — Cases  pursuing  a  chronic  course  are  rarely  en- 
countered, and  the  symptoms  usually  point  to  localized  cerebral  lesions 
(Jacksonian  epilepsy,  etc.). 

Prognosis. — The  disease  lasts  from  two  to  four  or  five  Aveeks, 
though  chronic  cases  may  continue  for  several  months.  When  the  con- 
vexity is  implicated,  however,  the  duration  is  only  one  or  two  weeks. 
It  should  be  emphasized  that  frequently  in  the  course  of  well-marked 
cases  a  decided  remission  in  the  leading  symptoms  occurs,  so  that  con- 
valescence is  suggested ;  but  this  is  deceptive,  and  is  almost  invariably 
followed  by  a  renewal  of  the  unfavorable  features  of  the  affection.  A 
few  cases  only  are  recorded  in  medical  literature  as  ending  in  recovery. 

Freyhan  has  reported  a  case  with  recovery  in  which  the  diagnosis 
was  proved  by  puncture  of  the  spinal  canal  and  the  withdrawal  of  fluid, 
in  the  sediments  of  which  tubercle  bacilli  were  found.  A.  Jacobi  has 
met  with  2  cases  that  terminated  favorably,  and  Leube  has  also  reported 
a  case  in  which  the  symptoms  were  characteristic,  and  at  the  autopsy, 
some  years  later,  old  tuberculous  lesions  were  found  in  the  meninges. 
It  is  to  be  recollected,  however,  that  the  course  of  tuberculous  menin- 
gitis is  probably  uninfluenced  by  human  agency. 

Acute  Pneumonic  Phthisis. 

[Acute  Phthisis ;  Florid  Phthisis ;   Galloping  Consumption.) 

This  may  be  primary  or  secondary,  the  latter  form  being  consequent 
either  upon  a  localized  tuberculous  area  in  the  lung,  tuberculous  pleurisy 
(acute  or  chronic),  tuberculous  peritonitis,  or  tuberculous  disease  of  some 
other  organ.  Acute  phthisis  may  occur  at  any  age,  though  it  is  rela- 
tively more  frequent  in  childhood  and  early  adult  life,  but  whether 
primary  or  secondary,  the  infection  of  the  lungs  is  rapid. 

Pathology. — Two  forms  may  be  recognized :  (1)  This  reveals  the 
appearances  of  an  acute  lobar  pneumonia,  one  lobe  only  being  impli- 
cated, as  a  rule,  though  sometimes  the  whole  lung  is  involved.  The 
process  leads  to  a  destruction  of  lung-tissue,  so  that  a  section  may  show 
the  existence  of  cavities.  The  latter  are  usually  small,  while  surround- 
ing them  may  be  seen  tubercles  in  hepatized  tissue,  and  here  and  there 
caseous  masses  of  a  yellowish-white  color  may  be  visible.  These  often 
indicate  old  or  pre-existing  foci.  It  is  sometimes  exceedingly  difficult 
to  distinguish  a  tuberculous  croupous  ])neuraonia  from  the  ordinary  form, 
and  the  most  careful  inspection  may  fail  to  reveal  the  presence  of  ele- 
mentary tubercles  in  the  acutely  consolidated  tissue.  In  cases  in  which 
this  disease  is  suspected,  however,  the  opposite  lung,  the  bronchial  glands, 
the  peritoneum,  and  other  organs  should  be  carefully  examined. 

The  lesions  presented  by  cases  that  have  run  a  long  course  are 
somewhat  characteristic,  though  not  always  the  same.     If  the  case  has 


ACUTE  PNEUMONIC  PHTHISIS.  283 

had  a  duration  of  eight  or  ten  T\-eeks,  apical  softening  with  more  or  less 
extensive  cayitj-formation  often  occurs.  Less  frequently,  a  lobe  or  an 
entire  lung  is  found  to  be  consolidated  throughout,  "  and  converted  into 
a  dry,  yellowish-Avhite,  cheesy  substance,  in  which  condition  it  may 
remain  till  the  end." 

(2)  Presenting  the  Ajypearances  of  Broncho-pneumonia. — This  vari- 
ety is  more  common  than  the  previous,  especially  in  children.  The 
evidences  of  bronchitis  affecting  the  finer  tubes,  together  with  con- 
solidation  of  the  lobules  to  which  the  tubes  lead,  are  striking.  As  in 
ordinary  broncho-pneumonia,  so  here,  the  solidified  areas  appear  as 
grayish-red  masses  in  the  early  stage,  while  later  they  are  of  an  opaque- 
white.  The  products  that  fill  the  air-cells  may  caseate  and  break 
down,  with  the  formation  of  irregular  cavities  that  vary  in  size.  When 
large  areas  are  involved  they  are  the  result  of  the  fusion  of  contiguous 
smaller  areas  of  hepatized  tissue.  The  trouble  often  begins  in  the 
upper  lobes  and  spreads  downward,  though  not  infrequently  the  lower 
lobes  are  most  extensively  involved. 

In  not  a  few  cases  the  masses  are  small,  multiple,  and  widely  dissem- 
inated throughout  the  luno;s.  and  miliary  tubercles  in  the  lungs  or 
pleurie  are  associated  with  the  broncho-pneumonic  lesions  before  de- 
scribed. In  nearly  all  cases  signs  of  pleurisy  may  be  noted,  as  is 
shown  by  pleural  adhesions  or  by  deposits  of  lymph  on  the  pleura. 
The  bronchial  glands  are  also  usually  infected,  and,  particularly  in  chil- 
dren, are  the  seat  of  tuberculous  processes. 

Baumler  has  called  attention  to  a  type  of  tuberculous  inhalation 
2Jneu?no7iia  consequent  upon  hemoptysis,  the  blood  and  contents  of  the 
cavities  being  drawn  into  the  finer  tubes  in  respiration.  This  form  of 
broncho-pneumonic  phthisis  sometimes  follows  pulmonary  tuberculosis 
in  the  early,  though  more  often  in  its  late,  stage.  On  microscopic  ex- 
amination tubercle  bacilli  are  found,  though  rarely  in  abundance,  in  the 
infiltrated  masses  and  in  the  walls  of  the  cavities. 

Clinical  History. — (1)  Acute  Cases. — Preceding  the  attack,  the 
patient  may  have  "  taken  cold  "  or  have  been  in  a  run-down  state  ;  more 
often,  however,  he  has  been  apparently  healthy.  The  onset  is  sudden, 
marked  by  a  rigor,  pain  in  the  side,  fever,  cough,  and  systemic  prostra- 
tion, and  there  may  be  bronchial  hemorrhage  which  may  last  one  or 
more  days.  The  total  amount  of  blood  expectorated  may  be  consider- 
able. In  the  majority  of  cases  the  cvpectoration  is  mucoid  at  first, 
and  then  becomes  rusty-colored,  often  containing  tubercle  bacilli, 
though  at  first  they  may  be  absent  and,  indeed,  not  appear  until  late  in 
the  disease.  Dyspnea  appears  early,  and  may  soon  become  extreme, 
and  the  fever  quickly  rises  to  104°  F.  (40°  C.)  or  over.  It  may  be  of 
the  continued  type,  or  it  may  early  assume  the  remittent  or  hectic  type, 
and  with  the  latter  forms  of  fever,  Avhicli  usually  begin  about  the  end 
of  the  first  week,  are  associated  night-siveats  and  rapid  emaciation.  The 
prostration  of  the  vital  powers  is  now  extreme.  The  expectoration  is 
more  abundant,  muco-purulent,  and  often  greenish-yellow  in  color. 

In  the  course  of  one  or  two  days  after  the  onset  we  obtain  physical 
'signs  that  vary  with  the  extent  of  the  lesions.  Usually,  as  before 
stated,  these  cases  present  the  anatomic  appearances  of  acute  lobar 
pneumonia — viz.  the  complete  consolidation  of  one  or  more  lobes,  which 


284  INFECTIOUS  DISEASES. 

is  usually  followed  by  signs  of  softening,  provided  the  patient  survives 
the  first  week  or  ten  days.  The  physical  signs  during  the  stage  of  con- 
solidation are  precisely  the  same  as  in  lobar  pneumonia.  The  signs  of 
softening  and  of  cavity  Avill  be  given  in  detail  in  the  description  of 
Chronic  Phthisis. 

The  course  is  usually  rapid,  occupying  from  two  to  six  Aveeks  on  the 
average,  though  rarely  cases  that  reach  the  stage  of  cavity-formation 
are  protracted  to  three  or  even  four  months.  Considering  the  brevity 
of  the  attacks,  the  extreme  degree  of  emaciation  (shown  especially  by 
the  hollow  cheeks  and  temples,  pinched  nose,  and  thin  hands)  is  truly 
remarkable.  The  patient  usually  maintains  a  hopeful  state  of  mind, 
notwithstanding  the  rapid  downward  course  of  the  aifection,  and  it  may 
be  admitted  that  recovery  is  possible.  The  parts  involved  are  in  such 
cases  destroyed  and  replaced  by  fibrous  tissue,  and  it  should  be  remem- 
bered that  the  apex  is  involved  in  most  cases.  It  sometimes  happens 
that  consolidation  only  is  present  in  the  second  lobe  aflfected,  while  in 
the  upper  lobe  one  or  more  cavities  have  already  been  developed.  The 
pleural  crepitating  friction  is  often  audible  before  consolidation  is 
complete. 

Diagnosis. — The  onset,  symptoms,  and  course  during  the  first  week 
may  be  those  of  ordinary  lobar  pneumonia,  but  in  some  cases  certain 
symptoms  may  arise  which  will  excite  suspicion  of  their  tuberculous 
character  in  the  early  stage.  Thus,  hemoptysis  rarely  occurs  in  a 
pneumonia  due  to  pneumococcus  infection,  and,  what  may  also  serve  as 
a  point  in  diagnosis,  the  appearance  of  the  patient,  as  well  as  his  pre- 
vious and  family  history,  may  be  suggestive.  The  points  of  discrimi- 
nation have  been  fullv  set  forth  in  the  section  on  Lobar  Pneumonia 
(pp.  150,  151). 

(2)  Subacute  Cases  (rarely  acute). — The  onset  is  less  sudden  than  in 
the  former  type,  while  the  patient's  antecedent  condition  may  either  be 
good  or  below  the  standard.  At  the  beginning  he  has  repeated  chills, 
though  hemoptysis  may  be  the  first  symptom  which  indicates  a  pre-ex- 
isting tuberculous  focus.  The  fever  rises  high,  and  is  apt  to  be  irregu- 
lar from  the  start;  the  pulse  and  respirations  are  rapid,  and  there  is 
a  muco-purulent  expectoration  which  may  either  be  profuse  or  scanty. 
Occasionally  it  is  fetid,  and  the  sputa  may  early  contain  elastic  fibers 
and  tubercle  bacilli,  though  more  often  these  are  noted  after  the  affec- 
tion has  become  fully  established.  During  the  progress  of  the  case, 
also,  hemoptysis  may  arise.  Later,  drenching  niglit-siveats  increase  the 
exhaustion  and  emaciation,  which  speedily  reach  an  extreme  degree, 
and  soon  or  late  a  typhoid  condition  of  the  system  is  developed. 

The  j^ht/sical  signs  are,  at  first,  those  of  general  bronchitis,  with  or 
without  indications  of  pleurisy.  Later,  small  areas  of  consolidation, 
which  often  increase  in  size,  are  indicated  by  impaired  percussion  reso- 
nance or  dulness  and  by  broncho-vesicular  (rarely  tubular)  breathing, 
with  subcrepitant  rales.  These  signs  may  be  unilateral,  though  more 
often  they  occur  bilaterally.  In  many  cases  softening  with  cavity-for- 
mation ensues,  with  the  usual  physical  signs  of  this  condition. 

Course  and  Duration. — For  some  time  the  patient  may  remain  out 
of  bed,  though  in  most  instances  the  disease  constantly  progresses. 
Less  frequently  there  are  exacerbating  periods  and  remissions.     Rarely 


CHRONIC  TUBERCULOSIS.  285 

these  cases  recover  with  a  loss  of  more  or  less  lung-tissue,  though  the 
condition  may  pass  into  chronic  phthisis.  It  is  important  to  recollect 
that  the  local  lesions  may  become  extensive,  as  the  result  of  fusion  of 
small  consolidated  masses,  until  an  entire  lobe  is  involved,  and  when  this 
occurs  the  symptoms  and  course  simulate  those  of  the  acute  type.  The 
duration  ranges  from  two  to  eight  weeks  or  more. 

Diagnosis. — This  variety  is  frequently  confounded  with  non- tubercu- 
lous broncho-pneumonia,  and  the  chief  distinctions  will  be  mentioned 
in  connection  with  the  latter  disease.  Bronchiectasis  may  be  accom- 
panied by  emaciation,  fetid  expectoration,  night-sweats,  and  the  signs 
of  cavity,  and  this  disease  has  been  mistaken  for  acute  phthisis.  Im- 
portant in  the  recognition  of  the  latter,  however,  are  marked  fever  and 
emaciation.  Moreover,  the  physical  signs  are  more  frequently  referable 
to  the  apices,  and  the  disease  is  more  steadily  progressive,  running  a 
shorter  course  than  bronchiectasis. 

Acute  Broncho-pneumonic  Phthisis  in  Children. — The  belief  that  the 
form  of  broncho-pneumonia  that  so  frequently  follows  certain  infec- 
tious diseases  (measles,  whooping-cough,  etc.)  is  in  the  majority  of 
instances  tuberculous  has  been  steadily  gaining.  Osier  recognizes  three 
groups  of  cases :  (a)  Those  in  which  the  child  suddenly  becomes  ill 
while  teething  or  during  convalescence  from  fever,  with  high  tempera- 
ture, severe  cough,  and  the  signs  of  consolidation  of  one  or  both  apices. 
Death  may  occur  within  a  few  days.  To  the  naked  eye  the  lesions  do 
not  appear  to  be  tuberculous,  {b)  In  this  group  the  children  show  the 
ordinary  symptoms  of  broncho-pneumonia,  and  the  cases  are  more  pro- 
tracted, death  occurring  about  the  sixth  week,  (c)  The  child  feels  ill 
during  convalescence  from  an  infectious  disease,  fever,  cough,  and  dys- 
pnea being  present.  The  intensity  of  the  symptoms  abates  within  a  fort- 
night, and  the  physical  examination  shows  the  presence  of  diffuse  bron- 
chitis with  scattered  minute  areas  of  consolidation.  Many  of  these 
cases  develop  into  chronic  phthisis. 

Chronic  Tuberculosis. 

( Chronic  Pulmonary  Tuberculosis ;   Chronic  Ulcerative  Phthisis?) 

This  form  is  much  more  common  than  the  acute,  the  term  embracing 
sub-varieties  to  Avhich  attention  will  be  incidentally  directed.  Its  most 
typical  clinical  form  follows  a  mixed  infection  as  a  result  of  a  septic  ele- 
ment superadded  at  some  time  to  the  primary  tuberculous  infection. 

The  Causal  Factors  have  been  detailed  under  General  Etiology. 

Pathology. — The  pathologic  characters  of  tuberculosis  in  general 
have  been  already  presented,  but  it  will  be  necessary  to  describe  briefly 
the  special  anatomic  conditions  met  with  in  chronic  ulcerative  phthisis. 

The  post-mortem  appearances  of  the  lungs  in  chronic  pulmonary 
tuberculosis  are  remarkable  for  their  great  diversity,  not  only  in  the 
extent  of  tissue  involved,  but  also  as  to  the  character  of  the  morbid 
processes.  Often  the  associated  lesions  form  no  unimportant  part  of 
the  picture.  In  nearly  all  fatal  cases  the  most  advanced  and  extensive 
lesions  are  found  near  the  apex,  and,  as  a  rule,  the  entire  upper  lobe  of 
one  of  the  lungs  is  implicated.  In  addition,  it  is  observed  that  the 
destructive  process  has  extended  to  the  lower  lobe  of  the  same  side  as 


286  INFECTIOUS  DISEASES. 

well  as  to  the  apex  of  the  opposite  lung,  the  lower  lobe  of  the  primary 
lung  generally  being  invaded  before  the  upper  part  of  the  other. 
Though  both  lungs  are  aflfected  in  fatal  eases,  they  represent  different 
stages  of  the  disease.  The  case  is  very  different  in  an  old  and  cured 
tuberculosis  of  the  lungs,  such  as  is  frequently  met  -with  in  persons  who 
have  died  of  some  other  affection.  Here  the  lesions  may  occupy  but  a 
small  part  of  one  lung,  and  usually  near  the  summit. 

Kingston  Fowler  has  investigated  the  question  of  the  points  of  elec- 
tion and  paths  of  distribution  of  the  lesions  in  chronic  phthisis,  and 
has  found  that  the  primary  lesion  is  not,  as  a  rule,  at  the  summit  of  the 
upper  lobe,  but  that  it  occurs  from  1  to  IJ  inches  (3.79  cm.)  below 
this  point  and  near  the  postero-external  borders.  Favored  by  normal 
respiration,  the  lesions  advance  downward,  so  that  on  physical  examina- 
tion the  first  evidences  of  disease  are  to  be  found  posteriorly  over  the 
lower  part  of  the  supraspinous  fossa,  while  anteriorly  the  early  signs 
are  met  with  immediately  below  the  middle  of  the  clavicle,  extending 
along  a  line  running  about  1^  inches  (3.79  cm.)  from  the  inner  end  of 
the  second  and  third  interspaces.  The  starting-point,  though  less  fre- 
quently, may  also  be  indicated  by  physical  signs  in  the  first  and  second 
interspaces  below  the  outer  third  of  the  clavicle,  with  subsequent  down- 
ward extension. 

From  personal  observation  of  the  post-mortem  lesions  of  this  disease, 
and  from  my  studies  at  the  bedside,  I  feel  convinced  that  the  initial 
lesion  is  frequently  located  anteriorly  and  near  the  apex,  corresponding 
on  the  chest-walls  to  the  clavicle  and  the  supraclavicular  spaces.  This 
site  has  seemed  to  me  to  obtain  more  often  on  the  right  side  than  on  the 
left.  Kingsley  has  shown  that  when  the  lower  lobe  becomes  involved 
the  consolidation  begins  about  1^  inches  (3.79  cm.)  below  its  apex  pos- 
teriorly, and  corresponding  externally  to  a  spot  opposite  the  fifth  dorsal 
spine.  From  this  point  it  spreads  downward  and  laterally  in  a  line  fol- 
lowing the  border  of  the  scapula  '"  when  the  hand  is  placed  on  the  oppo- 
site scapula  and  the  elbow  rests  above  the  level  of  the  shoulder."  The 
middle  lobe  on  the  right  side  is  usually  invaded  by  direct  extension 
from  the  upper.  The  seat  of  primary  infiltration  may  even  be  the 
lower  lobe,   but  this  is  an  occurrence  of  great  rarity. 

The  relative  frequency  of  involvement  of  the  two  sides  varies  accord- 
ing to  different  authorities.  A  careful  analysis  of  my  own  records,  and 
the  results  of  some  statistical  investigations  into  the  subject,  show  that 
out  of  a  total  of*  1236  cases  726  occurred  on  the  left  side  and  510  on 
the  right. 

In  all  cases  the  primary  lesions  are  due  to  tuberculous  infiltration., 
which  at  first  is  confined  to  certain  lobules,  though  it  may  later  involve 
extensive  areas  of  lung-tissue  [tuberculous  broncho-pneumonia.)  In 
most  instances  the  starting-point  of  the  morbid  changes  is  in  the  smaller 
bronchi  and  also,  according  to  Payne,  the  inside  of  the  alveoli.  Soon 
the  bronchioles  and  the  corresponding  air-cells  become  blocked  with  in- 
flammatory products.  These  areas  then  undergo  caseation  and  present 
the  usual  opaque,  grayish-yellow  appearance,  a  cross-section  of  these 
yellow  nodules  showing  the  central  bronchus  usually  plugged  with  exu- 
date and  surrounded  by  caseous  matter.  Softening  and  sometimes 
complete  liquefaction,  with  expectoration  or  absorption  of  the  altered 


CHRONIC  TUBERCULOSIS.  287 

morbid  products,  may  take  place,  and  this  disintegration  is  associated 
with  ulceration  in  the  wall  of  the  bronchus,  consequent  upon  secondary 
pyogenic  infection,  and  a  resulting  formation  of  small  cavities.  Ulcers 
may  form  in  the  bronchioles  before  necrotic  processes  supervene,  and 
they  are  generally  shallow,  with  sharply-defined  edges.  Recovery  may 
ensue  as  the  result  of  calcification  Avith  encapsulation  of  the  cheesy 
masses,  or  the  affected  area  may  undergo  fibroid  transformation — a  con- 
servative process  and  one  that  may  lead  to  actual  cure.  It  often  happens, 
however,  that  old  and  apparently  healed  tuberculous  lesions  undergo 
ulceration,  when  the  calcareous  masses  (pulmonary  calculi)  may  be  dis- 
lodged and  expectorated,  and  the  more  rapidly  the  caseous  masses  are 
formed  the  more  liable  are  they  to  softening.  Surrounding  the  healed 
areas  the  tissue  may  be  the  seat  of  atelectasis,  though  more  often  of 
emphysema.  Destruction  of  lung-tissue  also  results  from  interstitial 
inflammation  with  the  formation  of  new  connective  tissue,  the  latter  in 
turn  compressing  and  finally  obliterating  the  alveoli. 

Cavities  ( Vomicce). — These  result  chiefly  from  progressive  necrosis 
and  ulceration.  They  are  formed  mostly  by  dilatation  of  the  bronchi, 
whose  walls  are  tuberculous  and  suppurating.  But  they  may  also  arise 
independently  of  the  bronchi.  Cavities  vary  largely  in  number,  size, 
form,  and  in  other  characteristics.  They  are  often  multiple,  though 
usually  not  far  removed  from  one  another,  and  unite  as  they  increase  in 
size.  In  this  way  large  cavities,  involving  the  whole  of  one  lobe  and 
even  an  entire  lung  (except  the  extreme  anterior  margin),  may  be  formed, 
and  a  variable  number  of  small  pockets  connecting  with  the  bronchus 
may  thus  originate.  The  walls  of  the  cavities  are  almost  invariably 
irregular. 

Vomicae  may  be  classified  as  (1)  progressive  and  (2)  non-progressive. 

(1)  The  progressive  are  divisible  into  (a)  New  cavities  and  {b)  Old 
cavities. 

{a)  New  cavities  have  soft,  necrotic,  friable  walls  so  long  as  the  de- 
structive processes  are  rapidly  progressing,  and  the  same  state  of  things 
prevails  in  the  cavities  of  acute  phthisis.  They  may  develop  near  a 
healed  focus  or  near  old  cavities  with  limiting  walls,  and  when  situated 
near  the  periphery  of  the  lung  they  may  rupture  into  the  pleura,  caus- 
ing pneumothorax. 

(6)  Old  cavities.,  as  a  rule,  have  sharply-defined  walls  that  vary 
considerably  in  thickness.  At  first  they  consist  of  a  fibro-vascular 
zone,  which  has  an  inner  suppurating  surface ;  subsequently  the  lining 
of  this  zone  is  converted  into  an  exfoliating  membrane.  The  contents 
of  vomicEe  are  muco-purulent  or  purulent,  and  often  consist  of  a  shreddy 
and  sometimes  a  bloody  fluid.  Rarely  they  are  gangrenous.  Cavities 
also  contain  tubercle  bacilli  and  other  micro-organisms.  Percy  Kidd 
has  studied  the  question  of  the  relation  of  tubercle  bacilli  to  tuberculous 
pulmonary  lesions,  and  states  that  they  are  invariably  present  in  newly- 
developed  tubercles  and  fresh  cavities,  but  frequently  absent  in  old 
nodules.  Trabeculse  composed  of  blood-vessels  and  remnants  of  pul- 
monary tissue  often  traverse  the  cavities.  In  old  cavities  excavation 
may  be  complete,  not  a  vestige  of  normal  or  diseased  tissue  remaining 
in  them,  though  the  blood-vessels,  many  of  which  are  beaded  by  small 
aneurysmal   dilatations  along  their  course,  are  the  last  to   disappear. 


288  INFECTIOUS  DISEASES. 

Their  removal  is  effected  by  an  obliterating  inflammation.  Rupture  of 
these  miliary  aneurysms  or  the  erosion  of  a  large  vessel  is  an  event  that 
gives  rise  to  copious  hemoptysis.  Cavities  having  dense  walls  may  also 
increase  in  size  by  encroaching  upon  and  destroying  the  surrounding 
tissue,  huge  cavities  often  having  thin,  tense  walls.  But,  wherever  situ- 
ated, they  usually  begin  toward  the  summit  of  the  upper  lobe.  Another 
common  seat  is  the  mid-dorsal  region. 

(2)  Non-progressive  Cavities. — Quiescent  cavities  are  usually  small, 
though  variable  in  size,  according  to  the  stage  at  which  the  process  of 
contraction  is  arrested.  Medium-sized  and  large  vomicae  do  not  be- 
come totally  occluded.  They  may  be  multiple,  though  more  often  per- 
haps single,  and  associated  with  them  may  be  observed  dense,  fibrous 
nodules  representing  healed  foci.  Their  interior  may  be  lined  with  a 
smooth,  cuticular  structure  resembling  mucous  membrane. 

Interstitial  Pneumonia. — In  the  course  of  chronic  phthisis  interstitial 
inflammation  of  two  sorts  will  most  probably  arise :  (a)  A  consolidation 
excited  by  the  tubercle  bacilli  themselves,  and  hence  manifesting  a  de- 
structive tendency;  {h)  A  slowly-developed  interstitial  pneumonia  which 
aims  at  arrestin<j  the  progress  of  the  affection.  It  develops  in  close 
proximity  to  caseous  masses  and  around  cavities.  The  new  connective 
tissue  thus  formed  in  obedience  to  the  well-known  pathologic  law  tends 
to  contract  secondarily,  and  thus  vomicae  are  often  partly,  though  sel- 
dom entirely,  obliterated.  The  shrinking  of  the  connective  tissue  may 
also  result  in  compression,  and  finally  in  the  destruction  of  pulmonaiy 
tissue,  just  as  in  a  tuberculous  inflammation.  The  process  in  this  in- 
stance, however,  is  on  the  whole  conservative  and  calculated  to  repair 
tuberculous  lesions. 

Disseminated  Tuberculosis. — Miliary  Tubercles. — This  form  has  for 
its  chief  characteristic  miliary  tubercles,  which  are  scattered  not  only 
about  the  tuberculous  area,  but  also  throughout  the  rest  of  the  lung, 
and  usually  in  the  lower  lobe.  Most  of  the  tubercles  undergo  fibroid 
or  fibro-caseous  change.  These  minute,  hard  gray  or  grayish-yellow 
nodules  vary  in  size  from  a  mustard-seed  to  that  of  a  pea,  and  lung- 
tissue  that  is  more  or  less  studded  with  chronic  miliary  tubercles  is  apt 
to  look  pale,  while  the  surrounding  air-cells  are  emphysematous.  The 
condition  may  lead  to  pneumonia,  and  the  whole  aspect  then  becomes 
altered.  Here,  as  before  described,  fusion  of  miliary  tubercles  results 
in  larger  masses  which  become  caseous,  and  hence  the  method  of  cavity- 
formation  is  identical  with  that  observed  in  tuberculous  broncho-pneu- 
monia. In  the  disseminated  form  tubercles  may  also  be  found  in  many 
other  organs  than  those  indicated  (pleura,  trachea,  larynx,  bronchial  and 
other  lymphatic  glands,  peritoneum,  spleen,  kidneys,  liver,  brain,  mu- 
cosa, testes,  etc.). 

Lesions  of  the  Pleura. — This  membrane  is  hyperemic  and  coated  with 
fibrinous  exudation  coextensively  with  the  affection  of  the  parts  in 
chronic  ulcerative  phthisis.  The  pleural  membranes  are  only  more  or 
less  thickened  by  organized  adhesions,  but  in  the  latter  and  also  in  the 
pleura  tubercles  or  cheesy  masses  may  be  found.  Simple  and  other 
forms  of  pleurisy  are  also  met  with — sero-fibrinous.  purulent,  and  hem- 
orrhagic. 

Lesions  of  the  Bronchial  Glands. — At  first  these  are   enlarged   and 


CHRONIC  TUBERCULOSIS.  289 

edematous,  containing  tubercles,  and  later  they  present  foci  which  often 
undergo  purulent  disintegration  and  sometimes  calcification.  Other 
lymphatic  glands  than  these  may  be  alFected  (mesenteric,  etc.). 

Lesions  of  the  Larynx. — The  larynx  is  frequently  the  seat  of  tuber- 
culous infiltration  and  ulceration,  particularly  in  certain  parts,  such  as 
the  vocal  cords,  posterior  wall,  ary-epiglottidean  folds,  etc. 

Lesions  of  the  Heart. — Tuberculous  endocarditis  is  present  in  about 
5  per  cent,  of  the  cases,  and  congenital  stenosis  of  the  pulmonary  ori- 
fice is  noted  in  not  a  few  instances  (Chevers).  The  right  heart  is  often 
hypertrophied  or  dilated. 

Other  organs  may  present  lesions  in  chronic  phthisis,  and  these  will 
be  spoken  of  in  connection  with  the  clinical  history. 

Tuberculosis  of  the  intestinal  canal  is  a  common  though  late  lesion. 

Amyloid  degeneration  of  certain  organs  is  a  not  unusual  secondary 
event,  especially  of  the  kidneys,  liver,  spleen,  and  intestinal  mucosa, 
and  in  like  manner  enlargement  of  the  liver  due  to  fatty  infiltratwn  is 
noted  not  infrequently. 

Clinical  History. — The  modes  of  invasion  are  quite  diverse,  but 
with  few  exceptions  the  onset  is  either  (1)  gradual  or  (2)  abrupt,  and.  as  a 
rule,  the  health  has  been  previously  undermined  for  a  longer  or  shorter 
period. 

(1)  Gradual  Onset. — (ry)  Most  frequently  the  disease  originates  in 
a  manner  similar  to  the  origin  of  ordinary  bronchitis,  and  often,  com- 
bined with  the  symptoms  of  broncho-catarrh,  are  those  of  pleurisy. 
Tuberculous  bronchial  affections  often  follow  certain  acute  infectious 
diseases — influenza,  typhoid,  measles,  whooping-cough,  etc. — and  in  this 
form  are  rarely  curable.  The  physical  signs  may  be  negative  for  some 
time,  and  then  appear  at  the  apex  of  the  lung.  Over  a  small  area  there 
may  now  be  slightly  impaired  resonance  on  percussion,  with  harsh 
broncho-vesicular  breath-sounds  and  with  or  without  subcrepitant  rales. 
The  expansion,  as  noted  on  inspection  and  palpation,  over  the  affected 
spots  is  more  or  less  defective,  while  the  vocal  resonance  and  fremitus 
are  either  increased  or  unaltered ;  and  the  fact  that  the  lesions  are  more 
commonly  detectable  in  the  suprascapular  fossa  than  anteriorly  must  be 
remembered.  At  this  period  obvious  constitutional  disturbances  are 
present  (debility,  emaciation,  fever,  etc.). 

(b)  Onset  icith  Pleurisy. — This  may  be  sudden,  as  in  an  acute  pleu- 
risy with  effusion,  but  often  the  latter  condition  develops  insidiously.  Of 
90  cases  of  pleurisy  with  effusion,  one-third  terminated  in  chronic 
phthisis  (Bowditch).  It  may  begin  as  a  dry  pleurisy  at  the  apex,  either 
anteriorly  or  posteriorly,  or  the  evidence  of  pleurisy  may  be  associated 
with  the  more  common  or  bronchitic  onset. 

(c)  With  Grastro-intestinal  Symptoms. — There  is  impaired  digestion, 
and  soon  the  patient  becomes  anemic,  loses  flesh,  and  is  debilitated. 
Later,  the  first  indications  of  pulmonary  tuberculosis  develop  in  the 
lungs. 

(d)  With  indefinite  peritoneal  symptoms,  lasting  for  months  or  even 
years. 

{e)  With  Laryngeal  Symptoms. — This  is  a  rare  form.  It  begins  with 
hoarseness,  more  or  less  aphonia,  and  considerable  cough ;  there  is  also 
a  slight  muco-purulent  expectoration.     Laryngoscopic  examinations  may 

19 


290  INFECTIOUS  DISEASES. 

detect  tuberculosis  of  the  organ,  and  tubercle  bacilli  may  be  found  in 
the  sputum  before  involvement  of  the  lungs  is  discoverable. 

(2)  Cases  with  Abrupt  Onset. — (a)  The  most  important  group  under 
this  category  is  heralded  by  the  symptoms  and  signs  of  acute  pneumonia, 
more  commonly  of  the  lobular  variety.  As  compared  with  ordinary 
pneumonias,  these  present  some  peculiar  features :  the  fever  is  irregular 
and  the  expectoration  is  more  abundant,  is  blood-stained,  and  contains 
bacilli.  The  signs  are  usually  located  in  the  apical  region.  Resolution 
mav  occur,  but  recovery  is  not  complete,  and  the  condition  is  likely  to 
pass  into  chronic  phthisis. 

[h)  Onset  with  Fever. — Chills  and  fever  are  apt  to  arise  in  all  instances 
in  the  advanced  stage  of  pulmonary  tuberculosis,  and  these  symptoms 
may  also  initiate  the  attack.  There  is  no  mistake  in  diagnosis  more 
commonly  made  in  malarial  regions  than  to  ascribe  such  cases  to  pal- 
udism. 

(f)  Witli  Ilemopti/xi.s.—'Yhh  symptom  may  be  the  first  to  invite  at- 
tention to  lung-trouble.  In  the  majority  of  cases  the  amount  of  blood 
lost  is  considerable,  and,  less  frequently,  repeated  slight  hemorrhages 
occur.  Pulmonary  symptoms  may  be  absent,  sometimes  temporarily, 
and  in  rare  instances,  perhaps,  permanently  ;  but  in  a  great  proportion 
of  cases  the  clinical  picture  of  incipient  pulmonary  tuberculosis  is  re- 
vealed pursuing  its  accustomed  course  immediately  after  the  occurrence 
of  the  hemorrhage.  The  physical  signs  may  be  latent  for  a  time,  and, 
whilst  they  are  "usually  found  to  be  at  the  apex,  they  may  assume  the 
guise  of  a  pleurisy  in  the  scapular  or  infrascapular  region.  A  slight 
tuberculous  lesion  is  most  probably  present  in  these  cases  before  the 
occurrence  of  the  hemorrhage. 

The  symptoms  are  (1)  local  and  (2)  general. 

(1)  Local. — ('0  J^ain. — This  is  absent  in  many  cases  of  chronic 
phthisis  and  in  others  it  may  be  moderately  severe.  It  is  seated  usually 
at  the  base,  laterally  or  anteriorly,  and  not  rarely  there  is  pain  of  a 
lancinating  character  in  the  interscapular  region  in  the  early  stages  of 
the  affection.  This  symptom  is  of  diagnostic  worth  only  after  other 
forms  of  pain  (rheumatic,  neuralgic,  etc.)  have  been  excluded.  The 
most  common  cause  of  pain  is  pleuritis,  with  or  without  pleuritic  adhe- 
sions ;  it  is  increased  on  deep  breathing  and  coughing.  Intercostal 
neuralgia  and  pleurodynic  stitches  may  also  develop  in  the  course  of 
this  disease. 

(h)  The  Cough. — This  may  be  looked  upon  as  an  essential  feature, 
though  in  a  few  instances  it  may  be  slight  or  even  wanting  throughout. 
Its  severity  bears  no  constant  relation  to  the  extent  of  the  pulmonary 
lesions,  but  rather  to  the  degree  of  sensitiveness  of  the  patient.  It  is 
drv  and  hacking  at  the  beginning,  and,  if  the  larynx  be  involved,  the 
cough  is  marked  and  takes  on  a  hoarse  (|uality.  It  is  most  pronounced 
at  certain  periods  of  the  day — viz.  on  lying  down  at  night  and  on 
awaking  from  sleep.  Paroxysms  may  also  occur  after  meals,  and  these 
occasionally  induce  vomiting.  The  cough  is  at  times  distressing  and 
debilitating  in  its  effects. 

(c)  Expectoration. — At  the  beginning  the  sputum  is  scanty  and  mu- 
coid, rarely  hemorrhagic,  or  it  may  be  merely  streaked  with  blood ; 
later  it  may  become  muco-purulent,  and  the  appearance  of  small  gray 


CHRONIC  TUBERCULOSIS.  291 

or  grayish-yellow  flocculi  first  suggests  the  nature  of  the  aifection.  With 
the  onset  of  the  stage  of  cavity-formation  the  sputum  becomes  more  abun- 
dant and  more  distinctly  purulent,  and,  after  the  formation  of  cavities  of 
any  size,  airless,  opaque,  and  nummular  (coin-shaped)  masses  are  expec- 
torated. The  latter  are  greenish-gray  or  greenish-yellow  in  color,  and 
sink  rapidly  when  discharged  into  water.  They  are  often  mingled  Avith 
more  or  less  bronchial  secretion,  and  are  not  entirely  characteristic  of 
tuberculous  cavities,  being  sometimes  observed  in  pure  bronchitis.  They 
may  even  be  absent,  and  the  expectoration  be  merely  purulent.  The  open- 
ing of  a  fresh  cavity  may  be  followed  by  very  free  expectoration.  The 
sputum  is  sometimes  fetid,  and  exceptionally  it  is  horribly  offensive,  vary- 
ing greatly  in  amount  in  different  cases  and  at  different  stages  of  the  dis- 
ease. In  certain  cases  it  is  absent  throughout  the  greater  portion  of  their 
course,  and  is  especially  apt  to  be  slight  in  children  and  old  people.  In 
such  instances  it  may  be  impossible  to  collect  sufficient  sputum  to  ex- 
amine for  bacilli. 

3Iieroscopic  examination  discovers  alveolar  epithelium  (particularly 
in  the  earlier  stages),  pus-cells,  blood,  fat-globules,  elastic  fibers,  and 
tubercle  bacilli.,  the  detection  of  the  latter  being  the  most  important 
factor  in  the  diagnosis.  It  may  be  safely  stated  that  the  finding  of 
bacilli  in  the  sputum  is  prima  facie  evidence  of  chronic  phthisis  ;  on  the 
other  hand,  however,  their  absence  in  the  early  stage  does  not  exclude 
the  disease.  It  is  often  needful  to  make  repeated  and  delicate  examina- 
tions of  the  sputa.  It  is  also  of  the  utmost  importance  to  select  for  ex- 
amination the  small  grayish  masses  that  are  usually  to  be  found,  since 
they  early  contain  the  bacilli.  In  tuberculosis  in  the  aged  tubercle 
bacilli  are  not  always  detectable  in  the  sputum. 

"A  small  amount  of  the  purulent  portion  of  the  sputum  is  spread  in 
a  thin  and  uniform  layer  on  a  perfectly  clear  cover-glass  by  means  of 
forceps,  needles,  or  the  Ohse,  which  must  previously  be  held  a  moment 
in  the  flame  of  a  Bunsen  burner  or  a  spirit  lamp,  or  by  pressing  a  small 
amount  of  sputum  between  two  cover-glasses,  then  sliding  them  apart. 
It  is  then  dried  in  the  air,  or  more  quickly  by  holding  the  cover-glass 
with  forceps  some  distance  above  the  flame  of  a  burner  or  lamp.  Finally, 
it  is  to  be  passed  three  or  four  times  through  the  flame,  and  so  'fixed'  " 
(Musser). 

The  prepafation  may  be  stained  with  carbol  fuchsin  (basic  fuchsin  1, 
alcohol  10,  5  per  cent,  solution  of  carbolic  acid  90),  either  by  dropping 
a  few  drops  of  the  stain  on  the  smeared  side  of  the  cover-glass  and 
holding  it  above  the  flame  until  it  steams,  or  by  floating  its  face  down- 
ward upon  a  watch-crystal  containing  the  solution.  It  must  then  be 
decolorized  either  with  a  30  per  cent,  solution  of  nitric  acid,  allowing 
it  to  remain  until  the  red  color  has  entirely  disappeared  (about  fifteen 
seconds),  and  then  washing  and  counter-staining  with  methylene-blue, 
or  with  Gabbett's  solution  (methylene-blue  2  gm.,  sulphuric  acid  25 
c.cm.,  water  75  c.cm.),  in  which  it  must  remain  until  the  red  color  has 
been  replaced  by  a  faint  blue  (thirty  seconds  or  more).  Instead  of  car- 
bol-fuchsin,  anilin  gentian  violet  may  be  employed  (add  a  saturated 
alcoholic  solution  of  gentian  violet  to  a  filtered  saturated  solution  of 
anilin  until  a  metallic  luster  appears  on  the  surface).  The  specimen 
may  lie  either  several  hours  in  a  cold  solution  or  a  few  minutes  in  one 


292  INFECTIOUS  DISEASES. 

that  is  steaming.  Decolorize  with  the  nitric-acid  solution  and  counter- 
stain  with  rubin  or  Bismarck  brown.  It  is  often  much  simpler  to  smear 
the  sputum  directly  upon  the  slide,  and  then  examine,  when  stained, 
without  the  intervention  of  a  cover-glass.  A  much  larger  amount  of 
sputum  can  thus  be  prepared  at  a  single  operation. 

In  the  mici-oscopic  examination  use  a^-inch  (2.11  mm.)  oil-immersion 
lens  and  Abbe  condenser,  or.  at  the  least,  ^-  or  i-inch  (0.36  cm.  or  0.31 
cm.)  objective.  If  carbol-fuchsin  has  been  used  in  staining  for  the  ba- 
cilli, and  methylene-blue  as  a  contrast,  the  former  will  be  found  as  red 
rods  in  a  blue  field  (background),  while  if  gentian  violet  has  been  used, 
the  tubercle  bacilli  appear  as  dark  blue  rods,  with  all  other  bodies 
brown,  if  Bismarck  brown  is  used  for  the  contrast  stain.  There  may 
be  visible  in  the  field  a  few  bacilli  only,  particularly  during  the  early 
part  of  the  case.  In  the  stage  of  cavity  their  number  is  usually  in- 
creased, and  sometimes  they  are  quite  numerous.  Dorset  ^  describes  a 
rapid  method  of  great  practical  value  for  staining  the  organism  in  tissues, 
and  for  the  purpose  of  differentiating  between  the  tubercle  bacilli  and 
the  smegiua-bacillus  (the  latter  not  taking  the  stain),  as  follows  :  Cover- 
glass  prejiarations  are  made  and  fixed  in  the  ordinary  way,  and  then 
immersed  in  a  cold,  saturated  80  per  cent,  alcoholic  solution  of  Sudan  III 
for  five  minutes.  Any  excess  of  stain  is  then  removed  by  washing  in 
several  changes  of  70  per  cent,  alcohol  for  five  minutes.  The  bacilli 
are  thus  stained  a  bright  red  and  the  beaded  appearance  is  quite 
distinct. 

The  demonstration  of  elastic  fibers  is  also  an  important  aid  to  diag- 
nosis.    Fenwick's  method  is  the  following  :   Boil  the  s})utum  with  an 


Fig.  26.— Elastic  fibers  (after  StrumpeU). 

equal  (juantity  of  a  solution  of  caustic  soda  (gr.  xv-.^j — 0.972-32.0) ; 
pour  the  product  into  a  conical  glass  and  fill  Avith  cold  water.  The  sedi- 
ment is  subsequently  examined  with  care  for  elastic  fibers. 

The  form  and  apjyearance  of  the  elastic  threads  differ  according  to 
their  special  source.  If  they  come  from  the  alveoli,  there  is  an  inter- 
lacing of  the  fibers  which  may  preserve  the  globular  contour  of  the  air- 
cells.  If  they  come  from  the  blood-vessels,  they  are  single  and  elon- 
gated, or  two  or  three  of  the  fibers  may  be  arranged  side  b}^  side.  Elas- 
tic tissue  derived  from  the  bronchi  has  a  similar  appearance. 

The  presence  of  elastic  fibers  furnishes  incontestable  proof  that 
destruction  of  lung-tissue  has  taken  place.  To  show  that  this  loss  of 
structure,  however,  is  due  to  tuberculosis,  we  must  exclude  abscess  (an 
'  New  York  Medical  Journal,  Feb.  4,  1899. 


CHRONIC  TUBERCULOSIS.  293 

exceptional  event)  and  gangrene  of  the  lungs — diseases  in  which  it  also 
occurs. 

(d)  Hemoptysis. — This  symptom  of  phthisis  will  be  spoken  of  under 
Diseases  of  the  Lungs,  but  its  importance  as  a  diagnostic  feature  of  this 
disease  makes  special  reference  to  it  here  absolutely  necessary.  It  is 
present  in  the  majority  of  cases.  Gabrilowisch  ^  found  that  of  380 
patients  213,  or  56  per  cent.,  had  hemoptysis.  The  sputum  may  be 
merely  blood-stained,  or  the  hemorrhage  may  be  excessive  and  prove 
rapily  fatal,  though  hemoptysis  is  rarely  the  direct  cause  of*  death  in 
tuberculosis.  Slight  hemorrhages  are  usually  produced  by  mere  hyper- 
emia, and  are  most  apt  to  occur  during  the  early  stages ;  while  severe 
bleedings  are  produced  by  the  erosion  of  a  blood-vessel  or  rupture  of  a 
small  aneurysm,  and  are  most  prone  to  occur  during  the  stage  of  cavity. 
In  certain  cases  hemoptysis  is  frequent. 

A  third  or  capillary  form  of  hemorrhage  may  occur  in  phthisis 
with  cavity-formation,  and  in  this  variety,  which  is  of  a  rather  frequent 
occurrence,  the  purulent  sputum  is  uniformly  stained  with  blood.  It 
may  also  be  nummular,  but  presents  a  reddish-brown  or  chocolate  color. 
The  exciting  cause  is  seldom  obvious,  though  in  not  a  few  instances  ag- 
gravation of  the  cough,  and  in  others  great  mental  excitement,  would 
appear  to  excite  bleedings.  Slight  hemorrhages  often,  and  severe  ones 
rarely,  aiford  more  or  less  relief  to  the  pulmonary  condition.  On  the 
other  hand,  severe  bleedings  usually  exert  an  unfavorable  influence, 
being  followed  by  debility  and  anemia.  Moreover,  in  numerous  cases 
hemoptysis  is  followed  by  a  more  rapid  extension  of  the  local  lesions, 
with  corresponding  aggravation  of  the  local  and  general  manifestations. 
The  fact  remains,  however,  that  the  effect  of  severe  hemoptysis  upon 
the  progress  of  chronic  phthisis  is  by  no  means  always  untoward.  In  a 
case  of  my  own  there  occurred  periodically  copious  spontaneous  bleed- 
ings (in  spring  and  fall)  for  three  years,  which  were  as  regularly  fol- 
lowed by  marked  improvement  for  a  period  of  three  or  four  months. 
The  physical  signs  of  phthisis  then  developed.  In  a  large  number  of 
cases  of  pulmonary  tuberculosis  the  transition  from  warm  to  cold  or 
cold  to  warm  seasons  corresponds  with  increased  cough,  hence  with  in- 
creased pressure  in  the  pulmonary  circulation ;  and  so  bleeding  is  also 
favored,  particularly  in  those  having  a  hemorrhagic  tendency. 

(e)  Dyspnea  is  present,  but  is  not  a  marked  feature,  as  a  rule,  despite 
advanced  pulmonary  lesions.  Perhaps  the  chief  reasons  for  a  lessened 
demand  for  oxygen  on  the  part  of  the  system  are — first,  the  slow  and 
gradual  manner  in  which  the  lesions  develop  ;  and  second,  the  pro- 
nounced bodily  wasting.  The  respirations,  however,  are  moderately 
increased  in  rate,  averaging  from  20  to  30  per  minute,  and  this  compen- 
sates admirably  for  the  diminished  breathing-space.  The  dyspnea  may 
be  greatly  intensified,  however,  as  the  result  of  intermittent  pneumonia, 
pleurisy,  active  exertion,  or  great  mental  excitement,  and  toward  the 
close  of  fatal  cases  the  most  intense  dyspnea  may  be  manifested. 

Physical  Signs  in  the  Stage  of  Consolidation. — Inspection  gives  most 

important  results.      The  paralytic  or  phthisical  thorax  is  generally  pre'- 

sented  to  view.      It  is  flat,  particularly  the  upper  half;  the  intercostal 

spaces  are  wide ;  the  ribs  slope  at  a  sharp  angle  from  the  sternum,  mak- 

*  Herliner  klinische  Wochenschrift,  Jan.  2,  1899. 


294  INFECTIOUS  DISEASES. 

ing  the  epigastric  angle  acute  and  producing  elongation  of  the  chest. 
The  same  sharp  inclination  doAvnAvard  from  the  vertebral  column  is 
observed  laterally  and  posteriorly.  The  angle  of  Louis  is  prominent, 
and  the  depressions  (supra-  and  infraclavicular,  intercostal,  etc.)  are 
deepened,  the  costal  cartilages  being  often  prominent  and  the  sternum, 
particularly  in  the  lower  part,  sometimes  much  depressed  or  even  con- 
cave (funnel-breast).  The  scapuhis  stand  out  prominently  and  may  be 
distinctly  winged.  A  second  type  of  paralytic  thorax  is  narrow  and 
long.  Pulmonary  tuberculosis  may,  however,  arise  in  chests  of  appa- 
rently normal  build.  With  the  development  of  phthisis  at  the  apex  the 
depressions  of  the  side  affected  are  relatively  deeper,  while  the  clavicle 
often  stands  out  more  prominently.  The  paralytic  thorax  is  often  a 
resultant  of  developed  phthisis,  and  occurs  in  subjects  in  whom  the  chest 
was  normal,  preceding  the  invasion  of  the  disease.  Finall}',  both  nar- 
rowing and  flattening  of  the  upper  parts  of  the  chest  may  result  from 
great  emaciation. 

Defective  expansion  is  observed  early,  and  usually  at  the  apex  of  the 
side  first  affected  ;  subsequently  this  may  be  more  general,  and  finally 
bilateral.  To  note  the  motions  of  respiration  with  precision  the  exam- 
iner should  occupy  a  position  exactly  in  front  of  the  median  line  of  the 
patient's  body.  The  difference  in  the  movement  of  the  two  sides  often 
becomes  more  apparent  on  deep  respiration  than  on  quiet  breathing,  and 
while  at  rest  the  respirations  are  almost  normal,  but  exertion  decidedly 
increases  their  frequency. 

Palpation. — Testing  the  expansion  by  palpation  gives  better  relative 
results  than  does  inspection.  To  determine  the  comparative  movements 
of  the  apices  the  extended  hands  should  be  so  placed  (by  allowing  them 
to  diverge  below)  that  the  tips  of  the  fingers  touch  the  loAver  border  of 
the  clavicle,  and  then  the  patient  should  be  asked  to  breathe  deeply, 
though  slowly.  The  expansion  in  the  supraclavicular  spaces  is  tested 
by  standing  behind  the  patient  and  using  the  tips  of  the  fingers,  or  by 
allowing  the  two  first  fingers  of  each  hand  to  pass  parallel  with  the 
clavicles.  In  this  way  ''lagging"  over  the  apex  will  be  the  first  symp- 
tom recognized,  and  may  for  some  time  be  the  only  one. 

Tactile  fremitus  is  early  increased  with  oncoming  consolidation,  due 
to  the  growth  of  the  tubercles,  though  it  is  normally  more  marked  at 
the  right  than  at  the  left  apex.  If  there  be  great  thickening  of  the 
pleura,  however,  it  is  more  or  less  diminished,  and  if  there  be  pleural 
effusion,  it  is  usually  absent. 

3Iensuration. — The  difference  between  the  measurement  of  the  chest 
in  inspiration  and  expiration  in  any  person  of  average  health  should  be 
not  less  than  three  inches,  and  a  difference  below  two  and  a  half  inches 
points  strongly  to  tuberculosis. 

Percussion. — Resonance  is  deadened  more  and  more  as  consoli- 
dation progresses.  If  the  consolidated  areas  are  minute,  however,  the 
percussion-note  may  be  unchanged,  and  as  the  air-cells  surrounding  the 
latter  are  often  emphysematous  and  relaxed,  the  note  may  be  somewhat 
tympanitic.  In  many  cases  the  tympanitic  sound  and  deadness  are 
intermingled,  giving  rise  to  the  so-called  tympanitic  deadened  sound. 
Slight  dulness  is,  as  a  rule,  noted  first  below  the  clavicle,  though  in  not 
a  few  cases  it  is  first  detected  upon  and  above  the  clavicle.      The  corre- 


CHRONIC  TUBERCULOSIS.  295 

spending  regions  of  the  two  sides  must  be  compared  during  a  held  inspi- 
ration, and  also  during  a  held  expiration.  The  degree  of  dulness  can 
sometimes  be  better  estimated  by  comparing  the  apical  note  with  that 
obtained  lower  down  on  the  same  side,  allowing  for  the  normal  topo- 
graphic differences  of  intensity.  The  latter  method  is  especially 
applicable  to  cases  in  which  both  apices  are  involved.  Impaired  reso- 
nance may  be  detected  early  in  the  supraspinous  fossa,  and  less  frequently 
in  the  interscapular  space  if  the  subject  be  not  too  stout,  though  slight 
dulness  in  the  absence  of  other  signs  has  little  diagnostic  value.  As 
the  lung-tissue  becomes  airless  throughout  an  area  of  considerable  size 
it  is  markedly  deadened,  until  dulness  is  heard ;  finally,  with  extensive 
consolidation  the  note  may  be  wooden  and  the  feeling  of  resistance  be 
much  increased. 

Auscultation. — The  vesicular  breathing  may  be  sharpened,  owing 
to  narrowing  of  the  smaller  bronchi,  but  more  often  perhaps  it  is  dimin- 
ished by  the  swelling  and  secretion.  The  corresponding  regions  on  the 
two  sides  must  be  compared — first  during  quiet,  and  then  deep  breath- 
ing, and  it  should  be  remembered  that  prolonged  expiration  is  an  early 
and  important  diagnostic  mark,  at  first  being  somewhat  sharpened,  and 
later  distinctly  bronchial.  Tuberculous  bronchitis  may  cause  interrupted 
or  jerking  inspiration  at  the  apex.  If  heard  elsewhere,  little  value  is 
to  be  given  it.  With  lobular  consolidation  at  different  points  in  the 
region  affected,  the  conditions  favor  the  transmission  of  the  bronchial 
sounds,  but  these  are  toned  down  by  the  remaining  intact  air-cells ; 
hence  there  is  "transition  "  or  broncho-vesicular  breathing.  With  com- 
plete consolidation  pure  bronchial  breathing  is  audible,  and  with  the 
latter  two  forms  of  breathing  crepitant  or  subcrepitant  rales  are  heard. 
Sometimes  the  first  rales  have  a  low  whistling  sound,  which  accompany 
the  long  expiration ;  with  liquefaction  they  become  more  moist,  are 
louder  (sometimes  ringing),  and  often  bubbling,  and  may  be  heard  on 
inspiration  and  expiration.  If  scanty,  they  may  be  audible  on  inspira- 
tion only,  though  they  are  increased  by  coughing.  If  the  moist  crepi- 
tant and  subcrepitant  rales,  often  due  to  concurrent  bronchitis,  be  very 
numerous,  the  breath-sounds  will  be  obscured,  but  after  free  expectora- 
tion as  the  result  of  coughing  the  exact  quality  of  the  breath-sound  is 
appreciable. 

Pleuritic  friction-sounds  may  be  heard,  due  to  accompanying  pleuri- 
tis  sicca,  and  these  may  be  audible  before  the  bronchial  rales  reveal  the 
disease.  Friction-sounds  and  rales  often  occur  together.  Pleuro-peri- 
cardial  friction  is  present  when  the  "  lappet  "  of  lung  over  the  heart  is 
affected,  while  clicking  rales,  occasioned  by  the  heart's  systole,  are 
audible  when  the  same  area  is  pneumonic.  The  vocal  resonance  in- 
creases with  the  progress  of  the  consolidation,  and  when  the  latter  is 
complete  hronclio phony  (rarely  pectoriloquy)  is  present.  In  the  sub- 
clavian arteries  a  systolic  murmur  is  not  uncommonly  heard,  the  latter 
being  supposed  to  be  due  to  pressure  exerted  by  the  thickened  pleura 
upon  these  vessels. 


296 


INFECTIOUS  DISEASES. 


! 


Fig.  27.— 1.  Small  cavity  near  periphery,  with  thick  relaxed  walls,  containing  secretion  and 
communicating  with  a  bronchus  (vide  subjoined  table).  2.  Large  parietal  cavity,  with  thin,  tense, 
smooth  walls,  communicating  with  a  bronchus  {vide  table). 


Physical  Signs. 

(a)  Percussion-deadness  on  a  strong  blow, 
mere  impairment  of  resonance  on 
a  liirht  l)low :  Wintrich'.s  inter- 
rupted ehan^e  of  sound,  detectable 
■when  patient  is  upright,  but  not 
when   recumbent. 

(h)  On  auscultation  low-pitched  cavern- 
ous (hollow)  breathing;  gurgling 
(ringing)    rales. 

(c)  Pectorilo((uy  indistinct,  owing  to 
small  size  of  cavity  and  the  con- 
tained fluid. 


Physical  Signs. 

(a)  Amphoric  percussion-resonance, 
cracked-pot  sound,  and  Wintrich's 
change  of  sound. 


(b)  On     auscultation,    high-pitched     am- 

phoric  (musical)    respiration     and 
metallic  rales. 

(c)  Amphoric   (musical)    voice  and    am- 

phoric whisper. 


Physical  Signs  of  Cavity. — Inspection  shows  a  more  marked  retraction 
and  a  more  decided  lack  of  local  motion  than  during  the  previous  stage. 
The  degree  of  shrinking  is  proportional  with  the  extent  of  fibrous-tissue 
formation. 

Palpation  corroborates  inspection  as  to  lack  of  motion,  and  gives 
increased  tactile  fremitus  if  the  cavity  connects  with  an  open  bronchus 
and  if  it  contains  but  little  secretion.  Excessive  secretion  interferes 
with  conduction  of  sound. 

Percussion. — Resonance  is  generally  more  or  lesS  impaired  in  con- 
se((uence  of  the  consolidation  of  the  surrounding  lung-tissue.  The 
note  may  be  somewhat  tympanitic,  but  varies  with  the  position  of  the 
cavities,  the  amount  of  fluid  secretion  contained  by  them,  the  condition 
of  their  walls,  and  the  vibratory  capacity  both  of  the  latter  and  of  the 
individual  thorax.  Cavities  of  the  size  of  a  Avalnut  situated  in  the 
apices  usually  give  a  distinctly  tympanitic  note,  while  cavities  of  the 
same  dimensions,  or  even  larger,  in  the  lower  portion  of  the  lung  do 
not.  The  metallic  tone  is  especially  noticeable  over  large  cavities  with 
smooth  walls.  The  tympanitic  sound  may  be  deadened  by  closure  of 
the  connecting  bronchus  and  by  temi)orary  filling  of  tiie  cavities  with 
secretion,  and,  again,  if  they  are  surrounded  by  thickened  lung-tissue 
or  by  a  large  thickened  pleura,  there  may  be  impaired  resonance  or 
absolute  dulness  even.     Certain  special  conditions  change  the  tympan- 


CHRONIC  TUBERCULOSIS.  297 

itic  sound  over  a  cavity.  Thus  the  note  will  be  louder  and  exalted  in 
pitch  when  the  mouth  is  opened  wide,  and  lowered  when  the  mouth  is 
closed  (Wintrich's  sign),  there  being  dulness  when  the  mouth  is  closed 
and  tympanitic  resonance  when  the  mouth  is  open.  If  the  cavity  com- 
municates freely  with  the  bronchus,  it  may  be  necessary  to  change  the 
position  of  the  patient,  and  a  tympanitic  note  may  change  in  pitch  with 
change  in  posture  (Gerhardt's  change  of  sound).  If  the  patient  changes 
from  the  dorsal  to  the  upright  position,  resonance  may  give  way  to  more 
or  less  flatness,  since  the  fluid  contents  of  the  cavity  are  thus  brought 
into  contact  with  the  chest-wall ;  this,  although  an  almost  certain  sign 
of  a  cavity  when  present,  is  exceedingly  rare.  The  so-called  cracked- 
pot  sound  is  often  elicited  over  large  parietal  cavities  w-ith  thin  walls, 
and  may  be  quite  intense  ;  but,  since  it  also  occurs  in  many  other  patho- 
logic conditions,  its  diagnostic  significance  in  this  disease  is  subordi- 
nate.  There  may  even  be  normal  resonance  if  the  cavity  is  covered  by 
a  layer  of  unaffected  air-cells  of  considerable  thickness. 

Auscultation  over  small  vomicae  with  lax  walls  reveals  cavernous 
(low-pitched)  breathing,  while  over  large  cavities  with  tense  walls  (if 
parietal  and  communicating  with  a  tracheo-bronchial  column  of  air)  it 
gives  amphoric  (higher-pitched)  respiration.  Moist  rales  (bubbling  and 
gurgling,  according  to  the  consistency  of  the  secretion)  may  be  pres- 
ent, and  these  correspond  in  the  main  to  the  amphoric  breathing,  hence 
being  heard  most  frequently  over  large,  smooth-walled  and  periph- 
erally-located cavities.  The  gurgling  and  slushing  sounds  caused  by 
the  air  bubbling  through  the  secretion  in  a  cavity  are  always  intensified 
by  coughing. 

The  sounds  of  falling  drops  (metallic  tinkling)  may  be  heard  over 
large  vomicae  with  tense,  smooth  walls  containing  thin  secretion.  Pec- 
toriloquy and  amphoric  lohispers  are  the  vocal  sounds  heard  over  huge 
cavities,  and  to  the  latter  should  be  given  the  greatest  diagnostic  sig- 
nificance. 

General  Symptoms. — (a)  Fever. — Whilst  the  disease  is  progressing  fever 
is  a  constant,  significant,  and,  it  may  be,  the  earliest,  symptom.  If  a 
two-hourly  record  be  kept  for  a  few  days,  from  time  to  time  an  accurate 
conception  of  the  course  and  type  of  the  fever  can  be  formed.  In  the 
first  and  middle  stages  the  highest  temperature  occurs  about  4  or  5  p.  m., 
the  lowest  about  4  or  5  a.  m.  The  fever  may  be  continuous,  remittent,  or 
intermittent,  and  in  a  general  way  these  types,  in  the  order  named,  cor- 
respond to  the  stages  of  tuberculization,  softening,  and  cavity-formation. 
Modified  types,  due  to  the  fact  that  the  lesions  often  and  simultaneously 
represent  different  stages,  are  also  observed.  Apyrexial  periods  are  met 
with  in  the  early  as  well  as  the  late  stages  of  chronic  phthisis,  and  indi- 
cate cessation  of  the  processes  of  tuberculization  and  caseation. 

A  continued  fever  is  most  apt  to  be  met  with  during  the  initial  period 
of  phthisis,  the  evening  temperature  sometimes  registering  but  a  degree 
higher  than  the  morning.  A  similar  curve  may  be  presented  at  any  later 
time  if  acute  pneumonia  supervene,  though  it  is  to  be  recollected  that  the 
remissions  in  such  cases  are  usually  greater  than  in  primary  lobar  pneu- 
monia. 

A  remittent  fever  is  more  common  than  the  preceding  type.  It  may 
be  present  from  the  start,  but  is  oftener  seen  in  the  middle,  and  less  fre- 


298 


INFECTIOUS  DISEASES. 


quentlj  in  the  advanced,  stages  of  phthisis.     This  form  of  fever  points 
to  softening  (see  Fig.  28). 


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Fig.  28.— Temperature-chart  of  a  case  of  phthisis.    Quiescent  cavity  in  right  apex,  and  com- 
mencing excavation  in  left  apex.     Robert  (i ,  aged  lil  years;  dyer. 

An  intermittent  fever  is  also  frequent,  and  is  characteristic  of  cavity 
formation,  suppuration  being  invariably  associated  with  the  latter  process. 


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Fig.  29.— Temperature-chart  of  a  case  of  phthisis.    Cavity  in 
Wintrich's  sign,  etc.    George  C ,  aged  22 


left  apex,  giving  cracked-pot  sound, 
years ;  glass-worker. 


The  temperature  may  be  intermittent  from  the  start,  suggesting  malaria 
to  the  unguarded  ;   but  it  is  due  to  sepsis,  the  temperature  rising  during 


CHRONIC  TUBERCULOSIS.  299 

the  day,  beginning  usually  shortly  before  noon,  and  reaching  its  maximum 
at  from  5  to  8  p.m.  It  now  falls  slowly  until  about  4  or  5  A.  M.,  and 
then  rapidly  reaches  the  minimum — a  subnormal  point — usually  at  from 
6  to  10  A.  M.  For  a  considerable  portion  of  every  twenty-four  hours  the 
temperature  may  be  below  the  normal  (see  Fig.  29),  sometimes  dropping 
as  low  as  95°  F.  (35°  C). 

(h)  Night-sweats  occur  in  a  large  majority  of  the  cases.  They  may 
appear  during  any  part  of  the  course  of  phthisis,  though  most  apt  to 
occur  and  be  most  marked  during  the  progress  of  cavity-formation ;  they 
show  themselves  in  the  early  morning  hours  simultaneously  with  the  rapid 
decline  in  the  temperature,  and  may  appear  during  sleep  at  any  period 
of  the  day.  They  may  be  light  and  limited  to  the  neck  and  upper  por- 
tion of  the  thorax  ;  on  the  other  hand,  they  are  often  excessive,  saturat- 
ing the  bed-clothes  and  inducing  great  exhaustion.  The  drenching  sweats 
are  dependent  partly  upon  the  fever  and  partly  upon  the  existing  weak- 
ness, though  slight  exertion  may  also  engender  free  perspiration. 

(c)  Emaciation  occupies  a  prominent  place  in  the  symptomatology,  the 
muscular  and  fatty  tissues  being  involved  to  an  equal  degree  (Striimpell) ; 
the  extremities  and  soft  parts  of  the  thorax  are  most  affected.  It  must 
be  remembered  that  an  exalted  grade  of  emaciation  may  be  present  at  an 
early  period,  and  in  such  cases  it  may  be  assumed  that  the  thinness  of 
flesh  was  a  precursory  state.  In  nearly  all  cases  an  extreme  degree  of 
emaciation,  reducing  the  patient  to  a  slightly  covered  skeleton,  is  reached 
before  the  end.  The  causes  of  emaciation  are  chiefly  the  persistent  fever, 
the  loss  of  appetite,  and  the  feeble  digestive  and  assimilative  powers.  It 
is  an  almost  invariable  rule  that  during  the  afebrile  periods,  associated  as 
they  are  with  improved  appetite  and  digestion,  the  patient  gains  in  flesh 
and  strength. 

{d)  The  pulse  is  rarely  increased  in  frequency,  is  of  good  volume  and 
regular  in  rhythm,  though  of  low  tension  (soft).  When  suppurative  fever 
sets  in  the  pulse  becomes  very  frequent,  small,  and  compressible,  and  the 
capillary  pulse  is  often  observed ;  rarely  venous  pulsation  may  be  noted 
in  the  back  of  the  hands. 

(e)  Anemia  is  one  of  the  symptoms  evidencing  impaired  nutrition,  and 
seems  to  appear  in  certain  cases  before  the  more  obvious  local  lesions. 
The  objective  changes  pointing  to  anemia  are  pronounced  (pallor  of  lips, 
visible  mucous  membranes,  and  skin).  The  hlood  presents  nothing  cha- 
racteristic. In  the  early  stage  it  may  be  normal,  or  in  some  cases  chlo- 
rotic  in  type,  the  hemoglobin  being  decidedly  deficient ;  later  in  the  dis- 
ease, when  consolidation  is  advanced,  the  blood  may  be  wholly  normal ; 
but  when  there  is  cavity-formation  and  hectic  fever,  there  is  often  a  very 
considerable  leukocytosis,  as  many  as  50,000  leukocytes  per  cubic  milli- 
meter having  been  observed.  The  differential  count  shows  a  great  excess 
of  the  polynuclear  cells.  It  is  not  unlikely  that  the  condition  is  due  to 
secondary  infection  by  the  pyogenic  micro-organisms,  and  especially  by 
the  streptococcus. 

G-eneral  dehiUty  is  complained  of  in  all  cases,  and  is  prooressive. 

Symptoms  and  Complications  presented  by  Other  Organs. — (a)  The  Heart. 
— The  pulse  and  the  blood-appearances  have  already  been  described.  With 
retraction  of  the  upper  lobe  of  the  left  lung  the  area  of  the  heart's  impulse 
is  obviously  increased,  particularly  upward,  so  that  pulsation  may  be  visi- 


300  INFECTIOUS  DISEASES. 

ble  in  the  fourth,  third,  and  even  second  interspaces,  near  the  sternum, 
while  the  normal  apex-beat  may  be  wanting.  The  physical  signs  noted 
may  be  rarely  those  also  of  displacement  of  the  heart  to  the  right,  while 
the  necropsy  may  show  the  heart  to  be  in  its  normal  position.  Functional 
murmurs  both  at  the  apiex  and  at  the  pulmonary  orifices  are  often  audible, 
and  valvular  lesions  may  supervene.  Disease  of  the  tricuspid  segments 
is  not  infrerpient  in  plitliisis. 

(h)  Gastro-intestinal  Tract. — The  tongue  may  be  furred  :  more  often  it 
and  the  mouth  and  throat  are  red,  showing  increased  irritability.  The 
'pliarynx  may  be  the  seat  of  tuberculous  lesions,  which  may  interfere 
greatly  with  deglutition,  aphtlious  ulcers  being  common,  while  thrush  may 
also  appear  in  the  later  stages.  The  appetite  is  impaired  or  lost :  thirst 
is  annoying,  and  the  symptoms  of  subacute  and  chronic  gastritis  (inter- 
stitial and  parenchymatous)  often  obtain.  A  catarrhal  ulceration  and 
dilatation  may  be  associated  conditions  ;  and  the  stomach  may  be  so 
irritable  that  the  presence  of  food,  or  even  coughing,  excites  vomiting  : 
this  symptom  is  most  troublesome  during  the  last  stage  of  the  aifection. 
A  study  of  the  gastric  secretion  gives  variable  results,  there  being  an 
early  hyperacidity,  Avhile  later  the  secretion  is  subacid.  Croner  has 
found  normal  motility  constantly  present  in  the  early  stages. 

The  causes  of  gastric  symptoms  are  not  clear.  The  mucosa  is  the  seat 
of  venous  engorgement,  and  may  thus  occasion  the  catarrhal  changes 
that  are  present  in  many  instances.  There  are  not  a  few  cases,  how- 
ever, in  which  the  symptoms  are  serious  without  adequate  local  anatom- 
ic changes  to  explain  them. 

The  intestinal  symptoms  are  but  little  less  important  than  the  gastric. 
During  the  early  stage  constipation  is  a  frequent  condition,  and  yet  few 
cases  run  their  entire  course  without  manifesting  diarrhea.  The  latter 
symptom  may  occur  at  any  time,  but  is  most  prone  to  appear  at  an  ad- 
vanced period,  and  may  pursue  an  intermittent  course.  Occasionally  it 
alternates  with  periods  of  "  hectic  fever,"  and  late  in  the  affection  a  watery 
discharge  may  develop  [colliquative  diarrhea).  The  intestinal  lesions  are 
of  three  sorts  :  (a)  catarrhal,  (b)  ulcerative,  and  (c)  amyloid.  These  often 
arise  in  the  order  enumerated,  but  are  not  infrequentW  combined  in  va- 
rious ways.  Hemorrhoids  and  anal  fistulpe  are  among  the  common  com- 
plications. 

(c)  Genito-urinary  Organs. — There  is  frequently  an  albuminuria  that 
may  either  be  of  an  ordinary  febrile  nature  or  due  to  chronic  nephritis 
(productive  and  non-p>roductive).  Chronic  nephritis  is  usually  a  late  devel- 
opment, and  is  associated  with  a  rather  marked  albuminuria,  the  presence 
of  tube-casts  in  the  urine,  and  dropsy.  Amyloid  changes  may  also  set  in 
toward  the  close,  attended  by  their  characteristic  urinary  phenomena. 
As  secondary  events  tuberculous  pyelitis  and  cystitis,  with  the  appearance 
of  pus  and  rarely  blood  in  the  urine,  may  develop.  Hematuria  may  also 
result  from  temporary  congestion.  The  testes  may  be  implicated,  and  a 
routine  inspection  of  these  organs,  as  suggested  by  Osier,  should  not  be 
neglected. 

{d)  Cutaneous  System. — Cyanosis  occurs,  but,  being  of  a  moderate 
degree,  it  is  often  veiled  by  a  decided  pallor.  The  cheeks  often  wear  a 
"  hectic  flush,"  and  the  skin,  late  in  the  affection,  is  apt  to  be  dry,  harsh, 
and  scaly.    Among  the  cutaneous  appearances  are  pigmentary  stains  over 


CHEOXIC  TUBERCULOSIS.  301 

the  chest  (chloasmata  phthisicora).  and  seated  in  the  same  regions  as  ^\el\ 
as  upon  the  back  are  frequently  seen  brown  stains  (pityriasis  versicolor). 
The  hair  over  the  chest  often  becomes  gray ;  that  of  the  head  and  beard, 
long  and  harsh.  The  finger-ends  are  often  bulbous  (clubbed),  with  in- 
curved nails,  though  this  is  not  peculiar  to  chronic  phthisis,  and  crack- 
ing of  the  finger-nails  is  also  often  observed. 

(e)  Nervous  System. — The  mental  attitude  is  characteristically  hopeful 
and  buoyant,  even  in  the  advanced  stages.  Hence  the  patients  are  read- 
ily encouraged  by  the  unscrupulous  to  believe  that  their  condition  is 
improving,  despite  the  steadily  unfavorable  progress  of  the  disease,  and, 
indeed,  they  may  be  in  an  utterly  helpless  state,  and  yet  confidently  ex- 
pect to  recover.  The  cerebral  syrnptoms  are  rarely  marked,  and  the 
mind,  as  a  rule,  is  exceptionally  clear.  Tuberculous  meningitis  and  me- 
ningo-encephalitis  may  develop  secondarily,  and  I  have  met  with  cerebro- 
spinal meningitis  in  one  of  my  own  cases.  Focal  lesions,  due  to  the 
presence  of  tubercles,  may  produce  forms  of  paralysis  (aphasia,  hemi- 
plegia, etc.)  according  to  their  location.  Rarely  peripheral  neuritis 
(usually   an   extensor  paralysis  of  the  leg)  and  insanity  are  observed. 

(/)  Chest-muscles  and  Mammary  G-lands. — The  fonner  are  abnormally 
irritable,  and  sometimes  even  painful  on  percussion,  and  the  mammary 
gland  is  in  rare  instances  hypertrophied,  males  suffering  most ;  but,  as 
pointed  out  by  Allot,  the  affection  is  a  chronic  non-tuberculous  mammitis, 
and  hence  a  true  complication. 

Diagnosis. — The  early  recognition  of  chronic  pulmonary  tuberculo- 
sis often  tests  severely  the  diagnostic  acumen  of  the  physician.  The 
general  and  local  symptoms,  including  the  physical  signs,  may  afford 
merely  a  strong  suspicion  of  the  existence  of  phthisis,  and  in  such  in- 
stances repeated  examinations  of  the  sputum  for  the  bacilli  are  impera- 
tive, and  only  when  they  are  found  is  the  diagnosis  set  at  rest.  Repeated 
staining  of  the  sputum  may  be  necessary  for  the  detection  of  tubercle 
bacilli.  It  is  also  desirable  to  determine  whether  they  are  constantly 
present  by  re-examinations  at  intervals.  There  are  cases  in  which  the 
physical  signs  are  obvious,  yet  the  bacilli  are  either  not  detectable  or  only 
so  after  several  examinations ;  and  the  fact  that  a  certain  diacrnosis  is 
made  possible  only  by  the  demonstration  of  the  bacilli  in  the  sputum  in 
the  incipient  stage  of  the  affection  makes  a  continued  search  for  these 
micro-organisms  the  first  duty  of  the  physician  in  such  instances.  An 
absence  of  the  bacilli,  however,  does  not  justifH'a  denial  of  the  existence 
of  phthisis,  and  is  of  little  negative  value.  The  symptoms  of  greatest 
diagnostic  value  are  cough,  expectoration,  fever,  progressive  emaciation, 
and  the  constant  presence  of  certain  physical  signs  situated  at  the  apex 
on  one  side  (flattening  of  the  front  of  the  chest,  defective  expansion, 
slicfht  deadenino;  of  the  percussion-note,  and  a  change  in  the  vesicular 
murmur,  with  or  without  adventitious  sounds).  Francis  H.  Williams 
of  Boston  has  recently  produced  skiagraphs  that  show  the  presence  of 
tuberculous  deposits  and  pleuritic  exudates,  and  these  may,  at  times, 
give  the  earliest  positive  information  in  regard  to  these  conditions.^ 
In  the  hands  of  an  expert  more  reliable  knowledge  can  be  gained  by 
the  fluoroscope  than  by  practising  the  physical  signs. 

The  tuberculin-test  is  warmly  commended  by  A.  C.  Klebs  and  others. 

^  For  illustrative  cases  see  also  "Diagnosis  and  Treatment  of  Prebacillary  Stage  of 
Pulmonary  Tuberculosis,"  by  the  writer. 


302  INFECTIOUS  DISEASES. 

It  is  fairly  accurate,  and  out  of  a  total  of  1470  injections  in  dubious 
cases,  71.9  per  cent,  reacted  positively.'  Its  use  should  be  limited  to 
suspicious  cases,  and  medium-sized  initial  doses  are  to  be  employed. 
A  positive  reaction  demands  an  elevation  of  temperature  to  101°  F., 
and  this  rise  usually  occurs  within  twenty-four  hours,  but  it  may 
be  delayed  until  thirty-six  or  even  forty-eight  hours.  The  possibility 
of  reaction  occurring  in  cases  of  syphilis  or  leprosy  will  not  lead  to 
error,  if  it  is  noted  that  such  reactions  are  less  intense.  ■  It  is  import- 
ant to  determine  the  diagnosis  earl\%  and  this  is  often  practicable 
before  the  sputum-test  gives  a  positive  result.  A  slight  rise  of  the 
evening  temperature  (99.6°  F.  or  over)  is.  if  associated  with  any  dis- 
turbance of  health,  an  almost  infallible  diagnostic  symptom.  In  the 
more  advanced  stages  of  phthisis   the   diagnosis  is  rarely   difficult. 

Diflferential  Diagnosis. — In  the  very  early  stage  the  local  condition 
may  be  obscured  by  the  general  features,  and  most  frequently  by  the 
fever,  though  it  may  also  be  by  the  evidences  of  anemia  or  gastric 
catarrh,  with  a  falling  off  in   the   general   health  {vide  Onset). 

Bronchial  catarrh  is  with  great  difficulty  discriminated  from  beginning 
phthisis.  If  the  temperature  is  elevated  from  2  to  5  P.  M.,  and  not  at  all 
or  only  slightly  above  the  normal  night  temperature  in  the  evening,  the 
probabilities  are  greatly  in  favor  of  tuberculosis  (Barlow).  The  condition 
of  the  lungs  must  be  carefully  compared,  since  in  bronchial  catarrh  there 
is  no  dulness,  and  moist  rales,  that  vary  in  intensity  from  one  day  to 
another,  are  heard  equally  on  both  sides.  From  time  to  time  rales  may 
also  be  heard  at  the  bases  in  bronchitis.  In  phthisis  one  apex  is  more 
involved  than  the  other,  the  moist  sounds  not  being  heard  equally  low, 
and  after  repeated  coughs  with  subsequent  deep  inspiration  the  rales  are 
more  apt  to  remain  than  in  ordinary  bronchitis.  In  phthisis,  also,  there 
is  a  gradual  loss  of  tlesh  and  strength,  and  repeated  microscopic  exam- 
ination of  the  sputum  will  demonstrate  the  presence  of  the  bacillus  of 
Koch.  Phthisis  in  the  stage  of  cavity  may  be  confoundetl  with  1  ron- 
chiectasis  (vide  Diseases  of  the  Lungs). 

Fibroid  Phthisis. 

Definition. — Fibroid  phthisis  implies  induration  followed  by  con- 
traction of  the  affected  lung-tissue,  due  to  an  increase  in  the  connective- 
tissue  elements.  There  are  cases  in  Avhich  it  cannot  be  distinguished 
pathologically  from  chronic  pulmonary  phthisis,  but  from  a  clinical  point 
of  view  the  two  affections  present  distinctive  peculiarities.  The  majority 
of  instances  are  primarily  tuberculous,  though  manifesting  a  strong  tend- 
ency to  the  formation  of  fibrous  tissue — a  conservative  process ;  in  other 
instances  the  fibroid  change  may  be  primary,  followed  by  tuberculous 
infection  (vide  Pneumonokoniosis).  The  usual  form  arises  variously  as  a 
sequel  of  other  morbid  processes,  such  as — 

(1)  Pneumonias,  lobar  (rarely)  and  catarrhal  pneumonia  (commonly). 

(2)  Pulmonary  lesions,  such  as  a  tubercle  in  the  stage  of  consolidation 
or  cavity. 

(3.)  Chronic  tuberculous  pleurisy. 

(4)  Bronchial  catarrh  from  inhalation   of  irritants  (steel-,  coal-,  or 

^  "The  Value  of  tlie  Tnberculin-test  in  the  Diagnosis  of  Pulmonary  Tnliercnlosis," 
by  the  writer,  New  York  Medical  Joui-nal,  June  23,  1900. 


FIBROTD  PHTHISIS.  303 

mineral-dust).  As  stated  under  the  description  of  pneumonokoniosis 
(vide),  this  condition  may  be  found  to  be  a  tuberculous  process  accom- 
panied by  fibroid  change. 

Pathology. — The  process  in  the  beginning  is  very  often  localized  in 
one  apex,  and  less  frequently  in  the  middle  portion  of  the  lung  or  in  the 
bases.  It  may  remain  circumscribed,  but  more  often  it  extends  down- 
ward, and  gradually  invades  the  entire  lung.  It  is  unilateral.  Second- 
ary to  the  induration  and  contraction  there  is  dilatation  of  the  bronchi, 
and  rarely  bronchiectasis  may  precede  the  fibroid  induration. 

The  lung-tissue  is  hard  and  dense,  the  alveoli  being  obliterated.  It 
resists  cutting  and  creaks  on  pressure,  and  the  section  presents  a  smooth, 
dry,  gray,  often  marbled  aspect,  though  the  fibrous  tissue  may  undergo 
caseation.  Tuberculous  lesions  may  also  develop  in  the  opposite  lung 
and  in  still  other  organs. 

The  pleura  is  thickened  as  a  rule,  often  to  a  marked  degree,  and  its 
layers  are  adherent ;  the  unaffected  portions  of  the  lungs  frequently  be- 
come emphysematous.     The  right  ventricle  is,  as  a  rule,  hypertrophied. 

Symptoms. — These  may  be  briefly  stated,  since  they  do  not  diflFer 
from  those  of  cirrhosis  of  the  lung,  which  is  described  in  the  section  on 
Diseases  of  the  Lungs.  The  onset  is  extremely  insidious:  a  persistent 
cough  that  is  apt  to  occur  in  severe  paroxysms  in  the  mornings,  and  a 
purulent  expectoration,  are  for  a  long  period  the  leading  features.  If 
bronchiectasis  is  present,  the  sputum  may  be  fetid.  Di/spnea  is  marked, 
particularly  on  exertion.  Fever  is  slight  or  absent,  and  hence  emacia- 
tion progresses  slowly  or  may  not  even  be  noticeable. 

The  physical  signs  are  obvious,  and  are  identical  with  those  of  fibroid 
induration  of  the  lung  (vide  infra). 

The  course  of  this  disease  is  exceedingly  long,  ranging  from  ten  to 
twenty  or  even  thirty  years,  and,  as  I  have  before  stated,  both  lungs 
may  become  the  seat  of  tuberculous  disease.  Again,  as  in  chronic  pul- 
monary tuberculosis,  prolonged  suppuration  may  lead  to  amyloid  changes 
in  the  liver,  spleen,  kidneys,  and  intestines.  Dropsy,  due  to  secondary 
dilatation  of  the  right  ventricle,  often  closes  the  scene. 

Differential  Diagnosis. — Chronic  bronchitis  is  prone  to  be  mis- 
taken for  fibroid  phthisis.  In  the  latter  disease,  hoAvever,  there  are  uni- 
lateral retraction  and  the  signs  of  consolidation  or  of  an  apical  cavity, 
all  of  which  symptoms  are  absent  in  chronic  bronchitis. 

Complications  of  Pulmonary  Tuberculosis. — Lolar  pneu- 
monia, and  less  frequently  lobular  pneumonia,  may  develop  and  cause  a 
fatal  termination.  In  a  study  of  100  cases  H.  M.  King  found  the  most 
common  complications  of  a  non-tuberculous  character  were  lobar  pneu- 
monia and  nephritis. 

Erysipelas  may  arise  in  the  course  of  chronic  pulmonary  tuberculosis, 
though  the  proportion  of  cases  is  not  formidable.  Out  of  1165  cases  of 
erysipelas,  15  coexisted  with  pulmonary  phthisis.^  Some  contend  that  its 
occurrence  in  this  disease  may  be  beneficial,  but  my  own  observations  tend 
to  show  that  the  gravity  of  both  conditions  is  increased  when  occurring 
together. 

Typhoid  fever  may  rarely  be  met  with  in  sufferers  from  chronic 
phthisis,   though   I   have   seen   but   a   single  instance  come  to  autopsy. 

1  "  Points  in  the  Etiology  and  Clinical  History  of  Erysipelas,"  Journal  of  the  Ameri- 
can Medical  Association,  July  2,  1893. 


304  INFECTIOUS  DISEASES. 

In  another  fatal  instance  the  characteristic  symptoms  of  typhoid  were 
present  during  life,  but  no  post-mortem  examination  Avas  allowed.  It  is 
important,  however,  not  to  overlook  this  occasional  association  of  two  such 
common  affections. 

Chronic  nephritis  and  pulmonary  tuberculosis  are  often  found  in  the 
same  subject,  and  with  these  arterio-sclerosis  is  quite  commonly  combined. 

Chronic  endocarditis,  particularly  of  the  tricuspid  segments,  may  also 
occur  in  phthisis,  and  from  time  to  time  cases  of  valvular  heart-disease 
are  reported,  in  which  it  is  evident  that  passive  congestion  must  have  ex- 
isted for  some  time  before  the  tuberculous  condition  developed.  The  old 
doctrine  of  the  mutual  antagonism  between  disease  of  the  left  heart  and 
pulmonary  tuberculosis  finds  not  a  little  support  from  these  cases,  as  in  a 
large  proportion  a  very  considerable  tendency  to  encapsulation  of  the 
tuberculous  lesions  exists. 

Course  and  Duration. — Both  as  to  course  and  duration  this  dis- 
ease exhibits  unusual  variations.  If  not  promptly  treated  during  the 
time  in  which  there  is  hope  of  therapeutic  and  climatic  efficiency,  it  fre- 
quently progresses  with  more  or  less  rapidity  toward  the  grave.  On  the 
other  hand,  it  is  common  to  observe  periods  during  which  the  disease  is 
arrested  or  improved.  Generally,  the  improvement,  though  followed  by 
an  exacerbation,  endures  for  a  long  time,  and  permanent  cures,  even  in 
the  advanced  stage,  are  by  no  means  rare.  The  duration  of  pulmonary 
tuberculosis  varies  exceedingly,  though  from  the  collective  investigations 
of  different  authors  and  from  all  the  statistics  available  I  find  the  average 
duration  to  be  about  three  years.  The  late  Austin  Flint  long  ago 
directed  attention  to  the  innate  tendency  of  a  considerable  percentage 
of  the  cases  to  spontaneous  recovery — a  fact  that  simply  indicates  a  vic- 
tory for  nature's  silent  defensive  processes  in  the  struggle  for  existence. 

In  fatal  cases  death  is  by  (a)  gradual  asthenia  (most  frequently),  with 
retention  of  consciousness  until  the  end  approaches. 

{h)  Complicating  conditions  (bronchitis ;  pneumonia  :  pleurisy  ;  pneu- 
mothorax ;  amyloid  degeneration  of  the  intestines,  liver,  spleen,  kidney  ; 
Bright's  disease  ;  diabetes,  etc.). 

(c)  Tuberculosis  of  other  organs,  particularly  the  meninges,  intestines, 
and  genito-urinary  tract. 

(d)  Hemorrhage,  due  commonly  to  rupture  of  an  aneurysm  in  the  lung- 
cavity  ;  less  frequently  to  erosion  of  a  large  vessel.  Fatal  hemorrhage 
may,  when  the  vomica  is  of  large  size,  occur  without  hemoptysis,  as  in  a 
case  of  Roland  G.  Curtins  at  the  Philadelphia  Hospital. 

(e)  Syncope. — Though  of  comparatively  rare  occurrence,  there  are  a 
number  of  events  that  may  lead  to  sudden,  fatal  syncope — e.  g.  hemor- 
rhagic embolism  or  thrombosis  of  the  pulmonary  artery,  pneumothorax, 
thoracentesis  for  pleural  effusion,  walking  about  in  a  moribund  state,  etc. 

(/)  Asphy-ria  rarely  closes  the  scene  in  acute  pneumonic  phthisis,  and 
very  rarely  in  chronic  phthisis  complicated  with  pncumo-thorax,  or  with 
a  large  undiscovered  or  neglected  empyema,  or  with  sero-fibrinous  pleurisy. 

Tuberculosis  op  the  Alimentary  Tract. 

(1)  Lips. — Whilst  tuberculosis  of  the  lip  is  (|uite  rare,  the  possibility 
of  its  occurrence  must  not  be  forgotten.    In  a  case  of  v^y  own  it  assumed, 


TUBERCULOSIS  OF  THE  ALIMENTARY  TRACT.  305 

as  is  usual,  the  form  of  a  small  ulcer,  and  the  diagnosis  was  made  by  an 
examination  of  the  labial  mucus.  It  followed  an  accidental  lesion  of  the 
lip  from  biting,  and  was  not  associated,  as  are  most  cases,  with  laryngeal 
or  pulmonary  tuberculosis.  In  diagnosticating  the  condition  chancre  and 
epithelioma  must  be  excluded,  the  former  by  the  history,  and  the  latter 
chiefly  by  microscopic  examination  for  tubercle  bacilli. 

(2)  Tongue,  Palate,  and  Tonsil. — The  work  of  Orth,  Hanan,  Schlen- 
ker,  Kruckman,  and  others  has  shown  that  the  tonsils,  owing  to  their  fre- 
quent inflammation,  serve  as  the  point  of  entrance  of  the  tubercle 
bacilli.  The  fact  that  tuberculosis  of  the  tonsils  has  repeatedly  been 
found,  and  when  other  lesions  of  the  disease  were  absent,  points  to  the 
not  infrequent  occurrence  of  primary  tuberculosis  in  this  site.  The 
infiltrated  areas  often  present  small  grayish  spots,  but  the  appear- 
ance of  the  ulcers  is  not  characteristic,  frequently  bearing  a  strong 
resemblance  to  epithelioma  and  to  the  syphilitic  ulcer.  The  diag- 
nosis demands  either  inoculative  experiments  or  a  microscopic  exam- 
ination of  the  oral  mucus,  the  latter  being  oft  repeated  if  necessary. 
E.  D.  Smith  records  5  rare  cases  of  tuberculous  ulceration  of  the  soft 
palate  and  adjoining  tissues,  most  of  them  secondary  to  pulmonary 
tuberculosis. 

(3)  Pharynx  and  Esophagus. — Both  miliary  tubercles  and  ulcerative 
lesions  may  rarely  arise  on  the  posterior  wall  of  the  pharynx  by  direct 
extension  from  laryngo-pulmonary  tuberculosis  or  as  the  result  of  second- 
ary inoculation.  The  chief  symptoms  occasioned  are  the  excessive  secre- 
tion of  pharyngeal  mucus  and  muco-pus,  and  painful  deglutition.  Tuber- 
culosis of  the  esophagus  is  extremely  rare.  Osier,  however,  saw  a  case  in 
his  wards  in  which  the  ulcer  perforated  the  esophagus  and  caused  puru- 
lent pleurisy. 

(4)  The  Stomach. — Tuberculous  lesions  appear  only  exceptionally  in 
the  mucosa  of  the  stomach,  notwithstanding  the  fact  that  marked  gastric 
symptoms  are  of  frequent  occurrence.  It  should  not  be  forgotten  that 
nausea,  vomiting,  and  other  gastric  symptoms  may  be  directly  due  to  in- 
volvement of  the  larynx.  I  have  been  able  to  find  reports  of  4  such  cases 
in  addition  to  the  12  collected  by  Marfan.^  The  ulcers  may  be  single  (as 
in  Musser's  case)  or  multiple  (as  in  Osier's  case).  The  symptoms  are  not 
characteristic,  but  hematemesis  occurring  in  patients  sufi"ering  from  tuber- 
culosis of  other  organs  should  excite  a  strong  suspicion  of  the  existence 
of  ulcer.  Pain  coming  on  soon  after  meal-time  is  more  marked  in  tuber- 
culous ulcer  of  the  stomach  than  in  ordinary  gastric  lesions.  Perforation 
has  taken  place  in  some  cases,  with  its  usual  dire  consequence. 

(5)  Intestines. — The  lesions  may  be  (a)  primary,  or  (b)  secondary  to 
tubercles  of  other  organs  (lungs,  peritoneum,  etc.). 

(«)  Primary  tubercle  of  the  intestines  is  chiefly  met  with  in  children, 
for  the  reason  that  they  are  more  likely  to  swallow  the  tubercle  bacilli  with 
their  food,  and  especially  in  milk.  The  intestinal  route  of  infection  is, 
according  to  my  own  observation,  more  common  in  adults  also  than  is 
generally  supposed.  Many  cases  during  life  present  the  features  of  both 
intestinal  and  peritoneal  tuberculosis,  and  it  is  often  impossible  to  deter- 
mine which  of  these  was  the  primary  condition  ;  and  the  same  difiiculty 
arises  when  the  cases  come  to  autopsy.    Yet  I  have  never  seen  an  instance 

'  Paris  ITiesis,  1887. 
20 


306  INFECTIOUS  DISEASES. 

(post-mortem)  in  which  the  peritoneum  and  mesenteric  glands  were  not 
involved  to  an  equal  degree. 

(b)  The  secondary  variety  occurs  in  more  than  one-half  of  the  cases 
of  pulmonary  tuberculosis,  the  chief  seats  of  the  lesions  being  the  lower 
part  of  the  ileum,  the  cecum,  and  the  upper  part  of  the  colon.  The  rectum 
is  also  the  seat  of  secondary  tuberculosis  in  a  small  proportion  of  the  cases 
of  chronic  phthisis)  and  it  may  be  rarely  a  primary  seat  of  the  affection. 

The  morbid  process  begins  in  the  solitary  glands  in  Peyer's  patches, 
where  at  first  grayish,  firm  tubercles  grow  and  form  little  prominences. 
These  caseate,  becoming  yellow  in  appearance,  and  then  soften  and  disin- 
tegrate, producing  ulcers.  Osier  thus  describes  the  characteristics  of  the 
tuberculous  ulcer:  "  (f?)  It  is  irregular,  rarely  ovoid  or  in  the  long  axis, 
more  frequently  girdling  the  bowel ;  (h)  the  edges  and  base  are  infil- 
trated, often  caseous ;  (c)  the  submucosa  and  muscularis  are  usually  in- 
volved ;  and  {d)  on  the  serosa  may  be  seen  colonies  of  young  tubercles 
or  a  well-marked  tuberculous  lymphangitis."  In  all  acute  cases  the  sur- 
face-lesions show  little  tendency  to  repair  (Senn). 

In  chronic  cases  attempts  at  healing  are  the  rule  ;  and  the  cicatrices 
are  extensive  and  often  pigmented,  and  as  they  undergo  contraction  may 
produce  incomplete  or  even  com})lete  stricture  of  the  bowel.  At  a  point 
corresponding  to  the  seat  of  the  ulcers  local  peritonitis  invariably  develops. 
The  serosa  is  thickened  and  adherent,  and  the  ulcer  may  penetrate  through 
this  coat  without  causing  perforative  peritonitis,  while  rarely  a  fistulous 
connection  is  established  between  the  different  parts  of  the  intestine. 

Synrptoms. — In  children  the  symptoms  are  those  of  a  protracted 
catarrh  of  the  intestines,  or  they  may  be  absent.  Among  prominent 
features  are  diarrhea,  colicky  pains,  and  the  presence  in  the  stools  of 
pus,  blood,  and  particles  of  mucus  resembling  sago-grains.  In  many 
cases  there  is  constipation,  which  may  be  due  either  to  peritonitis  or 
cicatricial  stenosis.  The  general  symptoms  are  irregular  fevei'i;  Avasting, 
and  a  lack  of  development ;  they  may  antedate  tlie  local,  and  are  especi- 
ally valuable  for  diagnosis. 

In  adults  intestinal  tuberculosis  generally  gives  rise  to  symptoms 
similar  to  the  above,  and  when  they  .arise  in  the  course  of  pulmonary 
phthisis  they  are  highly  significant.  If  diarrhea  be  present,  it  stubbornly 
resists  treatment,  and  it  must  not  be  forgotten  that  this  symptom  may  also 
be  due  either  to  catarrhal  colitis  or  to  amyloid  cliange.  both  of  which 
processes  may  be  associated  wMth  chronic  phthisis.  Constipation  is 
common  and  often  marked,  and  local  tenderness  and  colicky  pains  are 
complained  of  frequently.  The  pulmonary  signs,  however,  may  be  in 
abeyance. 

If  the  abdominal  and  general  symptoms  are  such  as  to  excite  suspicion 
of  this  disease,  then  a  rigid  physical  examination  of  the  lungs  should  be 
made.  The  chief  seat  of  tlic  lesions  may  ])e  for  a  long  time  in  the  cecum, 
or  in  the  appendix,  when  the  symptoms — both  local  and  general — will  be 
those  of  appendicitis. 

The  diagnosis  of  primary  intestinal  tuberculosis  is  beset  with  special 
difficulties.  Sawyer'  has  in  special  instances  demonstrated  the  presence 
of  clusters  of  tubercle  bacilli  in  the  rectal  mucus,  and  in  this  way  the 
recognition  of  intestinal  tuberculosis  at  an  early  date,  or  before  diarrhea 

'  Medical  News,  May  23,  1896. 


TUBERCULOSIS  OF  THE  SEROUS  MEMBRANES.  307 

sets  in,  is  rendered  possible.  The  mucus  is  obtained  after  placing  the 
patient  in  a  position  as  if  to  examine  for  piles,  and  directing  him  to  bear 
down  as  though  at  stool,  by  gently  removing  a  small  quantity  from  the 
everted  membrane  with  a  sterile  loop.  It  is  then  spread  upon  a  clean 
cover -glass  and  treated  exactly  as  sputum  in  the  ordinary  examination. 
The  same  method  is  applicable  to  cases  of  secondary  intestinal  tuberculo- 
sis, but  here  the  history  and  associated  tuberculous  lesions  usually  serve 
to  remove  all  doubt. 

Tuberculosis  of  the  Serous  Membranes. 

General  tuberculosis  of  the  serous  membranes  secondary  to  pulmonary 
and  intestinal  tuberculosis  is  of  common  occurrence,  and  that  a  primary 
form  of  tuberculosis  of  the  serous  membranes  also  occurs  is  undoubted. 
Unfortunately,  accurate  means  of  discriminating  the  secondary  from  the 
primary  form  are  wanting,  since  often  in  the  secondary  variety  the  primary 
lesions  in  other  organs  are  insignificant. 

The  anatomic  alterations  resemble  those  of  ordinary  inflammation 
of  these  structures,  plus  the  presence  of  nodular  tubercles.  The  latter 
may  be  observed,  as  a  rule,  only  over  small,  scattered,  circumscribed 
areas,  though  not  infrequently  they  are  both  numerous  and  diffuse  (gen- 
eral miliary  deposit).  The  effusion  is  in  most  instances  sero-fibrinous, 
though  sometimes  it  becomes  purulent  subsequently,  and  not  infrequently 
is  hemorrhagic.  Most  instances  of  so-called  hemorrhagic  pleurisy  are  due 
to  pleural  tuberculosis. 

Clinically,  Cases  are  divisible  into  (1)  acute  serous  membranous  tubercu- 
losis and  (2)  chronic  tuberculosis.  The  acute  form  results  from  inocula- 
tion of  the  peritoneum  or  pleura,  induced  by  limited  foci  in  the  bronchial, 
tracheal,  or  mediastinal  lymph-glands,  or  in  the  Fallopian  tubes  in  women. 
The  chronic  type  is  apt  to  result  from  a  direct  extension  of  a  tuberculous 
process  from  some  organ  adjacent  to  the  pleura  or  peritoneum,  though  it 
may  attack  the  serous  membranes  primarily.  Belonging  to  this  class  of 
diseases  are  two  groups  of  cases :  those  attended  by  sero-fibrinous  or 
sero-purulent  effusion  and  the  presence  of  caseous  masses,  and  those  in 
which  there  is  a  tuberculous  deposit  with  increased  density  and  great 
thickening  of  the  pleural  layers,  and  slight  exudation.  The  pericardium 
may  be  similarly  involved. 

(a)  Tuberculous  meningitis  has  been  described  fully  in  the  present 
section  (vide  Miliary  Tuberculosis). 

(b)  Tuberculous  Pleuritis. — This  subject  will  be  referred  to  in  the 
section  on  Diseases  of  the  Pleura.  Its  import,  however,  is  such  that 
brief  special  consideration  is  demanded,  and  from  a  clinical  view-point 
the  cases  may  be  grouped  under  two  heads — namely,  acute  and  chronic 
tuberculous  pleurisy. 

The  acute  form  often  has  a  sudden  onset,  the  initial  symptoms  being  a 
rigor  or  repeated  fits  of  chilliness,  a  stitch-like  pain  in  the  side  affected, 
shallow,  catching  breathing,  a  cough,  and  fever.  The  ushering-in  symp- 
toms sometimes  suggest  lobar  pneumonia,  and  a  fatal  termination  is  not 
uncommon,  though  apparent  recovery  or  a  transition  into  chronic  tuber- 
culous pleuritis  also  occurs. 

Ohro7iic  tubercular  pleurisy  is  vastly  more  common  than  the  acute 


308  INFECTIOUS  DISEASES. 

form,  and  it  is  sometimes  primary,  though  more  often  secondary  to  pul- 
monary tuberculosis.  In  all  cases  of  the  latter  disease  in  which  the  per- 
iphery of  the  lung  becomes  involved  the  visceral  layer  of  the  pleura  is 
invaded.  This  leads  to  plastic  pleurisy  with  a'dhesion,  and  the  membranes 
contain  disseminated  tubercles  or  sero-fibrinous  tuberculous  pleurisy;  but, 
as  above  stated,  the  eftusion  may  be  hemorrhagic  and  may  also  become 
purulent.  When  the  tuberculous  pulmonary  focus  perforates  the  pleural 
sac,  pyopneumothorax  is  produced.  In  tuberculous  pleurisy,  as  opposed 
to  simple  pleurisy,  there  is  usually  an  absence  of  leukocytosis. 

Symptoms. — The  onset  is  very  insidious  and  often  unnoticed. 
There  may  be  few  symptoms,  and  yet  a  physical  examination  reveals  a 
large  sero-fibrinous  efl'usion.  The  cough  and  other  symptoms  are  fre- 
quently due  to  a  coexisting  tuberculosis  of  tlie  lungs,  but  the  presence  of 
subcrepitant  and  dry  rales  are  strongly  confirmatory  of  tuberculous  pleu- 
risy. By  and  by  the  evidences  of  pulmonary  tuberculosis  are  of  import- 
ance, or  the  supervention  of  acute  general  miliary  tuberculosis  makes 
clear  the  nature  of  the  case.  The  subacute  variety  with  effusion  may 
terminate,  after  absorption  of  the  exudate,  in  chronic  adhesive  pleurisy 
with  great  thickening  of  the  membrane.  The  latter  may  also  originate 
as  a  primary  proliferative  process. 

(c)   TUBERCULOSIS    OF    THE    PERICARDIUM. 

The  morbid  lesions  are  analogous  to  those  of  tuberculosis  of  the  pleura. 
The  effusion  may  be  enormous  on  the  one  hand  or  insignificant  on  the 
other,  and  it  is  often  hemorrhagic,  while  in  the  chronic  form  there  is 
marked  thickening  of  the  membrane  with  the  deposit  of  tubercles  and 
cheesy  masses.  The  affection  is  less  common  than  tuberculosis  of  the 
pleura,  yet  not  so  rare  as  was  formerly  supposed,  and  occurs  in  tlie  acute 
and  chronic  forms. 

Acute  tuberculous  pericarditis  is  rarely  a  primary  affection,  and,  as  a 
rule,  originates  secondarily  to  pulmonary,  pleural,  or  glandular  tubercu- 
losis. It  is  especially  prone  to  arise  in  tuberculosis  of  the  bronchial  and 
mediastinal  lymph-glands,  and,  as  the  latter  condition  is  frequent  in 
young  children,  so  tuberculosis  of  the  pericardium  is  relatively  frequent 
at  this  period,  though  it  may  occur  at  any  time  of  life.  Pericardial 
tuberculosis  also  results  from  direct  extension  from  a  contiguous  focus. 
The  symptoms  Avill  be  detailed  in  the  discussion  of  Pericarditis.  In  the 
diagnosis  of  the  affection  the  history  and  any  associated  tuberculous  pro- 
cesses detectable  must  be  taken  into  account,  and  a  point  of  some  diag- 
nostic value  rests  in  the  fact  that  tuberculous  pericarditis  does  not  show 
the  usual  inflammatory  leukocytosis. 

Chronic  Tuberculous  Pericarditis. — This  may  be  a  part  of  the  general 
tuberculosis  of  the  serous  membranes,  or  it  may  follow  the  infection  of 
the  bronchial  and  mediastinal  glands  (most  frequently),  lungs,  pleura,  or 
peritoneum.  Undoubtedly,  cases  of  primary  origin  also  occur,  but  they 
are  exceedingly  rare,  the  neighboring  lym.ph-glands  being  very  generally 
involved.  This  form  is  also  dependent  upon  direct  extension  from  the 
lungs,  the  spine,  and  sternum. 

From  personal  observation  I  am  convinced  that  the  cases  naturally 
fall  under  two  heads,  when  considered  clinically  :  those  without  effusion, 


TUBERCULOSIS   OF  THE  SEROUS  MEMBRANES.  309 

in  which  the  pericardium  is  adherent ;  and  those  with  more  or  less 
effusion.  The  former  are  the  more  frequent,  though  often  entirely  latent, 
the  adherent  pericardium  leading  to  hypertrophy  of  the  heart,  followed 
sooner  or  later  by  dilatation.  The  signs  are  therefore  those  of  adherent 
pericardium,  with  the  occasional  difference  that  the  dulness  may  extend 
higher  up  over  the  sternum,  in  consequence  of  the  presence  of  firm, 
cheesy  masses  at  the  base  of  the  heart  and  also  encirclins:  the  aorta.  The 
smaller  group  of  cases  (in  which  the  effusion  is  present)  resembles  dilata- 
tion of  the  heart  in  its  clinical  manifestations.  I  recall  one  instance  of 
this  sort  that  occurred  in  a  male  aged  about  sixty  years  at  the  Episco- 
pal Hospital,  the  autopsy  revealing  extensive  pulmonary  tuberculosis  and 
chronic  tuberculous  pericarditis,  with  the  presence  of  eight  ounces  of 
hemorrhagic  effusion. 


(r?)    TUBERCULOSIS    OF    THE    PERITOXEUM. 

This  is  dependent  upon  infection  by  means  of  the  bacilli  circulating 
with  the  blood,  or  upon  extension  of  tuberculous  inflammation  or  ulcera- 
tion from  adjacent  organs.  Mention  has  already  been  made  of  the  fact 
that  the  intestines  are  often  invaded  by  tuberculosis,  and  that  the  serosa 
is  quickly  involved  in  such  instances.  The  condition  may  rarely  be  pri- 
mary. This  involvement  may  remain  circumscribed  and  undergo  spon- 
taneous cure  if  the  intestinal  lesion  cicatrizes,  as  post-mortem  findings  fre- 
quently indicate,  but  in  extensive  peritoneal  involvement  spontaneous 
resolution  is  out  of  the  question.  These  cases  may  be  subdivided  into 
acute  and  chronic.  The  veri/  acute  eases  are  those  forming  a  part  of 
acute  general  miliary  tuberculosis,  or  due  to  perforation  into  the  peri- 
toneal sac  from  adjacent  organs,  and  x^dlebert's  classification  is  as  follows  : 
(a)  the  ascitic  form,  (b)  the  ulcerous  form,  and  [c)  the  fibroid  form. 
Though  these  groups  do  not  present  sharp  clinical  distinctions,  the  courses 
they  run  vary  considerably,  as  do  the  results  of  treatment.  In  the  ascitic 
form  the  exudate  is  purulent  or  sero-purulent,  and  is  often  encapsulated. 
In  the  ulcerous  the  tuberculous  new-formations,  which  may  be  quite 
large,  undergo  caseation  and  ulceration,  the  latter  process  being  progres- 
sive, so  that  it  may  perforate  the  Avails  of  the  intestines.  This  and  the 
ascitic  form  may  be  combined. 

In  the  third  or  fibroid  form  the  peritoneal  surfaces  are  adherent. 
There  is  little  if  any  exudation ;  the  tubercles  may  be  numerous  and 
diffuse,  or  may  be  found  only  in  scattered  localized  areas,  and  are  often 
pigmented.  The  lesions  may  represent  the  concluding  stage  of  acute  or 
subacute  tuberculous  peritonitis. 

Ktiology. — Most  cases  are  produced  by  extension  of  tuberculous  in- 
flammation from  adjacent  organs,  and  of  107  cases  analyzed  by  Phillips 
the  lungs  were  involved  in  99,  the  pleura  also  in  60.  and  the  bowel  in  80. 
Children  are  frequent  victims  to  intestinal  tuberculosis,  and  the  bacilli 
often  reach  the  peritoneum  through  the  intestines,  as  they  are  also  apt  to 
do  in  adults  suffering  from  chronic  phthisis.  Extension  from  the  pleura 
to  the  peritoneum  is  frequent  (pleuro-peritoneal),  but  from  the  peri- 
cardium it  is  relatively  infrequent.  In  females  the  starting-point  is  very 
often  the  Fallopian  tubes,  and  in  either  sex  it  may  be  the  appendix. 

Predisposing  Factors. — Age. — During  the  period  from  fifteen  to  forty 


310  INFECTIOUS  DISEASES. 

years  the  incidence  is  most  frequent,  though  it  is  not  uncommon  in  chil- 
dren under  ten  years,  nor  between  the  fortieth  and  fiftieth  years  of  life. 
Subsequently,  it  rapidly  decreases  in  frequency.  I  agree  with  Osier  in 
stating  that  in  America  negroes  are  more  prone  than  whites. 

Sex  has  a  tolerably  potent  disposing  influence.  Abdominal  surgeons 
have  taught  us  that  the  disease  occurs  more  frequently  in  females  than 
males,  owing  to  the  fact  that  the  Fallopian  tubes  are  a  favorite  seat  for 
primary  tuberculous  infection.  The  ratio  based  upon  sex  is  as  3  to  2  in 
favor  of  females. 

Symptoms. — Some  cases  develop  abruptly  with  severe  aywptoms,  as 
fever,  marked  constitutional  disturbance,  rapid  small  pulse,  abdominal 
pain,  voyniting,  and  sometimes  diarrhea.  The  temperature  may  be  quite 
high  (103°  to  104°  F.— 40°  C),  or  it  may  be  only  slightly  elevated  even 
in  the  worst  cases.  There  follow  quickly  such  symptoms  as  anemia^ 
marked  emaciation,  and  a  pronounced  typhoid  condition.  The  signs  of 
peritoneal  effusion  (rarely  large)  are  soon  in  evidence,  and  are  attended 
sometimes  by  a  suppurative  type  of  temperature,  sweats,  etc..  indicating 
the  presence  of  pus  in  the  peritoneal  sac.  A  few  cases  are  unattended 
by  ascites,  and  here  nodular  masses  are  palpable,  while  on  auscultation 
friction-sounds  may  be  audible  in  the  umbilical  region.  Tympanites  due 
to  intestinal  paresis,  is  common  in  cases  having  an  acute  onset. 

The  acute  stage  may  be  absent,  the  affection  then  being  marked  by 
slight  local  and  general  symptoms  (low  fever,  anemia,  slight  belly-pains, 
and  a  sense  of  distention).  The  skin  is  sometimes  pigmented,  and  usu- 
ally in  patches.  There  are  not  a  few  instances  in  Avhicli  the  affection  is 
latent,  and  in  one  case  of  this  sort  with  ill-defined  general  symptoms  pig- 
mentation of  the  skin  first  directed  my  attention  to  the  peritoneal  con- 
dition. 

The  physical  signs  of  moderate  ascites  frequently,  and  those  of  en- 
larged mesenteric  glands  sometimes,  are  present.  These  conditions  are 
often  combined  in  children,  constituting  the  so-called  tabes  mesenterica. 
I  cannot  conceive  of  the  occurrence  of  this  association  of  symptoms  with- 
out simultaneous  involvement  of  the  peritoneum,  and  doubtless  tubercu- 
losis of  the  latter  membrane  and  intestines  usually  coexists.  The  tuber- 
culous new  growth  in  the  peritoneum  may  also  form  a  distinct  tumor  not 
unlike  that  produced  by  glandular  enlargement,  while  the  intestinal  coils 
with  their  now  thickened  walls  are  sometimes  knotted  together  so  firmly 
as  to  simulate  a  dense  new  growth.  The  exudation  may  be  loculated 
owing  to  adhesions  between  peritoneal  layers  of  the  intestinal  coils,  etc., 
producing  a  localized  tumor  varying  in  size  and  position.  Such  saccu- 
lated exudations  most  frequently  occupy  the  pelvic  or  umbilical  regions, 
though  they  may  also  be  found  elsewhere  in  the  abdomen.  They  may  be 
multiple,  and  are  not  infrequently  too  small  to  be  recognized  by  the 
physical  signs,  being  often  discovered  during  laparotomy.  On  the  other 
hand,  they  may  occupy  a  large  portion  of  the  abdomen.  An  omental 
tumor  of  characteristic  elongated  form  (produced  by  a  shrinking  and 
curling  up  of  this  membrane)  is  demonstrable,  its  long  axis  generally 
taking  a  transverse  direction  just  above  the  umbilicus.  Gardiner  has 
observed  this  tumor  to  disappear  by  spontaneous  resolution  in  children. 

The  dry,  fibrous  variety,  which  is  not  infrequent,  is  often  latent,  and 
the  condition  may  be  general  or  localized.     It  is  decidedly  more  frequent 


TUBERCULOSIS  OF  THE  LIVER.  311 

in  adults  than  in  children,  though  the  symptoms  are  far  from  character- 
istic. Among  local  features  are  pains,  abdominal  distention  (giving  rise 
to  a  tympanitic  note  on  percussion),  tenderness  on  pressure,  and  sometimes 
a  tumor- ridge  extending  across  the  upper  abdominal  region.  Among  gen- 
eral symptoms  are  usually  anemia  and  emaciation,  with  or  without  fever. 
Indeed,  the  temperature  may  be  subnormal,  and  these  cases  may  show 
a  tendency  to  spontaneous  recovery. 

Diagnosis. — Unless  tuberculosis  of  other  organs  can  be  demon- 
strated the  diagnosis  is  often  impossible.  This  is  particularly  true  in 
cases  in  which  there  is  no  abdominal  pain  nor  tenderness.  Fever  and  the 
presence  of  a  tumor,  especially  if  the  latter  be  elongated  and  lies  trans- 
versely in  the  umbilical  region,  are  important  aids  ;  but  if  tuberculosis 
of  the  lungs,  pleura,  pericardium,  appendix,  and  the  tubes,  in  women,  can 
be  excluded,  the  rectal  mucus  and  the  urine  should  be  examined  for  tu- 
bercle bacilli.  From  the  acute  form  several  affections  must  be  discrimi- 
nated : 

{a)  Internal  Hernia. — This  comes  on  suddenly  ;  the  pain  is  strictly 
localized  and  paroxysmal ;  stercoraceous  vomiting  appears  in  a  few  hours  ; 
the  constipation  is  absolute,  and  tympanites  is  marked,  but  ascites  is 
absent. 

[h)  Similar  symptoms  belong  to  volvulus  and  to  the  quick  incarcera- 
tion of  loops  of  intestine  under  bands  of  adhesions;  on  comparison  they 
will  be  seen  to  differ  from  those  of  acute  tuberculous  peritonitis. 

(c)  Enteritis  is  discriminated /rom  acute  tuberculous  peritonitis  by  the 
presence  of  copious  mucous  discharges,  and  by  the  absence  of  associated 
tuberculous  lesions,  ascites,  tumors,  and  the  symptoms  of  the  pronounced 
typhoid  state. 

Chronic  tuberculous  peritonitis  often  closely  simulates  cancerous  perito- 
nitis, owing  to  the  fact  that  the  elongated  omental  tumor  may  be  met  with 
in  both,  associated  with  ascites,  abdominal  pain,  and  slight  fever.  In 
carcinoma,  hoAvever,  there  is  an  absence  of  the  tuberculous  history  and 
lesions,  and  the  presence,  sometimes,  of  a  gradually  increasing  tumor  of 
primary  growth,  the  slowly  oncoming  intestinal  obstruction  from  pres- 
sure, and  the  cancerous  cachexia.  Moreover,  tuberculous  peritonitis 
occurs  more  frequently  in  younger  subjects,  and  is  more  apt  to  be  inter- 
rupted by  periods  of  improvement,  followed  in  turn  by  rather  alarming 
symptoms. 

Locular  exudations  must  be  distinguished  from  ovarian  tumors,  and 
here  the  history,  together  with  tuberculous  lesions  elsewhere  in  the  body, 
the  occurrence  of  febrile  attacks,  and  intestinal  disturbance  with  pain, 
are  of  great  diagnostic  significance.  Such  cases  should  be  examined  by  a 
gynecologist,  since,  however  expert  the  examiner,  when  the  saccular  exu- 
dations are  located  in  the  pelvic  region  an  exploratory  laparotomy  must 
often  decide  the  nature  of  the  condition.  Finally,  it  must  not  be  forgot- 
ten that  the  vast  majority  of  cases  of  chronic  peritonitis  are  tuberculous. 

Tuberculosis  of  the  Liver. 

The  liver  was  formerly  overlooked  in  many  instances  of  tuberculosis, 
because  the  lesions,  particularly  in  acute  tuberculosis,  are  often  micro- 
scopic.    In  the  chronic  disseminated  variety,  however,  grosser  changes 


312  INFECTIOUS  DISEASES. 

are  observed,  the  organ  being  slightly  enlarged,  pale,  and  fatty,  and  pre- 
senting an  irregular  surface  like  that  of  an  orange.  On  section,  the  par- 
enchyma cuts  with  great  resistance,  being  very  dense  (tuberculous  cir- 
rhosis). Minute  gray  and  larger  yellow  masses  are  seen,  especially  just 
under  the  capsule,  and  small  cavities,  the  result  of  a  breaking  down  of 
the  cheesy  masses  and  containing  pus  and  bile,  are  also  observed.  These 
changes  are  most  pronounced  about  the  bile-ducts. 

Ktiology. — The  liver  is  implicated  in  all  instances  of  acute  miliary 
tuberculosis.  It  is  also  involved  secondarily  in  chronic  tuberculosis  of 
the  lungs,  pleura,  peritoneum,  spleen,  lymphatics,  etc. 

Symptoms. — This  is  a  common  condition,  the  organ  being  appreci- 
ably enlarged  and  its  surface  presenting  irregular,  palpable  prominences. 
The  clinical  features  of  perihepatitis  and  peritonitis  are  often  found  in 
combination.     Ascites  may  be  present,  but  is  rare. 

Tuberculosis  of  the  Genito-urinary  System. 

(1)  Tuberculosis  of  the  Kidueys. — This  may  be  primary  or  secondary, 
the  secondary  form  being  the  more  common,  and  it  may  be  either  unilat- 
eral or  bilateral.     Infection  occurs  through  the  blood  in  some  instances. 

Pathology. — The  process  begins  in  the  calices  and  apices  of  the  pyr- 
amids (papillae),  thence  proceeding  to  the  pelvis  of  the  kidney,  so  that 
early  the  condition  may  be  pyonephrosis.  The  morbid  changes  then  ex- 
tend to  the  ureters,  and  sometimes  to  the  bladder  and  prostate,  and  in- 
stances are  even  met  with  in  which  the  process  seems  to  have  crept  from 
below  upward,  starting  from  the  bladder  or  prostate.  The  tubercles  pass 
through  the  usual  stages  of  caseation,  necrosis,  and  suppuration,  and  de- 
struction of  the  renal  tissue  to  a  greater  or  lesser  degree  occurs,  with  the 
formation  of  cysts  containing  cheesy  material  in  which  lime-salts  may  be 
deposited.  When  the  process  invades  the  kidneys  through  the  blood,  it 
may  be  limited  largely  to  the  cortical  layer  and  give  rise  to  nodular 
tuberculosis  with  caseous  masses,  yet  with  little  loss  of  renal  substance. 
There  are  not  a  few  cases  in  which  the  chief  lesion  is  a  tuberculous  pye- 
litis. In  the  latter  class  the  ureters  show  extensive  involvement,  such  as 
thickening  of  the  coats  with  caseation  and  ulceration  of  its  mucosa ;  the 
bladder,  deep  urethra,  and  prostate  may  also  be  involved.  AVhile  it  is 
difficult  to  judge  of  the  relative  ages  of  the  lesions  in  different  organs,  I 
cannot  escape  the  conviction  that  in  this  group  of  cases  renal  tuberculosis 
is  an  ascending  process  and  follows  uretero-cystic  tuberculosis.  As  before 
stated,  however,  most  instances  are  descending.  Although  both  kidneys 
are  finally  involved  in  most  instances,  the  lesions  are  usually  much  more 
advanced  in  one  kidney  than  in  the  other,  and  hence  for  a  considerable 
period  the  disease  is  probably  unilateral. 

Etiology. — Of  disposing  factors  age  and  sex  deserve  especial  mention, 
most  cases  occurring  during  middle  life,  though  they  are  by  no  ineans  rare 
both  at  an  earlier  and  a  later  period. 

Sex. — The  disease  is  much  more  frequent  in  males  than  in  females. 
As  stated,  the  bacilli  reach  the  kidneys  with  the  blood-stream,  producing 
primary  renal  tuberculosis,  but  invasion  may  also  take  place  through  the 
lymphatics  or  through  direct  extension  from  adjacent  structures. 

Symptoms. — In  many  cases   there  are   either  no  renal   symptoms  or 


TUBERCULOSIS  OF  THE  GENITO-UBINARY  SYSTEM.  313 

none  until  a  late  stage  is  reached,  but  the  symptoms  of  pyelitis  are  usu- 
ally present.  Pyuria  may  be  the  only  symptom  for  a  long  time,  and  this 
symptom,  according  to  certain  authorities,  points  directly  to  cystitis. 
When  the  latter  condition  is  present,  however,  the  micturition  becomes 
frequent  and  there  is  vesical  tenesmus.  Pain  in  the  side  chiefly  affected 
is  complained  of,  and  is  sometimes  not  unlike  renal  colic  ;  hematuria  is 
not  rare ;  and  a  cystoscopic  examination  may  show  the  blood  to  be  of 
renal  origin  (Tuffier).  It  is  useful  also  in  showing  the  state  of  the  blad- 
der-mucosa.  The  demonstration  of  tubercle  bacilli  in  the  urine,  especi- 
ally if  arranged  in  S-shaped  groups,  is  diagnostic  (Frisch).  When  the 
bacilli  cannot  be  found,  inoculation-experiments  upon  guinea-pigs  and 
rabbits  furnish  an  accurate  criterion,  though  it  must  not  be  forgotten  that 
tubercle  bacilli  may  find  their  way  into  the  urine  from  more  distant 
tuberculous  foci.  Polyuria  is  sometimes  present,  as  well  as  albuminuria  ; 
the  urine  may  also  show  tube-casts  (rarely)  and  pus-cells.  Macroscopic 
cheesy  masses  are  occasionally  found. 

The  general  features  are  often  marked,  but  not  until  the  affection  be- 
comes advanced,  chills,  fever  of  a  suppurative  type,  emaciation,  and  in- 
creasing debility  being  the  chief  symptoms.  Associated  tuberculous 
lesions,  especially  of  the  lungs,  are  constantly  observed. 

Physical  Signs. — Inspection  may  show  a  tumor-like  prominence  on 
the  side  chiefly  affected,  though  rarely  of  large  size.  Palpation  often 
detects  tenderness,  and  the  limits  of  the  organ  may  be  defined  by  careful 
firm  pressure  with  the  finger-tips. 

Diagnosis. — It  is  difiicult  to  discriminate  calculous  pyelitis.  In  the 
latter,  however,  the  pain  is  severer,  the  tumor-mass  larger,  and  the  hem- 
orrhage more  frequent  than  in  tuberculous  nephritis.  The  discovery  of 
tubercle  bacilli  or  the  demonstration  of  tuberculosis  of  the  lungs  or  of 
other  organs  would  remove  all  doubt.      These  two  affections  may  coexist. 

(2)  Tuberculosis  of  the  Ureter  and  Bladder. — This  is  almost  always 
secondary  to  tuberculous  disease  of  the  pelvis  of  the  kidney  above,  or  of 
the  deep  urethra,  testes,  or  prostate  below.  When  primary,  as  rarely 
happens,  the  bladder  is  in  most  instances  invaded  last.  The  symjjtonis 
are  those  of  chronic  cystitis,  and  in  all  cases  in  which  no  other  cause  for 
the  latter  can  be  found  the  primary  tuberculous  lesion  must  be  sought  for 
and  the  urine  carefully  examined  for  bacilli.  The  usefulness  of  the  tu- 
bercle bacillus  as  a  final  point  in  diagnosis  is  impaired  in  this  situation  by 
the  fact  of  the  frequent  presence  of  the  smegma  bacillus  in  normal  urine. 
Some  observers  state  that  the  smegma  bacillus  can  be  distinguished  by 
decolorizing  with  absolute  alcohol,  Avhich  will  take  place  in  about  two 
minutes,  while  with  the  tubercle  bacillus  a  very  much  longer  time  is 
required.  Others  say  this  is  not  sufiicient,  and  that  only  their  methods 
of  culture-growth  or  inoculation  will  distinguish  them.  With  the  devel- 
opment of  ulcerative  lesions  hemorrhage  is  apt  to  arise. 

(3)  Tuberculosis  of  the  Vesiculse  Seminales,  Prostate,  and  Testes. — The 
prostate  gland  and  testes  are  frequently  invaded  in  genito-urinary  tuber- 
culosis, and  the  vesiculse  seminales  somewhat  less  frequently.  The  mor- 
bid process  leads  to  the  formation  of  cheesy  nodules,  which  may,  though 
comparatively  rarely,  disintegrate,  causing  excavations  or  perforation. 
Rarely,  the  tubercle  does  not  pass  through  the  stage  of  caseation,  but 
merely  shows  the  presence  of  numerous  embryonic  cells. 


314  INFECTIOUS  DISEASES. 

Etiology. — The  condition  is  usually  secondary,  but  the  existence  of 
primary  tuberculosis  in  these  organs  cannot  be  denied.  Testicular  tuber- 
culosis may  begin  at  any  period  of  life,  and  is  of  rather  frequent  occur- 
rence in  infants.  When  it  occurs  in  the  latter,  it  is  part  of  a  more  gen- 
eral tuberculous  infection,  and  is  in  many  instances  undoubtedly  congen- 
ital.    In  some  cases  it  may  be  a  late  hereditary  afi'ection. 

Symptoms. — In  the  testicle,  tuberculosis,  as  a  rule,  induces  a  pain- 
less, ])rotractcd  orchitis,  though  ^vhen  cavernous  lesions  occur  the  symp- 
toms are  more  acute.  In  prostatic  tuberculosis  the  bladder  is  highly 
irritable,  there  is  great  distress  felt  in  the  thigh  and  groin,  and  micturi- 
tion is  very  painful.  Catheterization,  particularly  if  the  urethra  (as  is 
very  rarely  the  case)  is  the  seat  of  tuberculous  ulceration,  causes  most 
excruciating  suffering,  and  there  may  be  signs  of  stricture.  Bectal 
palpation  detects  in  the  prostate  firm  nodules  varying  in  size  from  a  pea 
to  a  bean,  together  with  enlargement  of  the  organ. 

Diagnosis. — The  diagnosis  of  tuberculosis  of  the  prostate  is  easily 
made  from  the  vesical  symptoms,  the  presence  of  tuberculosis  in  other 
organs,  the  result  of  rectal  examination,  and  the  detection  of  bacilli  in 
the  urine.  Syphilitic  involvement  of  the  testicle  is  sometimes  excluded 
with  difficulty  ;  in  the  latter  disease,  however,  the  surface  of  the  swollen 
organ  presents  greater  irregularities,  and  is  even  less  painful  than  in  tu- 
berculosis. The  absence  of  the  history  of  syphilitic  infection  and  the 
presence  of  tuberculosis  in  other  organs,  particularly  in  the  uro-genital 
system,  are  valuable  points  in  the  discrimination. 

Tuberculosis  op  the  Fallopian  Tubes,  Ovaries,  and 

Uterus. 

Tuberculosis  of  the  tubes  in  women  is  a  not  infrequent  condition,  and 
mav  be  primary. 

Btiology  and  Pathology. — The  tubes,  as  a  result  of  infiltration, 
are  thick,  hard,  and  bound  down  by  false  membrane.  Their  ends  are 
generally  closed,  but  the  intervening  portion  is  dilated,  and  contains 
mucus,  pus,  and  cheesy  material.  A  catarrhal  salpingitis  is  generally  in 
association.  Uterine  tuberculosis  is  rare,  and  its  origin  is  usually  attrib- 
utable to  similar  involvement  of  the  tubes. 

The  disease  is  most  common  during  the  period  of  greatest  sexual 
activity,  but  young  children  may  suffer  (tuVZg  literature  of  Hennig),  and 
in  them  the  ovaries  and  uterus  may  be  implicated  Avithout  participa- 
tion of  the  tubes,  as  in  cases  reported  by  Gusserow.  At  any  period  of 
life  the  lesions  may  be  microscopic  ;  they  usually,  however,  excite  marked 
local  peritonitis,  which  may  become  general,  with  the  development  of 
ascites.     The  process  may  extend  to  the  vagina. 

Diagnosis. — The  age,  family  history,  and  signs  of  the  -tuberculous 
diathesis  must  be  noted.  The  disease  does  not  distinguish  itself  from 
other  tubal  tumors  by  anything  characteristic  on  bimanual  palpation. 
Cases  occur  with  ascites  and  also  without,  and  in  the  latter  variety  plaque- 
like thickening  of  the  subperitoneal  tissue  is  an  aid  to  diagnosis.  The 
uterine  secretions  should  be  examined  for  bacilli  in  all  obscure  cases. 
Ashton  advises  an  exploratory  incision  or  puncture  and  examination  of 
the  contents  of  the  peritoneum  or  tubes  for  bacilli. 


TUBERCULOSIS  OF  THE  BE  A  IN.  315 

Tuberculosis  of  the  Mammary  Glands. 

This  is  rare  ;  the  affected  glands  present  fistulge  and  ulcers,  with  indu- 
ration of  the  organ  and  retraction  of  the  nipple.  Warden  ^  reports  the 
finding  of  58  authentic  cases  in  literature.  Nearly  90  per  cent,  of  the 
patients  were  females,  and  most  cases  developed  in  the  third  decennium. 
The  symptoms  are  sharp  and  lancinating  pains  radiating  to  the  arm,  and 
tumor,  the  latter  consisting  of  one  or  more  nodules.  Pyogenic  secondary 
infection,  leading  to  obstinate  fistulse,  is  common.  The  axillary  glands 
are  often  enlarged.  A  positive  diagnosis  rests  crucially  upon  the  finding 
of  the  bacilli  in  the  pathologic  secretions. 

Tuberculosis  op  the  Brain. 

Pathology. — Tuberculosis  of  the  brain  occurs  in  two  forms,  one  of 
which,  acute  tubercular  meningitis,  has  been  previously  described,  while 
the  other  is  a  chronic  tuberculous  infection,  usually  localized,  of  the 
meninges  and  cortex,  and  causing  meningo-encephalitis.  Very  rarely 
the  membranes  remain  intact.  The  so-called  solitary  tubercle  is  an 
irregularly  round  mass,  varying  in  size  from  a  small  pea  to  an  apple  or 
even  larger.  It  is  generally  single,  though  sometimes  there  are' two,  and 
rarely  even  three,  nodules.  The  tubercle  may  be  imbedded  in,  and  be 
contiguous  with,  the  brain-substance,  or  may  be  separated  from  the  latter 
by  cysts.  The  peripheral  zone  is  formed  largely  of  connective  tissue,  is 
lighter  in  color  (often  translucent),  and  may  contain  miliary  tubercles, 
while  the  central  portion,  which  is  cheesy  as  a  rule,  may  liquefy  and  thus 
form  a  small  cavity  containing  a  purulent-looking  material.  They  are 
seen  with  greatest  frequency  in  the  inferior  portions  of  the  brain. 

The  new  growths  may  compress  the  longitudinal  sinus,  inducing  throm- 
bosis; they  may  interfere  markedly  with  the  circulation,  causing  cerebral 
softening;  and,  finally,  they  may  excite  acute  tuberculous  meningitis. 
Tuberculosis  of  other  organs  is  usually  found  as  an  associated  condition. 

Ktiology. — The  disease  occurs  with  especial  frequency  in  young 
subjects,  and,  according  to  the  statistics  of  Pribram,  in  about  three- 
fourths  of  the  cases  before  the  fifteenth  j^ear.  The  symptom-picture  is 
identical  with  that  of  brain-tumor  {vide  p.  1124), 

Tuberculosis  op  the  Spinal  Cord. 

The  lesions  are  those  of  solitary  tubercle  of  the  brain.  It  is  an  ex- 
tremely rare  condition,  and  almost  invariably  secondary.  (For  symptoms, 
vide  Spinal  Tumor  and  Meningitis.) 

Tuberculosis  of  the  Heart. 

In  acute  miliary  tuberculosis  gray  granulations  or  larger  yellow  tuber- 
cles may  be  found  throughout  the  tissues  of  the  heart.  More  frequently 
than  was  formerly  supposed  does  cardiac  tuberculosis  also  result  from 
chronic  tuberculosis  of  adjacent  organs.  Illustrative  cases  have  been 
reported  by  Townsend  and  Waldeyer.  Constantin  Paul  has  in  these 
^  Medical  Record,  October  1,  1898. 


316  INFECTIOUS  DISEASES. 

cases  observed  tubercles  in  the  Avail  of  the  left  auricle,  as  well  as  in  the 
infundibulum  of  the  pulmonary  artery  in  several  instances. 

Valvular  tuberculosis  is,  I  believe,  even  more  common,  though  few 
cases  have  been  reported.  Londe  and  Petit  in  one  instance  found  the 
heart  much  affected,  and  discovered  on  the  mitral  valve  several  vegeta- 
tions the  size  of  lentils,  which  showed  tubercle  bacilli.  I  have  seen  two 
cases — one  in  which  the  mitral,  and  another  in  which  the  tricuspid,  valve 
was  affected,  associated  with  latent  pulmonary  and  mediastinal  tuberculo- 
sis. Doubtless  there  are  cases  in  which  the  valve-lesions  form  the  central 
and  most  prominent  part  in  the  picture. 

Tuberculosis   of  the  Arteries  and  Veins. 

This  may  arise  consequently  upon  extension  of  a  tuberculous  process 
into  the  vessel,  as  in  chronic  phthisis.  It  causes  infiltration  of  the  arterial 
wall,  resulting  in  thrombosis,  or  the  vascular  tubercles  may  caseate  and 
soften,  thus  leading  to  hemorrhage.  In  tuberculous  meningitis  the  arte- 
rial lesions  are  conspicuous.  The  perforation  of  a  vein  by  an  old  focus 
is  followed  by  a  distribution  to  all  parts  of  the  body  of  numerous  bacilli 
and  acute  miliary  tuberculosis.  Infection  of  the  arteries  may  also  occur 
through  the  blood.  Of  1778  cases  of  pulmonary  tuberculosis,  throm- 
bosis occurred  19  times,  most  commonly  in  the  veins  of  the  lower  ex- 
tremities (II.    Ruhl   and   llierokles). 

General  Prognosis. — The  prognosis  is  best  reached  as  in  other 
infectious  diseases — namely,  by  taking  into  account  (a)  the  severity  of 
the  type  of  the  disease  ;  {h)  the  presence  or  absence  of  frequently  associ- 
ated diseases  or  complications ;  and  (c)  the  numerous  circumstances  con- 
nected Avitli  individual  patients. 

{a)  The  Severity  of  the  Disease. — Though  there  are  no  accurate  cri- 
teria, we  may  judge  of  the  severity  of  the  disease  by  its  progress,  by  the 
result  of  proper  treatment,  and  from  certain  symptoms.  If  the  fever  be 
high,  the  prostration  marked,  and  the  local  lesions  rapidly  advancing-,  we 
may  safely  infer  that  the  disease  is  of  aggravated  type.  With  these  cer- 
tain other  considerations  are  closely  connected — the  stage  of  the  affection 
and  the  extent  of  the  local  lesions.  Thus  at  an  early  stage  the  prognosis 
is  more  hopeful  than  at  a  late  period,  and.  similarly,  Avhen  the  lesions  are 
strictly  localized  at  one  apex  it  is  more  hopeful  than  when  they  have 
reached  the  stage  of  extensive  cavity-formation  or  are  bilateral.  As 
already  stated,  a  certain  proportion  of  the  cases  manifest  an  inherent 
tendency  to  spontaneous  arrest  or  even  cure,  and  this  may  occur  even 
after  the  stage  of  excavation  has  supervened.  Notwithstanding  this 
truth,  however,  it  is  well  to  make  in  all  undoubted  instances  of  the  dis- 
ease a  guarded  prognosis.  A  common  error  is  the  mistaking  of  a  tem- 
porary for  a  permanent  arrest  of  the  tuberculous  process,  and  in  the  nat- 
ural history  of  the  affection  the  fact  was  emphasized  that  its  course  was 
interrupted  by  periods  of  comparative  comfort  and  nwticeable  improve- 
ment, followed  by  sharp  exacerbations. 

{b)  Associated  Diseases  and  Complications. — These  unfavorably  modify 
the  prognosis — rajudity  of  pulse,  marked  temperature-variations,  a  pos- 
itive diazo-reaction,  chronic  nephritis,  gastric  complications,  and  intes- 
tinal and  laryngeal  involvement.     Some  of  the  accidents  of  the  dis- 


TREATMENT  OF  TUBERCULOSIS. 


317 


ease  may  also  precipitate  a  fatal  result  (vide  Modes  of  Death).  The  sud- 
den appearance  of  intercurrent  acute  pneumonia,  "whether  tuberculous  or 
not,  is  indicative  of  danger.  Other  complications  presented  by  the  lungs 
and  other  organs  have  been  detailed  in  the  Clinical  History. 

{c)  Circumstances  connected  with  Individual  Patients. — (1)  A  feeble, 
delicate  constitution,  either  acquired  or  inherent  (tuber(!iilous  diathesis), 
increases  the  gravity  of  tuberculosis. 

(2)  When  the  general  symptoms  show  marked  improvement,  and  espe- 
cially if  the  fever  subsides  and  the  patient  gains  flesh  and  strength,  the 
outlook  at  once  brightens. 

(3)  Hygienic  Surroundings. — When  the  hygienic  regimen  under 
which  the  patient  lives  is  of  the  best,  the  prospect  is  more  hopeful  than 
when  it  is  faulty.  An  improved  diet  often  decidedly  aids  favorable  prog- 
ress, while  a  defective  one  often  turns  the  scales  against  recovery. 
Equally  influential  for  good  is  a  pure  atmosphere,  while,  jjer  contra,  a 
vitiated  one  is  most  injurious. 

(4)  Age. — In  young  subjects  from  five  to  fifteen  years  of  age  tubercu- 
losis often  pursues  an  acute  course  and  the  mortality-rate  is  exceedingly 
high.  Chronic  tuberculosis  may  occur,  however,  less  frequently,  and 
under  appropriate  surroundings  may  lead  to  recovery.  In  chronic  phthisis 
"the  younger  the  patient  the  shorter  the  duration."  I  have  frequently 
observed  that  patients  who  give  a  history  of  pleurisy  or  other  phthisical 
manifestations  early  in  life  do  not  bear  chronic  phthisis  well  should  it 
develop  at  a  later  period.  During  old  age — a  time  of  life  at  which  tuber- 
culosis is  not  uncommon — the  disease  (especially  the  pulmonary  variety) 
is  usually  more  or  less  latent,  and,  owing  to  coexistent  emphysema  and 
chronic  bronchitis,  pursues  a  slow  course.^ 

(5)  The  gravity  of  tuberculosis  may  be  determined  with  some  degree 
of  accuracy  by  the  use  of  creasote  in  gradually  ascending  doses.  Hence 
this  agent  has  a  value,  not  only  from  a  diagnostic  but  from  a  prognostic 
view-point. 

Treatment  of  Tuberculosis. 

Prophylaxis. — (1)  This  embraces  thorough  and  prompt  disinfection 
of  the  sputum  as  the  best  preventive  element.  To  this  end  the  patient 
must  be  taught  to  expectorate  at  all  times  into  a  spittoon  or  spit-cup  which 


Fig.  30.— Pasteboard  spit-cup  for  receiving  infectious  sputum.    When  used  the  pasteboard  can  be 
removed  from  tlie  steel  frame  and  burned. 


contains  a  proper  disinfectant  solution,  and  when  the  breaking-down  stage 
has  arrived  portable  flasks  (e.  g.  Dettwiler's)  containing  an  antiseptic  so- 
lution must  be  worn  by  the  patient,  even  while  out  of  doors.     Afterward 

^  A  physician  should  not  neglect  to  examine  the  sputum  in  suspicious  cases  for  bacilli. 


318  INFECTIOUS  DISEASES. 

the  sputum  is  to  be  destroyed  by  boiling  or  burning  and  the  spit-cup 
sterilized.      Paraffin  flowers  are  most  desirable  for  consumptive  patients. 

(2)  Isolation. — After  the  stage  of  softening  is  reached  the  patient 
should  invariably  occupy  a  separate  apartment,  since,  despite  great  care, 
the  room  and  bed  occupied  by  the  consumptive  become  in  time  a  source 
of  infection.  Hence,  unwashable  hangings  and  upholstered  furniture, 
as  well  as  other  objects  that  facilitate  the  harboring  of  the  bacilli,  should 
be  removed  from  the  sick-room.  The  floor  of  the  apartment  should 
not  be  carpeted,  but  may  be  in  part  covered  with  rugs  that  can  be  fre- 
quently taken  up  and  shaken  in  the  open  air.  For  like  reasons,  special 
hospitals  and  sanatoria  for  the  treatment  of  the  tuberculous  poor  are  a 
necessity.  Fliigge's  important  researches  (vide  supra)  show  that  phthis- 
ical patients  should  wear  a  mask  day  and  night,  that  should  be  removed 
only  for  eating  and  to  expectorate.  I  quite  agree  with  Flick  in  recom- 
mending that  tuberculous  patients  in  the  infectious  stage  of  the  disease 
should  be  retired  from  occupations  in  which  they  may  infect  others. 

(3)  Compulsory  registration  of  tuberculous  (pulmonary)  patients  is 
desirable,  though  impracticable.  Newsholme  advocates  voluntary  noti- 
fication to  the  medical  health-officer.  This  plan  would  secure  proper 
disinfection  of  houses  in  Avhich  deaths  from  phthisis  have  occurred. 

(4)  Government  Inspection  of  Dairies  and  Slaughter-houses. — This  is 
the  serious  business  of  tlie  State,  and,  since  infection  through  food,  espe- 
cially milk,  is  quite  common  in  infants,  skilled  veterinary  inspection  of 
dairies  is  of  prime  importance.  Of  the  greatest  benefit  would  be  the 
killing  of  all  tuberculous  cattle,  and  of  less  though  decided  efficacy  the 
confiscatioti  at  the  abattoirs  of  all  carcasses  that  present  marked  lesions. 

(5)  The  popularizing  of  information  relating  to  the  dangers  of,  and 
the  means  of  stamping  out,  this  great  scourge.  This  may  be  in  part 
accomplished  by  mural  placards,  stating  simple,  plain  facts  about  the  way 
in  which  the  disease  is  spreading.  Armaingaud  suggests  the  placing  in 
the  homes  of  the  people  printed  matter  in  a  form  suitable  for  preservation. 

(6)  The  Removal  of  Known  Predisposition  to  the  Disease. — The  tuber- 
culous diathesis,  whether  inherited  or  accjuired,  must  be  overcome,  if  at 
all,  by  vigorous  measures  or  by  better  hygienic  living.  In  attempting  to 
remove  the  phthisical  tendency  the  physician  must  place  chief  reliance 
upon  the  most  favorable  environment  attainable.  The  value  of  a  change 
of  residence — from  the  city  to  the  country,  the  seaside,  or  the  mountains, 
according  to  circumstances  in  individual  cases — cannot  be  overestimated. 
It  often  renders  predisposed  persons  immune.  For  some,  and  particularly 
young  subjects,  an  equable  climate  (Southern  California  or  Florida),  that 
will  enable  them  to  live  an  out-door  life,  is  to  be  preferred.  Attention 
to  the  food  must  not  be  forgotten.  Milk  is  excellent  and  should  be  used 
freely.  Daily  sponging  of  the  neck  and  thorax  with  cold  water  is  bene- 
ficial, and  appropriate  light  gymnastics  should  be  instituted  if  the  subject 
be  old  enough.  In-door  occupations  are  to  be  forbidden,  and  the  ventila- 
tion of  living-  and  bed-rooms  must  be  looked  after  carefully. 

Flannels  are  to  be  worn  next  to  the  skin  all  the  year  round,  for,  while 
it  is  needful  to  lead  an  out-of-door  life,  we  nmst  seek  to  avoid  catarrhal 
aflfections,  to  which  these  subjects  are  very  prone,  and  which,  it  will  be 
recalled,  predispose  to  active  infection. 

Tuberculosis  is  apt  to  develop  especially  in  children  while  convalescing 


TREATMENT  OF  TUBERCULOSIS.  319 

from  acute  fevers,  and  hence  during  this  period  every  precaution  against 
catching  cold,  must  be  observed,  and  the  child  be  strengthened  speedily 
by  vigorous  feeding,  pure  air,  and  tonics.  In  children  predisposition 
often  results  from  obstructions  in  the  nose  and  from  persistently  enlarged 
tonsils ;  and  whenever  these  conditions  exist  they  should  be  promptly  re- 
moved. All  local  foci  of  tuberculosis  in  children — glandular,  osseous, 
and  articular — must  be  attacked  surgically. 

Treatment  of  the  Disease. — The  treatment  of  tuberculosis,  re- 
garded as  a  parasitic  disease,  presents  two  leading  indications.  One  has 
reference  to  the  destruction  of  the  specific  cause,  the  tubercle  bacilli,  by 
the  use  of  antiseptic  inhalations  or  of  some  parasiticide  taken  internally. 
Of  the  numerous  substances  used  by  inhalation,  few  have  given  satisfac- 
tory results,  this  being  largely  due  to  our  inability  to  convey  them  to  the 
smaller  bronchi  in  a  sufficient  degree  of  concentration.  They  are  best 
adapted  to,  and  most  efficacious  in,  cases  in  which  the  larynx  is  involved. 
While  the  antiseptic  treatment,  both  by  inhalation  and  by  means  of 
the  introduction  into  the  blood  of  antiseptic  substances,  is  to  be  carried 
out,  it  accomplishes  nothing  more  than  the  arrest  of  the  growth  and  de- 
velopment of  the  bacilli,  and  that  in  an  indirect  manner.  The  inhalation 
of  antiseptic  substances  may  be  accomplished  in. various  ways — by  inhal- 
ing vapors,  by  the  use  of  the  steam-atomizer,  or  by  some  form  of 
"respiration-inhaler."  I  have  long  employed  the  Robinson  inhaler,  the 
sponge  of  which  is  moistened  with  a  few  drops  of  a  mixture  made  of 
equal  parts  of  creasote,  chloroform,  and  alcohol,  the  patient  wearing  the 
inhaler  nearly  all  the  time  when  not  eating  or  sleeping.  Unfortunately, 
most  patients  object  to  the  constant  use  of  this  instrument.  The  chief 
among  other  antiseptics  thus  employed  are  carbolic  acid,  terebene  and 
terpin  hydrate,  turpentine,  thymol,  iodoform,  oil  of  peppermint,  and  a 
spray  of  a  solution  of  sulphurous  acid.  These  agents  may  be  variously 
combined.  The  injection  of  antiseptics  into  the  diseased  areas  in  the 
lungs,  as  recommended  by  Pepper,  has  been  for  the  greater  part  aban- 
doned. As  pointed  out  by  Osier,  however,  the  remarkable  results  that 
surgeons  have  recently  obtained  in  the  treatment  of  joint- tuberculosis  by 
injections  of  iodoform  point  to  this  as  a  remedy  which  will  probably  prove 
of  service  when  injected  directly  into  the  lungs. 

The  most  common,  because  least  objectionable,  mode  of  introducing 
this  class  of  substances  is  by  internal  administration.  According  to  the 
results  reported  from  all  quarters  of  the  world,  creasote  thus  employed 
alone  enjoys  the  confidence  of  the  profession;  and  in  common  with  nu- 
merous other  observers  I  have  found  its  continued  use  to  be  followed  by 
lessened  cough  and  expectoration,  lessened  fever,  and  by  a  lessening  or 
cessation  of  the  night- sweats,  with  a  gain  of  strength  and  weight  as  the 
natural  consequence.  In  my  own  hands  its  beneficial  effects  have  been 
manifested  at  the  end  of  two  or  three  weeks.  It  must  be  borne  in  mind 
that  the  dose  is  to  be  gradually  increased  to  the  point  of  gastric  tolerance, 
which  in  my  experience  usually  does  not  exceed  15  to  20  drops  (0.999) 
three  times  a  day.     Larger  doses  are,  however,  sometimes  tolerated. 

Following,  in  the  main,  the  practice  of  Trudeau,  who  has  used  this 
drug  quite  as  extensively  as  any  other  American  physician,  after  reach- 
ing the  point  of  tolerance  I  gradually  reduce  the  dose  to  and  maintain  it 
at  5  or  6  drops  (0.333),  three  times  daily.     Among  the  best  vehicles  are 


320  INFECTIOUS  DISEASES. 

hot  milk,  hot  water,  and  dihited  alcohol.  Recently  I  have  ordered  it  in 
capsules,  which  the  patient  himself  fills  at  tlie  time  of  using,  and  have 
found  it  a  popular  and  ready  mode  of  administration.  When  creasote  is 
not  well  borne  by  the  stomach  and  its  inhalation  is  seriously  objected  to 
by  the  patient,  it  may  be  given  by  enema,  the  dose  being  20  to  30  drops 
(1.332),  in  peptonized  milk  or  mixed  with  a  little  egg-white.  It  has  also 
been  employed  hypodermically  in  a  10  per  cent,  solution  in  oil  of  sweet 
almonds,  the  dose  of  which  is  1  dram  to  1^  drams  (4.0-6.0).  Lastly,  it 
has  in  rare  instances  been  employed  by  inunction. 

Guaiacol,  particularly  in  the  form  of  the  carbonate,  has  of  late  been 
quite  extensively  employed  in  place  of  creasote,  of  which  it  is  the  chief 
active  principle.  It  may  be  administered  in  pill  or  capsule,  the  dose 
being  slightly  less  than  that  of  creasote.  It  is  well  tolerated  by  the 
stomach,  and  is  broken  up  in  and  reabsorbed  from  the  intestinal  canal. 
Among  other  remedies  prescribed  for  their  supposed  parasiticidal  effect 
are  arsenic,  mercuric  chlorid,  and  alcohol,  but  they  are  clearly  inferior  to 
creasote  in  this  therapeutic  role. 

Tuberculin  was  at  one  time  supposed  to  exert  a  specific  influence  upon 
the  tuberculous  processes,  but  this  view  has  been  largely  abandoned.  Its 
chief  value,  as  well  as  employment  at  the  present  day,  is  as  an  agent  in 
forming  the  diagnosis. 

I  am  of  the  opinion  that  all  antiseptics  used  internally  in  this  disease 
have  for  their  chief  influence  a  modification  of  the  soil-conditions  on 
which  the  growth  and  multiplication  of  the  bacilli  depend.  They  are,  in 
truth,  of  great  value  in  fulfilling  the  second  leading  indication  of  treat- 
ment, which  is  to  overcome  the  bodily  receptivity  for  the  specific  bacillus, 
or  to  aid  the  natural  defensive  processes  in  limiting  the  destructive 
work  of  the  latter.  All  forms  of  tuberculosis,  however,  may  heal  spon- 
taneously in  any  stage,  this  being  especially  true  of  the  local  varieties 
so  common  in  children,  aflFecting  the  lymph-glands,  joints,  and  bones. 

A  large  proportion  of  pleurisies  are  tuberculous  in  nature,  and  although 
most  sufferers  from  this  disease  develop  pulmonary  tuberculosis  later  in 
life,  many  of  tbera  apparently  heal  without  the  aid  of  the  physician. 
This  is  shown  by  the  old  pleuritic  lesions  that  are  constantly  met  with 
at  autopsies  in  persons  dying  suddenly  of  other  diseases.  Spontaneous 
recovery  is  seen  oftenest  in  cases  that  have  not  progressed  to  the  stage  of 
cavity-formation.  Indeed,  in  the  instances  in  which  vomicae  of  consider- 
able size  have  formed,  cicatrization  or  complete  cure  is  out  of  the  ques- 
tion, though  they  may  become  encapsulated  ((juiescent).  The  percentage 
of  cases  in  which  encapsulated  and  obsolete  tuberculous  lesions  have  been 
observed  at  the  post-mortem  table  in  persons  dying  of  all  ciuises  differs 
widely  with  the  statistics  of  different  observers.  If  we  consider  the  cases 
that  are  latent  from  an  early  period  in  life,  together  with  those  of  all 
ages  after  childhood,  it  is  doubtless  true  that  in  more  than  50  per  cent, 
of  the  human  family  the  bacilli  not  only  gain  entrance  into  the  body,  but 
also  effect  a  lodgement.  And,  since  about  14  per  cent,  of  the  deaths 
from  all  cases  can  be  ascribed  to  tuberculosis,  it  follows  that  unless  the 
conditions  are  favorable  for  the  growth  and  development  of  the  bacilli 
there  is  manifested  a  strong  tendency  to  limitation  and  healing. 

In  removing  the  diathesis  medicines  are  unquestionably  of  less  value 
than   the   hygienic  treatment,  the  latter  in  the  widest  sense  of  the  term 


TREATMENT  OF  TUBERCULOSIS.  321 

aiming  to  reinforce  Nature's  efforts  at  spontaneous  recovery,  and  embrac- 
ing four  main  elements :  (1)  Climate ;  (2)  Feeding ;  (8)  Special  Reme- 
dies ;  (4)  Treatment  of  Leading  Symptoms. 

(1)  Climate. — The  all-powerful  influence  of  environment  has  already 
been  pointed  out.  Experience  and  observation  have  shown  that  certain 
climates,  selected  with  particular  reference  not  only  to  the  stage  of  the 
affection,  but  more  particularly  to  the  individual,  stand  foremost  as  suc- 
cessful modifying  influences  of  the  tissue-soil.  In  any  case  of  tubercu- 
losis that  climate  is  most  suitable  in  which  the  patient  "feels  well,  eats 
well,  sleeps  well,  and  gains  flesh  and  strength  "  (Delafield).  Until  the 
patient  finds  such  a  climate,  or  if  he  finds  no  single  climate  to  produce 
these  results,  he  should  travel  from  place  to  place  unless  special  contra- 
indications (excessive  debility,  etc.)  exist.  If  active  tuberculosis  has 
existed,  the  stay  in  a  suitable  climate  should  not  be  less  than  two  full 
years ;  and  if  the  patient  receive  benefit  from  a  high  altitude,  he  should 
remain  permanently.  Cases  in  which  hemoptysis  is  severe  and  of  fre- 
quent occurrence,  those  complicated  with  weak  hearts,  and  neurasthenic 
subjects  should  not  be  sent  to  the  higher  altitudes. 

The  climatic  requisites  for  a  consumptive  are  (a)  pureness,  (b)  equa- 
bility, and  ((?)  abundant  sunshine.  Less  beneficial,  though  important, 
are  (d)  dryness  and  (e)  altitude. 

(a)  Pu7'eness. — This  requirement  is  of  paramount  importance,  and 
thus  is  explained  the  fact  that  mountain  air  and  that  of  the  virgin  forest 
are  so  helpful  in  phthisis.  Forests,  and  particularly  pine-groves,  favor 
atmospheric  purification,  since  they  generate  ozone,  which  oxidizes  the 
impurities  contained  in  the  air. 

(b)  Equahility  has  reference  to  the  absence  of  rapid  variations  of  tem- 
perature. On  the  whole,  a  relatively  low  is  better  than  a  high  tempera- 
ture, the  former  being  stimulating,  and  the  latter  sedative,  in  effect.  It 
should  be  pointed  out  that  forests  also  greatly  favor  the  quality  of  equa- 
bility,^ both  as  to  temperature  and  relative  humidity.  They  tend  to 
maintain  an  almost  unvarying  degree  of  moisture  in  their  vicinity,  thus 
minimizing  the  diurnal  variations  of  temperature — a  point  that  is  of  far 
greater  importance  than  the  question  of  seasonal  variations.  Forests  in- 
tercept and  temper  the  bleak  winds  of  winter,  while  by  their  shade  and 
leaf-surfaces  they  afford  a  cooler  temperature  in  summer. 

(c)  Abundance  of  sunshine  is  demanded  by  the  consumptive.  The 
advantages  of  sunshine  are  obvious  from  the  observations  made  by  Munn^ 
in  the  year  1892,  when  in  Denver  there  was  sunshine  in  62  per  cent,  of 
the  possible  hours  during  which  it  could  occur.  A  dry  atmosphere  has 
advantages,  but  that  dryness  is  not  an  essential  element  is  shown  by  the 
fact  that  patients  often  do  well  at  places  having  comparatively  high  rela- 
tive humidity,  such  as  Florida,  Southern  Georgia,  Southern  California, 
and  the  resorts  on  the  south  coast  of  England.  The  rarefied  atmosphere 
of  high  altitudes,  on  account  of  its  stimulating  effect  upon  the  respiratory 
function,  aids  in  producing  good  results,  but  the  pulmonary  changes  in- 
duced (enlargement  of  the  air-cells,  with  augmentation  of  the  size  of  the 
chest)  make  it  necessary  for  patients  to  remain  for  the  rest  of  their  lives. 
That  it  is  not  an  essential  factor  is  shown  by  the  excellent  results  obtained 
in  the  ofttimes  purer  atmospheres  at  lower  levels. 

'^House-plants  as  Sanitary  Agents;  Sanitary  Influence  of  Forest  Growth,  p.  312,  by  the 
author.  ^  Medical  Neivs,  Aug.  18,  1894. 


322  INFECTIOUS  DISEASES. 

The  essential  climatic  factors  mentioned  are  found  in  certain  American 
and  European  resorts.  Of  the  former,  the  Adirondack  region,  Colorado, 
and  New  Mexico  are  especially  to  be  mentioned,  combining  as  they  do  in 
winter  a  uniform  cold,  much  sunshine,  and  purity  of  atmosphere.  A 
camp-  or  tent-life  in  the  open  air  cannot  be  too  strongly  advocated. 
According  to  my  own  experience,^  the  Adirondacks  meet  the  indications 
best  in  early  cases  or  in  patients  who  have  strength  enough  to  lead  an  out- 
door life,  and  in  whom  the  breaking-down  stage  is  not  too  far  advanced. 
Some  cases,  in  the  early  stage,  also  do  well  at  Thomas ville,  Ga.,  Southern 
California,  and  in  other  mild,  equable  climates.  The  latter  resorts  pos- 
sess the  added  advantage  of  affording  an  opportunity  of  gaining  a  liveli- 
hood. Among  foreign  resorts,  Davos  possesses  about  the  same  advan- 
tages as  may  be  met  in  Colorado,  New  Mexico,  and  the  Adirondacks, 
while  the  resorts  in  Southern  Italy  and  France  are  comparable  to  South- 
ern California,  Southern  Georgia,  Florida,  and  the  Bermudas  in  this 
hemisphere.  Good  culinary  and  home  comforts  are  considerations  of 
little  less  importance  than  the  climate. 

Briefly,  the  atmosphere  of  forest  resorts  possesses  certain  unmistakable 
advantages  for  this  group  of  sufferers.  Hence  they  should  be  sent  into 
the  neighborhood  of  the  nearest  forest  in  a  mild  latitude  where  reasonably 
good  food  and  other  comforts  of  life  are  obtainable.  In  this  connection 
the  superior  value  of  the  highly  o/onized  and  terebinthinized  atmosphere 
of  the  pine-groves  cannot  be  too  strongly  emphasized.  It  is  especially  ser- 
viceable in  cases  in  which  the  laryngeal  or  bronchial  element  is  marked. 

Sanatorium  Treatment. — Whilst  it  is  essential  to  send  patients  to 
suitable  resorts,  the  most  satisfactory  results  are  obtained  from  the  com- 
bined climatic  and  sanatorium  treatment.  Sanatoria  are  warmly  advo- 
cated by  Trudeau,  Knopf.  Bowditch,  and  others.  As  elsewhere  stated : 
If  properly  situated,  properly  officered  and  well-e(|uipped.  they  show 
results  that  surpass  all  other  known  methods  of  treatment  in  the  earlier 
or  incipient  stages  of  the  disease.  These  sanatoria  should  take  the 
form  of  cottages  and  pavilions.  The  principal  advantages  offered  are 
due  to  a  rigid  system  of  hygiene  under  the  close  supervision  of  compe- 
tent medical  officers.  There  are  three  gnnips  of  cases  among  the  middle 
and  lower  classes,  each  of  which  requires  institutional  treatment  Avith  dis- 
tinctive characteristics : 

Group  1. — The  numerous  cases  that  have  progressed  to  an  advanced 
and  practically  hopeless  stage.  These  refjuire  every  comfort  and  -kind 
care,  such  as  can  be  furnished  by  special  hospitals  for  consumption  in  a 
healthful  urban  locality. 

Group  II. — Incipient  cases  among  the  pauper  element.  For  such,  sana- 
toria conveniently  located  in  close  proximity  to  large  municipalities,  though 
with  special  reference  to  such  factors  as  purity  of  atmosphere  and  protec- 
tion from  chilly  blasts,  by  natural  elevations  or  the  woodland,  should  be  pro- 
vided.    It  is  not  possible  to  secure  for  them  the  most  salutary  climates. 

Group  III. — Phthisis  pulmonalis  among  the  middle  and  working  class, 
or  persons  having  small  means  The  members  of  this  group  will  find 
themselves  compelled  to  depend  principally  upon  ]irivate  philanthropy, 
and  probably  to  some  extent  also  upon  semi-State  institutions;  they  need 
sanatorium  treatment  in  the  best  climates,  and  there  is  no  valid  reason  Avhy 

1  Loccit.,  p.  313. 


TREATMENT  OF  TUBERCULOSIS.  323 

the  combined  sanatorium  and  climatic  treatment  should  not  be  attempted, 
since  such  an  undertaking  could  be  made  to  be  almost  self-sustaining.^ 

Among  home  sanatoria  are  the  Adirondack  Cottage  Sanatorium,  the 
Sharon  Sanitarium,  near  Boston,  the  Loomis  Sanatarium,  at  Liberty, 
N.  Y.,  and  the  Winyah  Sanitarium,  at  Asheville,  N.  C  Foreign  sano- 
toria  are  to  be  found  at  Falkenstein,  near  Frankford-on-the-Main,  Goer- 
bersdorf,  and  Hohenhonnef.  Solaria,  in  connection  with  city  hospitals 
for  advanced  cases,  would,  I  am  certain,  yield  gratifying  results. 

Home  sanatoria  can  be  readily  improvised  by  stocking  living  apart- 
ments, preferably  those  having  a  southern  exposure,  Avith  growing  plants. 
The  beneficial  influences  arising  from  the  presence  of  the  latter  are  as- 
cribable  to  two  functions — the  generation  of  ozone,  and  transpiration.^ 
Such  a  pleasant  retreat  furnishes  a  uniform  degree  of  moisture  in  the  air, 
and  is  especially  adapted  to  the  winter  season. 

(2)  Feeding. — The  diet  should  be  both  nutritious  and  generous.  Too 
close  attention  cannot  be  bestowed  upon  the  feeding  and  upon  the  condi- 
tion of  the  gastro-intestinal  tract.  Above  all,  w^hen  the  remedies  pre- 
scribed (cod-liver  oil,  syrupy  cough-mixtures)  interfere  in  the  slightest 
degree  with  the  function  of  the  stomach  they  must  be  stopped. 

Such  albuminous  articles  as  milk,  eggs,  flesh,  fish  and  fowl,  together 
with  an  abundance  of  fats,  should  be  taken.  The  hydrocarbons  are 
urgently  needed,  but  they  must  be  taken  with  care  lest  they  derange 
the  digestive  function.  An  early  breakfast  in  bed,  including  a  pint  of 
milk  "  with  an  egg  stirred  into  it,"  is  often  advisable.  Otis  asserts  that 
the  milk  should  be  sterilized,  as  there  is  no  more  reason  why  one  should 
use  raw  milk  any  more  than  raw  meat.  The  appetite  is  often  poor  or 
even  lost.  When  this  is  the  case  the  patient  should  keep  in  the  open  air 
or  try  a  brief  change  of  air  by  going,  if  it  be  possible,  to  the  seaside. 
It  is,  however,  generally  needful  to  resort  to  a  rigid  system  of  feeding, 
giving  a  small  quantity  of  food,  such  as  milk,  meat-juice,  egg-white,  and 
the  like,  at  brief  intervals.  The  French  method  of  forced  feeding  de- 
serves a  trial  if  there  be  absolute  loathing  for  food.  It  consists  of  first 
w^ashing  out  the  stomach  Avith  cold  Avater,  and  then  introducing  the  fol- 
loAving  mixture  thrice  daily :  1  liter  of  milk,  an  egg,  and  100  grams  of 
very  finely  poAvdered  meat.  As  a  rule,  the  patient  cannot  be  induced  to 
swallow  this,  and  it  then  must  be  poured  through  a  stomach-tube.  When 
the  temperature  is  above  100°  F.  (87.7°  C)  the  patient  should  be  kept  at 
rest.  In  a  minority  of  the  cases  the  appetite  is  ordinarily  keen,  often  as 
a  result  of  change  of  air,  and  these  usually  pursue  a  favorable  course. 
The  folio Aving  combination  Avill  be  found  useful  in  assisting  the  appetite: 

^.   Sodii  bicarb.,  Siss     (6.0); 

Tr.  nucis  vomicse,  foiiss  (10.0); 

Glycerini,  f^ss     (15.0); 

Inf.  cascarillge,  q.  s.  ad  f  |iv    (120.0). 

Sig.  oij  (8-0)  t.  i.  d.,  in  Avater,  fifteen  minutes  before  meal-timeo 

Other  simple  bitters  and  mineral  acids  may  be  tried,  and  there  are 
many  cases  in  which  the  judicious  use  of  stimulants,  particularly  wines 
and  malt  liquors,  aids  the  appetite  and  digestion  materially.     The  chief 

^  "  Sanatoria  and  Special  Hospitals  for  the  Poor  Consumptive  and  Persons  with  Slight 
Means,"  by  the  Author.  ^  Loc.  cit.,  p.  168. 


324  INFECTIOUS  DISEASES. 

indications  for  the  exhibition  of  alcohol  are  loss  of  appetite,  feeble  di- 
gestion, and  weak,  rapid  action  of  the  heart.  Occasionally  it  tends  to 
aggravate  these  indications,  rather  than  relieve  them,  and  in  this  event 
they  should  be  promptly  discontinued.  Brandy  or  whiskey  in  the  form 
of  milk-punch  may  be  given  freely  in  the  advanced  stage,  and  more 
especially  during  the  morning  hours.  Lavage  has  helped  some  of  my 
cases  immensely.  Lastly,  an  orderly  method  and  sound  judgment  must 
be  brought  to  bear  in  arranging  the  diet  and  drink. 

(3)  Special  Remedies. — These  increase  the  bodily  resistance  by  im- 
proving the  chief  nutritive  processes,  but  do  not  directly  affect  th€  tuber- 
culous lesions ;  among  them  cod-liver  oil  occupies  first  place.  It  seems 
to  have  more  than  a  mere  food-value.  It  is,  however,  exceedingly  tliffi- 
cult  to  estimate  the  therapeutic  importance  of  the  oil  while  other  measures 
— dietetic,  hygienic,  etc, — are  being  brought  to  bear.  It  sometimes 
causes  further  impairment  of  the  appetite  and  digestion,  or  sets  up  intes- 
tinal disturbances,  and  under  these  circumstances  its  effects  are  harmful ; 
on  the  other  hand,  when  well  borne  it  may  be  very  properly  employed. 
The  commencing  dose  should  be  small  (o  j — -t.O,  once  or  twice  daily,  to  be 
increased  after  a  time  to  3ij — 8.0,  two  or  three  times  daily).  It  should  be 
taken  about  meal-time.  When  the  pure  oil  is  not  well  borne,  it  maybe  given 
in  combination  with  an  alkali  (lime.  soda).  Should  the  oil  be  found  to  dis- 
agree after  it  has  been  used  for  a  considerable  length  of  time,  it  should  be 
temporarily  discontinued.  As  a  substitute  for  cod-liver  oil,  cream,  prefer- 
ably Devonshire,  may  be  tried  (^ij  to  5ss — 8.0  to  16.0,  three  times  daily). 

Serum-therapi/. — The  definition  of  this  term,  as  commonly  understood, 
embraces  also  the  employment  of  toxins  and  modified  toxins  produced 
in  various  media.  These  agents,  however,  are  all  used  for  the  establish- 
ment of  artificial  immunity,  as  opposed  to  the  object  of  the  methods  of 
treatment  described  above — the  maintenance  of  natural  immunity.  Koch's 
tuberculin  R,  Maragliano's  serum,  and  Pacjuin's  antitubercle-serum  have 
all  been  highly  recommended  as  remedies  in  tuberculosis  by  certain  clin- 
icians. On  the  other  hand,  unfavorable  results  in  cases  apparently  well 
suited  to  the  treatment  are  recorded.  A  definite  decision  as  to  the  practical 
value  of  this  method  cannot  be  reached  at  present,  although  the  discov- 
ery of  a  specific  remedy  of  similar  nature  may  be  confidently  expected. 

The  hypopliosphites  are  especially  serviceable  in  a  certain  proportion 
of  the  cases.  The  commencing  dose  should  be  1  dram  (4.0),  increased 
to  2  (8.0)  if  it  is  well  borne. 

Arsenic  is  warmly  advocated  for  its  general  influence  in  this  disease. 
The  dose  should  be  small,  so  that  it  may  be  given  for  a  long  time  without 
interruption.     Jacobi  speaks  highly  of  digitalis  in  tuberculosis  in  children. 

Iodoform-  or  europhen-inunctions  are  warmly  commended  by  Flick, 
who  asserts  his  belief  that  incipient  cases  almost  always  can  be  cured  in 
this  way,  and  that  advanced  cases  can  be  iuiproved. 

The  advent  of  an  acute  disease  may  arrest  and  cure  a  tuberculous 
process.  Thus,  the  symptoms  and  signs  of  advanced  tuberculosis  have 
disappeared  after  an  attack  of  virulent  small-pox  and  acute  rheumatism 
(Harris  and  Beales).  Hysteria  also  exercises  an  ameliorating  effect  upon 
pulmonary  tuberculosis,  according  to  the  observations  of  Gibotteau,^  who 
advises  against  treatment  of  the  former  disease  in  tuberculous  persons. 

(4)  Treatment  of  Leading  Symptoms. — (a)  Cough. — This  is  often  quite 

'  2'lic  rntcdllotia;  October,  1894. 


TREATMENT  OF  TUBERCULOSIS.  325 

annoying,  sometimes  interfering  with  sleep,  eating,  and  digestion,  and 
even  inducing  vomiting ;  but  it  is  to  be  remembered  that  cough  does  not 
claim  attention  unless  it  interferes  with  the  above-named  functions.  The 
special  cause  or  causes  of  the  coughing  should  be  determined  before  any 
attempt  is  made  to  treat  it.  It  may  be  attributable  to  catarrhal  irritation 
of  the  upper  air-passages  or  throat,  when  it  is  best  treated  by  topical 
applications,  which  may  be  made  with  the  applicator,  or  in  the  form  of 
sprays  and  inhalations.  The  following  substances  may  be  inhaled  :  com- 
pound tincture  of  benzoin,  combined  with  paregoric  or  carbolic  acid  ;  cre- 
asote,  alcohol,  and  chloroform,  in  equal  parts.  For  local  applications  by 
means  of  the  spray  sedatives  and  narcotics  should  be  preferred,  and  a 
solution  of  cocain  is  sometimes  most  efficient.  The  cause  may  be  found 
in  pleurisy  or  pleuritic  adhesions,  and  for  this  condition  counter-irri- 
tants, as  iodin,  sinapisms,  etc.,  may  be  used.  Pleuritic  coughs  often  de- 
mand codein  or  even  morphin  in  moderate-sized  doses.  The  cough  is  in 
most  instances  occasioned  by  the  tuberculous  bronchitis,  and  to  a  lesser 
extent  by  the  vomicae.  Cough-mixtures  are  usually  prescribed  to  meet 
these  indications,  but  as  usually  formulated  they  are  apt  to  disorder  the 
digestive  function,  and  in  so  far  as  they  have  this  effect  they  are  positively 
harmful.  Since  the  relief  obtained  from  their  use  is  due  to  the  sedatives 
and  narcotics  which  they  contain,  syrups  should  be  omitted  from  the  com- 
position. I  have  come  to  rely  upon-'creasote  by  inhalation  as  the  remedy 
par  excellence  for  tuberculous  bronchitis,  and  combine  it  with  spirits  of 
chloroform  and  alcohol.  To  meet  the  same  indication,  and  particularly 
when  expectoration  is  copious,  preparations  of  terebene,  terpin  hydrate,  and 
tar  may  be  resorted  to ;  and  when  the  cough  becomes  sufficiently  distress- 
ing to  urgently  demand  relief,  I  employ  codein  (gr.  -|— ^ — 0.008  to  0.016, 
every  three  or  four  hours)  in  the  form  of  a  granule.  In  the  latter  stages 
morphin  is  allowable,  since  it  is  at  this  time  that  constant  coughing  or 
severe  paroxysms  of  cough,  if  not  restrained,  lead  to  utter  exhaustion. 
Heroin,  in  doses  of  gr.  i  to  ^  (0.03—0.01)  three  or  four  times  a  day,  acts 
beneficially  in  allaying  the  cough  that  accompanies  phthisis.  Stimulant 
expectorants  may  be  needful,  and  when  this  is  the  case  ammonium  car- 
bonate in  the  infusion  of  wild-cherry  bark  is  perhaps  most  efficacious  and 
least  apt  to  disorder  the  digestion :  a  few  drops  of  the  deodorized  tinc- 
ture of  opium  or  spirits  of  chloroform  may  be  added. 

(h)  Fever. — Creasote  has  found  a  new  field  of  usefulness  in  the  treat- 
ment of  the  fever  of  tuberculosis.  In  my  experience,  at  all  events, 
the  cases  in  which  it  has  been  used,  as  above  indicated,  have  shown  a 
greatly  diminished  febrile  movement.  Cold  or  tepid  spongings  of  the 
body  at  intervals  of  one,  two,  or  three  hours,  according  to  the  intensity 
of  the  fever,  should  be  tried.  Internal  antipyretics  are  rarely  advisable, 
since  during  the  period  of  high  temperature  the  cardiac  action  is  much 
enfeebled ;  but  if  urgently  called  for,  the  following  may  be  employed : 
acetanilid  (dose  gr.  ij-iij — 0.129-0.194),  phenacetin  (gr.  iij-v — 0.194— 
0.324).  These  are  to  be  administered  about  two  hours  before  the  com- 
mencement of  the  daily  rise  in  temperature,  and  repeated  every  three  or 
four  hours  if  necessary.  Other  antipyretics  worthy  of  trial  are  the  min- 
eral acids  and  zinc  oxid,  but  not  quinin,  which  has  utterly  failed  in  my 
hands.  Keeping  the  patient  at  rest  when  the  temperature  is  above 
101°  F.  (38.3°  C.)  is  good  practice,  though  he  should  be  wheeled  into 
the  fresh  air  for  as  long  a  time  as  possible  during  the  day. 


326  INFECTIOUS  DISEASES. 

((?)  The  Night-sweats. — Among  remedies  that  control  the  sweats  most 
successfully  may  be  mentioned — atropin  (gr.  xir^eV — 0.0005-0.001); 
zinc  oxid  (gr.  ij-v — 0.129-324);  sulphuric  or  gallic  acid;  muscarin 
(TTLiij-vj — 0.399  of  a  1  per  cent,  solution);  agaricin  (gr.  \-\ — 0.008- 
0.016).  Sponging  with  equal  parts  of  alcohol  and  tincture  of  bella- 
donna is  very  effective,  but  my  own  best  results  have  been  derived 
from  the  use  of  atropin  (gr.  yyo~9V — 0.0005-0.0007)  in  combination 
with  agaricin  (^ — 0.008). 

{d)  Dysphagia  may  be  a  troublesome  symptom,  especiall}^  from  in- 
volvement of  the  larynx,  and  it  is  best  met  by  local  applications  of  a 
solution  of  cocain  in  glycerin  and  water  (gr.  x  to  5J-0.648  to  32.0), 
thrice  daily  before  meals.  In  advanced  cases  I  have  resorted  to  hypo- 
dermic injections  of  morphin  (gr.  -|^ — 0.008)  before  meal-time. 

{e)  Cr astro-intestinal  Disturbances. — In  nearly  all  cases  of  phthisis 
dyspeptic  symptoms  and  diarrhea  come  on  sooner  or  later,  and  for  this 
gastric  disorder  nothing  is  so  important  as  a  proper  regulation  of  the 
diet.  Perhaps  the  medical  treatment  of  the  gastric  symptoms  has  been 
dealt  w^ith  at  sufficient  length,  save  that  of  vomiting,  Avhich  may  come 
on  after  meals  and  constitute  a  distressing  concomitant.  Those  reme- 
dies giving  the  best  results  may  be  adduced  as  follow's :  cerium  oxalate 
(gr.  v-viij — 0.324-0.518),  in  capsules  before  meals;  calomel  and  soda 
in  fractional  doses;  hydrocyanic  acid  (iTLij-iij — 0.133-0.199);  and 
chipped  ice  with  brandy  sprinkled  over  it,  taken  at  short  intervals,  but 
especially  shortly  before  meal-time. 

(/)  Diarrhea. — The  most  important  factor  in  the  treatment  of  this 
symptoms  is  a  properly-restricted  dietary.  Alum  whey,  mutton  and 
chicken  essence  are  of  service,  but  curds  of  milk,  beef-tea,  and  solids 
are  not  suitable.  Of  the  numerous  medical  measures  that  have  been 
employed,  the  most  useful  are  bismuth,  acetate  of  lead,  opium,  thymol, 
salol,  benzo-naphtol,  and  naphthalin.  To  these  may  be  added  the  fol- 
lowing acid  diarrhea-mixture,  each  dose  containing^ — 

I^  Acid,  acetici  dil.  Ttlx        (0.666) ; 

Morphinse  acetat.,  ^^- \     (0.008); 

Plumbi  acetat.,  gr.  j-ij  (0.0648-0.1296). 

Complications  \vhen  they  arise  must  be  dealt  with  according  to 
accepted  therapeutic  principles. 


SYPHILIS. 

Definition. — A  chronic  infectious  disease  communicable  from  per- 
son to  person  by  direct  or  indirect  contact  with  a  specific  virus,  or  by 
heredity.  According  to  its  clinical  course,  it  is  characterized  by  six  periods  : 
(1)  Period  of  primary  incubation — the  time  Avhich  elapses  between  con- 
tact with  the  poison  and  the  appearance  of  the  chancre.  (2)  Period  of 
primary  symptoms  (the  chancre).  (3)  Period  of  secondary  incubation — 
the  time  which  elapses  between  the  appearance  of  the  chancre  and  the 
development  of  the  skin  eruptions.  (4)  Period  of  secondary  symptoms 
(the  skin  eruptions).  (5)  Intermediary  period  characterized  by  the  ab- 
sence of  lesions,  although  evidences  of  existing  dyscrasia  can  still  be 


SYPHILIS.  327 

found.  (6)  Period  of  tertiary  symptoms.  The  congenital  form  of  the 
disease  is  transmitted  at  the  time  of  procreation,  either  by  the  sperm 
virile  or  by  the  ovum. 

General  Pathology. — (a)  Primary  Lesion  or  Chancre. — This  ap- 
pears at  the  site  of  inoculation,  and  is  characterized  by  infiltration  of 
the  connective  tissue  chiefly  with  round  cells,  and  also  by  larger  epi- 
thelioid and  giant  cells.  This  is  followed  by  a  shalloAv  ulcer  of  the  size 
of  a  split  pea  or  larger,  of  which  the  base  is  quite  hard,  the  sclerosis 
being  due  partly  to  cellular  infiltration  and  partly  to  a  marked  thick- 
ening of  the  adventitia  of  the  arterioles  and  venules.  Adjacent  lymph- 
adenitis, more  or  less  marked,  is  constantly  present,  and  within  six 
weeks  all  the  peripheral  lymphatic-glands  in  the  body  are  swollen. 

(b)  Secondary  Lesions. — Mucous  patches  are  the  most  common.  Their 
favorite  sites  are  the  points  at  which  the  mucous  membrane  and  the 
skin  are  continuous  (mouth,  anus,  etc.) ;  their  contour  is  more  or  less 
rounded  or  oval ;  their  surface  readily  abraded  and  usually  ulcerated  ; 
and  their  size  varies  from  a  pin's  head  to  an  inch  or  more  in  diam- 
eter. Like  the  Hunterian  chancre,  their  periphery  is  more  or  less 
indurated.  Secondary  lesions  also  include  skin-eruptions  and  ocular 
inflammations,  etc. 

[e)  Tertiary  Lesions. — These  are  circumscribed  inflammatory  prod- 
ucts, the  result  of  the  blocking  up  of  the  lymph-spaces  by  the  broken- 
dotvn  round-celled  infiltration  of  the  secondary  period  (gummata),  ap- 
pearing in  the  connective  tissue,  bones,  periosteum  ("nodes"),  skin, 
muscles,  brain,  liver,  lungs,  kidneys,  heart,  testes,  etc.  The  gummata, 
though  usually  sharply  circumscribed,  may  take  the  form  of  difi"use 
infiltrations  of  the  affected  parts,  and  vary  greatly  in  size — from  a  pin's 
point  to  a  hen's  egg.  Usually  firm,  they  may  be  soft,  and,  particularly 
on  mucous  membranes,  tend  to  disintegrate,  forming  ulcers.  Their  color 
is  grayish,  and  on  section  they  show  a  caseous  semi-opaque  center,  w4th 
a  fibrous  and  more  or  less  translucent  periphery. 

Mieroacopically,  the  gummata  consist  of  small  round  cells.  The  mass 
thus  formed  may  either  be  absorbed  or  persist ;  but  in  most  instances 
coagulation-necrosis  occurs  in  the  center,  due  to  local  anemia,  and  there 
is  a  conversion  of  the  peripheral  zone  into  fibrous  tissue.  The  gummata 
are  enveloped  in  granulations  and  connective  tissue,  which  contracts, 
forming  cicatrices  that  often  contain  calcareous  masses  on  their  interior. 
The  lesions  of  certain  structures  (skin,  mucous  membranes,  bones,  and 
cartilages)  often  lead  to  destructive  ulceration  and  sloughing,  and  these 
ulcers  as  they  heal  also  form  typical  cicatrices. 

General  etiology. — Bacteriology. — Lustgarten  in  1884  described 
the  bacillus  of  syphilis,  Avhich  closely  simulates  that  of  tuberculosis  and 
the  smegma  bacillus.  It  occurs  in  rod-shaped  or  curved  forms  with 
slightly  enlarged  ends,  and  is  from  3  to  5  p.  long.  From  the  smegma 
bacillus  it  is  distinguishable  by  the  carbol-fuchsin  test :  though  demon- 
strable with  difiiculty  in  the  hard  chancre  and  in  secondary  lesions,  its 
pathogenic  potency  is  still  very  doubtful.  Inoculation-experiments  upon 
lower  animals  are  not  possible,  since  man  alone  is  susceptible. 

Predisposing  Causes. — Since  acquired  syphilis  originates  only  by  in- 
oculatioin.  it  is  obvious  that  a  break  in  the  cutaneous  or  mucous  surfoces 
is  essential  to  infection,  such  as  a  slight  abrasion,  fissure,  or  laceration. 


328  INFECTIOUS  DISEASES. 

etc.,  particularly  of  the  genital  mucosEe.  Other  surfaces  may  also  be 
the  seat  of  infection,  as  the  lips,  hands,  etc. 

Susceptibility  to  the  virus  is  universal,  and  no  age  is  exempt.  Me- 
mfection  is  exceedingly  rare,  but  does  occur. 

Contagion  of  Syphilis. — The  blood  of  a  syphilitic  during  the  second- 
ary period,  and  the  secretion  from  the  chancre  or  any  of  the  secondary 
lesions,  are  contagious,  the  lesion  at  the  point  of  ulceration  al-nays  being 
a  chancre.  The  physiological  secretions,  saliva,  sweat,  milk,  and  semen, 
do  not  convey  the  virus,  unless  contaminated  by  admixture  Avith  dis- 
charge from  some  of  the  lesions  of  the  primary  or  secondary  stage. 
The  semen,  Avhile  apparently  not  conveying  the  poison,  is  able  to  infect 
the  embryo,  and  in  turn  the  mother. 

Modes  of  Infection. —  (Ij  In  a  great  proportion  of  the  cases  syphilis 
is  transferred  by  illicit  sexual  intercourse,  there  being,  however,  other 
modes  of  transmission. 

(2)  Accidental  Iiioculation. — This  is  not  uncommon,  (a)  Most  fre- 
quently it  is  accomplished  through  the  pernicious  custom  of  indiscrim- 
inate kissing  (lip-chancre),  and  I  have  personal  knowledge  of  not  less 
than  8  instances  in  which  infection  has  occurred  through  labial  contact. 

(h)  The  site  of  inoculation  may  also  be  the  mouth  and  tonsils,  the 
virus  being  conveyed  during  the  low  practices  of  sexual  perverts.  The 
wet-nurse  may  infect  the  mouths  of  suckling  babes,  or,  vice  versa,  the 
infant  may  infect  the  nipple  of  the  nurse. 

(c)  The  obstetric  finger  may  become  infected.  Three  instances  of 
the  sort  have  come  under  my  own  observation,  and  Fournier  gives  the 
details  of  40  cases  of  primary  syphilitic  infection  of  the  hand.  In  30 
of  these  the  malady  Avas  acquired  in  medical  practice  (4  obstetricians, 
20  general  practitioners,  3  students,  and  3  midwives). 

(d)  Humanized  vaccine  virus  may  rarely  transmit  the  disease. 

(e)  Accidental  infection  has,  though  very  rarely,  taken  jilace  in  a 
variety  of  other  ways — e.  g.  handling  foul  rags  from  the  hospital  ward, 
by  bed-clothing,  drinking-cups,  the  pipe,  and  cigar. 

Kraft-Ebing  found  that  out  of  3455  cases  treated  at  the  University 
of  Christiania  from  1867  to  1894,  15y^^  per  cent,  were  of  extra-gcliital 
origin.      The  lesion  was  upon  the  lips  in  51  per  cent,  of  the  cases. 

(3)  Hereditary  Transinission. — Paternal  transmission  (through  the 
semen)  is  much  more  common  than  is  maternal,  the  period  of  greatest 
danjier  beinjj  immediatelv  after  the  father  has  become  infected  or  dur- 
ing  the  time  of  the  secondary  manifestations.  The  first-born,  if  the 
father  be  syphilitic,  is  apt  to  show  Avell-marked  lesions.  Appropriate 
treatment  of  a  syphilitic  parent  lessens  the  danger  of  transmission  verj^ 
materially,  however,  and  in  such  instances  there  is  little  tendency  to 
transmission  shown  after  the  third  year.  On  the  other  hand,  a  syphi- 
litic father  or  mother  may  beget  healthy  oft's))ring,  the  infant  liaving 
acquired  some  immunity  which  protects  it  from  its  mother  (Profeta's 
law).  Syphilitic  children  are  also  common  to  infected  women.  In  the 
majority  of  instances  of  hereditary  transmission,  however,  both  parents 
are  syphilitic,  and  under  these  circumstances  the  liability  to  infect  the 
offspring  is  much  augmented.  A  Avoman  Avho  has  become  infected  after 
conception  may  bear  a  syphilitic  child  ;  though  the  latter  may,  on  the 
other  hand,  escape  infection. 


SYPHILIS.  329 

Allusion  may  here  be  made  to  Colles's  laAv — that  a  woman  who  bears 
a  syphilitic  child  enjoys,  owing  to  a  sort  of  protective  vaccination  Avith 
the  specific  virus,  perfect  immunity,  and  this  in  the  absence  of  all  signs 
of  the  affection.      Coutts  ^  dissents  from  this  opinion. 

Clinical  History  of  Acquired  Syphilis. — (a)  Primary  Stage. — 
The  typical  initial  lesion  (chancre)  appears  about  three  weeks  after  in- 
fection, and  is  followed  soon  by  swelling  and  induration  of  the  nearest 
lymphatic  glands.  The  primary  sore  begins  as  a  red  'pajjide.  which 
rapidly  reaches  its  maximum,  and  then  undergoes  a  central  necrosis 
with  the  formation  of  a  small  ulcer.  The  adjacent  structures  become 
hard  or  cartilage-like — a  characteristic  to  which  the  lesion  owes  its 
name  of  "hard  chancre."  A  small  chancre  may  often  escape  detec- 
tion, especially  if  it  be  situated  inside  the  meatus.  When  situated  upon 
a  mucous  membrane  it  is  always  a  chancrous  erosion,  which  may  be  so 
mild  and  of  such  brief  existence  as  to  come  and  go  without  the  knowl- 
edge of  its  bearer.  Particularly  is  this  the  case  in  the  female.  The 
general  symptoms  are  negative  in  this  stage. 

{h)  Secondary  Stage. — This  is  announced  about  six  weeks  after  the 
appearance  of  the  infecting  chancre  by  moderate  fever  (101°-104°  F. 
— 38.3°-40°  C),  accompanied  by  languor,  headache,  bone-pains,  im- 
paired digestion,  and  a  slight  degree  of  prostration.  The  patient,  as  a 
general  rule,  shows  signs  of  anemia  (syphilitic  cachexia),  and  angina, 
with  hyperemia  of  the  fauces  and  hard  palate,  now  appears.  There 
may  be  minute  elevated  white  patches  upon  the  pharynx ;  the  tonsils 
may  enlarge,  and  on  both  shallow  ulcers  presenting  a  grayish  sharply- 
defined  border  appear.      They  neither  excite  pain  nor  spread. 

There  is  also  an  eruption,  which  is  at  first  usually  roseo?ar  and  widely 
distributed,  coming  out  abundantly  upon  the  trunk  (especially  the  chest), 
buttocks,  thighs,  and  forehead.  Another  early  eruption  is  the  papular. 
The  papules  are  small,  hard,  and  .do  not  ulcerate,  while  their  favorite 
seats  are  the  scalp,  chest,  and  dorsum  of  the  tongue.  The  distribution 
of  these  early  syphilids  is' symmetric  ;  their  outlines  are  rounded  ;  their 
color  like  that  of  a  slice  of  raw  ham  ("coppery");  they  are  polymor- 
phous ;  and,  as  a  rule,  they  excite  neither  pain  nor  itching. 

Other  and  later-appearing  eruptions  may  be  squamous,  vesiculo-pap- 
ular,  pustular,  and  tubercular.  These  shoAv  a  tendency  to  bunch  in 
certain  areas,  and  hence  are  less  diffuse  than  the  afore-mentioned  erup- 
tions.    Several  sub-varieties,  however,  may  appear  simultaneously. 

The  visible  mucous  membranes  (angles  of  the  mouth,  tongue,  gums, 
pharynx,  vulva,  vagina,  penis,  and  around  the  anus)  and  the  skin 
may  show  painful  condylomata  or  mucous  patches,  and  especially  is 
this  the  case  in  the  mouth,  Avhere  they  often  stubbornly  resist  treat- 
ment. Recurrences  at  varying  and  ever-decreasing  intervals  are  quite 
common. 

Other  frequent  symptomatic  conditions  arise  during  this  secondary 
period,  such  as  iritis,  laryngitis  (frequently),  choi'oiditis,  retinitis,  epi- 
didymitis (more  rarely),  and  alopecia.  The  hairs  of  the  eylids  and  eye- 
brows may  fall  off  and  the  finger-nails  become  brittle. 

The  secondary  symptoms  last  from  two  to  three  months  (the  usual 
duration)  to  a  year  or  more,  and  are  followed  by  a  period  of  ap^jarent 
1  "  Hunterian  Lectures,"  Lancet,  1896,  l!^o.  3889. 


330  INFECTIOUS  DISEASES. 

good  health  lasting  for  an  exceedingly  variable  interval  (from  a  few 
months  to  many  years)  before  the  tertiary  stage  sets  in.  During  the 
secondary  stage  the  symptoms  may  be  severe,  mild,  or  even  absent.  The 
severity  of  an  attack  of  syphilis  depends  upon  the  dose  of  infecting 
virus  on  the  one  hand,  and  upon  the  condition  (both  local  and  general) 
of  the  vital  functions  on  the  other.  This  fact  explains  why  a  single 
organ  or  system,  as  the  brain  and  cord,  is  attacked  in  one  instance  and 
some  other  organ  or  system  in  another,  and  the  eflfect  of  traumatism  in 
determining  the  topography  of  periosteal  "nodes"  is  a  good  example. 

(c)  Tertiary  Stage. — As  I  have  already  stated,  the  secondary  period 
is  generally  followed  by  a  variable  interval  of  freedom  from  symptoms, 
but  to  this  rule  there  are  numerous  exceptions,  and  among  not  uncom- 
mon occurrences  may  be  witnessed  the  appearance  of  tertiary  symptoms 
durino;  the  secondarv  staore.  Beloncrinof  to  the  third  sta^e  are  certain 
skin-eruptions,  especially  the  characteristic  rupia,  which  first  appears 
in  the  form  of  pustules  that  break  and  form  ulcers  that  are  covered  with 
dry,  laminated  crusts  "like  an  oyster-shell."  To  this  stage  also  belongs 
psoriasis,  especially  of  the  hands  and  feet.  Pustules  {fuhercidar)  which 
do  not  scale  over  also  appear.  These  eruptions  involve  the  true  skin, 
and  in  healing  leave  scars,  but,  unlike  the  secondary  cutaneous  lesions, 
they  are  neither  infectious  nor  contagious,  are  not,  as  a  rule,  symmetric, 
and  are  more  liable  to  be  attended  by  itching.  True  gummata  may 
develop  in  the  skin  and  subcutaneous  tissue,  and  these  break  down  and 
form  kidney-shaped  ulcers  which  tend  to  spread  in  a  serpiginous  man- 
ner. On  healing  (a  process  that  is  accomplished  with  difficulty),  scars 
result.  Gummata  may  occur  in  the  mucous  membranes,  and  pass 
through  the  stages  of  ulceration  and  cicatrization.  When  situated  in 
the  larynx  or  trachea  their  healing  is  attended  with  narrowing  of  the 
organ,  and  when  in  the  lower  bowel  or  the  rectum  dysenteric  symptoms, 
followed  by  actual  stenosis,  may  result. 

In  the  muscles  gummata  occur  and  form  small  hard  tumors.  They 
may  also  cause  periostitis  and  death  of  the  bones,  especially  of  the  nose, 
palate,  and  skull;  "nodes  "  are  thus  formed,  which  are  situated  chiefly 
upon  the  tibia  and  the  skull  in  larger  or  smaller  numbers,  and  also, 
though  less  frequently,  upon  other  bones.  These  are  exceedingly  pain- 
ful, particularly  at  night,  and  are  very  tender  under  the  pressing  finger. 
They  may  be  true  gummata,  but  more  often,  if  not  absorlaed,  they  either 
become  ossified  or  undergo  fibroid  change,  while  in  rarer  cases  they 
suppurate.  Chronic  enlargement  of  the  lymphatics  and  of  the  testicle, 
with  little  tendency  to  suppuration,  may  be  noticed.  The  pregnant 
female  is  apt  to  abort  or  miscarry,  either  as  the  result  of  the  action  of 
the  syphilitic  virus  upon  the  ovum  or  of  the  presence  of  gummatous 
growths  in   the  placenta. 

Gummata  also  occur  in  the  internal  organs  {visceral  syphilis),  and  of 
the  latter  I  shall  speak  presently,  taking  up  separately  some  of  the 
various  organs  and  systems  of  the  body.  Amyloid  defieneration  is 
freijuently  caused  by  the  acquired  form,  particularly  syphilis  of  the 
rectum   in   Avomen.  but   very  rarely  by  the  congenital. 

Malignant  Syphilis. — By  this  term  is  meant  a  virulent  and  a  fiital 
form  of  the  malady,  which  is  fortunately  rare.  The  various  stages 
manifest  themselves  early,  and  especially  the  tertiary,  as  on  the  forty- 


SYPHILIS.  331 

fifth  day  in  a  case  of  Mauriac.  The  course  is  rapid  and  the  condition 
resists  all  forms  of  treatment.  Roussel  narrates  a  case  in  which  death 
occurred  about  one  3'ear  after  the  commencement  of  the  disease- 
Clinical  Symptoms  of  Congenital  Syphilis.  —  These  may, 
though  rarely,  be  identical  with  those  of  acquired  syphilis,  if  we  except 
the  chancre.^  Occasionally  the  characteristic  symptoms  are  present  at 
birth.  On  the  other  hand,  in  the  vast  ma,jority  of  instances  they  appear 
between  the  first  and  fourth  months  of  life  {infra).  The  symptoms  of 
inherited  syphilis  may  be  grouped  according  to  the  time  of  appearance : 

(1)  In  the  New-born. — There  is  a  lack  of  physical  development. 
The  babe  may  be  greatly  emaciated,  it  has  snuffles,  and  singultus  occa- 
sionally sets  in  soon  after  birth.  Skin-eruptions  are  rare,  except  pem- 
jDhigus  neonatorum,  which  appears  as  bullae  on  the  palms  and  soles ; 
among  exceptional  cutaneous  phenomena  are  gummata  around  the  radio- 
carpal articulations,  palmar  psoriasis,  and  a  fleeting  roseola.  Ulcers 
and  fissures  (rhagades)  may  be  noticed  around  the  outlets  of  the  body 
(mouth,  anus,  etc.) ;  the  osseous  system  may  show  hyperostoses  of  the 
long  bones ;  and  the  liver  and  spleen  are  enlarged.  Comby  reports  8 
cases  of  pseudo-paralysis  due  to  syphilis  in  the  new-born. 

(2)  Early  Post-natal  Symptoms. — Most  subjects  of  syphilis  heredi- 
taria are  born  plump  and  without  taint.  Romiceano  ^  gives  the  results 
of  his  observations  of  723  cases  of  infantile  syphilis  in  which  the  dis- 
ease appeared  chiefly  between  the  first  and  fifth  months,  and  only  27 
times  in  all  after  the  sixth  month.  Rogers's  statistics  show  that  among 
249  cases,  217  showed  symptoms  before  the  end  of  the  third  month. 
The  first  symptom  is  generally  coryza  (syphilitic  rhinitis),  Avhich  is  be- 
trayed by  a  sero-purulent  or  bloody  discharge  and  a  peculiar  form  of 
obstructed  breathing  (snuffles),  rendering  nursing  difficult.  The  coryza 
may  in  some  cases  be  preceded  by  singultus  lasting  ten  or  twenty  days 
(Carini),  and  ulcers  may  form  in  the  nose,  leading  to  necrosis  of  the 
bones  and  producing  at  last  a  sunken  and  deformed  nose  which  is  highly 
significant.  The  coryza  may  extend  to  the  middle  ear  and  cause  otitis 
media,  with  deafness  and  otorrhea  as  the  chief  symptoms.  The  skull 
may  approach  the  natiform  in  shape,  and  the  signs  of  diaphyso-epiphys- 
eal  inflammation  develop. 

The  cutaneous  symptoms  appear  early.  The  skin  has  a  tawny  hue, 
and  an  erythematous  eruption  of  the  nates  and  genitals  is  frequently 
seen ;  this  is  patchy,  with  well-defined  margins,  and  has  the  character- 
istic coppery  color.  In  the  same  localities  papules  may  appear,  while 
pemphigus  may  attack  the  palms  and  soles.  Syphilitic  onychia  may  be 
present,  and  the  lips  and  angles  of  the  mouth  often  show  fissures  that 
are  of  real  diagnostic  worth.  Other  symptoms  are  ulcerations  of  the 
skin  and  mucous  surfaces,  falling  of  the  hair,  and  a  moderate  glandular 
enlargement. 

^Enlargement  of  the  spleen  is  a  frequent  characteristic  symptom,  and 
White  says  that  the  enlargement  of  the  organ  when  "  painless,  subacute, 
persistent,  often  preceding  the  eruptions,  should  be  included  in  the  list 
of  significant  symptoms." 

Swelling  of  the  liver  may  also  be  present,  but  is  of  little  diagnostic 
import.    Syphilitic  infants  occasionally  manifest  a  hemorrhagic  tendency. 

^  With  prenatal  syphilis  we  are  not  concerned.  ^  La  Progres  medicale,  Paris. 


332  INFECTIOUS  DISEASES. 

At  birth  bleeding  from  the  umbilicus  may  occur ;  later,  into  the  sub- 
cutaneous tissue  and  from  the  mucous  membranes  (gastro-intestinal, 
vaccinal,  nasal,  etc.).  As  pointed  out  by  Osier,  these  cases  must  not 
be  confounded  with  Winckel's  disease — an  acute  infectious  hemoglobinuria 
of  the  new-born. 

Among  nervous  symptoms,  restlessness,  sleeplessness,  and  a  harsh, 
shrill  cry  which  may  be  almost  constant  for  days  together  and  due  most 
probably  to  darting  pains,  are  the  chief.  Anemia  and  other  eyidences 
of  syphilitic  cachexia  soon  supervene. 

(3)  Late  Symptoms. — The  symptoms  of  syphilis  hereditaria  tarda 
may  be  arranged  in  groups  (Fournier) : 

(1)  Those  Indicated  by  the  G-eneral  Appearance. — There  is  a  retarded 
general  development,  as  shown  by  the  small  stature,  undeveloped  muscles, 
the  graceful  form,  and  infantile  appearance  at  ages  varying  from  four  to 
twelve  or  more  years.  The  skin  has  an  earthen  tint,  and  the  hair  may 
be  scanty  and  late  in  its  appearance  on  the  face  and  genitals. 

(2)  Skin-cicatrices. — Cutaneous  scars,  particularly  if  multiple  and 
extending  over  a  circumscribed  area,  are  important  diagnostic  signs. 
Their  form  is  usually  round  or  serpiginous,  and  their  chief  location  the 
mouth,  nose,  soft  palate,  and  lumbo-gluteal  regions. 

(3)  Lesions  of  the  /Skeleton. — The  natiform  skull.  "  with  a  transverse 
enlargement,  lateral  bulgings,  and  the  flattening  in  the  middle,"  is 
almost  pathognomonic.  Asymmetric  and  hydrocephalic  skulls  are  also 
to  be  considered,  in  many  cases,  as  signs  of  hereditary  syphilis,  as  is  a 
sunken  and  deformed  nose.  The  thickened,  "sabre-shaped"  tibia,  due 
to  gummatous  periostitis,  is  capital  evidence  of  the  disease,  while  the 
chicken-breasted  thorax  is  significant. 

(4)  The  testicles  show  an  arrest  in  development  (infantile  testicles). 
This  is  a  sclerotic  atrophy. 

(5)  Hutchinson's  triad,  under  Avhich  title  come  (a)  the  Hutchinson 
teeth ;  (h)  ear-conditions ;  and  (e)  affections  of  the  eye. 

(a)  The  Hutchinson  Teeth. — The  teeth  may  be  late  in  appearing,  and 
the  dental  arch  may  be  malformed,  the  teeth  presenting  various  irregu- 
larities in  form  and  condition  (dental  dystrophy). 

The  incisors,  especially  the  superior  median  of  the  second  dentition, 
are  notched,  and  show  a  thinness  of  the  free  edge,  an  atrophy  of  the 
summit,  and  crescent-shaped  erosions.  The  latter  are  truly  pathogno- 
monic (Fournier). 

{h)  Ear-conditions. — Otorrhea,  secondary  to  "naso-pharyngeal  catarrh, 
has  already  been  mentioned,  and,  in  addition,  at  or  about  the  time  of 
puberty  an  incurable  form  of  deafness  may  develop  speedily,  without 
the  presence  of  pathologic  lesions  to  explain  the  same. 

(r)  Affections  of  the  Eye. — These  are  interstitial  keratitis  and  iritis, 
affecting  both  eyes  successively. 


VISCERAL  SYPHILIS.  333 


Visceral  Syphilis. 

Syphilis  of  the  Brain  and  Cord. — Pathology. — The  most  characteristic 
and  not  infrequent  lesions  are  the  syphilitic  new-growths.  Their  size 
varies  from  that  of  a  bean  to  that  of  a  chestnut,  and  they  present  irreg- 
ular contours.  They  are  usually  situated  either  in  the  cerebral  hemi- 
spheres or  on  the  pons,  and  rather  superficially,  connecting  directly  or 
indirectly  with  the  dura  or  pia  mater.  They  may  not  infrequently  orig- 
inate in  the  dura  mater.  In  gummata  of  average  size  a  cut-section 
shows  caseation  in  spots  which  are  connected  and  surrounded  by  firm, 
translucent,  gray  or  reddish-gray,  fibrous  tissue ;  and,  according  to 
Gowers,  the  more  irregular  surfaces  and  the  irregular  caseation  serve  as 
important  distinctions  from  tuberculous  tumors.  When,  as  is  usual,  the 
gummata  touch  the  membranes,  meningitis — subacute  or  chronic,  with 
much  thickening — is  combined. 

As  I  have  said,  the  condition  may  begin  as  a  gummatous  meningitis, 
while  in  fewer  instances  it  may  start  as  a  gummatous  arteritis.  On  the 
other  hand,  a  gumma  may  secondarily  involve  a  blood-vessel  for  a  con- 
siderable distance,  weakening  its  walls,  with  resulting  rupture  and  intra- 
cranial hemorrhage  ;  or  it  may  bring  about  cerebral  thrombosis  with 
secondary  softening. 

Histologically  "  the  cerebral  gumma  differs  from  other  similar  bodies 
chiefly  in  the  presence  of  veiy  large  spider-like  cells  containing  an  exag- 
gerated nucleus  and  a  granular  protoplasm  which  extends  into  the  multi- 
ple, branching,  rigid  prolongations"  (Wood).  The  arteries,  particularly 
those  of  the  base,  may  show  syphilitic  sclerosis ;  this  renders  them  thick, 
hard,  opaque-whitish,  until  their  lumen  is  well-nigh  obliterated. 

Gummatous  growths  may  attack  the  cord.  In  a  case  recently  reported 
by  Osier  a  new-growth  occupied  the  cord  opposite  the  root  of  the  third 
cervical  nerve,  "and  there  were  gummata  in  the  cauda  equina."  The 
other  gross  changes  found  in  connection  with  cerebral  gummata  and  their 
secondary  lesions  (softening,  collateral  inflammation,  etc.)  are  also  ob- 
served in  syphilis  of  the  cord. 

Etiology. — Cerebral  syphilis  is  usually  a  late  (tertiary)  manifestation — 
appearing  from  one  to  thirty  years  after  primary  infection — "in  middle 
life  "  (Rothwell).  Lydston  and  others  have  shown  that  nervous  stigmata 
may  become  evident  during  the  secondary  stage,  even  as  early  as  three 
months  after  initial  infection.  It  oftenest  develops  in  cases  in  which 
the  secondary  symptoms  have  been  slight,  and  may  occur  in  those  in 
which  both  primary  and  secondary  manifestations  have  been  entirely 
overlooked.  Inherited  syphilis  aifects  the  nervous  system  less  frequently 
than  does  the  acquired  form,  but  cerebral  gummata  have  been  noted  at 
all  periods  from  the  time  of  birth  until  after  puberty. 

Symptomatology. — Imbecility  and  idiocy  may  be  due  to  inherited 
syphilis,  but  they  are  probably  too  often  attributed  to  this  cause.  The 
other  features  simulate  those  of  the  acquired  foi'm. 

The.  symptoms  of  the  acquired  form  are  with  few  exceptions  referable 
to  three  affections  :   (a)  epilepsy,    (b)  brain-tumor,  and  (c)  paralysis. 

(a)  Ejnlepsy  coming  on  after  the  twenty-fifth  year  is  usually  due  to 
the  ravages   of  syphilis,   and  a   careful   search   for  traces  of  scars  and 


334  INFECTIOUS  DISEASES. 

bone-lesions,  etc.  should  be  instituted.  The  appearance  of  the  disease 
may  be  preceded  by  psychic  disturbance,  headache,  dizziness,  and  loss 
of  memory.  Hysteric  manifestations  may  also  be  presented,  being 
probably  provoked  by  the  specific  lesions.  On  the  other  hand,  a  pro- 
tracted torpor  Tvhich  may  last  for  a  few  days  or  as  many  weeks  may 
develop.  In  one  of  my  own  cases  periods  of  marked  mental  excite- 
ment, that  persisted  for  three  or  four  days,  alternated  with  periods  of 
almost  complete  insensibility  of  about  equal  duration. 

{b)  Brain-tumor. — The  symptoms  pointing  to  brain-tumor  Avill  be  dis- 
cussed under  this  head  in  the  section  on  Nervous  Diseases.  The  syph- 
ilitic nature  of  the  cerebral  groAvth  cannot  be  determined  with  any 
degree  of  certainty  except  in  the  presence  of  a  clear  history  of  syphilis 
— congenital  or  acquired — and  the  characteristic  symptoms  or  traces  of 
the  primary,  secondary,  or  tertiary  lesions.  In  such  cases  the  diagnosis 
is  almost  undoubted. 

It  must  be  remembered  that  the  secondaries  are  either  sometimes 
absent  or  go  unnoticed,  and  if  the  patient  has  had  a  primary  sore,  the 
presence  of  the  characteristic  symptoms  of  brain-tumor  (headache,  optic 
neuritis,  convulsions,  etc.)  make  the  existence  of  specific  nerve-lesions 
highly  probable.  The  chancre  may  also  be  overlooked  or  denied,  and 
it  is  in  such  instances  as  the  latter  that  the  occurrence  of  convulsions 
in  persons  over  thirty  should  excite  suspicion,  and  lead  to  a  trial  of  the 
antisyphilitic  treatment  for  further  confirmation. 

((?)  Paralysis. — This  may  take  the  form  of  hemiplegia  (due  to  cerebral 
hemorrhage  or  tumor)  or  of  general  paralysis  {dementia  paralytica). 
The  relation  that  these  affections  bear  to  syphilis  will  be  indicated  in 
its  appropriate  place  in  this  work  in  the  description  of  Xervous  Dis- 
eases. The  fact  may  here  be  pointed  out  that  syphilis  may  induce  pre- 
cisely the  same  changes  met  with  in  general  paralysis  of  the  insane. 

The  history  of  syphilitic  infection,  together  with  symptoms  of  an 
atypical  type  of  spinal  tumor,  points  to  gumma  of  the  cord.  Syphilitic 
myelitis  usually  develops  within  five  years  after  infection,  and  may  pur- 
sue an  acute  or  subacute  course,  though  oftener  it  takes  the  form  of 
chronic  myelitis.  The  latter  attacks  by  preference  the  lumbo-dorsal 
section  of  the  cord — a  fact  corroborated  by  the  character  of  the  symp- 
toms. The  clinical  features,  however,  are  not  distinctively  syphilitic ; 
and  the  process  is  uninfluenced  by  the  most  vigorous  antisyphilitic 
measures.  When  the  etiologic  influence  of  syphilis  can  be  shown, 
especially  in  the  absence  of  other  causes,  the  diagnosis  of  syphilitic 
myelitis  rests  upon  more  certain  ground.  Acute  syphilitic  myelitis 
gives  an  unfavorable  prognosis. 

Greneral  JJia'/nosis. — The  onset  in  nervous  syphilis  may  be  acute  or 
subacute,  and  the  symptom-complex  embraces  a  multiplicity  of  phenom- 
ena, there  being  an  especially  erratic  distribution  of  the  attending 
palsies  and  early  marked  impairment  of  the  mind. 

Syphilis  op  the  Liver, 

In  my  experience  the  liver,  Avith  comparative  frequency,  bears  the 
stress  of  visceral  syphilis. 

Pathology. — The  lesions  may  be  thus  classified :  (a)  Diffuse  Syph- 
ilitic Hepatitis. — This  is  met  with  chiefly  in  congenital  cases,  though  I 


SYPHILIS   OF  THE  LIVER.  335 

have  seen  an  instance  in  an  adult  "who  died  of  cerebral  hemorrhage, 
the  occurrence  of  "which  in  adult  life  has  been  questioned  by  some. 
The  liver  is  uniformly  enlarged,  firm,  and  resists  the  cutting  knife.  Its 
color  is  grayish-yello"w. 

The  microscope  shows  a  marked  increase  in  the  connective  tissue  and 
a  cell-infiltration  throughout.  From  intense,  focal  cellular  infiltration 
miliary  gummata  may  result ;  these  undergo  contraction,  diminishing 
some"what  the  size  and  altering  the  shape  of  the  organ. 

{h)  Gummata. — These  may  be  seen  in  congenital  cases  (chiefly  the 
miliary  gummata).  As  seen  in  the  adult,  hepatic  gummata  are  dissem- 
inated nodules,  "with  the  usual  central,  cheesy  mass  surrounded  by  a  zone 
of  grayish  fibrous  tissue  and  varying  in  size  from  a  hazelnut  to  an  apple. 
They  form  separate  tumors,  "whose  favorite  seat  is  the  convex  surface  of 
the  organ,  especially  near  to  the  suspensory  ligament.  They  are  usu- 
ally tertiary  lesions,  and  do  not  appear  until  a  number  of  years  (two, 
three,  or  four)  after  infection.  These  so-called  syphilomata  in  the  ad- 
vanced stage  contract,  and  the  liver  "will  be  found  smaller  than  the  nor- 
mal. Deep  furrows,  due  to  contracting  fibrous  bands  traverse  the 
organ  in  different  directions  and  divide  it  into  lobes  of  various  dimen- 
sions. Gummata  frequently  undergo  fibroid  change,  but  more  rarely 
they  soften  and  liquefy  (AYilks).  On  the  other  hand,  before  contraction 
occurs  the  liver  is  increased  in  size  and  the  gummata  form  protuberances 
on  its  surface. 

(c)  Gummatous  Arteritis. — Briefly,  this  may  affect  both  the  portal 
vein  and  hepatic  artery,  though  syphilitic  endarteritis  is  situated  chiefly 
in  the  smaller  branches  of  the  latter. 

(fZ)  Perihepatitis. — Here  Glisson's  capsule  is  thickened,  oAving  to  aug- 
mentation of  its  connective-tissue  elements.  From  the  latter  there  dip 
into  the  hepatic  tissue  cicatricial  bands,  particularly  along  the  portal 
canals,  "which  may  change  someAvhat  the  shape  of  the  organ.  Section  shows 
admirably  the  pale  scar-like  tissue  (yi'cZe  Diseases  of  the  Liver). 

Clinical  History. — The  affection  may  exist  without  symptoms. 
In  the  congenital  form,  however,  we  have  signs  of  hepatic  enlargement, 
with  icterus,  the  spleen  being  likewise  large  and  firm,  as  a  rule.  The 
history  and  associated  lesions  are  necessary  to  a  certain  diagnosis. 

In  the  adult  syphilis  of  the  liver  does  not  usually  attract  attention 
until  the  gummata  interfere  with  the  portal  circulation.  As  they  un- 
dergo contraction  they  tend  to  occlude  some  of  the  portal  branches,  or 
they  may,  on  account  of  their  situation,  exert  pressure  upon  the  vena 
porta  itself.  In  either  event  the  evidences  (ascites  and  splenic  enlarge- 
ment) of  portal  obstruction  Avill  develop  as  in  alcoholic  cirrhosis.  The 
gastro-intestinal  symptoms  common  to  the  latter  disorder  are  also  pres- 
ent, and  obstructive  jaundice  may  supervene,  though  it  is,  compara- 
tively speaking,  rare.  Pain,  usually  localized  to  some  particular  spot 
over  the  right  hypochondrium,  is  sometimes  complained  of,  and  may  be 
quite  severe,  while  pressure  over  the  painful  area  elicits  great  tenderness. 

Physical  Examination. — In  the  early  stage,  while  tlie  organ  is  en- 
larged, fiattened,  irregular  protuberances  may  be  detected  by  the  pal- 
pating fingers.  At  a  more  advanced  period  ascites  may  interfere  with 
palpation,  and  in  such  cases  an  aspiration  of  the  fluid  will  enable  one 


336  INFECTIOUS  DISEASES. 

to  feel  the  syphilomata.  Finally,  in  the  stage  of  contraction  the  results 
of  palpation  are  obviously  negative. 

There  is  a  group  of  cases  in  Avhich  the  clinical  picture  is  that  of 
advanced  amyloid  disease  of  the  viscera.  The  liver  and  spleen  are 
enlarged,  the  urine  is  increased  in  amount  and  contains  albumin  and 
tube-casts,  and  finally  dropsy  supervenes. 

Diagnosis. — This  rests  upon  the  etiology,  the  presence  of  scars  in 
the  throat  or  on  the  skin-surface,  bone-lesions  (especially  irregularities 
of  the  tibial  surfaces),  or  other  evidences  of  the  ravages  of  the  disease, 
and  upon  moderately  good  general  health.  The  most  important  symp- 
toms are  the  hemispheric  prominences  on  the  surface  of  the  liver  and 
the  localized  pain. 

The  diagnosis  between  syphilitic  disease  of  the  liver  and  echinoeoecus- 
cysts  is  sometimes  extremely  difficult.  R.  Lennhoff  has  noted  in  a 
number  of  cases  of  echinococcus-cyst  that  on  deep  inspiration  a  furroAv 
forms  above  the  tumor,  between  it  and  the  edge  of  the  ribs ;  this  was 
confirmed  by  subse<juent  operation. 

The  clinical  findings  resemble  those  of  cancer  of  the  organ.  I  have 
contrasted  the  main  dissimilar  points  in  the  subjoined  table  : 

Syphilis  of  the  Liver.  Caxcer. 

History  of  heredity  or  of  infection.  History     of    heredity     or     of    primary 

groAvth. 

Occurs  congenitally,   or,   if  acquired,    at  Never  congenital.     Usually  occurs  after 

any  age.  the  age  of  forty. 

Often  accompanied  by  symptoms  of  ter-  Often   preceded  by  the  primary  growth 

tiary  syphilis — alopecia,   rupia,   syph-  in   pylorus,   uterus,  mammary   gland, 

ilitic   iritis,  etc.  etc. 

Jaundice  and  ascites  are  common,  espe-  Jaundice  and  ascites  are  rare.     Marked 

cially  the  latter.     Xo  cachexia.  cachexia. 

The   marL^n,  on   palpation,   is  markedly  Often  the  margin  reveals  the  presence  of 

irregular,  and  neitlier  nodular  nor  um-  umljilicatod  nodules. 

bilicated. 

Recovery   may    follow,  or   the   affection  Always  fatal.     Duration  usually  from  a 

may  last  for  years.  few  months  to  a  year. 

The  course  and  the  results  of  antisyphilitic  treatment  are  of  value 
from  a  diagnostic  view-point.  The  course  is  slow  and  often  interrupted 
temporarilv  by  improvement,  if  not  arrest  of  the  disease,  while  appro- 
priate treatment  may  lead  to  recovery,  as  in  two  of  my  cases. 

Syphilis  of  the  Alimentary  Tract. 

The  lesions  in  tlie  mouth  have  been  for  the  most  part  considered. 
In  the  tongue  gummata  often  develop.  A  decidedly  fissured  appearance 
of  the  organ  and  whitish  scar-like  patches  upon  the  surf\ice  may  be  ob- 
served in  syphilis,  but  have  no  essential  connection  with  that  disease. 
Gummata  also  appear  on  the  posterior  wall  of  the  pharynx  and  lead  to 
ulceration,  which  may  cause  fatal  hemorrhage  by  erosion  of  adjacent 
large  blood-vessels  (internal  carotid,  etc.).  The  walls  of  the  esophagus 
may  also  be  invaded,  resulting  usually  in  stenosis. 

The  stomach-Avalls  may  be  infiltrated,  though  they  are  rarely  ulcer- 
ated ;  syphilitic  ulcers,  however,  may  appear  in  the  intestines,  and  the 
condition    may  lead   to    perforation  and  peritonitis. 


SYPHILIS   OF  THE  LUNGS.  337 

Grummatous  infiltration  of  the  rectum  is  a  somewhat  frequent,  severe, 
and  clinically  important  affection.  It  is  much  more  common  in  Avomen 
than  in  men,  taking  place  in  the  "  submucosa  above  the  internal  sphinc- 
ter." It  has  frequently  caused  a  fatal  result  in  persons  who  failed  to 
show  post-mortem  specific  lesions  in  other  viscera,  and  hence  it  is  to  be 
classed  as  one  of  the  ravages.  The  result  of  the  gummatous  infiltration 
is  the  production  of  a  funnel-shaped  stenosis  of  the  rectum  which 
narrows  from  below  upward.  Above  the  stenosis,  and  directly  depend- 
ent upon  it,  there  is  dilatation  of  the  rectum  and  the  descending  colon. 
Here  may  also  be  found  ulcers — some  specific,  and  others  the  result  of 
mechanical  pressure  exerted  by  the  fecal  accumulations. 

Symptoms. — The  clinical  features  are  for  the  most  part  those  of  a 
gradually  induced  stenosis  of  the  rectum.  At  first  there  may  be  hem- 
orrhages, suggesting  internal  hemorrhoids.  The  action  of  the  bowels  is 
irregular,  and  is  followed  shortly  by  a  tendency  to  dysenteric  diarrhea, 
with  pains,  tenesmus,  and  scanty  stools  containing  mucus  and  pus.. 
Prolapse  of  the  rectal  mucosa  may  occur,  and,  owing  to  the  presence  of 
small  hemorrhoids,  the  true  nature  of  the  case  may  be  overlooked. 
The  disease  is  most  distressing,  and  leads  sloAvly  and  gradually  to  ex- 
treme emaciation  and  asthenia.  Death  may  be  due  to  the  latter  or  to 
some  complication  (perforative  peritonitis,  etc.). 

Diagnosis. — This  may  be  aided  by  a  clear  history  of  associated 
syphilitic  symptoms  or  of  specific  lesions,  including  amyloid  degenera- 
tion. A  sure  demonstration  can  only  be  made  by  rectal  examination. 
The  examining  finger  feels  the  sharp  edge  of  the  cicatricial  ring.  Cancer 
of  the  rectum  can  readily  be  eliminated  on  account  of  the  absence  in 
syphilis  of  the  "crater-like"  ulcer. 

Syphilis  of  the  Lungs. 

While  undoubted  cases  occur,  syphilis  of  the  lungs  is  rare  indeed. 

Pathology. — The  cases  are  pathologically  divisible  into  four  forms  : 
(a)  Gummy  tumors  ;  (b)  Interstitial  pneumonia ;  (c)  Brown  induration  ; 
[d)  Fetal  pneumonia. 

(a)  Gummy  Tumors. — These  appear  as  yellowish-white  scattered 
nodules,  varying  in  size  from  a  cherry-pit  to  a  hen's  egg.  Their  centers 
are  dry  and  caseous-looking,  and  their  peripheral  zones  fibrous.  They 
are  relatively  thicker  set  near  to  the  root  of  the  lungs.  Cicatricial 
bands  maybe  seen  connecting  not  only  the  separate  nodules,  but  stretch- 
ing outward  to  the  thickened  pleura.  Such  growths  may  undergo  soft- 
ening and  ulceration,  thus  forming  a  cavity  that  rarely  attains  to  large 
measurements ;  or,  on  the  other  hand,  in  favorable  cases  the  fibroid 
changes   and  cicatrization  may  lead  to  recovery. 

A  primary  lesion  is  atrophy  of  the  alveolar  walls,  with  hyaline  de- 
generation of  the  capillaries  (Councilman).  Broncho-pneumonia  (not 
distinctively  syphilitic)  may  be  associated. 

(b)  Interstitial  Pneumonia. — This  is  a  fibrous  infiltration,  showing  a 
predilection  for  the  right  lung.  Its  chief  seat  is  the  root  of  the  lung, 
whence  it  extends  along  the  bronchi  and  vessels,  and  usually  involves  a 
part  of  one  or  more  lobes.  Occasionally  its  starting-point  is  the  pleura, 
from  which  the  process  advances  along  lines  corresponding  to  the  inter- 

22 


338  INFECTIOUS  DISEASES. 

lobular  tissue.  Bronchiectasis  may  be  noticed.  Gummata  may  also  be 
associated,  or  may  have  been  present  and  been  practically  obliterated 
during  the  process  of  cicatrization.  I  have  seen  an  instance  in  -which 
the  merest  vestige  of  gummatous  material  remained. 

(c)  Brown  induration,  simulating  exactly  that  which  is  seen  in  asso- 
ciation -with  organic  valvular  diseases,  may  be  observed,  but  it  may  have 
no  necessary  connection  ^ith  syphilis. 

{cl)  Fetal  Pneumonia  (  Virchoiv's  White  Hepatization). — This  is  pecu- 
liar to  the  new-born,  in  which  miliary  gummata  first  occur,  followed  by 
hepatization  of  large  zones  or  an  entire  lung.  The  chief  changes  are 
an  infiltration  of  the  alveolar  walls,  while  the  air-cells  are  filled  with 
desquamated  epithelium ;  on  section  the  tissue  presents  a  grayish-white 
appearance. 

Symptoms. — From  what  has  just  been  stated  it  is  clear  that  a 
certain  limited  number  of  cases  present  symptoms  and  signs  that  simu- 
late ordinary  ulcerative  phthisis,  but  do  not  show  bacilli  in  the  sputum, 
and  hence  have  no  connection  with  genuine  phthisis.  There  is  another 
group  of  cases  in  which  the  picture  presented  to  view  is  almost  identical 
with  that  of  fibroid  induration  though  usually  giving  a  distinctly  syph- 
ilitic history.  I  am  not  prepared  to  say  that  there  is  an  acute  syphilitic 
broncho-pneumonia  analogous  to  acute  pneumonic  phthisis,  though  I 
fail  to  see  any  reason  why  malignant  syphilis  may  not  attack  the  lung 
and  take  that  form.  The  symptoms  may  be  too  few  and  too  mild  to 
afford  ground  for  suspicion. 

Diagnosis. — If  a  suspected  case  is  treated  early  and  accurately,  the 
result  may  serve  to  corroborate  the  diagnosis,  which  is  at  first  far  from 
being  final. 

Bronchiectasis,  dependent  upon  syphilitic  peribronchitis  or  intersti- 
tial pneumonia,  cannot  be  discriminated  from  other  forms  of  that  disease 
except  there  be  a  clear  history  of  infection,  and  unless  associated  scars 
or  active  syphilitic  lesions  coexist.  Pulmonary  tuberculosis  cannot  be 
distinguished  from  pulmonary  syphilis  without  a  careful  microscopic 
examination  of  the  sputum.  Moreover,  it  must  not  be  forgotten  that 
luetics  often  develop  ulcerative  phthisis,  and  hence  these  affections  are 
often  combined. 

Syphilis  of  the  Spleen. 

Pathologically,  syphilis  of  the  spleen  is  to  be  classed  with  the  general 
adenopathy  of  the  disease.  According  to  the  statistics  of  See  (relating 
to  hereditary  syphilis)  and  of  Avanzini  and  Schuchter  (relating  to  ac- 
quired syphilis),  in  about  25  per  cent,  of  the  cases  of  secondary  syphilis 
hypertrophy  of  the  spleen  may  be  noted.  This  augmentation  begins 
from  two  to  four  weeks  after  the  appearance  of  the  chancre,  and  gradu- 
ally increases,  persisting  throughout  the  secondai'y  period ;  it  is  not, 
however,  observed  during  the  tertiary  stage.  It  is  often  accompanied 
by  localized  pain — syphilitic  pleurodynia  (Besnier). 

Syphilis  of  the  Circulatory  System. 

The  Heart. — The  pathologic  divisions  are — (a)  Gummata,  which 
attack  chiefly  the  walls  of  the  left  ventricle.     They  are  usually  encysted. 


SYPHILIS  OF  THE  ARTERIES,  ETC.  339 

(h)  A  Fihro-sclerotie  Myocarditis. — The  process  begins  in  the  peri- 
vascular tissue  and  proceeds  from  the  vessel  walls  outward  (Mracek). 
It  is  diffuse,  as  a  rule,  and  leads  to  narrowing  of  the  lumina  of  the  cor- 
onary arteries  and  their  branches  or  to  aneurysmal  bulgings,  but  the 
pathologic  effects  of  these  lesions  are  seldom  detected  clinically.  Sud- 
den death  may  occur. 

{c)  Syjjhilitie  Endocarditis. — The  changes  are  of  the  fibro-sclerotic 
variety,  and  not  of  the  more  acute  verrucose  or  warty  type.  The  symp- 
toms to  which  the  lesion  gives  rise  are  depicted  under  Organic  Valvular 
Disease. 

Syphilis  of  the  Arteries. 

Two  forms  are  recognized :  (a)  Obliterating  Endarteritis. — Here  the 
syphilitic  product  consists  chiefly  of  proliferated  subendothelial  tissue, 
which  encroaches  more  and  more  upon  the  lumen  of  the  vessel — a  fact 
to  which  the  disease  owes  its  name.  This  so-called  "  Heubner's  degen- 
eration "  is  not  peculiar  to  syphilis,  but,  as  Osier  says,  "if,  however, 
there  are  gummata  in  other  parts,  or  if  there  be  gummatous  periarter- 
itis in  adjacent  vessels,  the  process  may  be  regarded  as  syphilitic." 

(h)  Gummatous  Periarteritis. — This  results  in  larger  or  smaller  nod- 
ules or  ovoid  masses  that  may  encircle  the  artery.  Among  common 
seats  are  the  cerebral  and  coronary  vessels,  the  growth  starting  in  the 
adventitia  and  proceeding  outward.  According  to  the  views  of  syphil- 
ographers  of  the  present  day,  it  is  to  be  classed  with  the  ravages  of  the 
disease,  and  hence  is  not  due  to  the  syphilitic  virus. 

Syphilis  of  the  arteries  has  an  important  etiologic  bearing  upon 
atheroma  and  aneurysm  {vide  Diseases  of  the  Arteries). 

Syphilis  of  the  Kidneys. 

Renal  syphilis  belongs  chiefly  to  the  tertiary  stage,  though  it  may 
appear  in  the  secondary. 

Pathology. — (a)  Amyloid  degeneration  is  a  common  renal  lesion. 
(h)  Granular  atrophy  (Jaccoud). 
(c)  Gumma. 
Symptoms. — Except  in  the  case  of   amyloid  degeneration  the  con- 
ditions are  impossible  of  correct  diagnosis.     Wagner  describes  a  special 
form  which  he  calls  acute  sypliilitic  glomei'ulo-nephritis.     Clinically,  it 
is  characterized  chiefly  by  hematuria,  and  ends  rapidly  with  uremia. 

Syphilis  of  the  Joints. 

The  following  division  of  the  affection  is  made  by  Hutchinson  of 
London : 

(1)  Synovitis  appears  during  the  secondary  stage,  but  soon  clears 
away  under  appropriate  treatment,  leaving  no  traces  behind. 

(2)  Perisynovial  gummata. 

(3)  Arthritis,  due  to  osseous  nodes  or  gummata  in  the  neighborhood 
of  the  joints. 

(4)  True  Chronic  Synovitis. — This  is  the  most  common  form  of  syph- 
ilitic arthritis. 


340  lyFECTIOUS  DISEASES. 

(5)  Syphilitic  cTiondro-arthritis  (Virchow). 

The  last  four  forms  belong  to  the  tertiary  lesions. 

Symptoms. — It  is  to  be  borne  in  mind  that  a  joint-aiFection  that  does 
not  yield  to  specific  treatment  is  not  necessarily  non-syphilitic. 

Perisynovial  gumma  attacks  most  frequently  the  tissues  around  the 
knee-joint;  it  is  very  chronic  in  its  course  and  is  more  commonly  seen 
in  women  than  in  men. 

Arthritis  due  to  osseous  nodes  has  a  special  diagnostic  feature  in  the 
severe  nocturnal  pains.  The  fourth  form  of  syphilitic  arthritis  (true 
chronic)  is  the  most  common  among  the  types  due  to  ac<juired  syphilis, 
while  the  symmetric  synovitis  of  the  knees  occurring  about  puberty  is 
perhaps  peculiar  to  the  congenital  cases. 

Syphilis  of  the  Testicles. 

The  lesions  are  of  two  forms :  [a)  Gummata. — These  produce  hard, 
usually  nodular,  swellings,  either  single  or  multiple,  and  of  moderate  size, 
that  occupy  the  substance  of  the  testicle  and  sometimes  the  epididymis. 

{b)  Interstitial  Orchitis. — This  is  a  fibro-sclerotic  change  that  leads  to 
slow,  gradual  atrophy.  Though  bilateral,  it  is  usually  more  marked  on 
one  side  than  the  other.  Epididymitis  occasionally  develops  as  a  lesion 
of  early  secondaries.  It  is  usually  unilateral,  painless,  and  quickly  dis- 
ajipears  under  treatment.     In  the  tertiary  stage  gummata  may  develop. 

Diagnosis. — In  gummatous  orchitis  the  swelling  of  the  testicle  is 
painless,  usually  nodular,  and  feels  much  like  a  scirrhous  growth. 
Rarely  it  ulcerates,  forming  a  fungous  testicle.  The  frequency  of  syph- 
ilitic involvement  of  the  organ  forms  a  leading  factor  in  the  diagnosis. 

In  tuberculous  disease  the  history  and  associated  lesions  differ  from  - 
those  of  syphilitic  orchitis,  and  the  epididymis  is  generally  affected. 
Atrophied  testicles  may  be  due  to  congenital  syphilis.  In  such  in- 
stances typical  scars,  eye-affections,  and  the  characteristic  physiognomy 
are  usually  to  be  noted.  Hydrocele  may  owe  its  origin  to  the  same 
cause.  Atrophy  of  the  testes  may  lead  to  impotency  and  sterility.  Such 
instances  are  not  to  be  mistaken  for  the  results  of  metastasis  in  mumps. 

General  Diagnosis  of  Syphilis. — Perhaps  sufficient  has  been 
said  regarding  the  importance  of  obtaining  a  correct  statement  with 
reference  to  the  primary  infection.  On  failure  to  find  evidence  of  a 
genital  chancre,  an  examination  for  extragenital  primary  sores  must  be 
instituted,  and  the  latter  will  be  found  to  be  by  no  means  rare,  even 
among  children. 

The  secondaries  are  rarely  puzzling,  especially  when  the  previous 
history  is  complete.  There  may  be  complicating  eruptions.  In  Bulk- 
lev's  records  of  300  cases,  23  well-recognized  affections  of  the  skin  Avere 
associated  Avith  syphilis.  In  this  connection  two  facts  need  to  be  em- 
phasized :  first,  that  a  syphilitic  eruption,  either  macular  or  papular, 
may  rarely  cause  troublesome  itching ;  and  second,  that  a  patient  with 
a  syphilitic  eruption  may  experience  itching  due  to  another  cause — 
namely,   eczema  or  scabies. 

Inherited  syphilis  maybe  diagnosticated  on  the  appearance  in  a  child 
under  five  months  of   snuffles    and    the  characteristic  skin-eruptions. 


SYPHILIS.  341 

Syijhilis  hereditaria  tarda  maybe  recognized  either  from  a  retrospective 
view  or  from  the  presence  of  active  lesions  and  symptoms. 

The  recognition  of  the  tertiary  manifestations  of  acquired  syphilis 
embraces  these  points  :  1.  The  consideration  of  the  fact  that  obscure 
cases  in  general  and  atypical  symptom-groups  are  often  due  to  the  syph- 
ilitic taint.  2.  Direct  information  or  proof,  as  the  result  of  careful 
inquiry,  to  show  that  the  primary  and  secondary  stages  (either  one  or 
other,  or  both)  have  transpired.  3.  The  evidence  presented  by  the 
patient  and  to  be  obtained  by  the  careful  objective  examination  of  the 
eves  (for  iritic  adhesion,  etc.),  throat  and  skin  (for  scars),  bones  (for 
necrosis  and  nodes),  and  the  testes.  4.  Certain  symptoms  are  signif- 
icant, such  as  nocturnal  pains,  paralysis  of  the  single  cranial  nerves, 
double  deafness  without  otorrhea,  etc.  5.  The  therapeutic  test  may  aid 
in  doubtful  cases. 

The  presence  of  scars  constitutes  a  most  important  factor  in  making 
a  retrospective  diagnosis.  Recent  scars  are  pigmented,  and  exhibit  a 
slow,  progressive  clearing  up,  until,  from  four  to  eight  years  after  in- 
fection, they  are  wholly  decolorized.  On  the  other  hand,  as  pointed 
out  by  Hyde,  eczemato-varicose  scars  remain  stationary.  These  scars 
are  apt  to  be  found  on  the  scalp  and  on  the  anterior  surfaces  of  the  legs. 
They  may  be  single  or  multiple,  and  may  exhibit  certain  defined  shapes 
(semilunar,  dumb-bell,  etc.). 

Justus's  blood-test  for  syjyJtilis,  which  consists  in  a  sharp,  transient 
reduction  of  the  hemoglobin  after  the  administration  by  inunction  or 
hypodermic  injections  of  mercury,  is  not  pathognomonic,  but  an  aid  in 
diagnosis. 

General  Differential  Diagnosis. — Numerous  affections  and  conditions — 
local  and  general — are  liable  to  be  confounded  with  syphilis.  Mere 
allusion  to  some  of  these  common  errors  of  diagnosis  can  be  made  here, 
while  others  must  be  omitted  altogether  : 

(a)  The  primary  sore  of  the  lip  has  been  mistaken  repeatedly  for 
cancer.  The  history  and  symptoms  of  syphilis,  together  with  the  ther- 
apeutic test,  must  clear  up  the  doubt. 

(b)  Certain  skin-eruptions  (lichen,  psoriasis,  papular  eczema,  etc.) 
may  be  mistaken  for  the  eruption  of  secondary  syphilis.  J.  V.  Shoe- 
maker ^  details  the  differential  diagnosis  in  a  recent  article,  which  the 
reader  who  desires  full  information  may  consult. 

(c)  Care  must  be  exercised  lest  the  specific  eruptive  fevers,  especially 
the  papular  stage  of  small-pox,  be  mistaken  for  secondary  syphilis. 

{d)  The  syphilitic  arthritis  which  may  develop  at  the  onset  of  the 
second  stage  must  be  discriminated  from  rheumatic  arthritis — an  easy 
task  if  only  the  attention  be  drawn  to  the  primary  lesion  and  the  cha- 
racteristic secondaries  in  cases  of  the  former  disease. 

(e)  Syphilis  in  the  tertiary  stage  may  simulate  chronic  gout  or  rheu- 
matism, and  unless  there  is  definite  evidence  of  syphilis  on  the  one  hand, 
or  typical  rheumatic  symptoms  and  history  on  the  other,  the  diagnosis 
may  remain  indefinitely  uncertain.     The  therapeutic  test  may  aid. 

(/)  Periosteal  nodes,  like   those  occurring  in  syphilis,  may  follow 
vaccination,  small-pox.  typhus  and  typhoid  fevers.     Here   the  history 
and  associated  phenomena  furnish  reliable  data  for  discrimination. 
1  Medir-al  Bulletin,  Xov.,  1893. 


342  INFECTIOUS  DISEASES. 

(g)  Carcinoma  of  the  tonsil  has  often  been  diagnosed,  and  the  tonsils 
have  been  excised  when  really  the  seat  of  a  syphilitic  lesion. 

(It)  Janeway  ^  asserts  that  chronic  syphilitic  fever  and  tuberculosis 
are  not  rarely  confounded. 

Treatment. — [a)  Prophylaxis. — To  prevent  the  transmission  of 
hereditai'y  syphilis  infected  persons  should  not  marry  within  four  years 
after  the  appearance  of  the  primary  sore.  "  Marriage  should  also  be 
prevented  when  the  patients  have  not  been  subjected  to  a  thorough  and 
prolonged  treatment"  (Porter).  If  at  the  end  of  the  third  year  the 
patient  presents  a  mucous  patch,   he  must  wait  one  year  longer. 

Should  a  healthy  mother  bear  a  S3'philitic  child,  she  must  not  be 
allowed  to  suckle  it.  This  precaution,  though  apparently  contrary  to 
the  principle  laid  down  in  Colles's  law,  is  not  superfluous,  since  the 
mother  might  be  infected  by  any  oozing  fissures  or  condylomata  upon 
the  lips  or  in  the  mouth  of  the  child  if  erosions  of  her  nipple  Avere  to 
occur.  Wet-nurses  should  not  be  employed  for  syphilitic  children,  but 
may  be  for  non-syphilitic,  even  when  the  mother  is  affected.  If  syphilis 
appear  in  the  mother  during  pregnancy,  antiluetic  treatment  should  be 
begun  and  persisted  in  even  after  apparent  recovery.  After  the  birth 
of  the  child  treatment  should  be  continued,  if  the  child  be  nursed  by 
the  mother,  with  a  view  to  medicating  the  milk. 

As  has  already  been  stated,  the  most  frequent  mode  of  infection  is 
irregular  and  illicit  sexual  congress,  and  it  follows  that  absolute  moral 
purity  would  go  further  toward  the  prevention  of  this  widespread  malady 
than  any  sanitary  code  or  legal  restrictions.  Physicians  cannot  too 
strongly  advocate  continence.  Should  prostitution  be  regulated  and 
controlled  by  the  state  ?  Experience  has  shown  that  but  a  slight  con- 
trol is  exercised  over  the  spread  of  syphilis  in  countries  where  system- 
atic regulation  of  prostitution  is  attempted  by  the  state.  I  am  of  opinion 
that  the  state  should  maintain  some  form  of  sanitary  regulation  and  con- 
trol, but,  unfortunately,  to  render  this  efficient  demands  that  prostitutes 
shall  be  officially  registered.  Such  a  sanitary  supervision  should  consist 
in  the  examination  of  every  prostitute  at  least  twice  a  week,  including 
a  microscopic  examination  of  the  uterine  and  vaginal  secretions,  and  the 
sending  of  every  diseased  prostitute  to  a  hospital  with  a  special  depart- 
ment for  such  cases. ^  Palmer  suggests  that  the  female  offender  is  usually 
not  aware  of  the  existence  of  a  primary  sore,  Avhile  the  male  is ;  hence 
the  latter  should  undergo  inspection  also.  Inspection  of  prostitutes, 
however,  unless  rigid  and  careful,  is  absolutely  valueless.  Chancres  are 
often  concealed  from  view  in  the  vagina  or  upon  the  lateral  aspect  of  the 
OS  uteri.  The  maintenance  of  legal  brothels,  however,  is  not  here  rec- 
ommended, either  from  a  moral  or  hygienic  standpoint. 

{h)  Medicinal  Treatment  of  Hereditary  Syphilis. — For  syphilis  of  the 
new-born,  mercury,  either  in  the  form  of  calomel  (gr.  J^-0.0064,  t.  i.d.) 
or  gray  powder  (gr.  -1—0.0324,  t.  i.  d.),  is  to  be  employed.  These  babies 
must  be  hand-fed.     The  issue  is  almost  unexceptionally  bad. 

"When  the  first  symptoms  appear  at  the  second  or  third  month  the 
above  method  of  treatment  is  generally  successful.  Among  the  poorer 
classes  no  objection  is  made  to  mercurial  inunctions,  and  these  are  often 

'  American  Journal  of  the  Medical  Sciences,  Sept.,  1898. 

'  The  Berlin  Commission  on  the  Prevention  of  Syphilis,  Dec.  1,  1892. 


SYPHILIS.  343 

preferable.  The  ointment  may  be  rubbed  into  the  armpits,  thighs,  or 
sides  of  the  abdomen,  which  should  be  covered  with  a  flannel  roller. 
The  parts  must  be  kept  clean  ;  and  the  mouth  washed  after  nursing  Avith  a  3 
per  cent,  solution  of  boric  acid.  Shaw  prefers  to  treat  infantile  syphilis 
by  inunctions,  because  of  the  digestive  disturbances  usually  following 
the  internal  administration  of  mercury  to  children.  SypJiilis  heredita- 
ria tarda  is  best  treated  by  the  use  of  potassium  or  sodium  iodid.  To 
the  iodid  may  be  added  mercuric  chlorid  in  suitable  doses,  though  the 
latter  may  sometimes  disagree  (Roberts).  In  addition  to  the  specific^ 
therapy,  tonic  measures  are  usually  indicated. 

(c)  Treatment  of  Acc[uired  Syphilis. — There  is  a  specific  plan  of  treat- 
ment which  should  be  commenced  as  soon  as  the  appearance  of  the  sec- 
ondaries has  set  the  diagnosis  of  the  given  case  at  rest.  This  is  the  use 
of  mercury,  and  rarely  of  potassium  iodid  also.  The  instances  in  which 
the  latter  alone  is  to  be  administered  are  rare.  Fournier's  "  chronic  in- 
termittent treatment  "  of  syphilis — which  consists  in  continuous  medica- 
tion for  two  or  three  years  with  mercury  and  iodin  alternately — is' 
warmly  advocated  by  some  syphilographers ;  but  the  continuous  mode 
is,  in  the  opinion  of  most  specialists,  of  greater  advantage  to  the  patient. 
Unless  mercury  disagree  or  the  patient  is  exceedingly  susceptible  to  its' 
physiologic  effects,  I  use  it  persistently  during  the  secondaries,  and  later 
at  intervals  until  the  end  of  two  years.  It  is  a  protracted  course,  and  a 
protracted  course  only,  of  the  specific  treatment  that  suffices  if  we  would 
obviate  the  dread  ravages  that  otherwise  are  so  apt  to  appear.  I  usually" 
employ  the  protiodid  (gr.  \—^ — 0.008-0.021,  three  times  a  dav),  an^ 
later  the  biniodid  (gr.  ^i^-^L-lo. 0021-0. 0027,  three  times  a  day).  We 
should  begin  by  giving  one  pill  three  times  daih',  and  increasing  one  pill 
each  day  until  the  premonitory  symptoms  of  ptyalism  appear  (ten- 
derness when  the  teeth  are  knocked  together,  and  ropy  saliva);  then 
the  pills  .should  be  reduced  \  or  |-,  depending  upon  the  number, 
taken.  By  this  procedure  the  physician  is  able  to  ascertain  for  each 
case  the  largest  dose  of  mercury  that  can  be  given  without  harm. 
Hutchinson  recommends  the  gray  poAvder  given  in  pill-form,  com- 
bined with  Dover's  powder  [da  gr.  j-0.0648),  this  pill  to  be  taken  from 
four  to  six  times  daily.  A  well-known  mixture,  freely  prescribed  in, 
many  dispensaries,  contains  mercuric  chlorid  and  potassium  iodid  in 
combination. 

Inunctions  of  mercurial  ointment  (gss — 2.0,  night  and  morning)  pro- 
duce excellent  results,  and  it  is  advisable  in  cases  in  Avhich  the  syphilids 
yield  unsatisfactorily  to  internal  dosage  to  suspend  the  latter  at  intervals 
of  six  or  eight  weeks  and  give  a  course  of  inunctions.  "White  advances 
the  view  that  in  the  later  stages,  with  the  involvement  of  the  deeper  tissues, 
the  combined  use  of  inunctions  over  the  affected  region  with  potassium 
iodid  internally  often  seems  to  have  distinct  advantages  as  compared 
with  the  administration  of  the  "mixed  treatment"  by  the  mouth.  It 
is  necessary  to  omit  the  inunction  once  in  seven  or  eight  days  for  one 
day,  and  to  take  a  warm  bath  to  aid  in  the  elimination  of  the  mercury. 

The  hypodermic  use  of  mercury  in  syphilis  is  to  be  adopted  only  when 
very  prompt  action  of  this  agent  is  desired.  Several  preparations  are 
used,  and  whether  these  are  soluble  or  insoluble  is  a  matter  of  little  mo- 
ment.    The  bichlorid  takes  first  place,  the  dose  being  gr.  1  (0.0162),  in 


344  INFECTIOUS  DISEASES. 

15  to  20  drops  of  water,  twice  a  week.  Calomel  probably  holds  sec- 
ond place  (dose.  gr.  j — 0.0648.  in  15  drops  of  glycerin,  twice  a  week). 
Among  other  preparations  employed  are  the  peptonate  of  mercury  and 
gray  oil.  All  injections  must  be  made  deeply  into  the  muscles.  The 
subcutaneous  injection  of  sterilized  serum  from  the  blood  of  lambs  and 
calves  has  been  successfully  practised  by  Tommasoli. 

TJie  method  of  fumigation  has  gained  favor,  particularly  in  the 
treatment  of  syphilis,  in  institutions  on  the  Continent.  Lane  rec- 
ommends that  calomel  (siss — 6.0)  be  put  in  a  china  bowl  about  half 
filled  with  water ;  a  spirit  lamp  is  placed  under  this,  and  the  pa- 
tient, ''sitting  above  it  wrapped  in  a  cloak,  has  a  deposit  of  mer- 
cury settle  all  over  his  body  as  the  calomel  is  sublimed."  He  should 
remain  wrapped  in  the  cloak  for  one  hour,  take  a  fumigation  once  daily, 
and  remain  in-doors.  From  six  weeks  to  three  months  are  necessary 
to  effect  a  cure. 

The  teeth  should  be  cleaned  thrice  daily.  Hygiene  plays  no  mean 
role  in  the  successful  management  of  syphilis.  The  diet  must  be  liberal, 
thoucrh  ffreen  vegetables  and  fruits  are  not  to  be  taken.  Alcohol  and 
tobacco  are  the  two  great  enemies  of  the  luetic. 

Auxiliary  measures,  when  the  disease  is  associated  with  other  lesions, 
are  important.  If  syphilis  occur  in  a  tuberculous  subject,  it  is  of  great 
value  to  add  the  potassium  iodid  to  the  mercurial,  and,  if  active  tubercu- 
lous lesions  are  present,  cod-liver  oil  and  creasote  as  well.  Anemia  and 
debility  call  for  iron  and  a  tonic  plan  of  treatment  generally.  Attention 
should  be  given  to  the  stomach,  bowels,  kidneys,  and  other  internal 
organs,  as  well  as  to  the  nervous  system. 

In  women  the  iodids  should  be  suspended  during  menstruation  if 
the  flow  of  blood  is  excessive,  but  not  the  mercury.  Says  Mauriac  : 
"  During  pregnancy  specific  treatment  is  well  tolerated,  and  often  re- 
quires to  be  pushed  to  a  point  a  little  short  of  intoxication  for  the  good 
of  both  the  mother  and  the  child,  close  watch  being  kept  upon  the  kid- 
neys, suspending  treatment  at  the  first  sign  of  albumin." 

(d)  Treatment  of  Tertiary  Syphilis. — For  most  tertiary  manifestations, 
including  visc-t-ral  <yphilis.  we  have  a  therapeutic  specific  in  potassium 
iodid.  This  should  be  used  alone,  the  inunctions  of  mercury  being 
added  if  the  iodid  fails  to  produce  the  desired  result.  I  give  the  potas- 
sium iodid  in  a  saturated  solution,  one  minim  being  equal  to  f  grain  of 
the  salt.  I  use  gr.  x  (0.648)  t.  i.  d.  at  the  first  dose,  and  increase  the 
latter  1  grain  (0.0648)  each  day  until  the  manifestations  for  which  it  has 
been  prescribed  disappear  or  iodism  is  induced.  It  is  best  given  in  milk. 
In  cases  showing  cerebral  symptoms  it  is  to  be  cautiously  used,  and  it  is 
then  my  custom  to  combine  the  iodid  with  potassium  bromid. 

In  hepatic  syphilis  the  mercurials  are  usually  combined  with  iodids 
from  the  start,  and  particularly  calomel  if  there  be  ascites  or  jaundice. 

In  nervous  syphilis,  especially  in  the  graver  forms,  I  begin  with  large 
doses  (gr.  xx — 1.296,  three  times  a  day),  and  augment  as  above  indi- 
cated. The  limit  of  doses  depends  upon  the  effect  produced.  I  have 
often  found  sodium  iodid  to  agree  better  with  the  stomach  than  the 
potassium  salt.  Most  syphilitics  tolerate  the  iodids  to  a  remarkable  de- 
gree ;  on  the  other  hand,  a  few  show  a  marked  idiosyncrasy  to  them. 
Among  unpleasant  effects  are  coryza,  conjunctivitis  with  edema  of  the 


LEPROSY.  *  345 

eyelids,  salivation,  and  certain  skin-eruptions  (erythema,  urticaria,  etc.). 
In  this  form  of  syphilis,  as  in  the  earlier  stages,  the  specific  treatment 
is  made  much  more  effective  by  attention  to  certain  hygienic  measures 
— fresh  air,  appropriate  diet,  bathing,  exercise,  and  rest. 


LEPROSY. 

[Lepra.) 


Definition. — A  chronic,  contagious  disease,  caused  by  the  bacillus 
lepras.  It  is  distinguished  by  constitutional  depression  and,  pathologi- 
cally, by  tuberculous  masses  in  the  muco-cutaneous  surfaces,  and  by 
changes  in  the  nerves. 

Historic  Note. — In  1889,  Morrow  stated  that  in  India  alone 
there  were  certainly  not  less  than  150,000  lepers,  while  at  present  it  is 
estimated  that  there  are  over  250,000.  Its  geographic  distribution 
probably  covers  more  than  one-third  of  the  entire  surface  of  the  globe. 
It  is  common  in  Africa,  Brazil,  in  the  East,  and  in  Norway.  In  the 
Sandwich  Islands  the  disease  is  of  comparatively  recent  origin,  and 
yet  of  great  and  increasing  prevalence,  a  leper  settlement  having 
been  established  consisting  of  more  than  11,000  cases.  Leprosy  is  not 
unknown  in  America,  and  in  Mexico  it  has  existed  ever  since  the  time 
of  Cortes  (Morrow).  Blanc  states  that  there  are  75  to  100  lepers  in 
Louisiana  alone.  It  was  introduced  into  California  and  Oregon  by  the 
Chinese,  and  into  Illinois,  Iowa,  Wisconsin,  and  Minnesota  by  Scandi- 
navian immigrants.  It  has  been  imported  from  the  Sandwich  Islands 
to  Salt  Lake  City,  and  from  Normandy  to  Tracadie  on  the  Gulf  of  the 
St.  Lawrence,  where  the  "disease  is  limited  to  two  or  three  counties 
which  are  settled  by  French  Canadians  "  (Osier).  Sporadic  cases  have 
been  met  with  in  most  of  the  larger  American  cities. 

Pathology. — The  bacilli  groAv  and  develop  in  clusters  in  the  tuber- 
culous nodules  in  the  skin,  residing  within  the  epithelioid  cells  and  leu- 
kocytes. These  so-called  lepra-cells  are  probably  derived  from  the  lym- 
phatic vessels  or  capillaries,  having  been  transformed  by  the  bacilli. 
Surrounding  the  granulomatous  masses  is  a  layer  of  connective  tissue. 
The  bacilli  are  also  found  in  the  lymphatic  glands,  the  spleen,  and  liver, 
but  rarely  in  the  blood.  The  nodular  tumors  form  projections  from  the 
skin-surface,  and,  being  poorly,  supplied  with  blood-vessels,  they  soon 
undergo  caseation  and  absorption  or  are  obliterated  by  dense  connective 
tissue,  which  leads  to  the  condition  known  2b?,  fades  leontina.  The  pus- 
organism  generally  exercises  an  influence  in  causing  suppuration  with 
ulceration,  which  may  manifest  a  marked  destructive  tendency.  Sim- 
ilar changes  occur  in  the  internal  organs  or  in  the  mucous  mem- 
branes. 

Nerve-lesions  are  induced  by  the  presence  of  the  bacilli  within  and 
around  the  nerves.  Here  they  first  set  up  an  irritation  with  hyperes- 
thesia (neuritis),  which  leads  to  atrophy,  with  marked  degenerative 
changes. 


346  •        INFECTIOUS  DISEASES. 

Btiology. — Bacteriology. — In  1880,  Hansen  discovered  the  bacillus 
leprae,  which  has  since  been  proved  to  be  the  special  agent  of  the  dis- 
ease. It  strongly  resembles  the  tubercle  bacillus,  but  differential  stains 
have  been  suggested  by  Unna  and  others.  The  British  Leprosy  Com- 
mission have  shown  that  the  bacillus  can  be  cultivated,  but  inoculation 
experiments  on  animals  have  not  as  yet  succeeded. 

Predisposing  Causes. — Every  one  is  susceptible  to  leprosy,  but  the 
disease  is  most  frequent  between  the  twentieth  and  fortieth  years,  and 
is  rare  in  childhood.  Sex  and  latitude  have  little  if  any  influence. 
Hereditary  transmission  probably  influences  about  one-fortieth  of  the  in- 
stances (Zambaco).  Heredity  is  denied  by  both  Hansen  and  Ram- 
inez.  As  pointed  out  by  Bidenkap,  leprosy  is  often  rare  in  large 
cities,  even  though  it  is  quite  prevalent  in  the  surrounding  rural 
districts. 

Modes  of  Infection. — The  disease  is  transmitted  by  contact ;  but 
Widal  and  others,  who  have  studied  the  disease  as  it  exists  in  the 
Hawaiian  Islands,  think  that  leprosy  is  contagious  only  by  inocula- 
tion. Morrow's  view,  that,  like  syphilis,  leprosy  is  generally  trans- 
ferred by  sexual  intercourse,  receives  support.  Hansen  holds  that 
the  "way  in  which  the  bacillus  enters  the  body  is  unknown ;  he  thinks 
it  probable  that  the  mouth  and  nasal  cavities  are  the  avenues  of 
entrance. 

Clinical  History. — Two  forms  are  recognized,  the  tubercular  and 
the  anesthetic,  while  a  third  or  mixed  type  is  described  by  some  authors. 
Neither  of  the  first  two.  however,  runs  its  entire  course  without  develop- 
ing into  a  third  or  mixed  form. 

The  incubation  is  usually  long  (three  to  five  years — Hansen),  but 
it  may  rarely  be  a  shorter  period.  Vague  prodromes  are  present  for 
years  (drowsiness,  chilliness,  irregularly  recurring  attacks  of  fever, 
debility). 

(1)  Tubercular  Form. — In  the  first  stage  there  is  a  patchy,  cutaneous 
eri/thema  with  a  slight  hyperesthetic  elevation  of  the  affected  areas. 
These  are  ofteuest  seen  on  the  face  or  upon  the  extensor  surfaces  of  the 
arms  and  knees.  They  may  vanish  after  a  while  and  leave  the  skin  pig- 
mented and  anesthetic,  and  later  the  pigment  may  disappear,  while  white 
spots  of  corresponding  size  remain  (lepra  alba). 

When  the  disease  progresses  less  favorably  tuberculous  nodules  (dusky- 
red  or  almost  brown  in  color)  develop  in  addition  to  anesthesia.  The 
small  ones  soon  disappear,  while  the  large  ones  are  either  absorbed  or 
break  down  and  ulcerate — changes  which,  as  they  advance  together  with 
the  slow  healing  process,  produce  marked  deformities.  The  skin  is 
greatly  thickened  and  presents  a  scaly  surface,  and  there  is  loss  of  sub- 
stance in  certain  parts,  while  others  are  enormously  enlarged  (eye- 
brows, nostrils,  lips,  etc.).  Among  the  many  symptoms  pointing  to  in- 
volvement of  the  mucous  membrane  are  ozena,  hoarseness  or  even 
aphonia,  and  the  signs  of  inhalation-pneumonia.  To  the  last-named 
disease,  as  well  as  to  ulcers  extending  deeply  into  the  mucosa  of  the 
pharj'nx  and  larynx,  death  may  often  be  ascribed. 

(2)  Anesthetic  Form. — In  this  variety  the  local  symptoms  point  usu- 
ally to  implication  of  the  nerves.     At  the  onset  there  are  pain  and  patchy 


LEPROSY.  -  347 

hyperesthesia,  while  minute  bullae,  due  to  trophic  changes,  put  in  an  ap- 
pearance on  the  arms  and  legs.  The  muscles  supplied  by  the  branches 
of  the  affected  nerve-trunk  v/aste,  and  the  superficial  nerves  feel  thick- 
ened and  nodular.  Bright-red  patches  of  vaso-motor  congestion  appear 
and  soon  become  anesthetic,  while  the  maculas  disappear.  Anesthesia 
may  proceed  without  the  latter  eruption.  Dry,  yellowish-white,  scaly 
patches  upon  the  trunk  and  extremities  are  also  visible.  Early  their 
centers  alone  are  anesthetic,  but  subsequently  the  loss  of  sensation 
spreads  even  to  healthy  portions  of  the  skin. 

Tropliic  alterations  reach  an  extreme  degree.  Bullae  of  consid- 
erable size  appear,  and,  bursting,  leave  perforating  or  destructive 
ulcers,  usually  upon  the  extremities.  As  the  result  of  absorption, 
wasting,  and  necrosis  great  deformities  are  produced.  The  hands  often 
take  on  a  claw-like  form,  and  the  fingers  and  toes  may  disappear  {lepra 
mutilans). 

Diagnosis. — The  early  diagnosis  rests  upon  the  presence  of  patchy 
erythema  with  hyperesthesia,  followed  by  the  development  of  anesthesia, 
with  a  disappearance  of  the  macular  eruption.  Nodular  neuritis  is 
pathognomonic  of  anesthetic  leprosy.  In  the  advanced  stages  of  either 
form  confusion  could  scarcely  arise.  The  nodular  form  of  tubercular 
syphilis  is  distinguished  by  the  distribution  of  the  lesions,  the  history, 
and  the  frequent  sensory  nerve-lesions.  Zambaco  and  others  have 
claimed  that  syringomyelia  and  Morvans  disease  are  in  most  cases  but 
forms  of  leprosy ;  but  this  has  been  disputed  by  Hoffman,  Schlesinger, 
Sahli,  and  others.  Syringomyelia  depends  on  lesions  of  the  central 
nervous  system,  while  leprosy  has  its  nervous  lesions  in  the  peripheral 
nerves ;  and  on  this  basis  the  two  may  be  differentiated.  The  first 
symptoms  in  syringomyelia  are  localized  usually  in  the  upper  extrem- 
ities, while  in  leprosy  they  are  generalized.  In  leprosy  the  tactile  sense 
is  usually  lost,  in  syringomyelia  usually  not  lost.  That  Morvans  dis- 
ease is  a  disease-entity  has  been  disputed. 

Serum-diagnosis  of  Leprosy. — Spronck  ^  asserts  that  the  serum  of 
leprous  patients,  so  far  as  examined,  will  agglutinate  the  bacillus  in  dilu- 
tions of  1  to  60  or  1  to  1000.  There  is  probably  no  relation  between 
the  agglutinizing  power  of  the  blood  and  the  clinical  symptoms,  the  form 
or  the  intensity  of  the  leprosy. 

Prognosis. ^Leprosy  runs  a  very  chronic  course,  lasting  sometimes 
two,  three,  or  more  decades.  The  prognosis  as  to  the  final  issue  is  hope- 
less, but  the  patient  may  live  in  comparative  comfort  for  many  years 
before  the  ravages  of  the  disease  cause  great  mutilation. 

Treatment. — Here  may  be  mentioned  the  fact  that  certain  diseases 
are  supposed  to  exercise  a  retarding  effect  on  leprosy  (pleurisy,  pneu- 
monia, variola,  phthisis).  Antagonistic  inoculation,  however,  as  prac- 
tised by  Beaven  Rake  and  others,  has  been  practically  negative  in  its 
effects;  and  the  same  is  true  of  the  treatment  by  Koch's  tuberculin. 
The  disease  has  thus  far  resisted  all  methods  of  treatment  looking  to  a 
cure.  Phillippo  found  that  gurjun  oil  was  serviceable,  ulcers  being 
rapidly  cured  by  its  application:  the  oil  may  also  be  appalled  as  an  oint- 
ment to  the  swollen  parts.  Internally,  chaulmoogra  oil  has  been  employed 
by  Berge  and  Phillippo  with  excellent  results,  the  dose  being  from  1  to 

1  Sem.  med.  Sept.  28,  1898. 


348  INFECTIOUS  DISEASES. 

2  drams  (4.0-8.0).  It  is  sometimes  administered  in  pearls  (eacli  con- 
taining ni  3  to  5  (0.199-0.333),  in  ascending  doses,  until  the  limit  of 
tolerance  is  reached.  Surgical  interference  may  become  necessary. 
Segregation  of  lepers  has  been  instituted  in  certain  localities  with  en- 
couraging results.  Hansen  states  that  isolation  has  proved  the  most 
useful  method  of  preventing  the  spread  of  the  disease. 


GLANDERS. 

{Farcy). 


Definition. — An  infectious  disease  of  equine  origin,  and  caused 
by  the  bacillus  mallei.  Two  forms  are  recognized — true  glanders  and 
farcy. 

Pathology. — The  characteristic  lesions  are  new  growths  (granu- 
lomata,  according  to  Virchow),  which  are  usually  nodular  in  character, 
though  they  may  be  diffuse.  These  masses  soften  and  form  ulcers  Avhen 
they  occur  on  the  nasal  mucosa,  and  abscesses  Avhen  they  are  situated 
subcutaneously.  Microscopically,  the  nodular  tumors  are  composed  of 
cells — lymphoid  and  epithelioid — together  with  the  specific  bacillus. 

Ktiology. — The  morbid  changes  above  described  are  caused  by  a 
specific  organism,  the  haciUus  mallei,  which  resembles  closely  the  tuber- 
cle bacillus,  though  it  is  a  little  thicker  as  well  as  shorter.  It  is  non- 
motile.  It  can  be  readily  grown,  and  as  readily  inoculated  into  horses, 
in  which  it  produces  the  disease  with  every  characteristic  symptom. 
Perhaps  the  simplest  method  of  staining  the  bacillus  mallei  "  is  to  treat 
a  cover-glass  preparation  with  warm  carbol-fuchsin,  and  then  wash  it  oflf 
with  a  2  per  cent,  solution  of  niti'ic  acid." 

Modes  of  Infection. — The  virus  is,  as  a  rule,  transferred  directly  from 
the  infected  animal  to  man.  hence  the  disease  occurs  almost  invariably 
among  males  and  persons  who  come  in  contact  Avith  horses  (hostlers, 
coachmen,  soldiers,  horse-dealers,  and  farmers).  Transmission  from 
man  to  man  has  been  observed,  but  rarely.  The  medium  of  con- 
vevance  is  either  the  inis  or  the  nasal  secretions,  which  may  drop  upon 
a  Avound  in  the  skin  or  mucous  membrane,  however  slight,  and  be 
absorbed. 

Immunity. — The  disease  is  rare  in  man,  because  of  almost  com- 
plete natural  immunity.  Singer  has  produced  artificial  immunity 
by  intravenous  injections  of  sterilized  cultures  of  the  glanders  ba- 
cillus. 

Clinical  History. — The  duration  of  the  incuhation-period  is  from 
three  to  five  days,  and  rarely  longer.  Both  glanders  and  farcy  may  be 
acute  or  chronic  in  their  course. 

(1)  Acute  Glanders. — At  first  the  signs  of  inflammation  develop  at  the 
point  of  infection,  h/niphanf/itis  and  swelling  of  the  adjacent  lAnuphatic 
glands  being  associated.  Fever  and  other  evidences  of  general  disturb- 
ance soon  appear,  and  at  the  end  of  two  or  more  days  the  nasal  mucosa 


GLAXDEES.  349 

becomes  implicated,  ulcers  forming,  from  which  a  fetid  muco-purulent 
(sometimes  blood-streaked)  discharge  takes  place.  Xose-bleed  is  com- 
mon. Later  an  eruption  comes  out  on  the  face,  the  trunk,  and  the  ex- 
tremities, particularly  about  the  joints.  It  is  papular,  quickly  becoming 
pustular,  and  the  pustules  may  dry  up  while  fresh  papules  are  develop- 
incr — a  characteristic  feature.  The  face,  particularly  the  nose,  now 
swells,  and  a  bluish-brown  tumor  covered  with  vesicles  appears.  Impli- 
cation of  adjacent  mucous  membranes — conjunctivae,  pharynx,  mouth, 
etc. — is  usual,  and  less  frequently  the  bronchial  and  gastro-intestinal 
mucous  membranes  are  involved.  The  ulcerative  processes  may  extend 
to  the  bones,  setting  up  necrosis.  True  arthritis  occurs  in  10  per  cent, 
of  the  cases  (H.  Morel). 

Diagnosis. — Cases  have  been  mistaken  for  variola  ;  but  the  history 
of  exposure,  mode  of  onset,  the  nasal  symptoms,  and  the  course  of  the 
eruption  differ  from  those  of  the  latter  disease.  In  doubtful  instances 
pure  cultures  should  be  made,  and  inoculated  into  a  rabbit  or  guinea- 
pig.  Death  of  the  animal  infected  usually  occurs  Avithin  twenty-four 
hours. 

(2)  Chronic  G-landers. — A  rare  disease  with  mild  but  vague  general 
symptoms,  as  muscular  and  arthritic  pains,  fever  at  intervals,  asthenia, 
and  progressive  wasting,  and  the  local  features  of  nasal  catarrh,  with  a 
bloody  muco-purulent  discharge.  Cough  may  be  present.  The  diag- 
nosis demands  the  making  of  pure  cultures  and  of  inoculation-experi- 
ments. 

(3)  Acute  Farcy. — In  this  form  the  virus  is  inoculated  into  the  skin, 
which  presents  the  chief  symptoms,  the  nasal  condition  being  in  abey- 
ance or  absent.  The  primary  lesion  is  of  an  aggravated  type,  accompanied 
by  a  large  crop  of  cutaneous  boils  and  abscesses,  which  often  follow  the 
lines  of  the  lymphatics.  Their  favorite  seat  is  in  the  vicinity  of  the 
joints.  The  constitutional  symptoms  simulate  those  of  acute  pyemia. 
The  diagnosis  is  reached  in  the  same  manner  as  in  the  preceding 
forms. 

(4)  Ckronic  Farcy. — Granulomatous  tumors,  resulting  in  abscesses, 
constitute  the  chief  clinical  peculiarity.  The  abscesses  are  situated 
primarily  in  the  subcutaneous  tissues,  and  often  near  the  joints.  As  a 
rule,  they  open  spontaneously  and  discharge,  first  a  thick,  creamv  pus, 
and  later  a  thin,  fetid  material.  They  sometimes  form  distinct  ulcers, 
which  extend  in  depth  until  the  bones  are  involved. 

The  general  symptoms  simulate  those  of  chronic  glanders,  the  fever- 
curve  being  of  the  hectic  type.  In  advanced  cases  emaciation  and 
prostration  become  extreme.  The  duration  varies  from  ten  to  eighteen 
months,  though  death  may  result  earlier  from  some  associated  dis- 
ease. 

The  diagnosis  cannot  be  made  without  a  clear  history  of  contact  with 
an  animal  known  to  be  affected  with  the  disease,  or  by  the  experimental 
method  and  artificial  cultures.  One  of  the  products  of  the  bacillus 
mallei  is  so-called  "mallein,"  which  has  been  used  by  Xocard  and  others 
as  a  diagnostic  agent  in  animals.  Its  injection  into  horses  sufferintr 
from  glanders  is  followed  by  a  febrile  reaction.  Schindelke  injected  more 
than  six  hundred  horses  with  Forth 's  mallein,  and  his  results  show  that 
a  reaction  of  3.5°  F.  (2°  C.)  is  an  almost  positive  proof  of  glanders;  a 


350  INFECTIOUS  DISEASES. 

rise  exceeding  1.85°  F.  (1.5°  C.)  affords  a  strong  presumption;  while  a 
rise  of  1.25°  F.  (1°  C.)  is  suspicious.' 

Prognosis. — Acute  glanders  and  acute  farcy  are  almost  invariably 
fatal.  The  chronic  forms,  hoAvever,  and  particularly  chronic  farcy,  end 
in  recovery,  under  appropriate  treatment,  in  nearly  one-half  the  cases. 

Treatment. — The  primary  lesion  should  be  dealt  with  surgically, 
and  thorough  disinfection  followed  by  cauterization  is  highly  recom- 
mended. Bayard  Holmes  advocates  the  opening  of  fresh  abscesses  and 
the  scraping  out  of  old  ones  under  an  anesthetic.  A  supporting  plan 
of  treatment,  by  generous  feeding  and  judicious  stimulation,  is  to  be 
adopted,  and  the  symptoms  are  to  be  met  as  they  appear.  The  product, 
"mallein,"  has  been  recommended  as  a  specific  in  this  disease,  but 
even  Bonome,  Avho  reports  an  instance  in  which  recovery  followed  its 
use,  contends  that  its  curative  properties  have  not  yet  been  demonstrated. 


ACTINOMYCOSIS. 

('^ Big-jaw,"  '''■Lumpy-jaw"  etc.) 

Definition. — An  infectious  disease  of  cattle,  less  frequently  of  man, 
caused  by  the  ray-fungus  (actinomyces),  which  grows  in  the  tissues,  de- 
veloping a  mass  Avith  secondary  chronic  intiauimation  and  metastatic 
growth,   as  well  as  a  secondary  pyemic  infection. 

Historic  Note. — In  1877,  Bollinger  gave  the  first  description  of 
the  ray-fungus,  which  he  had  observed  in  the  disease  known  as  "  big- 
jaw  "  in  the  ox.  Israel  of  Berlin  discovered  the  fungus  in  man  one 
year  later.  In  1879,  Ponfick  showed  clearly  that  actinomycosis  in  man 
and  cattle  was  one  and  the  same  disease.  Murphy,  who  described  the 
first  case  of  actinomycosis  hominis  in  America,  states  that  up  to  the 
present  date  more  than  500  cases  have  been  reported. 

Pathology. — A  macroscopic  mass  is  produced,  consisting  of  a  cen- 
tral fungous  mass  from  which  threads  of  mycelia  radiate  in  all  direc- 
tions, producing  the  ray  form  of  growth.  Individual  growths  are  of 
the  size  of  a  millet-seed,  but  their  aggregation  may  result  in  masses 
as  large  as  an  orange.  They  are  generally  yellowish  and  of  tallowy 
consistence. 

MicroscopicaUii,  the  little  or  single  ray-like  tumors  show  straight  or 
wavy  branching  filaments  {loipra).  Their  development  is  accompanied 
by  the  growth  of  dense  adjacent  connective  tissue.  In  addition,  ab- 
scesses containing  yellow  granules  in  the  pus  occur,  but  these  are  sec- 
ondary. The  usual  lesions  are  not  the  same  as  those  described  as 
occurring  in  beasts.  In  man  the  lesions  are  those  of  chronic  pyemia, 
and  consist  of  a  metastatic  abscess-formation. 

Bacteriology. — The  organism  of  the  disease  belongs  to  the  cladothrix 

variety  of  fungus,  and  may  be  cultivated,  though  with  difficulty.     The 

finer  threads  may  readily  be  stained  with  anilin  colors.   The  club-shaped 

projections,  however,  do  not  take  these  stains,  so  that  when  examininor 

'  Saunders'  Year-Book  for  1896,  p.  1013. 


ACTINOMYCOSIS.  351 

sections  Gram's  method  may  be  used.  Rabbits  and  coavs  have  been  suc- 
cessfully inoculated  Avith  cultures  of  the  actinomyces. 

Modes  of  Infection. — Infection  generally  takes  place  through  the 
mouth,  teeth,  and  pharynx  ;  and  rarely  the  gate  of  entrance  for  the 
virus  is  the  air-passages  or  the  skin.  It  is  generally  introduced  with 
the  food  or  drink,  and  Bostroem,  from  a  study  of  32  cases,  concludes 
that  the  poison  enters  the  economy  by  means  of  the  ingested  grains  of 
some  cereal.  Infection  cannot  occur  through  a  normal  mucous  mem- 
brane or  skin,  but  a  wound,  however  insignificant,  is  essential. 

Clinical  History. — (1)  Oral  Actinomycosis. — The  patient  often  com- 
plains of  toothache,  dysphagia,  and  of  difficulty  in  opening  the  jaw. 
The  latter  symptom  may  be  owing  to  induration  of  adjacent  muscles, 
and  is  a  very  characteristic  sign  (Partsch).  .  At  the  angle  of  the  jaw 
a  swelling  appears,  which  quickly  passes  into  suppuration  ;  later  it  opens 
(first  externally,  then  into  the  mouth)  and  discharges  pus  containing 
little  yellow  masses.  If  not  properly  treated,  extension  of  the  process 
takes  place  in  a  downward  direction,  even  to  the  abdominal  organs. 

The  upper  jaw  may  be  the  primary  seat  of  infection,  and  if  so  the 
base  of  the  skull  may  be  perforated  and  the  disease  attack  the  meninges 
and  brain.  Bollinger  has  seen  primary  actinomycosis  of  the  brain.  In 
these  instances  caries  of  the  spine  may  result  from  extension. 

(2)  Pulmonaiy  Actinomycosis. — I  am  satisfied  that  primary  pulmonary 
actinomycosis  is  comparatively  rare,  although  Karewski  and  Butler  have 
each  recently  reported  an  instance.  In  Butler's  case  the  disease  fol- 
lowed an  injury  by  a  falling  board.  The  disease  begins  with  pain  in 
the  side,  and  more  often  upon  the  left,  due  to  pleurisy.  There  are  cough 
and  a  peculiar  (often  fetid)  expectoration,  together  with  general  Avasting. 
A  microscopic  examination  of  the  sputum,  if  made  with  care,  reveals 
the  actinomyces. 

In  some  instances  the  symptoms  are  identical  with  those  of  dissemi- 
nated tuberculosis  (Brigidi),  though  generally  the  disease  is  unilateral. 
There  is  irregular  fever,  due  chiefly  to  suppuration. 

The  physical  signs  may  be  those  of  chronic  bronchitis  merely;  but 
there  are,  in  not  a  fcAv  cases,  extensive  destructive  changes  of  variable 
character  (abscess,  broncho-pneumonia,  etc.)  which  modify  the  sisns 
accordingly.  In  primary  pulmonary  actinomycosis  an  extension  to  ad- 
jacent organs  and  also  metastatic  groAvths  and  abscesses  occur. 

(3)  Intestinal  Actinomycosis. — The  condition  may  be  primary  or  sec- 
ondary. The  organism  groAvs  upon  the  mucosa  of  the  intestine  and 
excites  a  proliferation  of  the  underlying  connective  tissue  cells,  and  the 
formation  of  submucous  nodules.  The  latter  ulcerate,  and  perforation 
of  the  serous  coat  of  the  boAvel  may  occur,  inducing  peritonitis.  Peri- 
cecal abscesses  have  been  formed  in  like  manner. 

The  symptoms  point  to  intestinal  catarrh,  there  being  some  o-astric 
disturbance,  Avith  irregular  and  recurring  attacks  of  diarrhea.  The 
actinomyces  has  been  detected  in  the  stools.  Secondary  metastatic 
groAA'ths  (rarely)  and  abscesses  may  arise  in  other  organs  (liver,  spleen, 
ovaries,  etc.),  but  it  is  to  be  recollected  that  the  primary  seat  of  infec- 
tion may  also  be  the  spleen,  liver,  or  other  viscera. 

(4)  Cutaneous  actinomycosis  rarely  occurs.  The  skin  presents  chronic 
suppurating  ulcers  Avhich  shoAv  the  presence  of  the  rav-fungus,  and  the 


352  INFECTIOUS  DISEASES. 

condition  bears  a  close  resemblance  to  a  lupus  patch,  as  in  a  case 
reported  by  Darier  and  Gautier. 

Diagnosis. — This  rests  solely  upon  the  finding  of  the  actinomyces. 
The  wooden  hardness  of  the  tissues  beyond  the  borders  of  the  ulcers  or 
sinuses,  the  hardness  of  the  neighboring  muscles  in  oral  actinomycosis, 
and  the  yellow  granules  in  the  pus  are  all  significant,  but  merely  cor- 
roborative. To  detect  the  actinomyces,  says  Warren,  sections  may  be 
stained  in  Ziehl's  carbol-fuchsin  from  fifteen  minutes  to  half  an  hour, 
and  then  decolorized  in  a  1  per  cent,  picric-acid  solution  until  the  whole 
section  has  a  yellow  appearance.  Dehydrate  and  mount.  The  fungus 
appears  as  a  brilliant  red  aster,  while  the  surrounding  tissues  are  yellow. 

Course  and  Prognosis. — The  course  is  chronic.  Mild  cases  may 
recover  in  from  six  to  nine  months  or  earlier,  the  oral  form  being  per- 
haps the  most  favorable.  Schlange,  after  an  analysis  of  60  cases  of 
actinomycosis,  concludes  that  pulmonary  actinomycosis  may  terminate 
in  recovery,  though  rarely.  Death  usually  results  from  pyemia,  amy- 
loid degeneration,  and  Avastinor. 

Treatment. — This  is  mainly  surgical.  The  removal  of  the  parts 
involved  and  disinfection  with  acid-sublimate  solution  are  the  best  meas- 
ures. Billroth  in  a  case  of  abdominal  actinomycosis  communicating 
with  the  bladder  effected  a  cure  by  the  use  of  fifteen  tuberculin  injec- 
tions. Internally,  the  potassium-iodid  treatment,  as  first  recommended 
by  Thomassen  in  1885,  is  often  attended  with  success  when  decided 
iodism  is  produced. 


ANTHRAX. 

{Malignant  Pustule;  Splenic  Fever;    Wool-sorter^ s  Disease,  etc.) 

Definition. — An  acute,  infectious  disease,  caused  by  a  special  ba- 
cillus and  clinically  accompanied  by  the  development  of  a  characteristic 
pustule  (boil)  and  blood-poisoning  {external  anthrax).  The  disease  like- 
Avise  affects  the  gastro-intestinal  tract  and  the  lungs  {internal  anthrax). 
Both  forms  are  derived  chiefly  from  herbivorous  animals,  it  being  espe- 
cially prevalent  among  sheep  and  cattle.  The  existence  of  anthrax  in 
the  United  States,  in  Asia,  Russia,  and  parts  of  Europe  has  been  denied, 
but  it  occurs  rarely,  and  Bard  has  described  its  ravages  in  California. 

Pathology. — Post-mortem  rigidity  is  marked.  The  blood  is  dark 
and  thick  and  coagulates  poorly,  and  in  it,  particularly  in  the  spleen, 
as  well  as  in  the  liver,  kidney,  and  lungs,  one  may  find  the  spores. 

Besides  the  local  lesions  of  the  skin  (/.  e.  ulceration,  gangrene,  edem- 
atous infiltration),  and  besides  the  degeneration  of  the  heart,  kidneys, 
and  liver  that  is  common  to  the  severe  and  rapid  infectious  diseases,  the 
especially  striking  lesion  is  the  constant  and  great  s])lenic  enlargement. 

The  bowel  may  show  hemorrhagic  infiltration  and  gangrene,  and  the 
mesenteric  and  retroperitoneal  glands  may  be  enlarged  and  hemorrhagic. 

Ktiology. — Bacteriology. — The  special  agent  is  the  bacillus  anthra- 
ci^  or  its  toxin,  or  both.  Gratia  and  Jonne  give  as  the  microscopic 
characteristics  of  anthrax,  as  seen  in  the  blood,  the  following :  (1)  The 


ANTHRAX.  353 

anthrax  bacillus  has  the  form  of  a  rod  of  a  length  varying  from  5/i  to 
20«,  and  in  breadth  from  1//  to  1.5/i.  It  is  broken  up  into  short  artic- 
ulations from  l.bfx  to  2/i  long,  placed  end  to  end  like  the  sections  of  a 
tenia,  the  ends  of  each  articulation  being  slightly  swollen,  giving  the 
appearance  of  a  bamboo  cane ;  (2)  clear  spaces,  appearing  like  a  bicon- 
cave lens,  exist  between  the  ends  of  the  articulations,  and  result  from 
the  slight  concavity  of  these  ends ;  (3)  a  capsule,  often  distinctly 
marked,  surrounds  the  rod,  seeming  to  form  a  protoplasmic  support 
for  the  individual  articulations.  These  threads  of  anthrax  bacilli  stain 
best  with  Loffler's  blue.  They  grow  readily  on  various  media  (agar, 
gelatin,  potatoes,  etc.)  into  interlacing  thread-like  filaments  which  dis- 
tinctly show  spore-formation,  the  threads  assuming  the  appearance  of 
strings  of  beads.  They  resist  desiccation,  many  of  the  germicides,  and 
boiling  water  even  for  a  few  minutes.  Inoculations  are  followed  by  the 
production  of  the  pustule  of  anthrax. 

The  virus  (spores)  gains  entrance  into  the  human  body  through  the 
skin  (slight  wounds,  abrasions,  or  scratches),  the  intestines  (with  food), 
or  through  the  lungs  (rarely).  The  sting  of  insects  (mosquitoes,  flies) 
may  also  transfer  the  poison  to  man. 

Predisposing  Causes. — Occupation  is  most  influential:  persons  who 
come  into  direct  contact  with  afi"ected  animals  (hostlers,  butchers,  shep- 
herds), and  workers  in  factories  who  handle  the  hair  or  hides  of  such 
animals,  being  liable. 

Immunity. — Pasteur's  well-known  protective  inoculation  with  attenu- 
ated virus  has  been  extensively  practised  in  anthrax  localities,  with  very 
favorable  results.  Hankin.  by  means  of  albumose,  which  he  separated 
from  cultures,  claimed  to  have  produced  immunity  against  the  most 
virulent  anthrax.  Peterman,  however,  reinvestigated  the  question  of 
immunity  by  the  albumose  of  anthrax,  and  found  it  without  protective 
action,  except  in  the  case  of  cultures  on  ox-serum,  which,  when  injected 
in  large  quantities  into  the  veins,  conferred  temporary  immunity. 

Clinical  History. — The  period  of  incubation  is  from  one  to  three 
days.     Two  leading  clinical  types  are  distinguished: 

(1)  External  Anthrax. — (a)  3Ialignant  Pustule. — At  the  point  of 
infection  (the  hand,  arm,  neck,  or  face,  or  other  exposed  part)  a  small 
papule  first  appears,  and  develops  into  a  vesicle  of  considerable  size  with 
bloody  contents.  This  vesicle  breaks,  leaving  a  characteristic  dark- 
bluish  or  black  scab  (anthrax),  and  encircling  the  primary  vesicle  an 
areola  of  miliary  vesicles  may  be  noticed.  The  base  of  the  original  ves- 
icle now  becomes  swollen  and  indurated,  and  this  brawny  edema  spreads 
rapidly  to  the  adjacent  tissues  until  an  extensive  area  is  involved.  The 
neighboring  lymph-glands  may  or  may  not  be  inflamed ;  if  so,  they  are 
apt  to  be  connected  with  the  pustule  by  red  lines  (lymph-vessels,  veins). 

Severe  general  disturbances  accompany  the  local  disorder  in  the  course 
of  a  couple  of  days,  and  comprise  fever,  decided  prostration,  sweats,  splenic 
enlargement,  and  delirium  tending  toward  coma.  If  recovery  occur, 
the  edematous  swelling  subsides  and  the  black  scab  is  cast  off.  In 
unfavorable  instances  collapse  develops,  and  the  case  ends  fatally  between 
the  fourth  and  eighth  days.  In  such  instances  intestinal  symptoms 
(diarrhea)  or  nervous  phenomena  of  aggravated  type  may  attend. 

(b)  Anthrax  Edema. — In  a  certain  proportion  of  the  cases  the  sys- 

23 


354  INFECTIOUS  DISEASES. 

temic  infection  is  out  of  proportion  to  the  locul  disturbance,  the  latter 
consisting  of  an  edematous  sAvelling  -without  the  presence  of  an  eschar. 
The  eyelids,  lips,  tongue,  and  upper  extremities  may  be  the  seat  of 
extensive  swelling,  though  there  is  no  change  in  the  color  of  the  skin. 
This  is  a  dangerous  condition,  and  may  result  in  gangrene. 

(2)  Internal  Anthrax. — [a)  Intesthial  Mycosis. — In  this  form  certain 
general,  indefinite  symptoms  are  the  primary  features,  such  as  headache, 
pains  in  the  limbs,  anorexia,  languor.  Soon  acute  gastro-intestinal 
features  supervene,  sometimes  preceded  by  a  chill.  As  a  rule,  vomit- 
ing occurs,  followed  by  abdominal  pains  and  diarrhea,  and  the  stools 
often  become  bloody.  Hemorrhage  may  also  occur  from  other  outlets. 
Other  symptoms,  as  dyspnea,  marked  cyanosis,  and  restlessness,  are 
noted,  followed  sometimes  by  stupor,  general  convulsions,  or  spasms 
of  single  muscles  or  groups  of  muscles.  There  is  moderate  fever,  and 
the  spleen  is  enlarged.     Death  is  preceded  by  collapse. 

Interesting  epidemic  outbreaks  of  internal  anthrax  have  occurred, 
due  both  to  drinking-water  derived  from  infected  wells  and  also  to  dis- 
eased meat.  Murisier  has  related  the  history  of  an  epidemic  in  which 
200  persons  fell  ill  after  eating  meat  from  a  certain  cow.  The  animal 
was  quartered  by  a  butcher  who  had  previously  slaughtered  an  ox 
afflicted  with  anthrax,  and  had  not  disinfected  his  instruments  ;  four 
days  after  this  25  persons  were  attacked  b}"  the  disease. 

(6)  Wool-sorters'  Disease. — This  occurs  among  the  operatives  in  fac- 
tories in  which  imported  wool  or  hair,  mostly  from  Russia  and  South 
America,  is  sorted,  and  to  produce  the  typical  affection  the  infection 
must  be  swallowed  or  inhaled  in  the  form  of  dust.  3Iixed  cases,  or  those 
showing  both  external  and  internal  antlirax,  may  be  met  with  among 
workers  in  curled-hair  establishments  and  the  like.  The  onset  is  sudden, 
with  a  chill  that  is  accompanied  by  pains  in  the  back  and  legs,  prostration, 
and  a  sharp  rise  of  temperature  to  102°  or  103°  F.  (39.4°  C).  The  local 
symptoms  may  either  be  chiefly  pulmonary  or  gastro-intestinal.  The 
former  consist  in  dyspnea,  chest-pains  or  feelings  of  constriction,  cough, 
and  rarely  the  physical  signs  of  oroncliitis ;  the  latter  comprise  vomit- 
ing and  a  diarrhea  that  is  followed  by  collapse,  Avith  marked  lividity. 
Nervous  symptoms,  delirium,  convulsions,  or  coma  are  often  prominent 
in  serious  forms  ;  but  a  fatal  ending  may  occur  while  the  mind  is  un- 
clouded.    The  course  ranges  from  one  to  five  days. 

((')  Rag-pickers'  Disease  ("  Hadernkrankheit '"). — This  has  been 
identified  by  Eppinger  as  the  same  form  of  disease  as  "  wool-sorters' 
anthrax."  It  occurs  among  the  rag-sorters  in  the  paper-mills  near  Graz. 
Infection  occurs  in  the  respiratory  tract.  The  symptoms  observed  are 
high  fever,  followed  by  collapse,  with  depression  of  the  body-heat,  pain- 
ful and  paroxysmal  cough,  cyanosis,  very  weak  heart,  together  with  the 
signs  of  pleuritic  effusion  and  consolidation  of  the  lung. 

Diagnosis. — The  history  (occupation,  etc.)  and  the  apj)oarance  of 
the  malignant  pustule  in  external  anthrax  leave  little  room  for  doubt. 
The  diagnosis,  however,  should  be  confirmed  by  an  examination  of  the 
contents  of  the  pustule  for  the  presence  of  bacilli,  and  if  found  they 
should  be  cultivated  and  inoculated  upon  a  guinea-pig  or  rabbit. 

The  recognition  of  internal  anthrax  is  more  difficult,  but  the  con- 
dition  may  be  suspected  if  the  more  characteristic  pulmonary  or  gastro- 


HYDROPHOBIA.  355 

intestinal  symptoms,  together  with  those  of  systemic  intoxication,  de- 
velop in  persons  whose  occupation  entails  exposure  to  infection.  In 
these  doubtful  cases  the  only  safe  course  is  to  show  the  presence  of  the 
bacilli  in  the  blood. 

Progfliosis. — In  external  anthrax  occurring  in  healthy  persons  the 
disease  often  pursues  a  favorable  course  ;  moreover,  radical  surgical 
measures  have  decreased  the  death-rate  decidedly.  Internal  anthrax, 
however,  is  a  deadly  affection.  As  regards  "  wool-sorters'  disease," 
those  who  survive  for  one  week  usually  recover  (Bell). 

Treatment. — In  malignant  pustule  it  has  been  recommended  to 
destroy  the  point  of  infection  by  caustic  or  by  the  hot  iron,  and  then 
dust  with  powdered  mercuric  chlorid  with  a  view  to  destroying  the 
mass.  It  seems  to  me,  however,  that,  unless  the  pustules  be  small  and 
remain  so,  removal  by  excision  should  be  preferred,  and  Klein  and 
others  have  reported  recoveries  after  removal  of  the  primary  focus  of 
infection.  In  preventing  extension  of  the  brawny  edema  hypodermic 
injections,  several  times  daily,  of  a.  solution  of  carbolic  acid  at  points  a 
little  distance  from  the  site  of  the  pustule  have  given  the  best  results. 
Hallopeau  recommends  that  in  order  to  prevent  extension  the  neighbor- 
ing structures  be  bathed  with  a  10  per  cent,  solution  of  carbolic  acid 
(first  dissolved  in  alcohol)  in  oil  or  glycerin.  He  applies  the  same  to 
the  surface  of  the  anthrax.  Internally,  stimulants,  antiseptics,  and 
nourishing  food  constitute  our  chief  reliance. 

In  internal  anthrax  efforts  at  treatment  avail  nothing.  Osier  recom- 
mends active  purgatives  with  a  view  to  removing  the  infecting  material. 


HYDROPHOBIA. 

{Rabies.) 


Definition. — A  specific,  infectious  disease  peculiar  to  carnivora  and 
to  a  less  extent  to  herbivora,  which  may  be  communicated  to  man  bv 
direct  inoculation.  It  is  characterized  by  slight  fever,  spasm  of  the 
larynx  and  pharynx,  delirium,  a  short  stage  of  paralysis,  coma,  and,  in 
the  great  majority  of  cases,  by  death. 

Pathology. — The  facies,  pharynx,  and  esophagus  may  be  con- 
gested, the  latter  organ  being  sometimes  markedly  edematous ;  pulmon- 
ary congestion  has  also  been  noticed.  The  mucous  membranes  may 
show  here  and  there  points  of  hemorrhage,-  and  Fitz  has  observed  blood- 
extravasations  into  the  perivascular  spaces  of  the  brain.  Soft  thrombi 
may  fill  the  cerebral  vessels,  especially  the  veins,  while  the  blood  has  a 
dark  color  and  its  clots  lack  firmness. 

The  chief  lesions  are  found  in  the  medulla,  and  particularly  in  the 
region  of  the  respiratory  center,  in  which  the  nuclei  of  the  hypoglossal, 
pneumogastric,  and  glosso-pharyngeal  nerves  are  seated.  On  micro- 
scopic examination  Gowers  found  the  cord  in  rabies  to  show  merely 
hyperemia  in  the  gray  substance  ;  ^  in  the  medulla,  however,  he  ob- 
served in  addition  a  cell-infiltration  of  the  perivascular  lymph-sheaths 
and  sometimes  of  the  adjacent  tissues  as  well.  Small  areas  infiltrated 
with  leukocytes  (miliary  abscesses)  were  noted,  and  scattered  throuo-h 


356  INFECTIOUS  DISEASES. 

the  adjacent  tissues  were  seen  small  round-cells  in  unusual  numbers. 
Fitz  and  Shattuck  found  as  the  most  constant  change  an  infiltration  of 
the  adventitia  of  the  veins  with  small  round-cells.  Rarely,  the  kidneys 
may  show  cloudy  swelling.     The  cadaver  putrefies  rather  early. 

Ktiology. — Pasteur  has  found  the  poison  abundantly  present  in  the 
nerve-ctnters,  and  has  transferred  the  disease  by  taking  bits  of  brain- 
substance  or  medulla  derived  from  an  infected  animal  and  inoculating 
them  into  healthy  subjects. 

Bacteriology. — Spenelli.  Rivolta,  Foil,  Ferran,  and  others  have  de- 
tected and  described  a  bacillus  which  they  believe  to  be  specific.  Memmo  ^ 
seems  to  have  established  its  claims  as  the  special  organism  of  this  dis- 
ease. He  has  successfully  induced  the  disease  in  dogs,  rodents,  and 
birds,  with  the  typical  differences  characteristic  of  each. 

The  usual  mode  of  infection  in  man  is  through  the  bite  of  a  rabid 
animal,  the  virus  being  contained  principally  in  the  saliva,  and  in  an 
immense  majority  of  cases  (about  90  per  cent.)  the  dog  is  the  offending 
partv.  The  cat.  wolf,  cow,  and  horse  also  suffer  from  the  disease,  and 
in  rare  instances  they  communicate  the  disease  to  man.  The  skunk  is 
also  liable,  and  its  bite  has  often  transmitted  rabies,  especially  to  per- 
sons sleeping  in  the  open  air  or  in  tents  which  the  animal  can  enter. 
The  virus  gains  access  to  the  system  through  the  broken  skin,  and  not 
through  the  mucous  membranes. 

Susceptibility  to  the  poison  e.xists  in  about  one-half  the  instances  in 
which  persons  are  bitten  by  rabid  animals,  though  in  some  cases  this  ap- 
parent immunity  may  be  owing  to  slight  or  even  non-infection. 

Clinical  History. — The  incuhat ion-period  lasts  from  six  weeks  to 
three  or  four  months,  though  in  young  subjects  and  in  cases  in  which 
the  infection  is  severe  the  symptoms  cfevelop  earlier.  Certain  prodro-  ■ 
mal  symptoms  are  manifested,  as  a  rule,  and  generally  last  only  a  day 
or  two ;  I  have,  however,  seen  two  instances  in  which  melancholia,  due 
probably  to  the  dread  of  what  might  follow,  showed  itself  immediately 
after  the  reception  of  the  bite  and  persisted.  The  usual  premonitory 
symptoms  are  headache,  loss  of  appetite,  sleeplessness,  great  depression 
of  spirits,  and  sometimes  darting  pains  that  radiate  from  the  seat  of 
the  bite.  The  adjacent  lymph-glands  may  become  swollen,  and  slight 
difficulty  in  swallowing  is  experienced. 

Following  the  invasion  are  two  stages  :  (1)  The  Stage  of  Excitement. 
— The  patient  wears  an  expression  of  the  most  intense  anxiety.  Hyper- 
esthesia is  present  and  attains  to  a  marked  degree,  and  the  special  senses 
exhibit  the  keenest  vigilance,  a  noise  or  a  draft  of  air  often  causing 
great  psychic  disturbance  or  a  violent  reflex  spasmodic  contraction  of 
the  larynx.  Quite  early  the  mere  sight  of  water  is  dreaded  by  the  pa- 
tient, and  forms  a  characteristic  feature  of  the  disease.  This  symptom 
has  given  the  name  hydrophobia  to  the  disease,  and  springs  from  the 
fear  of  inducing  a  painful  spasm  of  the  larynx.  The  patient  has  thirst 
which  he  cannot  assuage.  There  may  be  maniacal  excitement,  and  the 
spasmodic  contractions  of  the  larynx  may  become  so  strong  as  to  excite 
urgent  dyspnea,  with  the  emission  of  curious  sounds.  The  muscles  of 
the  mouth  may  also  exhibit  convulsive  movements,  causing  the  patient  to 
make  snapping  sounds ;  these,  however,  are  secondary.  There  is  as.so- 
1  Centralbl.f.  BakL,  Abt.  i.,  Bd.  xx.,  17,  18. 


HYDROPHOBIA.  357 

ciated  great  restlessness,  with  frequent  lateral  rolling  of  the  head,  and 
foaming  saliva  may  be  ejected  from  the  mouth.  The  symptoms  occur 
in  paroxysms,  and  during  the  intervals  the  patient  is  generally  free 
from  excitement.  There  is  fever  as  a  rule,  the  temperature  ranging 
from  100°  to  102°  F.  (37.7°-38.8°  C.)  or  over,  but  it  may  be  absent; 
the  pulse  is  moderately  accelerated  and  is  sometimes  irregular,  and  to- 
ward the  end  of  this  stage  the  reflex  spasms  of  the  respiratory  apparatus 
develop  spontaneously.  Mental  aberrations  may  set  in,  and  melancholia 
often  leads  to  suicidal  tendencies. 

(2)  The  Paralytic  Stage. — In  the  concluding  stage  the  patient  passes 
from  a  condition  of  debility  into  actual  unconsciousness  or  coma,  with- 
out spasms.  This  lasts  from  twelve  to  eighteen  hours,  during  which 
cardiac  asthenia  rapidly  increases,  and  life  soon  ends  by  syncope. 

In  man  there  is  o^  paralytic  form  of  rabies,  but  it  is  rare  as  compared 
with  the  delirious  or  psychic  type.  Thirty  cases  have  been  reported 
by  Gamaleia,  and,  according  to  this  observer,  the  paralytic  type  is  apt 
to  follow  deep  and  multiple  bites.  The  paralysis  begins  near  the  part 
bitten,  and  spreads  until  it  becomes  general,  finally  involving  the  respir- 
atory centers.  In  rodents  quiet  madness  ("  dumb  rabies "),  without 
maniacal  excitement,  is  the  rule. 

Diagnosis. — The  hyperesthesia,  the  fear  of  water,  the  reflex  spasms 
on  attempting  to  swallow,  accompanied  by  dyspnea  and  great  mental 
agitation,  form  a  very  characteristic  grouping  of  symptoms.  Bits  of 
brain-substance  or  medulla  of  the  rabid  animal  that  has  inflicted  a  bite 
should  be  quickly  obtained,  and  a  subdural  inoculation  of  a  rabbit  be 
made.  If  virulent,  the  paralytic  form  of  the  disease  will  ensue  in  from 
fifteen  to  twenty  days.  Hysteria  may  be  misleading,  but  here  the  pre- 
vious history  suffices. 

The  name  lyssophobia  has  been  given  to  cases  that  simulate,  but 
have  no  relation  to,  hydrophobia,  and  Mills  has  advanced  the  warning 
that,  with  however  so  suggestive  symptoms  following  a  dog-bite,  the 
given  case  cannot  be  assumed  to  be  a  case  of  hydrophobia  until  other 
possibilities  are  excluded.  It  is  highly  probable  that  there  is  a  form  of 
hydrophobia  Avhich  is  the  result  of  the  wide  publicity  given  to  genuine 
and  suspected  cases  alike.  The  characteristic  symptoms  may  be  present, 
but  they  are  comparatively  mild  and  the  afi'ection  does  not  develop. 
This  so-called  pseudo-hydrophohia  appears  only  in  neurotic  and  hys- 
teric subjects,  and  runs  a  longer  course  than  does  the  disease  itself. 
Recovery  is  the  rule,  and  yet  I  feel  convinced  that  even  a  lyssophobic 
condition  growing  out  of  fear  of  the  disease  may  cause  death.  Burr 
reports  an  interesting  case  of  the  kind  that  occurred  in  Osier's  clinic, 
attended,  however,  with  recovery. 

Prognosis. — Few  if  any  cases  of  rabies  in  man  recover  if  the  dis- 
ease be  allowed  to  develop.  Preventive  measures  have  been  the  means 
of  reducing  the  frequency  of  the  disease. 

Treatment. — Prophylaxis. — Upon  the  reception  of  a  bite  thorough 
disinfection,  followed  by  cauterization  of  the  wound  with  caustic  potash, 
etc.,  is  a  measure  that  can  be  quickly  can-ied  out.  The  Avound  is  then 
to  be  kept  open  for  a  period  of  four  or  five  wrecks.  Systematic  muz- 
zling of  dogs  is  to  be  encouraged  and  advised. 

Preventive  inoculation  as  perfected  by  Pasteur  is  a  precautionary 


358  INFECTIOUS  DISEASES. 

measure  of  the  utmost  importance.  This  famous  investigator,  after  dis- 
covering that  the  virus  of  the  disease  could  be  obtained  in  a  pure  state 
from  the  central  nervous  system,  showed  that  its  virulence  undergoes 
modification  by  passage  through  animals.  Thus  the  potency  of  the 
virus  is  increased  by  its  inoculation  from  rabbit  to  rabbit  (by  placing 
bits  of  spinal  marrow  beneath  the  dura  mater),  the  period  of  incubation 
at  the  same  time  growing  shorter,  till  at  last  it  is  but  seven  days.  On 
the  other  hand,  the  virulence  is  decreased  or  attenuated  as  the  result  of 
similar  experiments  upon  the  monkey.  Pasteur  also  found  that  if  frag- 
ments of  the  spinal  cord  were  suspended  in  a  dry  atmosphere  they  lost 
gradually  their  virulence  and  finally  became  inert.  From  these  an 
emulsion  is  prepared  which  is  employed  in  the  antirabic  inoculations  in 
man.  In  this  way  he  secured  a  virus  of  knoAvn  and  reliable  strength, 
and  with  this  he  could  readily  render  the  dog  refractory  by  inoculating 
with  very  weak  virus  ;  then,  by  increasing  from  day  to  day  the  virulency 
of  the  inoculations,  complete  immunity  was  established. 

Protective  Inoculation. — "  The  patients  are  first  inoculated  with  a 
cord  fourteen  days  old,  and  the  inoculation  is  repeated  daily  for  nine 
days,  each  time  with  a  cord  one  day  fresher.  In  w  inter  the  oldest  cords 
used  are  five  days  old,  and  in  summer  cords  that  have  been  drying  for 
four  days  are  also  employed  "  (Warren). 

For  patients  who  have  been  bitten  on  the  fiice,  hands,  or  bare  feet, 
as  well  as  for  those  who  have  been  bitten  long  before  commencing  treat- 
ment, the  special  preventive  method,  the  so-called  "  intensive  treatment," 
is  applicable.  Briefly,  this  consists  in  eliminating  some  of  the  inocula- 
tions of  intermediary  strengths,  thus  lessening  the  number  of  injections, 
and  also  in  administering  the  latter  at  shorter  intervals  than  in  the  usual 
method  of  treatment.  The  success  of  the  Pasteur  method  is  almost  uni- 
versally attested.  Pottevin  gives  the  following  summary  of  figures  from 
the  Pasteur  Institute  :  From  1886  to  181)4,  13,817  persons  were  bitten, 
with  a  mortality  of  0.5  per  cent.  Of  these,  1347  were  bitten  on  the  head 
(mortality,  1.26  per  cent.);  8722  on  the  hands  (0.76  per  cent,  of  deaths), 
and  5746  on  the  other  parts  of  the  body  (mortality,  0.28  per  cent.). 

The  established  affection  defies  all  known  methods  of  treatment. 
Our  aim  should  be  to  diminish  the  intensity  of  the  painful  spasms  and 
the  psychic  disturbances.  The  patient  should  be  isolated  from  sounds, 
light,  and  excitement  of  every  sort.  Food,  as  a  rule,  must  consist  of 
nutrient  enemata,  though  by  the  local  application  of  cocain  the  sensi- 
tiveness of  the  throat  may  be  diminished  sufficiently  to  enable  the 
patient  to  take  Yu\n\d  nourishment  (Osier).  For  controlling  the  spasms 
chloroform  by  inhalation  is  most  effective ;  chloral  internally  and  mor- 
phin  hypodermically  may  also  be  tried  with  advantage.  The  patient's 
anxiety  is  best  relieved  by  a  cheerful  demeanor  on  the  part  of  the 
attendants. 


TETANUS. 

( Tri.smvs ;  Lockjaw.) 


Definition. — An    acute,   infectious    disease  caused  by  the    tetanus 
bacillus.     It  is  characterized  by  painful  spasms,  affecting  first  and  chiefly 


TETANUS.  359 

the  muscles  of  the  jaw  and  neck  (trismus),  and  secondly  those  of  the 
trunk,  especially  the  extensors  of  the  spine  and  limbs  (opisthotonos). 
The  disease  may  be  idiopathic,  though  more  often  it  is  traumatic.  In 
certain  institutions  and  certain  localities  (e.  g.  eastern  end  of  Long 
Island)  it  occurs  endemically,  and  among  new-born  children  and  the 
colored  race  it  may  prevail  epidemically  (trismus  neonatorum). 

Patliolog'y. — No  constant  post-mortem  lesions  have  been  found. 
The  virus  probably  acts  chiefly  upon  the  nervous  centers  of  the  medulla 
and  the  cord,  producing  inflammation  (and  sometimes  softening  of  the 
gray  substance  of  the  cord).  According  to  Brown-Sequard,  the  charac- 
teristic lesions  are  consequent  upon  an  ascending  rieuritis  starting  from 
the  wound,  and  it  is  true  that  the  nerves  often  present  traumatic  lesions 
with  redness  and  swelling  of  the  neurilemma.  Tetanus  neonatorum 
often  shows  inflammation  of  the  umbilicus. 

Htiologfy. — Bacteriology. — In  1885,  Nicolaier  discovered  the  bacil- 
lus of  tetanus,  and  in  1886,  Rosenbach  first  found  it  in  man.  It  is  a 
long,  slender  rod,  at  one  end  of  which  appears  a  swelling  due  to  the 
formation  of  a  spore  in  that  locality,  thus  giving  the  organism  an  ap- 
pearance like  that  of  a  pin  or  drumstick.  The  bacilli  are  easily  stained 
by  Abbott's  method,  and  are  purely  anaerobic.  Pure  cultures  can  be 
made,  but  with  difficulty,  since  other  varieties  of  bacteria  are  found  in 
association,  and  if  pure  cultures  are  injected  into  animals,  typical  teta- 
nus follows.  Brieger  has  obtained  the  poison  from  sterilized  cultures  of 
the  bacillus  in  the  pure  state,  and  termed  it  "•  tetanin  " — a  most  viru- 
lent poison  in  the  minutest  quantity.  The  bacilli  are  most  probably 
limited  to  the  point  of  infection,  and  here  develop  the  toxin,  which  "  is 
carried  mostly  along  the  nerves  to  the  spinal  cord  "  (Stintzing). 

Modes  of  Infection. — In  the  outer  Avorkl  tetanus  bacilli  are  found  to 
be  both  numerous  and  widely  distributed.  They  abound  in  the  earth 
(garden-soil  in  particular),  putrefying  liquids,  manure,  in  rubbish,  and 
dust  of'  streets  and  houses,  etc.  The  fact  that  the  bacillus  of  tetanus  is 
anaerobic  explains  why  tetanus  in  man  is  a  comparatively  rare  disease, 
and  also  why  it  is  most  apt  to  follow  puncture  and  contused  wounds.  It 
may  be  assumed  that  an  injury,  however  slight,  serves  as  the  portal  of 
entrance  for  the  poison.  The  locality  of  the  injury  is  almost  always  on 
the  extremities,  particularly  on  the  hands  and  the  feet ;  the  disease  is 
most  common  in  ivarm  climates  ;  and  as  regards  age,  it  is  most  common 
between  ten  and  thirty,  if  we  except  tetanus  neonatorum.  Idiopathic 
tetanus  may  follow  exposure  to  cold  or  sleeping  on  the  damp  earth,  and 
in  tetanus  neonatorum  the  infection  may  be  communicated  either  by  care- 
less nurses  or  by  dirty  dressings  of  the  stump,  etc.  (Papienske). 

Immunity. — Behring  and  Kitasato  have  rendered  animals  immune 
by  the  injection  of  cultures  of  the  bacillus  after  the  addition  of  iodin 
trichlorid  to  diminish  their  strength,  and  this  serum  has  been  success- 
fully used  to  protect  others  against  tetanus. 

Clinical  History. — The  duration  of  incubation  depends  upon 
whether  the  given  case  pursues  an  acute  or  a  chronic  course.  In  acute 
tetanus  it  lasts  from  one  to  two  weeks,  while  in  chronic  the  first  symp- 
toms usually  appear  after  the  second  week.  In  idiopathic  tetanus  the 
symptoms  generally  appear  shortly  after  exposure  to  the  special  causes. 

Symptoms  of  Acute  Tetanus. — (1)  Mild  prodromal  symptoms  (languor, 


360  INFECTIOUS  DISEASES. 

headache,  etc.)  may  precede  the  more  intense  characteristic  phenomena, 
which  develop  gradually.  At  first  the  patient  complains  of  stiffness 
and  tension  in  the  muscles  of  mastication  and  back  of  the  neck,  and 
soon  tonic  spasm  of  the  masseters  renders  the  facial  muscles  more  or 
less  immobile  and  locks  the  jaws  {trismus  or  lockjmv).  The  rigidity  of 
the  cervical  muscles  is  shown  by  the  retraction  of,  and  by  attempts  at 
raising,  the  head.  The  physiognomy  is  distinctive;  it  is  immobile,  the 
forehead  being  often  wrinkled  and  the  corners  of  the  mouth  retracted, 
producing  a  peculiar  smile  {sardonic  grin).  Next  the  muscles  of  the 
body  become  rigid,  first  the  trunk  {orthotonos),  and  then  the  spine  is  bent 
or  bowed  and  the  convexity  presents  anteriorly  {opisthotonos).  Lateral 
arching  of  the  body  also  occurs,  though  rarely  {jjleurostliotonos).  The 
belly-muscles  are  hard  and  board-like,  and  their  contractions  may  throw 
the  body  forward  {emprostliotonos).  The  arms  generally  remain  movable, 
but  the  legs  may  be  rigidly  extended.  The  position  of  the  body  is  one 
of  constant  ricriditv,  but  from  time  to  time  convulsive  seizures  of  variable 
duration  occur,  causing  most  agonizing  suffering,  thoracic  oppression, 
dyspnea,  and  more  or  less  cyanosis,  due  to  interference  with  the  respira- 
tory function  (especially  spasm  of  the  glottis).  Sharp,  lancinating  pains 
occur  at  the  base  of  the  chest  and  point  to  contraction  of  the  diaphragm. 
"  Convulsive  dysphagia  "  (as  in  hydrophobia)  is  rarely  observed.  These 
spasms  are  usually  refiex,  due  to  the  action  of  slight  external  irritants. 
The  reflexes  are  increased.  The  intellect  remains  clear.  Profuse  per- 
spiration is  a  significant  symptom. 

Fever  of  a  moderate  degree  is  generallv  present.  The  temperature, 
however,  may  suddenly  leap  to  110°  or  112°  F.  (43.3°-44.4°  C),  form- 
ing an  ominous  symptom,  these  extreme  elevations  of  temperature  being 
probably  due  to  pai'alysis  of  the  centers  that  regulate  bodily  heat.  Con- 
versely, fever  may  be  absent  throughout  the  attack,  and  a  brief  post- 
mortem rise  of  temperature  be  seen.  The  pulse  is  quickened,  and  in 
the  worst  cases  may  become  very  rapid  (140  to  IGO  beats  per  minute), 
small,  and  irregular.  The  urine  may  be  suppressed  or  its  passage  im- 
peded by  the  muscular  contractions.     The  bowels  are  constipated. 

(2)  Chronic  Tetanus. — The  same  symptoms  are  manifested  as  are  seen 
in  the  acute  form,  but  the  condition  does  not  progress  so  rapidly.  In 
some  instances  the  symptoms  soon  become  aggravated,  to  be  followed, 
however,  by  periods  of  decided  relief  from  the  painful  spasms,  so  that 
during  the  latter  the  patient's  strength  can  be  maintained  by  means  of 
stimulants,  etc.  Intervals  of  partial  freedom  from  the  excruciating  pains 
grow  longer  in  favorable  cases,  until  finally  the  period  of  convalescence 
may  be  reached,     llelapscs,  however,  are  common. 

(3)  Cephalic  tetanus  (first  described  by  Kose)  usually  follows  injuries 
to  the  head  (face).  Its  most  characteristic  symptoms  are  rigidity  of  the 
inasseter  muscles,  spasm  of  the  pharyngeal  muscles,  causing  dysphagia, 
chronic  contraction  of  the  muscles  of  the  neck  and  abdomen  (rare),  and 
paralysis  of  the  facial  nerve  on  the  same  side  as  the  injury.  The  latter 
symptom  is  due  to  local  infection  by  a  toxin.  Recovery  takes  place  in 
about  2o  per  cent,  of  tlie  instances,  according  to  Willard's  statistics. 

Diagnosis. — In  view  of  the  usual  history,  the  predominating  feat- 
ure— trismus — together  with  the  early  ajipearance  of  rigidity  at  tlie 
back  of  tlie  neck.  will,  as  a  rule,  render  the  diagnosis  a  simple  one. 


TETANUS.  361 

Strychnin-poisoning  must  be  eliminated,  in  which  the  following  table 
will  assist : 

Tetanus.  Strychnin-poisoning. 

History. 

Reception  of  a  wound,  generally  followed      Ingestion  of  strychnin,  followed  immedi- 
by  a  period  of  incubation.  ately  by  the  symptoms. 

Mode  of  Development. 

Begins  with  lockjaw  ;  later  spreads  down-      Begins   with   gastric   disturbance    or    a 
ward  (the  arms  and  hands  escaping).  tetanic  contraction  of  all  the  extrem- 

ities. 

Symptoms. 

Reflex  spasms  not  present  at  the  outset.  Violent   convulsions    present    from    the 

onset. 

Rigidity    is    persistent,    except    in    the  Intervals  of  complete  relaxation  occur. 

chronic  form. 

The   course   is   prolonged   into   days  or  Course  is  brief,  terminating  in  death  or 

vreeks.  recovery. 

Cultures    made    from  the  discharges  of  Examination  of  the  gastric  contents  shows 

the  wound  show  the    bacillus    tetani.  strychnin. 

Tetany  gives  rise  to  a  spasm  of  long  duration  aifecting  the  extrem- 
ities (hands  in  particular)  and  the  larynx,  Avith  absolute  intermissions ; 
it  is  also  characterized  by  a  peculiar  posture. 

Hydrophobia  is  discriminated  from  tetanus'  by  the  history  of  a  bite 
from  an  animal,  by  the  predominance  of  the  reflex  spasm  of  the  respir- 
atory apparatus,  by  the  intensity  of  the  psychic  disturbance,  and  by 
the  absence  of  lockjaw^  and  opisthotonos. 

Course  and  Prognosis. — In  the  acute  form  the  course  is  brief, 
and  the  prognosis  is  most  unfavorable.  Death  results  from  asthenia, 
heart-failure,  or  asphyxia  (during  the  paroxysm).  According  to  Richter's 
statistics,  88  per  cent,  of  military  cases  are  fatal.  In  idiopathic  cases 
the  mortality-rate  is  under  50  per  cent.  Chronic  tetanus  gives  a  less 
grave  prognosis  than  does  acute.  In  the  new-born  recovery  is  so  rare 
that  when  it  occurs  the  diagnosis  may  be  called  into  question. 

Treatment. — In  traumatic  cases  the  wound  must  be  disinfected  and 
thoroughly  cauterized.  In  order  to  do  this  eifectively,  the  agents  em- 
ployed must  be  brought  in  contact  with  every  portion  of  the  wound,  so 
that  punctured  Avounds  must  first  be  laid  open.  Excision  of  the  Avound, 
and  even  amputation,  may  be  advisable  in  some  cases.  The  fact  that 
the  deadly  poison  is  developed  at  the  site  of  infection  gives  to  the  local 
measures  supreme  importance  in  the  treatment  of  tetanus. 

The  patient  should  occupy  a  secluded  room  with  little  light  and  a 
carefully  regulated  temperature.  A  single  nurse  AA'ill  suffice,  and  all 
sources  of  external  irritation  should  be  avoided.  A  nourishing  diet  is 
demanded,  and  rectal  feeding  must  be  instituted  as  soon  as  it  is  found 
that  food  cannot  be  administered  joer  oram,  or  the  food  may  be  intro- 
duced by  means  of  a  small  stomach-tube  or  catheter  passed  through  the 
nostril.  Stimulants  should  not  be  spared  Avhen  the  heart's  action  be- 
comes quick  and  feeble.  In  one  of  my  own  cases  hypodermic  injections 
of  strychnin  and  digitalis  probably  saved  the  patient's  life.  The  spasms 
are  best  controlled  by  chloroform-inhalations,  and  during  the  intervals 


362  INFECTIOUS  DISEASES. 

the  patient  should  be  kept  under  the  influence  of  niorphin.  administered 
subcutaneously.  Among  other  capital  remedies  are  chloral  hydrate  and 
Calabar  bean.  The  former  may  be  exhibited  in  rectal  injection  (gr.  xl 
— 2.59  at  a  dose),  to  be  repeated  at  intervals  of  six  to  eight  hours  until 
the  spasm  is  overcome.  The  heart,  however,  must  be  carefully  guarded. 
Rarelv,  potassium  bromid,  curare,  nitrite  of  amyl,  belladonna,  and  can- 
nabis indica  are  useful. 

Tetanus-antitoxin  has  been  recommended  for  the  cure  of  the  disease, 
and  is  prepared  in  both  fluid  (antitoxin  serum)  and  dry  form.  A  dried 
preparation  (which  does  not  deteriorate)  is  also  obtainable  from  Merck 
and  his  agents  in  the  form  of  tubes  containing  from  4  to  5  grams  each ; 
at  the  time  used  it  may  be  dissolved  in  Avater  or  in  glycerin.  Of  Tiz- 
zoni's  dried  antitoxin  2.25  grams  are  to  be  given  at  the  first  dose,  and 
0.6  gram  at  subsequent  doses.  As  shown  by  recent  experimentation, 
antitetanic  serum  may  prevent  further  invasion,  but  it  cannot  cure  infec- 
tion that  has  already  reached  the  spinal  cord  and  brain.  The  dose,  as 
recommended  by  Copley,'  should  be  large  (3<>  c.c.  at  once,  to  be  repeated 
at  least  every  six  hours  until  improvement  is  seen).  Stintzing  states 
that  96  cases  of  tetanus  have  been  treated  to  date  with  Behring"s  serum, 
with  35  deaths.  Behring  insists  upon  giving  the  serum  not  later  than 
twenty-six  hours  after  the  commencement  of  the  attack.  Intracerebral 
injections  of  antitoxin  (Roux  and  Borrel)  offer  no  peculiar  advantages. 

Prophylactic  injections  of  serum  containing  at  least  500  antitoxic 
units  should  be  used  immediately  upon  the  disinfection  of  the  primary 
focus. 


INFECTIOUS  DISEASES   OF  UNKNOWN  ETIOLOGY. 

MUSCULAR    RHEUMATISM. 
(.Vt/al<jia.) 

Definition. — A  common,  painful  disease  of  the  muscles  and  of  the 
structures  to  which  they  are  attached  (fasciie  and  periosteum),  probably 
due  to  an  attenuated  form  of  the  virus  of  acute  articular  rheumatism. 
Leube  contends — and  very  properly,  I  think — that  muscular  rheuma- 
tism is  a  general  disease  with  local  symptoms.  The  latter  may  be  seated 
in  different  parts  of  the  body,  and  in  this  way  give  rise  to  a  number  of 
leading  sub-varieties,  and  it  may  either  accompany  acute  and  chronic 
rheumatism  or  it  may  be  experienced  as  an  independent  disease.  I  have 
also  met  with  several  instances  in  which  it  followed  joint-rheumatism, 
and  Leube  has  seen  it  precede  the  latter.  Certain  authors,  however, 
believe  that  the  affection  is  a  neuralgia  of  the  sensory  nerves  of  the 
muscles. 

Pathology. — In  fatal  cases  (these  are  exceedingly  rare)  the  affected 
muscles  show  a  swelling  of  the  fibers  and  more  or  less  granular  change. 
In  long-standing  cases  there  is  an  atrophy  of  the  muscles,  due  to  trophic 
disturbance.  Strauss  describes  well-circumscribed  nodules  in  the 
muscles. 

'  Brit.  Med.  Journ.,  ¥eh.  11.  1899. 


MUSCULAR  RHEUMATISM.  363 

The  changes  are  essentially  those  of  myositis.  In  the  acute  form 
there  is  often  an  extensive  round-cell  infiltration  of  the  connective  tissue, 
with  swelling  and  partial  degeneration  of  the  muscular  fibers  and  the 
formation  in  them  of  vacuoles.  In  the  chronic  form  there  is  a  prolifer- 
ation of  the  interfascicular  connective  tissue. 

il^tiology. — Among  the  disposing  influences  that  are  most  impor- 
tant in  the  causation  of  the  affection  are — (1)  The  rheumatic  diathesis 
(appropriate  soil) ;  (2)  Heredity ;  (3)  Exposure  to  cold,  damp,  and  strong 
air-currents,  especially  after  heavy  exercise  or  during  free  perspiration  ; 
(4)  Sex,  owing  to  the  more  frequent  exposure  of  men  Avhile  following 
their  occupations ;  (5)  Age.  It  is  met  with  at  all  ages,  but  acute  and 
subacute  forms  most  frequently  occur  among  children  and  young  adults, 
while  the  chronic  form  most  frequently  affects  elderly  persons  ;  (6)  Pre- 
vious attacks  increase  the  susceptibility  to  the  disease,  as  in  acute  artic- 
ular rheumatism. 

Symptoms. — In  the  majority  of  instances  the  clinical  symptoms 
are  local.  Out  of  200  cases  Leube  found  fever  in  about  one-third,  the 
temperature  rarely  exceeding  102°  F.  (38.8°  C.)  for  two  days  in  dura- 
tion, and  far  more  often  remaining  normal.  In  one-sixth  of  Leube's 
cases  there  was  a  cardiac  murmur,  that  disappeared  under  treatment  in 
one-half  of  this  number.  The  most  conspicuous  local  symptom  is  the 
pain,  which  is  sometimes  sharp,  lancinating,  and  paroxysmal,  though  it 
may  be  deeply  seated,  dull,  and  constant.  It  is  aggravated  at  night  by 
contraction  of  the  affected  muscles,  by  weather-changes,  and  in  acute 
forms  by  pressure.  In  long-continued  cases  pressure  Avith  the  broad 
side  of  the  hand  usually  affords  relief.  The  duration  ranges  from  a 
few  hours  to  several  days,  but  may  be  much  longer.  The  rheumatic 
nodules  are  common  in  the  shoulder-  and  calf-muscles. 

Leading  Clinical  Varieties. — (1)  Lumbago  {Myalgia  Lumhalis). — This 
is  the  most  common  form,  and  may  be  taken  as  the  type  of  the  myalgias. 
The  onset  is  sudden,  sometimes  intensely  so,  and  the  lumbar  muscles  are 
exceedingly  painful  and  sensitive.  Motion,  such  as  stooping  or  turning 
the  body  or  rising  from  the  sitting  position,  causes  intense  exacerbations 
of  pain.  The  affection  occurs  most  frequently  in  laboring-men,  its  course 
being  brief,  as  a  rule,  and  recurrences  frequent.  Erben,  from  a  study 
of  200  cases  of  lumbago,  finds  that  the  trouble  is  principally  an  affection 
of  the  lumbar  vertebrae,  or  a  neuralgia  of  the  cutaneous  nerves. 

(2)  Pleurodynia. — This  term  implies  involvement  of  the  intercostal 
muscles,  and  less  frequently  of  the  pectorals  and  the  serratus  magnus. 
It  is  unilateral,  and  oftener  affects  the  left  than  the  right  side,  and 
causes  untold  suffering,  since  it  is  constantly  aggravated  by  the  normal 
respiratory  excursions.  The  pain  is  also  intensified  by  pressure,  reach- 
ing, etc.,  and  by  movement  of  the  trunk,  sneezing,  and  coughing. 
Similar  symptoms  may  be  occasioned  by  traumatism  in  which  the  fibers 
of  the  thoracic  muscles  are  lacerated,  and  there  is  also  great  danger  of 
confounding  pleurodynia  Avith  costal  periostitis  and  with  pleurisy. 

(3)  Torticollis  (Myalgia  Cervicalis). — Here  the  muscles,  some  or  all, 
on  one  side  of  the  neck,  and  at  times  the  throat,  are  implicated.  The 
head  is  held  toward  the  affected  side,  so  as  to  relax  the  group  of  muscles 
involved,  and  on  attempting  to  turn  it  the  patient  rotates  his  entire  body 
in  a  pivot-like  manner.     The  complaint  is  frequent  in  young  persons. 


364  INFECTIOUS  DISEASES. 

(4)  Cephalodynia. — By  this  term  is  meant  rheumatism  of  the  head- 
muscles  of"  the  scalp  and  fasciae.  It  is  by  no  means  an  infrequent  con- 
dition, and  may  be  either  general  or  local,  being  sometimes  limited  to 
the  frontal,  temporal,  or  occipital  muscles.  The  pain  is  severe  and 
greatly  increased  on  motion  of  the  scalp. 

(5)  Other  terms  descriptive  of  localized  forms  of  muscular  rheuma- 
tism are  employed :  (a)  Omodynia  (myalgia  of  the  deltoid) ;  {b)  Dorso- 
dynia  (involvement  of  the  muscles  of  the  upper  part  of  the  back,  etc.) ; 
{c)  Abdominal  rheumatism  (myalgia  of  the  muscles  of  the  abdomen) ; 
(d)  Rheumatic  myositis  of  the  extremities. 

Diagnosis. — This  is  assured  by  the  etiologic  influences  and  the 
presence  of  pain,  which  is  greatly  increased  by  muscular  contraction. 
The  presence  of  fever  does  not  exclude  the  affection.  It  differs  from 
neuralgia  in  that  there  are  no  painful  points,  and  in  that  firm  pressure 
with  the  broad  hand  often  affords  relief.  Dermato-myositis  must  not  be 
confounded  with  muscular  rheumatism.  Unverricht  first  distinguished 
the  former  from  the  latter,  showing  that  there  are  present  pain  and 
swelling  of  the  muscles,  as  in  muscular  rheumatism,  but  additionally 
redness  (erythema)  and  hyperesthesia  of  the  skin,  while  the  joints  usu- 
ally escape.  Rovere,  however,  reports  a  case  occurring  in  the  course 
of  diabetes  mellitus  in  which  there  was  a  joint-inflammation  resembling 
that  of  rheumatism.  Of  general  s^'mptoms,  the  chief  are  fever  and 
physical  prostration.  The  spleen  is  enlarged,  and  angina  and  hemor- 
rhages have  been  noted.  The  disease  is  obviously  infectious,  probably 
septic  in  nature,  and  occurs  in  fatal  as  well  as  in  the  mild  or  favorable 
forms.  Dermato-myositis,  unlike  muscular  rheumatism,  which  is  more 
common  among  men,  is  seen  more  frequently  in  women,  especially 
servants. 

The  prognosis  is  good,  the  disease  never  directly  endangering  life, 
though  a  person  may  be  more  or  less  incapacitated  for  work  by  muscu- 
lar rheumatism. 

Treatment. — Severe  and  acute  forms  demand  the  use  of  opiates 
internally  and  anodyne  and  hot  applications  externally.  When  cases 
are  seen  early,  morphin,  administered  hypodermically,  may  serve  to  relieve 
the  pain  and  cut  short  the  disease.  In  acute  cases  the  salicylates  and 
other  antirheumatic  remedies  are  to  be  employed.  Hot  fomentations 
give  comfort,  and  the  Turkish  bath  may  end  the  attack  if  it  can  be  used 
sufficiently  early.  The  hot-water  bag,  sponging  with  water  as  hot  as 
can  be  borne,  or  dry  heat  in  the  form  of  bags  filled  with  heated  salt  or 
heated  hops,  will  all  do  good  service.  For  the  dull  pain  which  is  so  dis- 
tressing in  some  cases  of  torticollis  the  affected  muscles  may  be  covered 
with  flannel,  over  Avhich  a  Avarmed  flatiron  may  be  passed  for  a  few 
minutes.  This  is  an  efficient  expedient.  For  lumbago  acupuncture  is 
highly  commended.  Needles  of  from  three  to  four  inches  (T.o-lO  cm.) 
in  length  (ordinary  bonnet-needles,  sterilized,  Avill  do)  are  thrust  into 
the  lumbar  muscles  at  the  seat  of  the  pain  and  withdrawn  after  five  or 
ten  minutes  (Osier).  Blisters  have  been  recommended,  but  I  have  tried 
them  frequently  without  beneficial  effects  in  any  case.  In  subacute  and 
obstinate  cases  I  have  recentlv  obtained  good  results  from  the  use  of  a 
20  per  cent,  ointment  of  salicylic  acid  freely  rubbed  into  the  skin.  Active 
friction  with  anodyne  and  stimulating  liniments  (the  latter  when  pain  is 


CHRONIC  ARTICULAR  RHEUMATISM.  365 

not  great)  is  worthy  of  trial.  Massage  and  electricity  (the  constant  cur- 
rent in  particular)  are  sometimes  efficient,  and  in  chronic  cases  potas- 
sium iodid,  guaiacum,  and  arsenic  (the  latter  in  small  doses)  should  be 
tried.  The  same  measures  of  prophylaxis  are  to  be  adopted  as  in 
chronic  rheumatism,  and  the  condition  of  the  general  health  must  also 
be  looked  to,  every  endeavor  being  made  to  maintain  the  proper  quality 
of  blood  and  perfect  nutrition. 

CHRONIC   ARTICULAR  RHEUMATISM. 

Definition. — An  affection  o'f  the  articular  structures  which  develops 
slowly  and  gradually  and  may  be  dependent  upon  the  same  causes  as 
the  preceding  forms.  Rarely  it  is  a  sequence  of  acute  or  subacute 
attacks. 

Pathology. — The  joints,  as  a  rule,  do  not  show  pronounced  gross 
lesions,  there  being  some  degree  of  synovial  injection  and  also  some, 
though  not  much,  effusion.  Inflammatory  thickening  of  the  articular 
and  periarticular  structures  (capsule,  ligaments,  sheaths  of  the  tendons, 
etc.)  with  contraction,  is  noted,  and  is  a  change  which  deforms  and  stif- 
fens some  joints  to  a  certain  extent.  Superficial  erosions  of  the  carti- 
lages may  also  be  witnessed,  and,  as  stated  under  the  Clinical  History 
of  Acute  Articular  Rheumatism,  muscular  atrophy  supervenes  in  long- 
standing cases  of  arthritis.  The  probable  causes  of  these  important 
changes  have  been  pointed  out  in  connection  with  the  latter  disease. 
When  the  shoulder-joint  is  the  seat  of  chronic  inflammation,  this  mus- 
cular atrophy  (affecting  chiefly  the  deltoid)  reaches  its  highest  degree 
of  development. 

Htiology. — [a)  Age  predisposes  to  the  affection.  Though  it  may  ap- 
pear at  any  age,  the  greatest  number  of  cases  is  furnished  by  the  years 
from  forty  to  sixty,  {b)  Sex  exerts  a  slight  influence,  the  disease  being 
observed  most  frequently  among  females,  {c)  External  agencies,  as  pov- 
erty and  occupations  which  entail  exposure  to  cold  and  dampness,  act 
as  predisposing  influences,  {d)  Heredity  may  operate  to  favor  its 
development. 

Symptoms. — The  involved  joints  may  not  present  any  markedly 
visible  evidences  of  disease,  and  perhaps  the  most  prominent  local  symp- 
tom is  pain,  increased  often  at  night  as  well  as  by  approaching  cold  or 
damp  weather.  Both  the  larger  and  smaller  joints  are  involved,  though 
the  former  to  a  greater  degree,  and  yet,  though  usually  multiple,  the 
disease  may  be  limited  to  one  joint  (knee,  hip,  shoulder,  etc.).  The 
joints  are  somewhat  swollen,  at  times  slightly  reddened,  tender  upon 
pressure,  and  their  mobility  is  generally  restricted.  Pain  and  stiffness 
are  most  marked  in  the  morning  hours  (after  rest),  and  often  largely 
disappear  with  each  returning  evening  (after  use).  All  the  local  symp- 
toms are  subject  to  exacerbations  and  remissions.  A  peculiar  crepi- 
tation maybe  elicited  on  applying  the  hand  over  the  affected  joints  dur- 
ing motion,  and  eventually  ankylosis,  with  some  degree  (usually  slight) 
of  distortion  of  the  joints,  may  occur. 

The  general  features  are  usually  conspicuous  by  their  absence.  No 
fever  is  present,  and,  in  most  instances,  there  is  no  serious  impairment 
of  the  general  health.  On  the  other  hand,  as  the  result  of  constant 
suffering,  a  wretched  general  condition  with  marked  anemia  and  debility 


366  INFECTIOUS  DISEASES. 

may  finally  be  reached,  such  patients  often  passing  sleepless  nights  and 
suffering  severely  from  dyspepsia.  Chronic  endocarditis  may  develop 
alonor  ^vith  the  chronic  articular  chano;es — a  not  uncommon  association, 
though  frequently  the  history  of  a  previous  attack  of  acute  rheumatism 
is  also  obtainable,  to  which  the  endocarditis  may  be  attributed  (for  the 
diff"erential  diagnosis  of  this  disease  vide  Arthritis  Deformans). 

Prognosis. — Full  recovery  is,  ^ith  but  few  exceptions,  out  of  the 
question.  A  cure  may  rarely  be  eff"ected  if  the  case  come  under  appro- 
priate treatment  in  the  incipient  stage.  The  disease,  however,  rarely 
shortens  the  duration  of  life,  though  it  may  do  so  by  interfering  Avith 
the  nutritive  processes,  the  latter  effect  resulting  from  loss  of  sleep  (due 
to  pain)  and  inability  to  take  active  exercise. 

Treatment. — {a)  The  local  measures  hold  first  place.  The  affected 
joints  should  be  enveloped  in  flannel  at  all  times,  and  underneath  the 
latter  may  be  applied  cold  cloths,  and  the  whole  covered  with  oiled  silk. 
On  the  other  hand,  sponging  the  joints  frequently  with  hot  water  also 
furnishes  good  results,  relieving  decidedly  the  pain  and  stiff"ness.  Bier, 
A,  Graham  Reed,  and  others,  employed  a  hot-air  treatment  with  good 
effects.  Blisters  have  been  employed.  In  removing  effusions  they  are 
most  efficacious.  In  the  absence  of  synovial  eff'usion  the  thermo-cautery 
is  to  be  preferred  to  blisters,  and  for  the  swelling  and  stiffness  massage 
with  passive  movement  aff"ords  excellent  results.  Massage  is  also  valu- 
able when  atrophy  of  the  adjacent  muscles  exists;  and  in  these  so-called 
"rheumatic  paralyses"  electricity  is  an  important  help.  lodin  and 
stimulating  liniments  are  more  or  less  serviceable. 

{h)  Hygienic  Measures. — The  diet  should  be  abundant  and  nourish- 
ing ;  it  Miay  embrace  milk,  eggs,  the  lighter  forms  of  meat,  fats,  fari- 
naceous articles,  and  cruciferous  vegetables  ;  wines  and  alcohol  may  be 
permitted.  Dietetic  abuses,  however,  tend  to  aggravate  the  arthritic 
condition.  The  patient  should  adopt  and  continue  moderately  active 
exercise  until  compelled  to  omit  it  on  account  of  the  advancing  joint- 
lesions.  Cold  spongings  of  the  skin-surface,  followed  by  active  friction, 
have  a  good  effect  in  tliat  they  lessen  cutaneous  sensitiveness. 

(c)  Internal  remedies  do  not  control  the  morbid  process  directly, 
although  arsenic,  iodin,  potassium  iodid,  guaiacol.  and  other  agents  are 
much  used  for  this  purpose,  but  their  eff"ects  are  usually  limited,  and 
never  brilliant.  It  should  be  our  aim  to  maintain  the  general  health  at 
a  maximum  level  by  tlie  employment  not  only  of  the  sanitary  means 
before  alluded  to,  but  also  by  tonics  (iron,  quinin.  strychnin,  etc.).  I 
have  found  a  course  of  cod-liver  oil,  continued  for  a  long  period  of  time, 
the  most  serviceable  form  of  internal  medication. 

{d)  In  general  terms  hydrotherapy  is  an  important  adjuvant  to  the 
treatment. 

The  thermal  springs  whose  waters  are  alkaline  or  contain  sulphur, 
and  of  which  the  hot  springs  of  Arkansas  and  Virginia,  and  the  Rich- 
field Springs,  New  York,  furnish  good  examples,  have  been  strongly 
advocated,  and  sometimes  prove  curative  in  their  eff"ects.  I  have  seen 
excellent  results  from  the  methodic  use  of  hot-water  baths  at  a  constant 
temperature  (100°  to  105°  F.— 37.7°  to  40.5°  C),  combined  with  passive 
motion  and  careful  manipulation  of  the  affected  parts.  If  the  latter  be 
adopted,  every  precaution  must  be  used  to  avoid  exposure  to  cold  or 


WEIL'S  DISEASE.  367 

draft  during  and  after  the  baths,  which  should  not  be  prolonged  beyond 
ten  minutes. 


WEIL'S  DISEASE. 
{Acute  Febrile  Jaundice;  Fiedler  s  Disease.) 

Definition. — An  acute  febrile  disease,  probably  specific  in  origin, 
and  characterized  by  jaundice,  remittent  fever,  and  muscular  pains.  It 
usually  runs  a  definite  course  and  terminates  by  lysis. 

Pathology. — During  the  comparatively  recent  studies  of  the  post- 
mortem lesions  occurring  in  this  disease  very  little  has  been  noted.  The 
liver  and  spleen  are  sometimes  the  seat  of  an  active  hyperemia,  and 
occasionally  some  gastro-intestinal  irritation  is  present.  The  cortical 
substance  of  the  kidneys  is  s-\vollen  and  mottled,  and  the  epithelium  of 
the  tubules  and  glomeruli  shows  cloudy  swelling. 

etiology. — The  special  organism  of  the  disease  is  unknown ;  in- 
deed, it  may  be  an  acute  febrile  jaundice  of  varied  etiology.  Jaeger 
claims  that  it  is  due  to  infection  by  the  hacillus  proteus  jiuorescens. 

Predisposing  Causes. — Among  these  may  be  mentioned  the  fol- 
lowing : 

(a)  Age. — The  age  of  the  patient  usually  varies  from  twenty  to 
forty  years.  A.  Holz  records  a  case  in  a  woman  fifty-one  years 
old. 

(b)  Oecupation. — Butchers  are  most  commonly  afi"ected. 

(e)  Sex  and  Season. — Most  of  the  recorded  cases  occurred  in  males 
and  during  the  summer  months. 

{d)  Locality. — The  cases  have  appeared  in  groups,  in  both  rural  and 
urban  localities. 

Symptoms. — The  disease  is  usually  ushered  in  by  a  cJdll,  followed 
by  fever,  headache,  and  pain  in  the  muscles  that  may  be  agonizing. 
Jaundice  usually  appears  on  the  second  day,  and  may  either  be  slight 
or  very  intense ;  if  it  be  due  to  obstruction,  the  stools  are  gray-colored, 
showing  the  absence  of  bile.  The  fever  is  of  the  remittent  type,  run- 
ning from  ten  to  fourteen  days  and  terminating  by  lysis.  Nausea, 
vomiting,  and  diarrhea  may  rarely  occur.  The  liver  and  spleen  are 
often  enlarged,  the  latter  being  tender  on  pressure.  The  urine  is  febrile, 
high-colored,  and  often  shows  the  presence  of  albumin,  with  tube-casts, 
and  sometimes  blood  (hemoglobinuria).  In  grave  (but  rare)  cases  cere- 
bral symptoms,  such  as  delirium,  convulsions,  and  coma,  may  occur  and 
prove  fatal. 

The  diagnosis  rests  on  the  acute  onset,  fever,  nephritis,  and 
icterus.  Schlammfieber,  which  prevailed  mainly  among  young  per- 
sons who  had  worked  in  the  recently-flooded  districts  near  Breslau 
during  the  summer  of  1891,  and  assumed  epidemic  proportions,  has 
not  been  satisfactorily  classified.  Mliller  shows  its  resemblance  in 
many  respects  to  Weil's  disease,  which  may  occur  at  times  without 
jaundice  (?'). 

Prognosis. — The  prognosis,  both  as  to  life  and  recovery,  is  good. 
AY.  E.  Hughes,  notwithstanding,  records  two  cases  that  died  within  forty- 
eight  hours  of  the  onset. 

The  treatment  is  purely  symptomatic. 


368  INFECTIOUS  DISEASES. 

MALTA    FEVER. 
{Mediterranean  Fever ;  Rock  Fever  ;    Undulant  Fever.) 

Definition. — A  protracted  infectious  disease,  caused  by  the  micro- 
coccus meliten.sis.  and  characterized  clinically  by  irregular  fever,  copious 
sweats,  rheumatoid  pains,  and  frequent  relapses. 

History. — It  is  endemic  in  Malta,  and  from  time  to  time  is  encoun- 
tered there,  as  well  as  at  Naples  and  other  Mediterranean  ports,  in  epi- 
demic form.  Kinyoun  first  suspected  the  presence  of  Malta  fever  on 
this  side  of  the  Atlantic,  and  has  pointed  out  that  Malta  fever  is  widely 
distributed  along  the  coast  and  in  the  islands  of  the  Gulf  of  Mexico. 
Recently,  Musser  and  Sailer  recognized  the  affection  in  Philadelphia  in 
a  soldier  Avho  had  come  from  Porto  Rico.  No  essential  pathologic 
lesions  have  been  identified  with  the  disease.  Hughes '  noted  an  enlarge- 
ment of  the  spleen  and  of  the  mesenteric  glands,  also  irregular  patches 
of  congestion  in  the  alimentarv  tract,  and  criave  cases  exhibited  bron- 
chitis  or  broncho-pneumonia. 

Ktiology. — Bacteriology. — The  micrococcus  melitensis  (Bruce)  has 
been  found  in  certain  tissues  (the  spleen  in  all  fatal  cases),  and  is  readily 
recognized  morphologically  and  by  culture.  Bruce,  in  two  cases,  and 
Hughes,  in  four,  reproduced  the  disease  in  monkeys  by  the  inoculation 
of  pure  cultures  of  the  organism.  Young,  healthy  adults  are  princi- 
pally affected,  and  ant-ihygienic  conditions  increase  morbidity. 

The  incubation-period  lasts  from  a  few  days  to  twenty  or  thirty. 

Symptoms. — The  disease  is  of  slow  and  gradual  development,  and 
the  features  simulate  those  of  beginning  typhoid  fever.  Headache, 
anorexia,  malaise,  and  slight  fever  (often  preceded  by  shiverings) ;  the 
face  mav  be  congested,  and  epistaxis  may  be  present.  The  bowels  are 
constipated,  and  the  stools  may  be  blood-streaked.  The  spleen  is  always 
enlarged,  and  frequently  painful,  particularly  on  pressure.  There  is 
fever  of  a  remittent  type,  with  undulating  course,  lasting  one,  two,  or 
three  weeks  ;  this,  after  an  apyre.xial  period  of  two  or  three  days,  is 
followed  bv  a  relapse,  with  rigors,  higher  fever,  delirium,  and  sometimes 
by  diarrhea  and  increased  prostration. 

The  relapse  frequently  lasts  from  five  to  six  weeks,  and  then,  after  a 
week  or  two,  a  second  relapse  may  ensue  ;  symptoms  somewhat  sim- 
ilar to  the  first — rigors,  intermittent  form  of  fever,  extreme  prostration, 
and  general  rheumatoid  symptoms.  The  latter  may  be  so  well  marked  as 
to  prohibit  muscular  movements  of  any  kind.  The  case  now  either  termi- 
nates in  recovery  or,  after  the  lapse  of  one  or  even  two  months,  there  may 
be  a  repetition  of  the  whole  symptom-complex.  In  grave  cases  the  tem- 
perature is  continuous,  and  death  may  occur  in  hyperpyrexia  (Hughes). 
Certain  complications,  as  touches  of  pleurisy  and  pneumonia,  rarely  appear. 

Diagnosis. — From  the  use  of  pure  cultures  of  the  special  organ- 
ism the  blood  of  Malta-fever  patients  gives  a  typical  agglutination. 
Thus  the  affection  is  with  ease  and  certainty  distinguished  from  typhoid 
fever  and  erratic  forms  of  malaria.  In  no  other  manner  can  it  be  dis- 
criminated from  typhoid  fever  in  the  earlier  stages.  If  malaria  is  sus- 
pected, a  microscopic  examination  of  the  blood  should  be  made. 

Duration  and  Prognosis. — Soldiers  shoAv  an  average  stay  in  the 

'  A  nnales  de  f  Institut  Pasteur. 


FEBRICULA.  369 

hospital  of  ninety  days  CBruce) ;  the  duration  in  obstinate  cases,  how- 
ever, may  exceed  six  months.  The  death-rate  is  low — about  2  per  cent. 
Treatment. — This  should  be  sustentative  or  supportive,  in  view  of 
the  uncertain,  protracted  course.  Nourishing  liquids  and  usually  stimu- 
lants are  required  during  the  febrile  stage.  Fever  is  to  be  combated  by 
the  application  of  cold  (cold  bath,  wet  pack,  or  sponging).  Certain  symp- 
toms are  required  to  be  treated  on  general  principles.  Tonics,  including 
hematinics,  coupled  with  a  change  of  climate,  favor  convalescence. 

FEBRICULA. 

( Simple  Continued  Fever  ;  Ephemeral  Fever.) 

Definition. — A  brief  febrile  attack,  unattended  with  definite  local 
lesions,  and  of  varied,  often  indeterminate,  etiology.  A  true  ephemeral 
fever  is  one  that  lasts  about  twenty-four  hours,  while  the  term  simple 
continued  fever  or  febricula  is  given  to  cases  lasting  a  longer  time — from 
three  to  six  or  more  days. 

The  cases  are  so  diversified  with  reference  to  their  etiology  and 
clinical  relations  as  to  make  it  desirable  to  group  them  roughly  under 
several  heads : 

(a)  A  large  group  of  cases  in  which  a  gastro-intestinal  disturbance 
is  the  only  assignable  cause.  The  latter  may  take  the  form  of  indi- 
gestion due  to  cold  or  more  often  to  errors  in  diet  (particularly  the  use 
of  tainted  food-stufis),  accompanied  by  absorption  of  toxic  substances ; 
or  it  may  consist  of  the  gastro-intestinal  catarrh  so  frequently  met  with 
in  young  children. 

{h)  Undeveloped  or  abortive  forms  of  the  infectious  diseases  (typhoid, 
typhus,  rheumatism).  These  affections,  particularly  during  times  of 
epidemic  prevalence,  may  run  a  brief  course  without  manifesting  any 
of  their  distinctive  characters.  In  abortive  types  (particularly  of 
typhoid  fever)  the  invasion-symptoms  are  apt  to  be  well  marked,  but 
the  more  characteristic  features  fail  to  appear.  Thus  diseases  that 
ordinarily  manifest  a  characteristic  eruption  (e.  g.  scarlet  fever,  measles, 
erysipelas)  may  run  their  course  without  doing  so,  or  the  eruption  may 
escape  observation. 

(c)  It  may  follow  exposure  to  the  summer  sun  or  excessive  Jieat,  or 
exhaustion  of  the  nervous  system. 

(d)  It  is  not  infrequently  the  result  of  a  slight  and  unnoticed  local- 
ized inflammation  (tonsillitis,  bronchitis,  lymphadenitis,  etc.). 

(e)  The  inhalation  of  sewer-gas  or  other  noxious  vapors  (such  as  em- 
anations from  decomposing  organic  matter)  may  produce  an  aberrant 
form  of  the  fever,  and  sewer-air  has  been  mentioned  elsewhere  as  a 
cause  of  a  mild  form   of  sapremia  (vide  Septicemia). 

Symptoms. — It  is  to  be  remembered  at  the  outset  that  a  single 
symptom,  peculiar  to  all  cases,  is  the  fever.  The  onset  is  generally 
sudden,  and  especially  in  ephemeral  fever,  but  it  may  be  gradual ;  if 
sudden  there  is  rarely  either  a  chill  or  vomiting,  while  in  neurotic  chil- 
dren a  convulsion  may  occur.  The  temperature  ascends  quickly  to 
102°-103°  F.  (39,4°  C.)  or  over,  pursues  the  continued  type,  and  at 
the  end  of  one,  two,  or  more  days  subsides  abruptly  by  crisis.  There 
are  accompanying  symptoms,  many  of  which  are  due  to  the  fever,  such 

24 


370  INFECTIOUS  DISEASES. 

as  headache,  hebetude,  mild  delirium,  flushed  countenance,  a  full  rapid 
pulse,  anorexia,  constipation,  scanty  high-colored  urine,  and,  not  rarely, 
herpes  labialis.  Defervescence  may  be  attended  with  critical  sweats, 
diarrhea,  or  a  copious  flow  of  urine.  Special  types  [e.  g.  cerebral,  gas- 
tric) may  be  observed,  due  to  the  predominance  of  the  symptoms  pre- 
sented by  individual  organs  or  systems. 

In  another  class  of  cases  the  access  of  simple  fever  may  be  less  sud- 
den, the  maximum  level  attained  being  somewhat  lower  and  the  attend- 
ing phenomena  less  acute  and  pronounced.  The  course  is  more  pro- 
tracted, though  rarely  exceeding  a  week  or  ten  days,  and  the  deferves- 
cence is  not  so  abrupt. 

The  diagnosis  necessitates  the  exclusion  of  other  acute  fevers.  The 
affections  from  which  it  is  most  difficult  to  distinguish  febricula  are 
typhoid  fever,  scarlet  fever,  tonsillitis,  larval  pnemnonia,  and  menin- 
gitis (in  children).  In  febricula,  however,  there  is  an  absence  of  local 
manifestations  and  of  physical  signs  pointing  to  consolidation  of  the 
lungs  ;  characteristic  skin-eruptions  are  also  absent. 

The  prognosis  is  good. 

Treatment. — Few  cases  require  treatment  other  than  rest  in  bed 
and  liquid  nourishment  for  several  days.  Cooling  drafts  internally,  and 
mild  forms  of  hydrotherapy  (spongings,  ice-caps)  externally,  are  indi- 
cated. If  traceable  to  gastro-intestinal  disturbance,  a  laxative  usually 
proves  beneficial  and  effective.  It  should  be  followed  by  intestinal 
antiseptics.  Unless  it  is  clear  that  the  given  case  is  non-infectious  and 
non-contagious,  isolation  of  the  patient  should  be  ensured. 

MILK-SICKNESS. 

Definition. — A  peculiar  infectious  disease,  occurring  both  in  man 
and  in  the  lower  animals,  when  it  is  known  as  "  trembles."  The  dis- 
ease is  unknown  east  of  the  Alleghany  Mountains,  but  throughout  many 
of  the  Western  and  South-western  States  it  formerly  prevailed  very  ex- 
tensively, with  fatal  effect.  It  has,  however,  been  almost  exterminated 
as  the  result  of  denudation  of  the  forests  and  the  advancing  cultivation 
of  the  virgin  soil.  It  still  prevails  in  parts  of  North  Carolina  (Osier), 
and  until  very  recent  times  has  been  seen  in  certain  parts  of  Illinois. 

No  peculiar  pathologic  lesions  have  been  described. 

Ktiology. — It  is  believed  to  be  due  to  a  special  poison  derived  from 
the  earth,  but  as  yet  we  are  ignorant  of  its  exact  nature.  Phillips 
claims  to  have  found  a  spirillum  in  the  blood. 

Modes  of  Infection. — The  disease  attacks  cattle  most  frequently  (espe- 
cially unweaned  calves),  horses,  sheep,  goats,  and  less  often  many  undo- 
mesticated  animals ;  wherever  trembles  prevails  among  cattle,  milk-sick- 
ness is  met  with  in  man.  It  is  thought  that  the  poison  is  communicated 
to  man  in  the  milk,  butter,  and  cheese,  or  in  the  flesh  of  infected  animals. 

Among  disposing  factors  are  the  seasons,  the  disease  being  most  fre- 
quent in  the  late  summer  and  autumn.    It  is  most  common  in  adult  life. 

Symptoms. — The  period  of  incubation  may  be  short  or  long  in 
duration,  and  prodromata,  such  as  headache,  anorexia,  languor,  and 
oncoming  fatigue,  may  be  noted.  These  symptoms  increase  in  severity, 
and  are  soon  eclipsed  by  the  more  characteristic  features — nausea  and 


MILIARY  FEVER.  371 

vomiting,  a  hot  pain  in  the  stomach,  and  a  peculiar  fetor  of  the  breath. 
There  is  an  unquenchable  thirst,  a  swollen,  tremulous  tongue,  and  abso- 
lute constipation.  Fever  is  present,  but  it  is  slight,  and  the  surface- 
temperature  is  often  below  the  normal.  The  nervous  symptoms  include 
restlessness,  merging  into  mental  dulness  with  marked  indifference,  and 
the  latter  condition  passing  in  grave  cases  into  a  stupor  that  may  deepen 
into  actual  coma.  Convulsions  may  arise  or  the  patient  may  drop  into 
a  fatal  typhoid  state. 

The  diagnosis  rests  chiefly  upon  the  history  (particularly  upon 
the  coexistence  of  "  trembles  "  in  cattle)  and  the  exclusion  of  other  acute 
intoxications. 

The  prognosis  is  generally  favorable,  though  a  fatal  termination 
due  to  asthenia  may  occur  within  a  few  days  of  the  time  of  the  onset. 

Treatment. — Prophylaxis  consists  in  the  avoidance  of  those  foods 
that  act  as  bearers  of  the  disease.  Apart  from  the  use  of  supporting 
measures  (appropriate  diet  and  stimulants),  we  can  attend  only  to  the 
symptomatic  indications.      Medicated  enemata  should  not  be  omitted. 


MILIARY  FEVER. 

{Sweating  Sickness.) 

Definition. — An  infectious  disease,  characterized  by  copious  sweats 
and  a  vesicular  (miliary)  eruption.  In  certain  countries  it  has  prevailed 
epidemically  (France,  England,  Italy,  Germany),  and  in  1887  a  severe 
epidemic  occurred  in  France.  Schaffer  ^  reports  the  occurrence  of  a  re- 
cent epidemic  in  an  Austrian  province  in  the  spring  of  1893,  lasting  for 
nearly  three  months.  Out  of  5079  persons  (the  total  population  of  the 
district),  159  suiFered,  as  follows  :  17  men,  14  women,  and  128  children. 
At  the  present  day  it  seems  to  be  met  Avith  only  in  Picardy,  in  a  few 
other  French  provinces,  and  throughout  a  limited  area  in  Italy. 

Neither  have  definite  pathologic  lesions  nor  the  sjyecifie  exciting  cause 
been  found.  Among  predisposing  influences  the  following  have  been 
noted :  (a)  Most  epidemics  occur  in  spring  and  summer ;  [h)  It  is  more 
common  among  women  than  men,  and  most  frequent  during  the  middle 
period  of  life.  A  large  percentage  of  the  entire  population  of  an  in- 
vaded district  (usually  limited  in  area)  is  attacked. 

The  symptoms  that  characterize  miliary  fever  are  fever  with  its 
usual  accompaniments,  irritation  of  the  skin,  a  sense  of  oppression  in 
the  epigastrium,  copious  and  persistent  sweating,  followed,  on  the  third 
or  fourth  day  of  the  disease,  by  an  eruption  of  miliary  vesicles. 

The  vesicles  burst,  and  within  forty-eight  hours  scaly  desquamation 
is  generally  completed.  In  severe  types  the  nervous  phenomena  (delir- 
ium, etc.)  are  grave  in  character  ;  hemorrhages  may  occur,  and  at  times 
fatal  collapse  may  follow.      Relapses  are  not  uncommon. 

The  prognosis  is  affected  largely  by  the  character  of  the  epidemic, 
the  average  death-rate  being  8  or  9  per  cent. 

Quinin  has  met  with  almost  universal  favor  as  a  remedy,  but  the 
expectant  plan  of  treatment  is  the  most  appropriate,  the  indications 
being  fulfilled  as  they  arise. 

1   Weiner  med.  Blatter,  1893,  No.  32. 


372  INFECTIOUS  DISEASES. 

FOOT-AND-MOUTH  DISEASE. 
(Epidemic  Stomatitis ;  Aphthous  Fever.) 

Definition. — An  acute  infection  of  certain  lower  animals  (cattle, 
sheep,  pigs,  goats),  caused  by  a  micro-organism  as  yet  undiscovered, 
although  Klein  has  described  a  micrococcus.  It  is  characterized  by  fever, 
by  the  appearance  of  vesicles  and  ulcers  in  the  mucosa  of  the  mouth,  in 
the  furrows  about  the  feet  and  on  the  udder,  and  by  the  rapid  develop- 
ment of  asthenia  and  marked  emaciation.  Though  a  disease  of  mild 
character,  its  territorial  range  is  so  vast  as  to  entail  untold  loss  to  Euro- 
pean countries.  Young  animals  or  sucklings  perish  in  great  numbers  on 
account  of  the  deteriorated  quality  of  the  milk,  which  assumes  a  yellowish- 
white  appearance  and  has  a  bitter,  nauseating  taste. 

During  epidemics  of  foot-and-mouth  disease  the  poison  may  be  trans- 
ferred to  man,  in  Avhom  the  disease  is  known  as  epidemic  stomatitiii,  the 
poison  generally  being  transferred  by  means  of  milk.  Boiling  the 
latter  destroys  the  virus,  but  rarely  the  infection  may  be  transmitted 
through  butter  and  cheese  made  from  the  milk  of  infected  cattle.  Com- 
munication by  inoculation  (while  milking)  may  also  occur.  The  disease 
does  not  seem  to  be  transmissible  through  the  meat  of  diseased  animals.^ 
In  America  a  few  instances  only  of  transference  from  animals  to  man 
are  recorded. 

Sytnptoms. — The  incubation-period  lasts  from  three  to  five  days. 
A  rigor  may  mark  the  onset  or  merely  slight  shiverings,  followed  by 
fever  and  malaise,  and  soon  vesicles,  such  as  are  described  under  Aph- 
thous Stomatitis,  appear  upon  the  tongue  and  inner  surface  of  the  lips. 
The  mouth  is  hot,  the  mucosa  reddened  and  swollen,  and  salivation  is 
present.  A  form  of  miliary  eruption  that  may  become  pustular  may 
also  appear  on  the  skin-surface,  and  particularly  on  the  fingers  and 
hands.     Hemorrhages  have  been  observed  in  severe  epidemics. 

The  diagnosis  is  made  with  ease  if  the  disease  be  prevailing  at  the 
same  time  among  lower  animals.  The  peculiar  coincidence  of  the  erup- 
tion in  the  mouth  and  extremities,  sparing  the  rest  of  the  body,  has  not 
been  noticed  in  any  other  eruptive  disease  (Whittaker). 

Course  and  JPrognosis. — The  course  is  mild  and  ends  in  about 
one  week,  the  disease  being  very  rarely  fatal. 

Treatment. — Propliylaxis  requires  the  use  of  milk  from  healthy 
animals  (cows  or  goats),  together  with  measures  looking  to  the  care  of 
the  stables  and  isolation  of  diseased  cattle.  A  reliable  method  of  immu- 
nization against  foot-and-mouth  disease  has  not  as  yet  been  discovered.^ 
For  treatment  the  reader  is  referred  to  the  article  on  Aphthous  Stoma- 
titis. 

GLANDULAR  FEVER. 

Definition. — By  this  term  is  meant  an  acute  infectious  disease  of 
children,  characterized  by  adenitis  affecting  the  lymph-glands  of  the 
neck,  especially  the  anterior  cervical. 

*  Zuell's  translation  of  Fried berger  and  Frohner's  Pathology  and  Therapeutics  of  the 
Domestic  Animali^. 

^  Siegel,  "Experiments  in  Immunization  against  the  Poison  of  Bites  and  Scralclies." 
Quoted  in  the  I'hUadelpkia  Med.  Jour.,  January  28,  1899. 


GLANDULAR  FEVER.  373 

History. — A  detailed  description  of  glandular  fever  was  first  given 
by  E.  Pfeiffer,  in  1889,  under  the  name  of  Drilsenfieber,  but  it  had  prob- 
ably been  previously  described  by  Filatow,  of  Moscow.  Donkin,  Fischer 
and  Dawson  Williams,  in  England,  and  J.  Park  West  have  given  excel- 
lent descriptions  of  the  disease. 

Pathologfy. — The  anterior  cervical  lymphatic  glands  are  involved 
first,  and  it  is  "  probable  that  the  infection  finds  its  point  of  entrance 
through  either  the  tonsils  or  the  pharyngeal  mucous  membrane  "  (Wil- 
liams).    The  adenitis  may  also  aflect  the  inguinal  and  axillary  glands. 

!^tiology. — The  special  micro-organism  of  the  disease  is  unknown. 
The  complaint  occurs  usually  in  the  form  of  hou^e-epidemics.  West,  of 
Ohio,  however,  has  described  the  most  widespread  epidemic  hitherto  re- 
corded. There  were  96  cases  in  43  families,  and  rarely  did  a  child 
exposed  to  the  infection  escape.  The  disease  usually  occurs  during 
childhood ;  the  ages  of  West's  cases  ranging  from  seven  months  to  thir- 
teen years.  A.  E.  Roussel  has  reported  four  cases,  one  occurring  in  an 
adult.  Most  cases  occur  between  the  months  of  October  and  May, 
inclusive. 

The  incubation-period  lasts  usually  from  five  to  eight  days. 

Symptoms. — The  onset  is  sudden.  The  child  holds  the  neck  stiffly, 
since  movement  causes  pain ;  there  are  anorexia,  nausea,  and  less  com- 
monly vomiting,  the  bowels  are  constipated,  and  often  there  is  abdominal 
pain.  The  child  may  complain  of  pain  and  swelling ;  an  examination 
of  the  pharynx  may  show  some  chronic  enlargement  of  the  tonsils,  and 
in  some  cases  injection  of  the  pharyngeal  mucosa,  actual  pharyngitis 
being  rare.  The  temperature  oscillates  from  101°  to  103°.  Nervous 
symptoms  (delirium,  hebetude)  are  rarely  observed. 

The  glandular  enlargement  becomes  obvious  on  the  second  or  third 
day,  and  in  most  cases  is  observed  first  on  the  left  side,  then,  after  a  few 
days,  on  the  other  side  of  the  neck  also.  The  glands  vary  in  size  from 
a  bean  to  a  hen's  egg,  and  are  painful  on  palpation.  They  rarely  suppu- 
rate. Other  groups  of  glands  (axillary,  inguinal)  may  be  successively 
involved.  Cough  and  dyspnea  may  point  to  involvement  of  the  bron- 
chial and  tracheal  glands.  The  mesentery  glands  were  enlarged  in  38.5 
per  cent,  of  West's  cases.  Splenic  enlargement  occurs  in  50  per  cent. 
of  the  cases,  while  the  liver  is  voluminous  in  almost  all  cases.  The 
average  duration  is  sixteen  days  (West).  Among  comjjlications  may  be 
mentioned  hemorrhagic  nephritis,  bronchitis,  and  otitis  media. 

Diagnosis. — The  recognition  of  glandular  fever  embraces  the  exclu- 
sion of  such  affections  as  tonsillitis  and  jjJiar^ngitis,  in  the  course  of 
which  adenitis  might  arise. 

Prognosis. — Recovery  is  the  rule. 

Treatment. — The  course  of  the  disease  is  probably  uninfluenced  by 
treatment.  Locally,  cold  compresses  and  fomentations  are  useful.  Inter- 
nally, West  advises  castor-oil  in  the  early  stage,  followed  by  minute 
doses  of  calomel  (gr.  ^2"  ^o  -ro)  t'^vice  or  thrice  a  day. 


PART  II. 

CONSTITUTIONAL    DISEASES. 


DIABETES. 

{Diabetes  Mellitus.) 


Definition. — A  nutritional  affection,  attended  by  an  abnormal 
amount  of  sugar  in  the  blood,  and  characterized  clinically  by  persistent 
glycosuria,  by  polyuria,  and  by  a  progressive  loss  of  flesh  and  strength. 

Nature  of  the  Affection. — This  is  still  undetermined.  Post-mortem 
lesions  of  different  organs  and  structures  of  the  body  have  been  met 
with  in  diabetes — a  foct  that  has  given  rise  to  a  variety  of  views, 

(1)  That  it  is  dependent  upon  organic  disease  of  the  pancreas,  espe- 
cially granular  atrophy,  or  upon  marked  functional  disturbance  of  this 
organ.  It  has  been  shown  experimentally  that  extirpation  of  the  pan- 
creas is  followed  by  diabetes,  and  yet,  according  to  Minkowski  and 
Ldpine,  if  a  small  portion  remains  glycosuria  does  not  result.  On  the 
other  hand,  Sandmeyer  extirpated  the  pancreas  of  two  dogs,  leaving 
from  one-ninth  to  one-fifth  of  the  organ.  The  animals  became  diabetic 
— one  four  and  the  other  thirteen  months  after  the  operation — and  the 
first  dog  succumbed  two  months  and  the  other  eight  months  later. 

It  may  safely  be  assumed  that  total  loss  of  function  always,  and  par- 
tial loss  sometimes,  leads  to  diabetes.  Again,  from  the  observations  of 
Hansemann  in  the  Berlin  Pathological  Institute  and  the  Augusta  Hos- 
pital, it  would  seem  certain  that  the  coincidence  of  pancreatic  disease 
and  diabetes  occurs  oftener  than  either  diabetes  or  pancreatic  dis- 
ease alone,  and,  in  truth,  oftener  than  both  these  separate  affections 
combined.  Lupine  and  Martz  have  been  able  to  produce  a  glycolitic 
ferment  by  treating  the  pancreas  after  their  own  special  method,  which 
need  not  be  detailed  here.  This  ferment  is  identical  with  that  which  is 
contained  in  the  blood,  and  in  the  presence  of  which  glycogen  is  assim- 
ilated ;  pancreatic  diabetes  occurs,  therefore,  when  through  organic  dis- 
ease or  functional  disturbance  the  formation  of  this  ferment  is  wholly 
or  even  partly  arrested.  Another  source  of  the  glycolitic  ferment  is  the 
salivary  secretion. 

(2)  If  the  glycogenic  function  of  the  liver  be  interfered  Avith  mate- 
rially, diabetes  follows.  This  may  result  from  organic  hepatic  disease 
or  the  fault  may  lie  solely  with  the  nervous  system.  Puncture  of  the 
floor  of  the  fourth  ventricle  will  also  cause  glycosuria,  and  section  of 
the  pneumogastric  nerve  is  followed  by  vaso-motor  paralysis  of  the  he- 
patic vessels,  disappearance  of  glycogen  from  the  liver,  and  the  appear- 

.374 


DIABETES.  375 

ance  of  sugar  in  the  urine.  This  view  explains  how  the  cord  and 
central  lesions  and  disturbance  of  the  sympathetic  system  produce 
diabetes. 

(3)  The  so-called  alimentary  glycosuria  has  frequently  been  induced 
experimentally  by  Miura  and  others.  It  results  from  the  ingestion  of 
more  carbohydrates  and.  peptone  than  can  be  stored  in  the  liver  as  gly- 
cogen, so  that  some  of  the  latter  finds  its  way  into  the  hepatic  vessels 
with  consecutive  glycosuria. 

(4)  The  administration  of  'phloridzin  produces  glycosuria  both  in 
animals  and  man.  There  are  two  view's  as  to  the  cause  of  phloridzin 
diabetes  :  (a)  that  the  kidneys,  owing  to  the  action  of  the  phloridzin  on 
the  renal  epithelium,  eliminate  the,  sugar  from  the  organism  ;  {h)  that 
an  excessive  formation  of  glucose  occurs.  The  condition  of  the  blood 
in  phloridzin  glycosuria  testifies  to  the  decomposition  of  proteids  rather 
than  to  the  mere  elimination  of  sugar  (Lepine). 

(5)  The  Microbic  Theory. — Paul  Ernst  and  others  have  observed  all 
forms  of  fungi  in  diabetes,  thus  showing  that  the  disease  is  favorable  to 
the  development  of  various  micro-organisms,  but  as  yet  none  have  been 
shown  to  sustain  an  etiologic  relationship. 

(6)  Pavy's  view  regarding  diabetes,  recently  advanced,  is  that  the 
carbohydrates  of  the  food  are  converted  into  fat  by  the  protoplasmic 
action  of  cells  in  the  intestinal  villi,  and  enter  the  system  in  the  same 
way  as  do  fats  taken  as  such.  The  surplus  carbohydrates  that  escape 
the  action  of  the  cells  of  the  villi  are  transmuted  into  glycogen  in  the 
liver.  The  glycogen  stored  in  the  liver  obviously  forms  fat  also,  since 
this  organ  has  some  fat-forming  function,  and  there  are  thus  two  barriers 
preventing  the  carbohydrate  matter  from  entering  into  the  blood,  and 
if  either  is  deranged  hyperglykemia  with  the  consequent  glycosuria 
results. 

No  single  view  explains  all  cases  of  diabetes.  The  influence  of  the 
nervous  system  is  undoubted,  but  the  role  it  assumes  is  imperfectly  known. 
In  light  cases  the  carbohydi'ates  are  not  warehoused  in  the  liver  and 
muscles,  and  the  excess  of  glycogen  not  burned  up  in  the  tissues.  In 
severe  cases  the  carbohydrate  moiety  of  the  proteids  of  the  food  or  tissues 
furnishes  the  sugar  excreted  in  the  urine  (Stengel).  Lastly,  the  precise 
form  of  disturbance  of  metabolism  that  prevents  a  normal  disposal  of 
carbohydrates  is  unknown. 

Patliolog'y. — The  pancreas  in  more  than  one-half  the  instances 
shows  morbid  changes.  The  most  frequent  lesion  is  the  granular  atrophy 
of  Hansemann,  occurring  in  36  out  of  40  cases  of  pancreatic  diabetes. 
Bard  and  Pic  found  150  cases  of  primary  cancer  of  the  pancreas  on  record, 
and  in  only  17  was  glycosuria  noted.  Fibroid  induration  of  the  pancreas 
is  sometimes  observed  in  diabetics,  and  is  due  to  syphilis.  Diffuse  cancer 
of  the  organ  may  lead  to  diabetes,  but  not  readily,  Hansemann  having 
observed  2  cases,  and  I  also  2,  without  diabetes.  Calculus,  with  atrophy, 
may  or  may  not  be  associated  with  diabetes.  Occlusion  of  the  pancreatic 
duct,  atrophy  from  pressure,  and  cystic  degeneration  may  be  met  in  this 
disease.  Of  100  cases  of  acute  necrosis  of  the  pancreas  collected  by 
Fitz  and  Seitz,  only  2  had  diabetes. 

The  liver  is  often  enlarged  and  the  seat  of  fatty  degeneration.  Ac- 
cording to  French  writers,  there  is  a  diabetic  cirrhosis  of  the  organ  [cir- 


376  CONSTITUTIONAL  DISEASES. 

7'hose  pigmentaire),  the  pigment  being  derived  from  destroyed  blood-cells. 
I  observed  an  instance  associated  with  syphilitic  hepatitis. 

The  Kidneys. — There  may  be  noted  a  benign,  often  intermittent, 
form  of  albuminuria,  and  a  well-marked  nephritis,  with  fatty  degenera- 
tion, is  often  present.  The  tubal  epithelium  may  show  a  hyaline  change, 
and  the  lesions  of  acute  nephritis  may  be  present. 

Nervous  System. — In  rare  instances  organic  disease  of  the  medulla 
(tumors,  sclerosis,  etc.)  is  found.  Cysts  have  been  met  with  in  the  w^hite 
matter  of  the  cerebi'um,  and  perivascular  changes  have  also  been  de- 
scribed (Osier).  Changes  in  the  posterior  columns  of  the  cord  have  been 
noted,  afld  a  peripheral  neuritis,  simple  or  multiple,  is  commonly  though 
not  constantly  seen.  The  so-called  .diabetic  tabes  is  generally  supposed 
to  be  due  to  multiple  neuritis.  Sclerosis  and  enlargement  of  the  ganglia 
of  the  sympatlietic  system  have  been  noted  in  a  few  cases. 

The  Lungs. — The  commonest  lesions  in  the  lungs  are  gangrene  fol- 
lowing pneumonia  and  the  so-called  diabetic  phthisis.  Fatty  emboli  are 
found  in  the  pulmonary  vessels. 

The  Heart. — Arterio-sclerosis  with  cardiac  hypertrophy  is  often  met 
with,  but  does  not  constitute  a  peculiar  lesion.  Marie  found  pigmentary 
degeneration  of  the  muscular  fibers  and  sclerosis  of  the  pigmented 
fibrous   tissue. 

The  Skin. — Cutaneous  pigmentation,  brown  or  even  red-black,  and 
more  or  less  uniform,  has  been  reported  in  9  cases  (Hanot  and  Chauffard). 
It  is  associated  with  hypertrophic  cirrhosis  of  the  liver. 

Tlie  Stomacli. — Dilatation  and,  according  to  Jacobson,  marked  catar- 
rhal changes  are  common  in  the  early  stage. 

Tlte  Blood. — The  normal  proportion  of  sugar  in  the  blood  (0.15  per 
cent.)  is  usually  increased,  though  there  is  no  immediate  connection  be- 
tween the  percentage  of  sugar  in  the  blood  and  in  the  urine  in  diabetes. 
Both  in  experimental  and  pathologic  diabetes  hyperglykemia  may  be 
marked,  with  moderate  or  slight  glycosuria,  and  Ldpine  has  shown  that 
diuretics  diminish  hyperglykemia  by  increasing  the  glycosuria.  The 
blood-plasma  contains  much  fat.  It  is  probable  that  the  albuminoid 
matters  in  the  blood  may  produce  glucose.  Glycogen  probably  exists 
in  the  blood-corpuscles,  and  not  in  the  plasma,  "  where  it  would  be 
destroyed  by  the  diastasic  ferment  "  (Dastre),  and  it  is  a  normal  ele- 
ment of  the  blood,  apparently  belonging  to  the  leukocytes  (Huppert 
and   Czerny).     The  corpuscles  show  no  special  alterations. 

General  Btiology. — {a)  Heredity  is  generally  believed  to  exert  a 
predisposing  infiuence,  since  cases  are  observed  to  succeed  one  another 
in  the  same  family,  [b)  Season  also  exerts  an  influence,  diabetes  appear- 
ing more  freiiuently  in  the  months  of  March,  April,  July,  and  Novem- 
ber (Davis),  (r?)  The  male  sex  suffers  much  more  frequently  than  the 
female.  Wegeli,  however,  found  in  107  cases  that  children  of  both  sexes 
were  affected  in  an  e(pial  proportion,  (d)  Age. — Most  cases  occur  between 
thirty-five  and  sixty  years  of  age.  Infantile  diabetes  is  rare,  and  occurs 
most  freciuently  about  the  age  of  five,  though  it  has  been  met  with  under 
one  year.  (<?)  The  Hebrew  race  is  especially  susceptible.  The  colored 
race  rarely  suffers,  although  of  a  series  of  77  cases  8  or  10.3  per  cent, 
were  in  negroes  (Futcher).  (  f )  The  better  classes  of  society  furnish 
most  instances,  and  particularly  that  large  element  composed  of  neurotic 


DIABETES.  377 

subjects,  {g)  A  nervous  shock  or  strain  or  prolonged  mental  anxiety 
acts  as  a  predisposing  cause.  (Ji)  Occupation. — The  urine  of  607  indi- 
viduals engaged  in  manual  labor  that  required  great  muscular  and  respi- 
ratory activity  showed  no  sugar  in  any  case ;  while  the  urine  of  100  in- 
dividuals engaged  in  intellectual  Avork  of  a  more  or  less  fatiguing  charac- 
ter, but  always  intense  and  sedentary,  showed  sugar  in  10  of  the  cases 
(Worms).  (J)  Obesity  predisposes,  somewhat,  particularly  to  the  lipogenic 
form,  [j)  Certain  chronic  diseases — e.  (7.  syphilis,  malaria,  gout — pre- 
dispose, {k)  Pregnancy  has  a  slight  though  decisive  influence.  {I)  It 
sometimes  folloAvs  acute  infectious  diseases,  (m)  Locality. — Diabetes  mel- 
litus  is,  comparatively  speaking,  rare  in  America,  although  Hare's  statis- 
tics indicate  that  diabetes  is  becoming  more  prevalent.  In  certain  other 
countries  (Normandy,  India,  France)  diabetics  appear  to  be  constantly 
increasing  in  number,  the  mortality  in  Paris  having  more  than  doubled 
from  1883  to  1892,  inclusive.  The  disease  is.  much  more  frequent  in 
cities  than  in  rural  districts.  Contagion. — Among  770  cases  observed 
by  Senator  there  were  9  instances  of  man  and  wife  suffering  from  the 
disease.  In  a  series  of  5,000  cases  1.8  per  cent,  of  conjugal  diabetes 
occurred  (Schram). 

Special  Etiology. — Under  this  head  may  be  arranged  the  following 
groups  of  cases :  (1)  Diabetes  due  to  pancreatic  disease.  (2)  Cases  oc- 
casioned by  hepatic  disease  [organic  and  functional).  (3)  Those  com- 
paratively rare  instances  caused  by  disease  of  the  brain  (tumors,  sclerosis, 
or  irritative  lesions  of  the  diabetic  center)  and  spinal  cord.  (4)  Diabetes 
follows  traumatism,  and  especially  injuries  to  the  head.  Not  infre- 
quently it  occurs  after  injuries  to  other  parts  of  the  body,  such  as  the 
spine,  sacral  region,  abdomen,  etc.  In  212  cases  of  traumatism  of  the 
head  Higgins  and  Ogden  found  20  cases  of  glycosuria,  though  only  a 
small  proportion  of  the  cases  (2)  exhibited  a  permanent  glycosuria  from 
the  date  of  injury.  Ebstein,'  after  an  exhaustive  study  of  6  of  his  own 
cases  and  of  44  gathered  from  literature,  concludes  that  there  can  be 
no  question  of  the  direct  causal  relation  of  traumatic  neurosis  and 
diabetes.  ^ 

Clinical  History. — For  the  sake  of  accuracy  and  convenience  of 
description,  the  cases  will  be  divided  into  the  acute  and  chronic  forms. 

1.  Acute  Diabetes  Mellitus. — The  instances  are  few  and  the  course  is, 
as  a  rule,  rather  subacute  than  acute,  manifesting  a  predilection  for  the 
young  and  middle-aged.  The  07iset  is  more  abrupt  than  in  the  chronic 
form,  but  the  characteristic  features  do  not  differ  from  those  of  the  lat- 
ter. Many  of  the  cases  due  to  pancreatic  disease  are  of  this  class. 
Exceptionally,   acute  diabetes  occurs  in  the  aged. 

2.  Chronic  Diabetes. — The  symptoms  are  evolved  slowly  and  gradu- 
ally, as  a  rule,  and  prominent  among  prodromal  conditions  is  dyspepsia 
or  chronic  gastric  catarrh.  We  may  also  note  certain  nervous  disorders, 
such  as  headache,  mental  irritability,  moroseness,  and  insomnia,  with  or 
without  gastro-intestinal  symptoms.  In  some  cases  the  patient  suffers 
merely  from  general  debility  and  malaise,  and  either  frequent  micturi- 
tion, polyuria,  or  unnatural  thirst  is  apt  to  be  noticed.  Rarely,  dia- 
betes has  an  abrupt  onset,  as  after  an  injury,  a  sudden  nervous  shock  or 
a  chill.     With  the   development  of  the  affection  the  polyuria  becomes 

'■  Deutsche  Arch.f.  klin.  Med.,  April,  1895. 


378  CONSTITUTIONAL  DISEASES. 

marked,  as  a  rule,  the  thirst  great,  the  appetite  keen,  and  glycosuria 
appears.  In  spite  of  the  enormous  quantities  of  food  taken,  progressive 
emaciation  and  debility  attend. 

Leading  Symptoms  and  Complications  in  Detail. — (1)  The  Urinary 
Symptoms. — The  daily  amount  of  urine  varies  from  four  or  five  pints  to 
as  many  gallons.  In  very  mild  cases  and  in  intercurrent  febrile  attacks 
it  may  be  slightly,  if  at  all,  increased  in  quantity.  Its  color  is  pale, 
and  its  specific  gravity  ranges  from  1020  to  1050,  rarely  being  as  low 
as  1015 ;  it  has  an  acid  reaction,  a  sweetish,  aromatic  odor,  and  a  dis- 
tinctly sweetish  taste.  Sugar  is  present,  the  amount  varying  from  ^  of 
1  per  cent,  to  2  per  cent,  in  mild  cases,  to  5  or  even  10  per  cent,  in 
severe  attacks.  The  total  amount  eliminated  in  the  twenty-four  hours 
varies  from  five  or  ten  ounces  to  a  pound  or  more. 

Other  forms  of  sugar  than  glucose  (inosite  and  levulose)  may  be  con- 
tained in  the  urine,  and  glycogen  has  rarely  been  found.  The  urine 
may  also  contain  fermentation-products  (acetone,  alcohol,  and  diacetic 
acid).  Acetone  strikes  a  Burgundy-red  color  on  the  addition  of  the 
chlorid  of  lime.  Hirschfeld's  studies  upon  the  excretion  of  acetone  in 
diabetics  show  that  in  severe  forms  an  increased  amount  is  excreted, 
constituting  a  real  pathologic  and  distinctive  featuie  {acetonuria). 

The  urea  is  greatly  increased,  Kaufman  finding  the  quantity  in  the 
blood  of  diabetic  dogs  to  be  doubled.  Uric  acid  is  either  normal  in 
quantity  or  slightly  diminished,  but  a  large  amount  of  ammonium  is 
present,  indicating  an  increase  of  organic  acids.  The  phosphates  may 
also  be  present  in  greatly  increased  proportion  (Ralfe),  and  in  such 
cases  the  glycosuria  may  be  more  or  less  intermittent.  This  has  been 
described  as  a  special  variety — phosphatic  diabetes.  Lipuria  may  be 
present. 

Slight  albuminuria,  often  with  an  intermittent  tendency,  is  common 
even  in  the  early  stages,  and  is  not  of  grave  significance.  Well-marked 
nephritis  with  its  characteristic  phenomena  may  develop,  though  usually 
in  advanced  diabetes;  and  if  albuminuria  be  marked,  the  amount  of 
sugar  excreted  may  be  considerably  diminished.  The  development  of 
chronic  interstitial  nephritis,  however,  is  not  a  favorable  complication, 
as  some  have  supposed.  With  or  without  nephritis,  arterio-sclerosis 
may  be  observed,  and  pyelo-nephritis  (rarely)  and  cystitis  (not  rarely) 
may  appear  as  complications.  As  the  result  of  fermentative  processes 
in  the  bladder  gases  may  form  {pneumaturia).  Impotence  is  a  not  in- 
frequent, and  often  an  e;irly  and  a  very  significant,  symptom  ;  later  this 
condition  may  improve  spontaneously. 

(2)  Digestive  Symptoms. — Although  a  general  feature,  thii'st  may  be 
discussed  under  this  head.  This  symptom  may  be  most  distressing, 
necessitating  the  drinking  of  large  quantities  of  water  at  frequent  inter- 
vals both  by  night  and  by  day.  The  amount  of  water  taken  stands  in 
direct  relation  to  the  amount  eliminated,  though  not  necessarily  to  the 
daily  amount  of  sugar  excreted.  Notwithstanding  the  fact  that  the  in- 
creased amount  of  water  is  needed  to  dissolve  the  sugar,  cases  of  con- 
firmed diabetes  are  met  with  in  which  thirst  is  not  marked  and  the 
amount  of  urine  passed  but  little  above  the  normal.  Cases  are  also 
encountered  in  which  the  amount  of  urine  is  large  and  the  percentage 
of  sugar  excreted  very  low.     The  cause  of  the  unusual  thirst  is  not 


DIABETES.  379 

quite  clear,  though  it  is  probable  that  the  chief  factor  is  the  increased 
systemic  demand  for  liquids. 

The  appetite  is  abnormally  large  and  sometimes  almost  insatiable 
(bulimia),  and  there  may  be  an  intense  craving  for  carbohydrates.  I 
have,  however,  met  with  two  instances  of  well-developed'  diabetes  in 
which  the  appetite  was  not  inordinate.  The  cause  of  the  ravenous  ap- 
petite is  probably  to  be  found  in  the  defective  assimilative  processes. 
Considering  the  quantity  of  food  consumed,  the  digestion  is  often  sur- 
prisingly good,  but  the  association  of  dyspepsia  and  diabetes  is  by  no 
means  an  uncommon  one.  As  a  rule,  there  is  constipation,  though  brief 
intervening  attacks  of  diarrhea  may  occur. 

The  tongue  is  generally  dry,  large,  often  presenting  a  rough  and 
fissured  surface,  and  it  may  either  be  coated  or  red  and  glazed.  The 
gums  sometimes  swell,  and  may  ooze  blood.  The  saliva  is  scanty  and 
its  reaction  persistently  acid,  while  the  salivary  secretion  may  show 
sugar  on  testing.  The  teeth  decay,  and  aphthous  stomatitis  or  thrush 
may  attack  the  oral  cavity. 

The  liver  is  frequently  somewhat  enlarged,  though  the  biliary  secre- 
tion usually  is  not  disturbed;  jaundice  may,  however,  arise  as  a  com- 
plication. Marie  has  given  a  description  of  pigmentary  "  hypertropliic 
cirrhosis  with  diabetes  mellitus,"  of  which  only  9  undoubted  cases  have 
been  published.  It  appears  late  in  adult  life,  and,  in  addition  to  the 
symptoms  of  diabetes  mellitus,  slight  ascites,  considerable  hypertrophy 
of  the  liver  and  spleen,  with  brown  or  even  gray-black  cutaneous  pig- 
mentation, are  among  the  chief  features  noted.  There  is  no  true  icterus 
as  a  rule,  but  the  urine  is  highly  colored  and  contains  bile-pigments. 

(3)  Cutaneous  Manifestations. — Diabetic  urine,  on  account  of  the 
sugar  it  contains,  has  irritant  properties,  and  often  produces  in  the 
female  pruritus  vulvce,  a  most  troublesome  symptom  and  one  that  should 
always  excite  suspicion  of  this  disease.  In  the  male,  balanitis  often 
occurs,  due  to  the  effect  of  the  decomposing  urine,  and  from  the  same 
cause  the  genitals  and  adjacent  cutaneous  surfaces  may  be  the  seat  of 
eczema.  This  seems  to  be  more  common  in  women  than  in  men.  The 
skin  is  usually  harsh  and  dry.  though  rarely  copious  perspiration  may 
be  observed,  and  particularly  if  phthisis  be  a  complication.  The  hair 
often  falls  off,  and  in  one  of  my  cases  onycJiia  with  shedding  of  the  nails 
occurred.  Among  the  commonest  of  the  early  cutaneous  symptoms  are 
furuncles  and  hoils.  Later  large  carluncles  often  appear.  G-angrene 
(especially  of  the  feet)  due  to  arterio-sclerosis  is  not  infrequent,  and 
edema,  arising  independently  of  nephritis,   is  not  uncommon. 

(4)  Nervous  Symptoms. — Diabetic  coma  is  the  most  important  symp- 
tom, marking  a  fatal  termination  in  more  than  half  the  cases.  It  is  of 
most  frequent  occurrence  in  instances  showing  rapid  wasting  and  in  the 
young,  and  is  heralded  by  a  fruity  odor  in  the  exhaled  breath  and  in 
the  urine.  The  polyuria  and  glycosuria  lessen,  while  acetonuria  in- 
creases as  a  rule.  The  tolerance  for  the  carbo-hydrates  is  increased 
(Hirschfeld).  The  cases  may  be  arranged  into  the  following  clinical 
groups  : 

Group  1.  To  this  belong  abortive  forms  that  terminate  in  quick  re- 
covery. This  process  may  be  repeated  several  times  at  intervals,  and 
at  last  a  fatal  coma  may  supervene. 


380  CONSTITUTIONAL  DISEASES. 

Group  2.  Perhaps  the  largest  group,  in  which  the  diabetic  coma  fol- 
lows some  form  of  exhausting  exercise.  It  may  end  fatally  in  a  few 
hours  or,  though  less  frequently,  in  three  or  four  days. 

Group  3.  This  is  a  comparatively  small  class,  and  is  characterized 
by  collapse  of  the  circulation  (small,  rapid,  feeble  pulse,,  cyanosis,  etc.), 
leading  to  coma.  It  is  induced  either  by  over-exercise  or  by  intoxica- 
tion. I  have  seen  2  typical  instances,  but  feel  that  it  may  be  ques- 
tioned whether  most  of  these  cases  should  be  classed  as  diabetic  coma. 

Group  4.  Without  previous  dyspnea  or  distress  there  appear  such 
symptoms  as  headache  and  signs  of  intoxication,  and  these  are  followed 
quickly  by  deep  and  fatal  coma  (Frerichs). 

Group  5.  Here  diabetic  coma  is  preluded  by  symptoms  of  some 
localized  disorder,  such  as  gastro-enteritis,  pharyngitis,  pneumonia, 
gangrene,  or  carbuncle.  The  attack  sets  in  with  headache,  delirium, 
distress,  and  dyspnea  both  inspiratory  and  expiratory.  Cyanosis  may 
develop  early,  and,  if  so,  cardiac  failure  precedes  the  coma.  The  dura- 
tion is  from  one  to  five  days.  This  group,  which  was  first  described  by 
Frerichs,  may  have  a  different  onset,  and  I  have  seen  two  fatal  cases,  one 
attended  by  carbuncle,  the  other  with  gastric  symptoms. 

Group  6.  Hirschfeld  has  recently  described  a  class  of  cases  in  which 
we  find,  in  old  persons,  a  moderate  glyco.suria  and  coma  supervening 
under  the  influence  of  gangrene  or  carbuncle. 

The  causes  of  diabetic  coma  are  still  obscure.  Hirschfeld  points  to 
insufficient  nutrition  from  an  exclusive  meat  diet  as  an  important 
factor.  Kussmaul  believed  diabetes  to  be  due  to  acetone.  Kulz, 
Stadelman,  and  others  have  more  recently  found  /5-oxybutyric  acid 
in  the  urine,  and  this  (or  the  acetone  derived  from  it)  is  now  gen- 
erally held  to  be  the  immediate  excitant  of  diabetic  coma  (which 
is  an  acid-intoxication).  This  acid  results  from  an  inci'eased  destruc- 
tion of  the  proteids.  Lastly,  coma  must  sometimes  be  of  uremic  origin, 
while  those  cases  that  follow  suppuration  and  gangrene  may  be  septic 
in  nature. 

Peripheral  neuritis  is  common.  The  most  freijuent  form  is  diabetic 
tabes,  indicated  by  an  absence  of  the  knee-jerks,  darting  pains,  paresis 
of  the  extensors  of  the  foot,  and  by  the  peculiar  gait  (steppage).  Other 
symptoms  pointing  to  neuritis  may  be  numbness,  tingling,  and  certain 
trophic  disturbances — shedding  of  the  nails  and  perforating  ulcer  of  the 
foot.  R.  T.  Williamson  found  the  knee-jerk  absent  in  25  of  50  cases 
recorded  ;  and  in  18  of  21  cases  of  diabetic  coma.  Schupfer  ^  attrib- 
uted absence  of  patellar  reflex  to  toxic  effects  in  most  cases.  Neuralgia 
may  be  a  troublesome  symptom,  particularly  when  it  is  of  the  symmet- 
rical sciatic  type,  and  it  points  to  neuritis.  The  same  is  true  of  para- 
plegia, a  condition  that  may  be  met.  Herpes  zoster  was  observed  in 
one  of  my  cases. 

Psychopathia  (e.  g.  irritabilit}^  of  temper,  hypochondriasis)  may 
sometimes  be  present,  and  temporary  hemiplegia  has  been  noted. 

(5)    Special-sense   Sipaptoms. — Not   infrequently  cataract   develops, 

leading  to  blindness.     Its  cause  is   not    clear.      Transient  ptosis    and 

strabismus    may  also    appear,    and  among  other  ocular  conditions  are 

optic-nerve  atrophy,  retinitis  (often  due  to  associated    nephritis),  and 

^  Soc.  Lancisiana  Roma,  Jan.  24,  1898. 


DIABETES.  381 

hemorrhage.      Amaurosis  is  rarely  observed.     Among  the  aural  symp- 
toms I  would  mention  otalgia,   otitis  media,   and  mastoid  disease. 

(6)  Muscular  Symptoms. — In  diabetics  there  is  a  tendency  to  cramps, 
especially  in  the  calf  of  the  leg,  that  appears  during  the  night  and  on 
waking  in  the  morning.  Unschuld  found  it  present  in  33  out  of  109 
cases.  Another  variety  of  cramps  that  may  appear  at  any  hour  of  the 
day  may  occur  with  the  so-called  "gastric  crisis."  In  these  attacks 
colickv  pain  in  the  epigastrium,  with  vomiting,  and  febrile  reaction 
attend. 

(7)  Respiratory  System. — Serious  pulmonary  complications  may 
appear  in  the  advanced  stages.  The  most  frequent  is  pulmonary  tuber-, 
culosis,  which  has  the  customary  termination,  and  does  not  differ  from 
the  usual  form  of  the  disease.  A  second,  quite  frequent  complication  is 
gangrene  (circumscribed  or  general).  The  peculiar  offensive  odor  of  the  ex- 
pectoration may  be  wanting  here.  A  serious  form  of  pneumonia  (lobar 
or  lobular)  sometimes  occurs,  and  may  terminate  in  gangrene. 

(8)  Circulatory  System. — The  pulse  may  be  of  natural  frequency 
and  tension.  In  other  cases  it  is  somewhat  slow,  and  the  tension  may 
be  increased.  This  is  often  due  to  an  associated  arterio-sclerosis.  The 
heart  is  sometimes  quite  weak.  As  to  frequency,  the  pulse  varies 
greatly :  it  may  be  slow  (brachycardia).  not  exceeding  40  or  50  beats 
per  minute,  or  it  may  be  accelerated.  Dyspnea,  a  tendency  to  syncope, 
and  gastric  disturbance  may  be  seen  in  combination. 

(9)  Sexual  Symptoms. — Impotence  may  be  an  early  symptom.  Dia- 
betes may  be  acquired  during  pregnancy :  per  contra,  the  diabetic  may 
conceive,  though  rarely,  and  bear  a  healthy  child ;  but  death  of  the 
foetus  occurs  in  about  one-half  of  the  cases.  Premature  delivery  occurs 
in  a  large  proportion  of  the  reported  cases  (-6).  After  delivery  the 
condition  is  generally  ao:crravated. 

(10)  Constitutional  Symptoms. — Usually  there  is  a  constantly  increas- 
ing loss  of  flesh  and  strength.  In  the  mildest  types,  however,  good 
bodily  nutrition  and  a  fair  degree  of  strength  may  be  maintained. 
When  emaciation  is  progressive  the  polyuria  is  apt  to  be  proportional. 
The  temperature  is  at  first  normal,  later  usually  subnormal,  though  in- 
tercurrent febrile  attacks,  due  to  complications,  are  often  witnessed. 

Clinical  Varieties. — (a)  InfantUe  Diabetes. — Heredity,  traumatism, 
and  convalescence  from  severe  acute  infectious  disease  are  the  most 
potent  causes.  The  type  is  severer  and  the  course  shorter  than  in 
adults.  On  the  other  hand,  a  comparatively  mild  chronic  form  is  rarely 
met  in  children. 

(h)  Pancreatic  Diabetes. — This  is  a  grave  variety,  and  may  present 
evidences  of  pancreatic  involvement.  There  may  be  epigastric  pain ; 
the  fats  are  poorly  assimilated  ;  and  the  physical  signs  may  rarely  point 
to  pancreatic  growth.  Fitz  ^  states  that  out  of  166  cases  treated  in  the 
Massachusetts  General  Hospital  fatty  stools  were  not  recorded  in  anv 
instance.  Marked  polyuria  and  great  thirst  may  be  absent,  and  albu- 
minuria is  rare. 

{c)  Alimentary  or  Lipogenic  Glycosuria. — This  is  caused  by  dietetic 
errors,  and  especially  by  excesses  in  eating  and  drinking,  combined 
with  physical  inactivity.     Block  experimented  on  50  patients,  and  found 

^  Yale  Med.  Journ.,  March,  1898. 


382  CONSTITUTIONAL  DISEASES. 

that  the  amount  of  grape-sugar  that  could  be  given  before  glycosuria 
appeared  differed  Avideiy  in  different  diseases.  Frequently  the  smallest 
quantity  Avas  required  in  nervous  diseases,  and  particularly  in  cerebral 
affections.  Von  Jaksch  induced  alimentary  glycosuria  in  cases  of  hys- 
teria and  in  cases  of  phosphorus-poisoning  with  fatty  degeneration  of 
the  liver.  This  form  of  the  disease  is  often  a  temporary  affair,  and 
restoration  to  health  may  defy  further  attempts  at  the  production  of  gly- 
cosuria.    The  percentage  of  sugar  in  the  urine  is  usually  small. 

Prognosis.— In  acute  diabetes  the  duration  varies  from  a  few  days 
to  eight  or  ten  weeks,  while  in  chronic  diabetes  the  course  ranges  from 
one  or  two  to  five  or  even  ten  years.  When  the  disease  commences  in 
the  declining  period  of  life,  the  course  is  longer  still.  The  severe  forms 
are  generally  fatal,  and  occur,  as  a  rule,  at  an  early  period  of  life  and  in 
persons  with  an  hereditary  taint.  The  mild  types  and  those  that  occur 
later  in  life  offer  a  more  hopeful  prognosis,  and  in  certain  cases  the 
withdrawal  of  all  carbohydrates  from  the  diet  will  cause  the  sugar  to 
disappear  from  the  urine.  Of  the  special  varieties,  alimentary  glyco- 
suria is  altogether  favorable  in  its  course,  traumatic  diabetes  somewhat 
less  so,  while  tne  prognosis  of  ihe  pancreatic  form  is  quite  unfavorable. 

Stout  persons  bear  saccharine  diabetes  better  than  lean.  Pre-exist- 
ing affections  may  render  the  prospect  quite  gloomy,  and  certain  com- 
plications indicate  grave  danger  (coma,  phthisis,  gangrene,  pneumonia, 
cardiac  weakness,  nephritis).  Of  108  such  cases,  64  per  cent,  termin- 
ated fatally  (Wegeli),  and  between  tLe  ages  of  four  and  five  years  20 
out  of  29  cases  perished. 

Diagnosis. — Diabetes  is  distinguishable  by  means  of  (1)  its  causal 
influences  and  its  pathologic  antecedents  and  relations  ;  (2)  its  gradual 
onset,  often  marked  by  certain  suspicious  symptoms  {e.g.  debility,  im- 
potence, symmetrical  sciatica,  cataract,  furuuculosis)  ;  (3)  the  persistent 
(rarely  intermittent)  presence  of  glycosuria,  polyuria,  and,  later,  ace- 
tonuria  and  albuminuria  ;  (4)  the  inordinate  thirst  and  appetite  ;  (5) 
cutaneous  boils,  carbuncles,  gangrene,  pruritus  vulvae  in  the  female, 
balanitis  in  the  male  ;  (6)  neuritis  (especially  double  sciatica),  diabetic 
tabes,  and  coma  ;  (7)  muscular  cramps  ;  (8)  special  complications  ;  and 
(9)  the  long  course  with  slowly  progressive  asthenia  and  wasting. 

In  suspicious  cases,  even  before  the  discovery  of  sugar  in  the  urine, 
grape-sugar  may  be  administered  for  diagnostic  purposes.  If  glycosuria 
result,  the  cases  are  to  be  treated  just  as  in  pure  diabetes.  Transient 
glycosuria,  however,  is  not  the  genuine  affection.  Grape-sugar  must  be 
eliminated  for  weeks,  months,  or  yeai's  (von  Noorden). 

Blood-test. — Bremer  has  found  that  the  red  corpuscles  in  a  drop  of 
diabetic  blood  cannot  be  stained  with  anilin  colors  as  can  those  of  nor- 
mal blood.  In  this  respect  the  beliavior  of  the  corpuscles  of  leukemic 
and  diabetic  bloods  are  identical.  Williamson's  blood-test,  which  rests 
upon  the  power  of  diabetic  blood  to  change  (decolorize)  a  weak  solution 
of  niethylene-blue  to  a  yellowish-green  or  yellow  color,  gives  promise  of 
great  diagnostic  value. 

Treatment. — 1.  A  properly  regulated  diet  is  of  the  first  importance. 
Such  food-articles  as  contain  starch  or  sugar  (honey,  sugar,  ordinary 
flour  or  bread,  biscuits,  rusks,  toast,  arrow-root,  oatmeal,  cracked  wheat, 
potatoes,  tapioca,  sago,  peas,  beans,  turnips,  carrots,  parsnips,  asparagus, 


DIABETES.  383 

artichokes,  squashes,  beets,  corn,  rice,  hominy,  the  stalks  and  "ft'hite 
parts  of  cabbage,  lettuce,  broccoli,  figs,  grapes,  prunes,  apples,  pears, 
bananas,  jams,  syrups,  sweet  pickles,  chocolate,  cocoa,  liquors,  and 
especially  sv.eet  Tvines)  are  either  to  be  altogether  prohibited  or  re- 
stricted to  definite  quantities,  as  will  be  pointed  out  below.  Among 
articles  to  be  forbidden  are  also  the  livers  of  animals,  mollusks  (oysters, 
etc.),  and  the  inside  meat  of  crabs  and  lobsters.  The  chief  diet  must 
be  animal,  since  the  non-nitrogenous  substances  are  to  a  very  limited 
extent,  and  in  some  instances  not  at  all,  assimilated.  My  own  plan  is 
to  first  note  the  effect  of  a  rigid  dietary  as  follows: 

(a)  Animal  food :  Fresh  meats,  poultry,  game,  bacon,  ham.  fish  of 
all  kinds,  including  crabs  and  lobsters  (except  the  inside  meat  of  the 
latter).  "Fatty  substances  in  large  quantities  (sviij — 256.0 — daily),  with 
a  view  to  restricting  nitrogenous  destruction,  are  highly  commended  by 
Klemperer,  and  the  free  use  of  butter  is  also  urged,  eggs,  cream-cheese, 
curds,  and  buttermilk  being  allowed. 

(h)  Vegetables  :  Saur-kraut,  lettuce,  sorrel,  mushrooms,  water-cresses, 
spinach,  chicory,  celery,  cucumbers,  mustard-cress,  and  pickles  of  vari- 
ous sorts  (except  sweet). 

(c)  Bread :  The  crust  of  a  French  roll,  first  recommended  by  Flint. 
Ebstein  has  recently  very  highly  recommended  aleuronat  bread  ;  it  con- 
tains a  large  proportion  of  vegetable  albumins. 

(f?)  Fruits  :  Lemons,  oranges,  and  nuts  (except  chestnuts). 

{e)  Beverages :  Milk  enough  for  cooking-purposes  ;  tea  and  coffee, 
sweetened  with  glycerin  or  saccharin  ;  alkaline  mineral  waters  (Sara- 
toga-Vichy, Seltzer-water),  simple  water  with  a  slight  amount  of  brandy, 
and  acidulated  drinks.  Also  Bass's  ale,  in  Avhich  all  the  sugar  is  con- 
verted into  carbonic  acid  and  alcohol. 

This  strict  diet  usually  causes  the  sugar  to  diminish  greatly  in 
amount,  and  in  many  cases  to  disappear  entirely.  If  the  patient  keeps 
well-nourisbed  and  strong,  we  may  continue  it  indefinitely,  or  carbo- 
hydrates may  be  added.  Xothing  is  gained  by  relieving  the  glycosuria 
and  polyuria  if  it  be  accomplished  at  the  expense  of  the  general  strength 
of  the  patient.  Yon  Xoorden  claims  that  a  non-carbohydrate  diet  im- 
proves tissue-metabolism,  thus  increasing  the  system's  power  of  ware- 
housing carbohydrates,  and  recommends  a  rigid  albuminoid  diet  at  in- 
tervals of  a  few  months.  The  abuse  of  albuminoids  may  increase  the 
sugar  in  the  urine  (Naunyn),  and  in  tAvo  cases  under  my  observation  this 
ended  in  diabetic  coma.  S.  Solis  Cohen,  after  repeated  trials,  recom- 
mends levulose  as  a  form  of  sugar  that  can  be  assimilated  without  aug-- 
menting  the  excretion  of  glucose.  With  lean  patients  he  uses  |j  (32.0)  per 
day  ;  with  stout  persons,  only  enough  to  act  as  a  sweetening  agent.  Lactose 
has  been  found  to  give  similar  results.  Hale  also  strongly  urges  levulose, 
after  considerable  personal  experience.  As  a  substitute  for  the  latter 
agents  a  small  amount  of  ordinary  bread  (which  contains  55  per  cent,  of 
starch)  or  potatoes,  as  the  patient  prefers,  may  be  allowed.  The  effects 
upon  the  general  condition  of  the  patient,  as  well  as  upon  the  glyco- 
suria (ascertained  by. a  daily  quantitative  estimation  of  the  sugar  in  the 
urine),  are  to  be  carefully  noted,  and  the  proportion  of  carbohydrates 
may  be  increased  gradually  until  the  limit  of  the  system's  ability  to 
assimilate  them  is  found.     A  more  generous  dietary  is  allowable  only 


384  CONSTITUTIONAL  DISEASES. 

after  the  sugar  has  been  absent  from  the  urine  for  a  couple  of  months, 
and  then  it  is  to  be  adopted  in  a  gradual  manner.  A  skimmed-milk 
diet  has  been  recommended  by  Donkin,  Tyson,  and  others,  but  I  have 
found  it  to  be  vastly  inferior  to  the  one  above  laid  down,  and  hence  it 
should  not  be  tried  unless  the  latter  cannot  be  taken. 

2.  Next  to  an  appropriate  diet  stand  certain  directions  as  to  proper 
hygienic  living  :  {a)  All  forms  of  mental  excitement  and  worry  must  be 
avoided ;  {b)  moderate  and  regular  physical  exercise  aids  metabolism,  and 
is  thus  directly  useful ;  massage  may  be  substituted  for  active  exercise 
w  hen  the  latter  is  prohibited  on  account  of  weakness ;  {<•)  the  diabetic 
requires  a  temperate  and  eijuable  climate;  id)  a  daily  tepid  bath  if  the 
patient  be  feeble,  and  a  cold  bath  if  he  be  strong,  are  to  be  commended ; 
(g)  flannels  should  be  worn  next  to  the  skin  all  the  year  round;  (/)  the 
living  and  sleeping  apartments  must  be.  thoroughly  ventilated ;  {g)  the 
teeth  must  receive  careful  attention  in  order  to  prevent  caries. 

3.  The  medicinal  measures  deserve  only  third  place  in  the  treatment 
of  diabetes,  and  of  these  opium  is  still  the  chief.  It  is  not  necessary  to 
employ  it  in  all  cases,  but  it  may  be  tried  if  the  dietetic  and  hygienic 
treatment  before  recommended  cannot  be  carried  forward  or  fails  to 
effect  a  cure.  Opium  seems  not  only  to  exert  an  influence  over  the 
polyuria  and  the  excretion  of  sugar,  but  it  almost  invariably  lessens  the 
intense  thirst  and  conduces  to  refreshing  sleep.  The  drug  is  well  tol- 
erated by  diabetics.  The  commencing  dose  may  be  gr.  j  (0.0648)  three 
times  daily,  and  later  increased  to  gr.  v  (0.324)  or  even  to  gr.  x  (0.648) 
three  times  daily.  If  morphin  be  employed,  we  may  begin  with  gr.  ^ 
(0.0162)  and  increase  the  dose  to  gr.  j  (0.0648)  or  more  three  times 
daily.  Pavy  warmly  advocates  the  use  of  codein  (gr.  i-iij — 0.0324- 
0.1944,  three  times  a  day).  My  own  best  results  have  been  obtained 
from  the  use  of  the  latter  remedy  in  the  form  of  the  sulphate,  in  ascend- 
ing doses,  commencing  with  gr.  ^  (0.0162)  three  times  a  day,  and  aug- 
menting the  dose  by  gr.  \  (0.0162)  every  second  day  until  gr.  ij — 0.129 
(rarely  more)  are  taken  thrice  daily.  Codein  possesses  the  advantage 
of  being  less  constipating  and  less  likely  to  disturb  the  digestive  func- 
tion than  either  opium  or  morphin.  In  patients  of  a  full  habit  the  alka- 
line waters  exercise  a  valuable  influence  ;  Bethesda,  Carlsbad,  and  Vichy 
of  France  have  long  had  a  reputation.  For  the  foreign  water  our  native 
alkaline  waters  may  be  substituted,  especially  the  Saratoga-Yichy. 
While  these  are  valuable  adjuncts,  they  are,  however,  without  the  cura- 
tive and  specific  effect  that  is  claimed  for  them  by  certain  authorities. 

Among  other  therapeutic  agents  that  have  been  employed  are  the 
following:  the  solution  of  the  bromid  of  arsenic,  TT|.iij-v  (0.199-0.333) 
three  times  a  day,  after  meals — in  some  cases  a  useful  adjuvant  to  the 
treatment  above  outlined;  potassium  bromid,  gr.  xx  (1.296),  three  times 
a  day,  approximating  in  efficacy  the  latter  remedy  ;  guaiacol.  TTtv-x 
(0.333-0.666),  three  times  a  day  in  a  tablespoonful  of  milk  or  cod-liver 
oil,  has  given  excellent  results  (Clemens) ;  antipyrin  (gr.  x — 0.648,  three 
times  a  day)  ;  sodium  salicylate,  gr.  xv  (0.972),  three  times  daily,  lessens 
the  formation  of  sugar  ;  and  strychnin,  gr.  -^  (0.0021),  three  times 
daily,  is  an  almost  invariably  useful  remedy.  Of  the  numerous  rem- 
edies in  whose  favor  convincing  evidence  is  wanting,  but  which  are 
employed  by  different  clinicians,  the  following  may  merely  be  enume- 


DIABETES  INSIPIDUS.  385 

rated  :  Fowler's  solution,  potassium  iodid,  iodoform,  lactic  acid,  glycerin, 
nitroglycerin,  creasote,  quinin,  jambul,  litiiium,  and  methylen-blue. 

The  treatment  of  diabetes  \>j  fresh  pancreas  or  by  dry  or  glycerin 
extracts  has  been  generally  unsuccessful.  Fitz,  however,  mentions  a 
case  in  which  remarkable  improvement  followed  the  exhibition  of  raw 
calf-pancreas.  These  preparations  have  been  employed  to  supply  the 
ferment  (internal  secretion)  essential  to  the  assimilation  of  sugar.  R. 
Lepine  has  obtained  from  the  fresh  pancreas,  from  saliva,  and  from  the 
diastase  of  malt  a  glycolitic  ferment  by  a  method  which,  he  tells  us,  still 
requires  to  be  perfected.  This  agent  he  has  used  in  4  cases  of  diabetes 
with  a  fair  degree  of  success.  Williams  tried  grafting  sheep's  pancreas 
in  diabetics  in  two  cases,  but  the  results  were  unsatisfactory.  Gilbert 
and  Carnot  found  that  extract  of  liver,  administered  by  rectal  injection, 
caused  a  marked  decrease  in  the  excretion  of  sugar. 

Thyroid  extract,  in  small  doses,  was  followed  by  immediate  improve- 
ment in  two  of  my  cases ;  it  is  especially  indicated  in  alimentary  gly- 
cosuria. 

4.  Symptomatic  Treatment. — Most  symptoms  demanding  therapeutic 
interference  the  competent  physician  is  prepared  to  meet  by  following 
general  rules.  The  management  of  diabetic  coma,  however,  will  be 
briefly  discussed.  Believing  it  to  be  due  to  an  acid-intoxication,  Klem- 
perer  gave  large  amounts  of  alkalies  in  9  cases  by  intravenous  injection, 
without  preventing  a  fatal  issue.  To  counteract  the  acids  of  the  organ- 
ism, sodium  bicarbonate  (drams  5,  daily)  is  advisable  (Robin). 

The  normal  saline  infusion,  used  by  hypodermoclysis,  has  given  fa- 
vorable results  in  some  cases. 

Klemperer  urges  the  use  of  fatty  substances  in  large  quantities  as 
the  best  means  of  restricting  nitrogenous  destruction,  and  thus  prevent- 
ing the  condition  to  which  diabetics  so  frequently  succumb.  When  a 
disgust  develops  for  fats  a  substitution-method  of  treatment  consists  in 
administering  alcohol  (giss — 48.0 — per  day).  Like  carbohydrates,  alco- 
hol in  small  quantity  checks  waste  and  may  lead  to  an  accumulation  of 
flesh  (HirschfcL.).  Strychnin,  digitalis,  or  ether  may  be  tried  hypo- 
dermically  during  the  attack.  Prolonged  tepid  baths  with  occasional 
douching  have  seemed  to  produce  beneficial  results  in  some  cases,  and 
are  worthy  of  a  trial  in  all.  Elimination  from  the  bowels  is  to  be  in- 
creased, and  oxygen  should  be  inhaled. 


DIABETES  INSIPIDUS. 

Definition. — A  chronic  nervous  affection,  characterized  by  con- 
stant thirst  and  an  excessive  flow  of  urine,  which,  however,  is  free 
from  sugar  and  albumin  and  is  of  low  specific  gravity. 

Path.olog'y. — No  definite  or  characteristic  lesions  have  been  noted, 
though  some  degree  of  enlargement  of  the  kidneys,  together  with  saccu- 
lation, due  to  pressure  backward  upon  the  renal  structure  by  the  enor- 
mous quantities  of  urine  in  the  bladder  and  ureters,  has  been  observed. 
The  ureters  and  pelves  of  the  kidneys  may  be  dilated,  and  the  bladder, 

26 


386  CONSTITUTIONAL  DISEASES. 

owing  to  constant  over-distention.  may  be  hypertropliied.  The  nervous 
lesions  are  diversified,  but  are  not  peculiar  to  simple  poh'uria.  Most 
important,  perhaps,  are  the  tuberculous  and  other  tumors  about  the  lloor 
of  the  fourth  ventricle. 

etiology. — {(i)  Diabetes  insipidus  is  often  induced  by  nervous  injiu- 
ences — shock,  fright,  etc. — and  may  also  be  of  traumatic  origin.  In  the 
majority  of  the  latter  cases  it  follows  injuries  to  the  head,  but  also,  more 
rarely,  it  may  be  traced  back  to  injuries  of  other  parts  of  the  body. 
Tuberculous  and  other  lesions  in  the  vicinity  of  the  tioor  of  the  fourth 
ventricle  may  ])roduce  polyuria.  It  has  also  been  caused  by  paralysis 
of  the  sixth  nerve,  with  or  without  meningitis,  (b)  It  may  occur  during 
convalescence  from  acute  infectious  diseases.  I  have  seen  2  instances 
after  influenza  in  young  subjects,  (c)  Intemjjerance,  especially  the  con- 
sumption of  inordinate  quantities  of  malt  liquors,  proves  a  cause.  In 
several  of  my  own  cases  the  amount  of  urine  passed  was  out  of  all  pro- 
portion to  the  (juantity  of  fluid  ingested.  One  of  these  patients  con- 
sumed three  pints  of  beer  daily,  while  the  urine  excreted  amounted  to 
eight  quarts,  (d)  fferediti/. — Weil  found  in  four  generations  of  a  certain 
family  consisting  of  91  members,  that  23  exhibited  continuous  polyuria 
— all,  however,  remaining  in  good  health,  (e)  Age. — The  disease  is  rela- 
tivelv  more  freijuent  in  childhood  and  early  adolescence  than  is  diabetes 
mellitus.  Of  70  cases  collected,  22  were  under  ten  years  of  age,  and  13 
between  ten  and  twenty  (Roberts).  Diabetes  insipidus  may  be  congeni- 
tal, (f)  The  great  proportion  of  cases  occur  in  males  as  compared  with 
females. 

Nature  of  the  Affection. — The  specific  cause  of  the  disease,  if  it  have 
one,  is  as  yet  undiscovered.  We  are  totally  ignorant  of  its  true  nature, 
though  the  facts  discovered  by  Bernard,  that  either  a  puncture  at  a  cer- 
tain spot  in  the  floor  of  the  fourth  ventricle  or  section  of  the  vagus  causes 
polyuria,  go  to  show  that  it  is  of  nervous  origin.  It  is  true  that  the 
disease  may  come  on  in  persons  apparently  in  robust  health  without 
discernible  causative  agencies.  In  many  instances,  such  as  organic 
affections  of  the  brain  or  abdominal  tumors,  the  condition  is  purely 
symptomatic,  and  these  are  probably  not  to  be  classed  as  cases  of  gen- 
uine diabetes  insipidus,  which  is  a  vaso-motor  neurosis,  usually  of  cen- 
tral, though  sometiuies  of  reflex,  origin. 

Clinical  Symptoms. — The  onset  is  gradual,  as  a  rule,  but  when  it 
follows  a  fright  or  traumatism  it  may  develop  quickly.  There  are  two 
main  symptoms — the  passage  of  an  enormous  (juantity  of  limpid  urine, 
and  the  constant  thirst.  The  daily  amount  of  urine  varies  from  20  to 
60  pints  (10-30  liters) ;  it  is  transparent,  and  the  specific  gravity  is  low 
(1001  to  100.5).  While  the  percentage  of  solids  is  lessened,  the  totnl 
is  usually  about  normal,  and  may  even  be  increased.  Albumin  and 
sugar  are  rare,  but  in  a  few  cases  inosite  has  been  detected.  The  act 
of  micturition  is  of  very  frequent  occurrence,  and  the  cjuantity  of  urine 
passed  at  each  sitting  surprisingly  large.  The  persistent  thirst  necessi- 
tates frequent  drinking,  but  the  voracious  appetite  seen  in  diabetes  mel- 
litus does  not  mark  this  disease,  in  which  the  appetite  is  only  slightly 
increased.  As  a  result  of  the  polyuria  the  skin  and  mucous  membranes 
are  abnormally  dry,  as  in  genuine  diabetes.  But.  unlike  the  latter 
affection,  a  fair  degree  of  bodily   nutrition   is   maintained  as  a  rule. 


ARTHRITIS  DEFORMANS.  387 

The  saliva  and  other  digestive  secretions  are  scanty,  and  this,  together 
with  the  good  appetite,  is  a  fact  which  explains  the  disturbances  of 
digestion  sometimes  met  with.  The  tolerance  of  the  system  to  alcohol 
is  often  phenomenal.  Associated  nervous  phenomena  are  frequently 
observed,  such  as  neurasthenic  symptoms,  insomnia,  and  chorea. 

Prognosis. — The  majority  of  instances  proceed  to  recovery  sooner 
or  later,  while  others  pursue  an  almost  endless  course — forty  or  even  - 
fifty  years  in  duration — and  the  patient  meanwhile  retains  his  general 
good  health.  There  is  a  small  group  of  grave  cases  that  are  due  to 
organic  diseases  either  of  the  brain  or  abdominal  organs.  Death  may 
also  be  occasioned  by  some  intercurrent  complicating  condition. 

Diagnosis. — The  clinical  recognition  of  diabetes  insipidus  rests 
upon — (a)  the  enormous  amount  of  urine  passed ;  (F)  its  low  specific 
gravity ;  and  {c)  the  absence  of  sugar  and  albumin. 

Differential  Diagnosis. — Among  affections  that  must  be  differentiated 
are  diabetes  meUitus,  which  has  a  single  point  of  resemblance — namely, 
the  polyuria  ;  hysterical  polyuria.,  which  is  transient  and  accompanied 
by  other  hysterical  manifestations ;  and  chronic  interstitial  nephritis, 
which  generally  distinguishes  itself  by  the  presence  of  albumin  and 
hyaline  casts  in  the  urine,   arterio- sclerosis,   and  cardiac  hypertrophy. 

Treatment. — The  amount  of  drinking-water  is  to  be  moderated  in 
a  gradual,  cautious  manner.  To  insist  upon  a  sudden  great  reduction 
is  productive  of  harmful  effects,  but  the  patient  should  be  warned  not 
to  exceed  his  actual  necessities.  I  also  find  that  methodic  physical 
exercise  acts  very  beneficially. 

Of  medicines,  nervines,  especially  valerian  and  its  preparations,  are 
useful  in  the  idiopathic  variety  of  the  complaint,  and  may  be  given 
in  the  form  of  the  ammoniated  elixir  (sj-ij — 4.0-8.0)  three  or  four 
times  daily.  The  valerianate  of  zinc,  quinin,  and  iron  may  be  variously 
combined,  according  to  the  indications  presented  by  special  cases.  Ergot 
and  gallic  acid  have  long  enjoyed  a  high  reputation  in  this  disease.  The 
commencing  doses  should  be  moderate,  and  then  be  increased  until  full 
physiological  doses  are  employed,  this  method  often  bringing  about  ad- 
mirable results.  Antipyrin,  acetanilid,  the  bromids,  and  arsenic  have 
been  extensively  employed  and  lauded  by  different  writers  in  the  treat- 
ment of  this  affection.  My  own  best  results  have  been  attained  by  the 
use  of  ergot.  Next  to  this  agent  the  bromids  and  acetanilid,  given 
alternately  at  intervals  of  a  couple  of  weeks,  have  been  found  to  be 
most  useful.  If  a  primary  disease  exists,  it  must  be  met  on  intelligent 
general  therapeutic  principles. 


ARTHRITIS  DEFORMANS. 

{Rheumatoid  Arthritis;  Rheicinatic  Gout.) 

Definition. — A  chronic  disease,  characterized  by  progressive  changes 
in  the  arthritic  structures  (cartilages,  synovial  membranes,  etc)  and  by 
osseous  periarticular  formations,  producing  great  deformity.  The  affec- 
tion may  rarely  be  acute  in  its  course. 


388  CONSTITUTIONAL  DISEASES. 

Pathology. — It  is  here  that  the  identity  of  the  disease  is  distin- 
guishable. Among  early  gross  changes  there  may  be  an  effusion  into 
the  affected  joints,  but  this  disappears  later.  The  cartilages  are  ab- 
sorbed, the  process  beginning  centrally,  where  there  are  both  the  maxi- 
mum amount  of  friction  between  the  opposed  cartilaginous  surfaces  and 
the  minimum  blood-supply.  Disappearance  of  the  cartilages  is  natur- 
ally followed  by  contact  of  the  ends  of  the  bones,  the  latter  becoming 
polished  and  resembling  ivory  as  the  result  (eburnated).  The  friction 
between  the  bony  extremities  may  lead  to  absorption  of  the  latter. 

At  the  periphery,  where  pressui-e  is  slight  or  even  absent,  the  carti- 
lages become  greatly  thickened  in  consequence  of  persistent  irritation, 
and  later  become  ossified,  forming  osteophytes  which  overlie  the  articular 
surfaces.  These  may  lock  the  joints.  Bony  nodules  may  also  be  formed 
from  the  periosteum  of  the  bony  shafts. 

Almost  simultaneously  the  synovial  membranes  become  inflamed,  a 
proliferation  of  their  cells  taking  place,  and  this  exudate  may  undergo 
organization  and  rarely  ossification.  Later  the  capsule  and  the  lu/a- 
ments  are  thickened,  causing  a  restriction  of  movement  of  the  affected 
joints  and  producing  pseudo-ankylosis.  Less  frequently  they  soften 
and  weaken  to  such  an  extent  that  often  partial,  and  sometimes  com- 
plete, dislocation  of  the  joints  ensues  ;  but  displacement  of  the  ends  of 
the  bones,  amounting  even  to  complete  luxation,  may  also  be  due  to 
absorption.  This  is  often  observed  in  the  head  of  the  femur,  producing 
the  so-called  morbus  coxce  senilis.  Muscular  wasting  occurs  and  may  be 
profound.     Neuritis  has  been  noted. 

The  histo-patholojjic  changes  consist  in  cell-proliferation,  with  fibril- 
lation and  softening  of  the  matrix  of  the  cartilages,  followed  by  absorp- 
tion due  to  pressure.  At  the  margin,  however,  proliferation  of  the  cells 
leads  to  massive  nodulation. 

Htiology. — The  natm^e  of  the  disease  is  still  dubious,  though  the 
old  view,  that  it  is  closely  connected  with  rheumatism  on  the  one  hand 
or  gout  on  the  other,  should  be  abandoned.  J.  K.  Mitchell  long  since 
maintained  that  rheumatoid  arthritis  is  of  nervous  orii/in,  being  espe- 
cially dependent  upon  affections  of  the  spinal  cord,  and  without  stopping 
to  adduce  all  of  the  facts  that  tend  to  support  this  theory,  the  following 
deserve  mention  :  (1)  Diseases  of  the  cord  (locomotor  ataxia,  etc.)  are 
known  to  cause  arthritic  conditions  ;  (2)  The  character  of  certain  causal 
factors,  such  as  nervous  shocks,  griefs,  etc.  ;  (3)  The  symmetry  of  the 
joint-deformities  ;  (4)  The  time  of  occurrence  ;  and  (5)  Noticeable 
trophic  disturbances  that  are  fre(juently  associated.  Falli  ^  autopsied 
4  cases,  2  of  which  were  typical,  and  in  the  latter  lesions  were  found  in 
the  anterior  horns  of  the  spinal  cord,  atrophic  in  the  first  case,  but 
degenerative  as  well  as  atrophic  in  the  second.  According  to  Falli,  not 
all  cases  of  arthritis  deformans  are  to  be  interpreted  as  instances  of 
nervous  disease.  Another  theory  of  the  disease  is  the  microbic,  which 
has  received  some  measure  of  support. 

Bacteriology. — Dor  claims  to  have  succeeded  in  finding  a  definite 
organism.  He  also  claims  to  have  reproduced  the  disease  by  injecting 
cultures  directly  into  the  blood  of  rabbits,  and  considers  the  germ  an 
*•  attenuated  culture  "  of  the  staphi/loeoceus  pyogenes  aureus,     v.  Dun- 

>  II  Polirlinico,  Dec,  1894. 


Fig  31— Hand  of  AI    R.,  aged  fiftv  years,  showing  characteristic  deformity,  including  outward 
deflection  of  fingers,  in  advanced  arthritis  deformans. 


ARTHRITIS  DEFORMANS.  389 

gern  and  Schneider  isolated  after  death  from  the  mucus  of  the  gall- 
bladder, and  also  from  the  exudate  in  the  joints,  small  diplococci  that  did 
not  resemble  the  organisms  previously  described  by  Blaxall  and  Schliller. 
Injections  of  the  cultures  into  the  knee-joint  of  rabbits  resulted  in  the 
production  of  lesions  similar  to  those  observed  in  the  patient. 

Predisposing  Causes. — (a)  Nervous  shocks,  mental  worry,  and  deep 
grief,  (h)  Females  are  more  frequently  victims  than  are  males,  the  pro- 
portion, according  to  the  statistics  of  Garrod,  being  about  one  to  five  in 
favor  of  the  former  sex.  To  account  in  part  for  its  greater  frequency 
in  Avomen  is  the  fact  that  sterility  and  certain  ovarian  and  uterine  com- 
plaints seem  to  exert  a  strong  etiologic  influence,  (c)  Age  exerts  a  de- 
cided influence.  It  is  most  frequently  contracted  in  the  third  decade  of 
life,  though  it  has  been  noted  as  late  as  the  end  of  the  fifth.  It  occurs 
also  in  children,  though  rarely.  Out  of  307  cases  treated  in  the  Devon- 
shire Hospital  during  1892,  only  2  per  cent,  manifested  the  disease  be- 
fore the  age  of  ten.  [d)  Heredity  has  been  traced  in  some  instances, 
and  in  many  du  family  tendency  to  joint-afifectien.  (f)  Though  it  occurs 
in  all  classes  of  society,  the  2?oor  or  those  exposed  especially  to  debili- 
tating influences  are  more  liable  than  the  rich.  (/)  Ewart^  recognizes 
some  mixed  conditions  in  -which  rheumatoid  arthritis  may  supervene  on 
the  gouty  diathesis. 

(1)  Symptoms  of  the  Chronic  Form. — At  first  one  joint,  usually 
of  the  hand,  is  slowly  involved  ;  soon  the  corresponding  joint  on  the 
opposite  side  is  attacked.  These  may  recover  apparently,  but  are  soon 
reinvaded  and  grow  progressively  worse.  The  affected  joints  slowly  en- 
large, and  are  moderately  painful,  particularly  on  movement.  Pain, 
however,  may  either  be  slight  or  even  absent,  or  severe  (rarely  agoniz- 
ing) in  character.  There  is  neither  redness  nor  tenderness,  as  a  rule, 
but  on  palpation  an  effusion,  variable  in  extent,  is  generally  detectable. 
The  course  during  the  early  stage  is  often  marked  by  periods  of  im- 
provement, alternating  with  exacerbations  in  the  local  symptoms,  and 
especially  in  the  SAvelling  and  pain.  While,  as  intimated,  one  or  two 
joints  only  are  affected  at  the  start,  gradually  those  of  the  feet,  arms, 
legs,  and  trunk  are  invaded  symmetrically,  until,  in  the  Avorst  cases, 
every  joint  is  deformed. 

The  most  characteristic  symptom  is  the  deformity,  which  manifests 
itself  earliest  in  the  hands.  The  fingers  are  generally  pointed  toward 
the  ulna,  rarely  toward  the  radius,  and  the  presence  of  the  osteophytes 
and  the  immensely  thickened  capsular  ligaments,  together  with  the  re- 
tracted muscles,  all  tend  to  alter  entirely  the  shape  of  the  joints.  The 
fingers,  for  example,  are  flexed  and  extended  upon  the  hand,  and  some- 
times overlie  one  another.  With  the  progress  of  the  deformity  a  partial, 
and  less  often  a  complete,  luxation  of  the  joints  occurs  (see  Fig.  31). 
The  joints  may  become  finally  either  quite  fixed,  owing  to  the  presence 
of  the  periarticular  osteophytes,  or  a  limited  degree  of  movement  may 
remain. 

Palpation  and  auscultation  of  the  involved  joints  reveal  crepitation 
during  movement.  Strangely  enough,  the  thumb  remains  intact,  com- 
pensating for  the  loss  of  the  functional  movement  of  the  fingers  to  a 
remarkable  extent.  In  addition,  the  hand  is  sometimes  less  affected 
^  International  Medical  Magazine,  April,  1899. 


390  CONSTITUTIONAL  DISEASES. 

than  the  rest  of  the  joints — a  fact  which  enables  the  patient  to  perform 
a  great  variety  of  even  delicate  movements.  The  adjacent  muscles  be- 
come Avasted  and  are  the  seat  of  contractures,  causing  flexion  of  the 
limbs,  especially  of  the  thigh  upon  the  abdomen  and  the  leg  upon  the 
thigh.  Other  trophic  changes,  such  as  paresthesia  and  pigmentation  or 
glossy  areas  of  the  skin,  may  be  observed.  In  3  of  my  cases  onychia 
was  present.  In  extreme  instances  the  decubitus  is  lateral  and  the 
patient  utterly  helpless. 

The  course  of  the  disease  throughout  the  more  advanced  stages  is 
exceedingly  variable.  Its  advance  may  be  arrested  and  the  general 
health  remain  unimpaired,  and  this  may  take  place  after  implication  of 
but  a  few  joints,  so  that  the  entire  affection  may  be  confined  to  a  com- 
paratively small  part  of  the  body,  either  in  the  upper  or  lower  extrem- 
ities. In  progressive  cases  more  or  less  gastro-intestinal  disorder  arises  ; 
the  symptoms  of  indigestion  appear,  the  appetite  is  impaired,  and 
anemia  develops.  The  patients  sufferings  make  him  irritable.  Hypo- 
chondriasis may  be  a  concomitant.  In  establislicd  cases  the  pulse  is  per- 
sistently rapid  and  the  skin  inclined  to  free  ])crspiration. 

Clinical  Varieties. — (1)  Of  the  chronic  form  there  are  certain 
subvarieties.  The  disease  may  be  limited  to  a  single  joint  (monartic- 
ulw),  this  form  most  commonly  affecting  the  hip-joint,  when  it  is  known 
as  morbus  coxce  senilis.  It  is  seen  generally  in  old  men,  and  often  fol- 
lows an  injury.  Its  features — pathologic  and  clinical — including  the 
muscular  wasting,  are  the  same  in  kind  as  those  of  the  polyarticular 
variety.  Monarticular  arthritis  deformans  may  also  be  confined  'to 
the  shoulder-joint  or  the  knee,  and,  as  in  the  preceding  form,  men 
who  have  passed  the  middle  period  of  life  are  mainly  affected. 

A  special  variety,  which  is  generally  not  monarticular,  involves  only 
the  vertebne  {spondylitis  deformans).  This  may  be  combined  with 
morbus  coxce  senilis,  or  the  condition  may  be  confined  to  the  cervical 
spine,  as  in  a  recent  case  of  my  own,  thus  preventing  flexion  of  the 
head.  A  fair  degree  of  rotation  usually  remains,  but  it  sometimes  hap- 
pens that  the  entire  spinal  column  is  involved  and  held  in  a  perfectly 
rigid  position. 

Still  another  form  in  which  the  distal  joints  of  the  fingei's  become 
knobbed  {Heberden  s  nodes)  demands  separate  description.  Heberden's 
nodosities  occur  chiefly  in  women  between  the  thirtieth  and  fortieth 
years,  though  I  have  seen  one  case  which  began  after  the  fiftieth  year. 
According  to  Heberden,  who  first  described  them,  the  nodes  have  no 
intimate  association  with  gout,  and  this  view  coincides  with  my  obser- 
vations. At  first  the  affected  joints  become  .swollen,  tender,  slif/Iitly  red, 
and  painful,  and  then  seemingly  undergo  great  improvement.  The  con- 
dition however,  is  progressive,  advancement  occurring  in  the  form  of 
fresh  exacerbations,  which  are  often  traceable  to  errors  in  diet,  and  are 
separated  by  periods  of  remission.  The  morbid  process  is  the  same  as 
in  rheumatoid  arthritis,  and  the  destructive  changes  in  the  joints  pro- 
ceed until  distinct  hard  nodules  are  formed.  These  are  usually  most 
marked  at  the  sides  of  the  extensor  surfaces  of  the  second  phalanges. 
The  disease  does  not  spread  to  any  of  the  larger  joints,  and,  although 
incurable,  it  is  free  from  danger  to  life. 

(2)  The  Acute  Form. — This  is  comparatively  rare,  and  occurs  com- 


ARTHRITIS  DEFORMANS.  391 

monly  between  the  ages  of  twenty  and  thirty.  It  occurs  in  children, 
and  is  more  common  in  women  than  in  men.  Among  its  common  ante- 
cedents in  women  are  pregnancy,  delivery,  excessive  lactation,  and  the 
menopause.  Multiple  arthritis.,  affecting  both  the  large  and  small  joints, 
sets  in  acutely,  and  there  are  pain  and  either  a  slight  redness  or  a  con- 
siderable swelling,  due  chiefly  to  an  effusion  which  is  intra-  rather  than 
periarticular.  There  are  only  a  slight  tendency  to  migration  from  joint 
to  joint,  and  a  slight  febrile  disturbance. 

Still  described  a  form  of  chronic  joint-disease  in  children  which  he 
thinks  presents  difference?  sufficiently  marked  to  suggest  a  distinct 
clinical  and  pathologic  entity,  and  differing  from  the  rheumatoid  arth- 
ritis of  adults.  It  is  defined  as  a  progressive  enlargement  of  the  joints 
associated  with  general  enlargement  of  the  glands  and  enlargement  of 
the  spleen.  He  has  studied  22  cases,  19  of  which  came  under  his  per- 
sonal observation.  It  occurs  before  the  second  dentition.  Stiffness, 
general  thickening  of  the  tissues  around  the  joints  without  redness  or 
tenderness,  except  in  very  acute  cases,  with  limitation  of  movement  and 
more  or  less  rigid  flexion  of  the  joints,  characterize  the  arthritic  dis- 
turbance. The  most  distinct  feature  of  the  disease  is  the  enlarcfement 
of  the  lymphatic  glands,  those  in  relation  to  the  involved  joint  being 
primarily  affected.  The  glandular  swelling  is  general  and  constant. 
Enlargement  of  the  spleen  is  also  a  striking  feature.  Cardiac  compli- 
cations are  absent.      The  course  of  the  disease  is  slow. 

Differential  Diagnosis. — The  diagnosis  between  the  chronic  form 
of  the  disease  and  cltronic  rheumatism  is  not  always  an  easy  one.  In 
the  latter,  however,  a  few  of  the  larger  joints  only  are  involved,  while 
there  is  an  absence  of  the  peculiar  deformity  and  marked  fixity  of  the 
articulations.  On  the  other  hand,  cardiac  complications  are  absent  in 
chronic  rheumatoid  arthritis,  and  the  course  is  progressive.  A  mon- 
articular arthritis  which  difters  in  its  morbid  process  from  rheumatoid 
arthritis  sometimes  affects  the  shoulder-joint.  It  is  not  uncommon,  and 
is  "  characterized  by  pain,  thickening  of  the  capsule  and  of  the  liga- 
ments, wasting  of  the  shoulder-girdle  muscles,  and  sometimes  by  neuritis  " 
(Osier).  I  have  met  with  5  instances  of  this  sort,  in  all  of  which  pain 
was  intense  and  the  course  .subacute.     All  ended  in  recovery. 

The  acute  form  is  frequently  confounded  with  acute  articular  rheu- 
matism, from  which  it  is  to  be  discriminated  by  the  special  etiologic 
factors,  the  less  severe  pain,  the  less  marked  redness,  the  slight  tendency 
to  migration  from  joint  to  joint,  the  slighter  febrile  disturbance,  and  by 
the  practical  freedom  from  cardiac  complications.  Gout  will  be  distin- 
guished in  the  description  of  that  disease. 

Prognosis. — Though  incurable,  rheumatoid  arthritis  is  not  imme- 
diately dangerous  to  life,  and  in  a  certain  proportion  of  the  cases  im- 
provement, and  in  a  smaller  proportion  arrested  progress  of  the  disease, 
may  be  expected. 

Treatment. — This  especially  involves  measures  that  aredirected  to- 
ward the  improvement  of  bodily  nutrition — a  generous  dietary,  systematic 
warm  bathing,  and  an  abundance  of  fresh  air,  with  properly-regulated 
physical  exercise.  Tonics  may  be  necessary  to  invigorate  the  economy, 
and  iron  to  overcome  the  anemia.  The  prolonged  use  of  cod-liver  oil 
in  conjunction  with  other  remedies  has  given  me  excellent  results.      Of 


392  CONSTITUTIONAL  DISEASES. 

special  agents,  the  most  satisfactory  in  their  effects  if  administered  early 
are  iodin  and  arsenic.  An  eligible  form  of  tlie  latter  is  arsenious  acid, 
given  in  granules  (gr.  -^^ — 0.0018,  after  food)  ;  the  former  may  be  ad- 
ministered in  the  form  of  a  saturated  solution  of  sodium  iodid,  of  which 
ten  to  fifteen  drops  may  be  given  in  milk  one  hour  after  food.  The 
patient  may  be  sent  to  a  Avarm  climate  in  winter  and  to  a  cooler  one, 
preferably  a  mountain-resort,  in  summer.  These  patients  also  do  well 
at  certain  mineral  springs,  such  as  the  sulphur  springs  of  Virginia,  the 
hot  springs  of  Arkansas  or  Toplitz.  at  Baden  in  Switzerland,  and  the 
Avarm  sodium  chlorid  baths  in  Wiesbaden.  Hot  mineral  spas  should  only 
be  resorted  to  in  the  early  period  of  the  aifection.  Striimpell  has  seen 
excellent  results  follow  the  employment  of  hot  sand-baths,  which  can  be 
used  at  home.  Stewart  advocates  the  Tallerman  method  of  treatment — 
i.  e.  of  superheated  dry  air.  Short  employs  the  apparatus  ordinarily 
used  in  hospitals  for  the  administration  of  hot-air  baths,  with  a  view  to 
producing  diaphoresis.     Fibrous  anchylosis  may  be  treated  surgically. 

Eliminative  Treatment. — Guaiacol  carbonate  may  be  given  in  doses 
of  from  5  to  15  grains  (0.3—1.0  gm.)  daily  and  rapidly  increased.  This 
acts  by  combining  with  the  bacterial  toxins,  to  be  eliminated  as  guaiacol 
sulphate  (Bannatyne). 

The  local  mean.^-  are  of  the  highest  value.  If  the  joints  be  inflamed, 
cold  compresses,  covered  with  oiled  silk,  to  which  some  narcotic  agent 
may  be  added,  will  afford  relief.  This  should  be  followed  by  thorough 
and  systematic  massage,  which  is  our  best  measure  for  the  reduction  of 
the  swelling  (by  promoting  absorption  of  the  inflammatory  exudate)  and 
for  lessening  joint-rigidity.  It  also  restores  the  atrophied  muscles  and 
assists  the  general  health.  Swedish  movements  are  useful  in  maintain- 
ing mobility  and  often  in  restoring  that  which  has  been  lost. 


GOUT. 

{Podagra.) 

Definition. — A  form  of  perverted  nutrition  due  to  an  auto-infection, 
accompanied  by  the  formation  of  a  variable  (usually  increased)  amount 
of  uric  acid,  and  characterized  clinically  by  attacks  of  acute  arthritis, 
with  or  without  uratic  deposits  in  and  around  the  joints. 

Nature  of  the  Affection. — The  numerous  theories  that  ])rcvail  at  pres- 
ent in  regard  to  the  disease  are  irreconcilable,  but  it  seems  certain  that 
there  is  (a)  an  excessive  absorption  of  nutritive  substances,  both  solid 
andli([uid:  (^)  a  disordered  metabolism  growing  out  of  the  effects  of 
imperfect  physical  development,  combined  with  too  little  physical  exer- 
tion ;  (f)  a  defective  elimination  of  waste-products,  although  in  some 
cases  a  normal  elimination  of  waste-products  exists. 

There  are  a  number  of  uric-acid  theories,  some  of  which  may  be 
briefly  mentioned  :  1.  Garrod  contends  that  an  acute  attack  of  gout  is 
invariably  produced  by  an  excess  of  uric  acid  in  the  blood,  due  to  increased 
formation  and  greatly  decreased  elimination  ;  also,  that  inflammation  is 


GOUT.  393 

caused  by  the  deposition  in  the  joints  of  sodium  urate.  2.  Haig  holds 
that  there  is  a  diminished  alkalinity  of  the  blood,  and  that  the  latter  can- 
not therefore  hold  the  uric  acid  in  solution,  so  that  it  is  deposited  in  the 
form  of  urates..  3.  Ebstein  thinks  it  probable  that  there  exist  an  ex- 
cessive production  and  accumulation  in  the  blood  of  uric  acid.  The  sur- 
charged blood  excites  local  inflammation,  followed  by  necrosis,  and  uric 
acid  deposits.  4.  Sir  William  Roberts  believes  that  acute  attacks  of  gout 
are  dependent  upon  the  precipitation  of  the  crystalline  biurate  of  sodium  ; 
that  the  urate  is  transformed  into  the  less  soluble  biurate  in  the  blood. 

5.  V.  Noorden  concludes  that  the  essential  process  is  a  tissue-necrosis 
attributable  to  the  presence  of  a  hypothetic  ferment,  and  that  the  uric 
acid,  which  is  without  etiologic  efiect,  is  deposited  at  the  necrotic  focus. 

6.  Klemperer  ^  has  shown  as  the  result  of  observations  made  in  cases  of 
gout,  that  as  long  as  the  function  of  the  kidneys  is  not  materially  inter- 
fered Avith  the  presence  of  considerable  amounts  of  uric  acid  in  the 
blood  must  be  attributed  to  increased  formation.  But  the  presence  of 
an  equivalent  of  uric  acid  in  the  blood  in  certain  affections  other  than 
gout  (g.  g.  leukemia)  shows  that  this  factor  is  not  the  sole  cause  of  gout. 

7.  Morhorst,  in  dealing  with  the  pathogenesis  of  gout,  states  that  in 
any  alkaline  liquid  the  basic  substances  combine  with  uric  acid,  if  this 
be  present,  to  form  a  urate.  These  uratic  precipitations  are  met  in  non- 
vascular tissues  only,  the  alkalinity  of  which  is  less  than  that  of  the  blood, 
and  that  they  are  the  essential  cause  of  the  symptoms.  8.  Kolisch  main- 
tains that  the  more  serious  features  in  gout  only  exist  in  the  presence  of 
impairment  of  the  renal  function.  When  the  kidneys  are  healthy  the 
alloxuric  bodies  are,  in  great  part,  excreted  as  uric  acid;  but  when  they 
are  diseased  the  xanthin  bases  are  increased  at  the  expense  of  the  uric 
acid.  Chittenden  and  others,  however,  hold  that  the  xanthin  bases  are 
practically  free  from  toxic  effects.  9.  Luff  thinks  that  uric  acid  is  formed 
in  the  kidneys  from  a  combination  of  urea  and  glycocin,  an  increased 
amount  of  the  latter  substance  being  formed  in  the  liver. 

The  recent  view  that  failure  of  the  renal  function  precedes  the  de- 
velopment of  gouty  manifestations,  although  not  established,  and  the 
older  view,  that  an  increased  proportion  of  uric  acid  is  found  in  the 
blood  in  gouty  subjects,  seem  to  be  the  most  widely  accepted. 

Pathology. — The  post-mortem  history  of  gout  is  concerned  princi- 
pally with  the  arthritic  changes,  including  the  deposits  of  the  urate  of 
sodium  in  the  cartilages,  the  ligaments,  and  the  synovial  membranes. 
These  are  fluid  in  their  earliest  state  and  contain  numerous  small  crys- 
talline masses ;  they  soon  inspissate  and  later  become  hard  and  dry 
(tophi).  The  latter  excite  secondary  inflammatory  changes  that  may 
lead  to  fibrous  overgrowths,  distortion,  and  fixation  of  the  joints.  Gouty 
tophi  may  be  absorbed  or  they  may  finally  be  discharged  through  the 
skin  in  consequence  of  an  ulcerative  process.  The  chalky  concretions 
have  been  found  also  in  the  cartilages  of  the  ears,  less  frequently  of  the 
nose,  eyelids,  and  larynx.  They  have  also  been  described  in  the  peri- 
osteum and  along  the  tendons  of  the  palms  of  the  hands,  where  they 
produce  a  characteristic  form  of  contraction  of  one  or  more  fingers  (Du- 
puytren's  contraction).  Charcot  has  found  them  in  the  penis.  If  death 
occur  in  the  acute  attack,  hyperemia  and  swelling  of  the  capsule,  liga- 

^  Deutsche  medicinische  Wochenschrift,  1895,  No.  40,  p.  653. 


394  COXSTITUTIOXAL  DISEASES. 

ments,  and  synovial  membrane  are  found,  together  ^vith  an  inflammatory 
exudation  into  the  joint. 

The  kidneys  are  usually  involved,  the  changes  being  similar  in  char- 
acter to  those  observed  in  the  joints,  and  innumerable  areas  of  necrosis, 
followed  by  uratic  deposits,  are  seen  throughout  the  organs,  though 
chiefly  in  the  papillie.  Osier  says  that  "the  presence  of  these  uratic 
concretions  at  the  apices  of  the  pyrami<ls  is  not  a  positive  indication  of 
gout."  N.  S.  Davis,  Jr..  points  out  that  the  kidneys  are  aff"ected  in  spots, 
-with  intermissions  in  the  degenerative  changes,  Avhich  are  microscopical 
in  size,  until  finally  large  areas  are  involved.  Granular  contracted  kid- 
ney (chronic  interstitial  nephritis),  with  or  without  arteriosclerosis,  is 
sometimes  caused  by  the  gouty  condition  {vide  Interstitial  Nephritis). 

The  Iteart  and  blood-vessels  always  present  changes.  Gout  induces 
arterio-sclerosis.  and  the  latter  in  turn  cau.-^es  cardiac  hypertrophy, 
particularly  of  the  left  ventricle.  In  chronic  cases  fatty  degeneration 
of  the  heart-muscle  sometimes  occurs,  and  chronic  valvulitis,  with  de- 
posits of  urate  of  sodium  in  the  valves,  has  been  noted.  Chronic  bronchi- 
tis, asthma,  and  emphysema  are  among  the  more  common  changes 
connected  Avith  the  respiratory  tract,  acute  conditions  being  rare. 

Ktiology. — The  following  are  the  principal  contributing  causes  : 

{a)  Heredity. — Garrod's  dictum,  '"that  more  than  one-half  of  all 
gouty  subjects  can  distinctly  trace  their  ailment  to  an  hereditary  taint," 
is  doubtless  correct,  heredity  from  the  grandparents,  which  is  not  of  in- 
frequent occurrence,  being  included  in  this  estimate.  If  the  better 
class  of  society  alone  be  considered,  the  percentage  will  probably  be 
still  larger.  It  must  not  be  forgotten,  however,  that  patients  out  of 
pride  represent  other  articular  affections  as  gout,  {h)  A  fie. — Primary 
attacks  are  most  frequent  in  middle  life.  They  are  rare  before  puberty, 
though  exceptionally  seen  even  in  suckling  infants;  but  after  the  age  of 
puberty  they  become  more  frequent.  After  the  fiftieth  year  they  de- 
crease rapidly  in  frequency,  and  are  very  rare  in  quite  advanced  life. 
The  cases  that  develop  quite  early  in  life  often  show  a  striking  heredi- 
tary taint,  (r')  Se.r. — The  arthritic  form  is  less  fre<iuent  in  women  than 
in  men,  while  the  former  are  disposed  to  the  irregular  type  of  chronic 
gout  quite  as  strongly  as  the  latter,  {d)  Diet. — Over-indulgence  in  the 
pleasures  of  the  table,  together  with  defective  physical  exercise,  consti- 
tutes a  potent  factor,  and  this  even  in  persons  who  are  endowed  with 
exceptional  powers  of  digestion,  (e)  Alcohol,  and  particularly  the  fer- 
mented liquors,  are  among  the  chief  favoring  influences.  The  fact  ex- 
plains the  relatively  greater  frequency  of  gout  in  certain  countries  {e.  g. 
England  and  Germany),  in  Avhich  the  heavier  beers  and  ales  are  freely 
used,  than  in  America,  where  lighter  fermented  drinks  are  more  popular. 
The  cases,  however,  are  on  the  increase  in  this  country.  (/)  Social  State. 
— Most  cases  occur  among  the  upper  class  of  society,  but  there  is  also  a 
well-defined  form  of  "poor-man's  gout  "  due  to  an  excessive  use  of  malt 
beverages,  (g)  Lead. — Workers  in  lead  furnish  numerous  typical  ex- 
amples of  gout.  Garrod  found  that  in  30  per  cent,  of  the  hospital 
cases  the  patients  ha<l  been  painters  or  workers  in  lead.  He  also  showed 
that  the  administration  of  lead  salts  to  gouty  persons  almost  invariably 
determined  a  gouty  paroxysm.  Whether  lead  produces  gout  by  arrest- 
ing the  excretory  processes,  especially  from  the  bowel  and  kidney,  and 


GOUT.  395 

by  thus  inducing  a  fibroid  change  in  the  kidney  and  liver,  as  is  held  by 
Oliver  of  New  Castle,  is  not  definitely  settled.  Poore  points  out  that 
gout  produced  by  lead  or  chronic  kidney  trouble  is  constantly  associated 
with  anemia  and  emaciation,  and  forms  a  distinct  clinical  entity,  [h) 
Cornillon  and  others  detail  cases  in  which  injuries  Avere  followed  by  the 
first  nppearance  of  the  disease. 

Clinical  History. — 1.  Acute  Gout. — The  earliest  manifestations  of 
the  disease  are  apt  to  take  the  form  of  a  more  or  less  typical  attack  of 
acute  arthritic  gout.  The  latter  is  usually  preceded  by  certain  iwodromal 
symptoms,  which  vary  in  difi"erent  cases,  but  are  almost  constantly  simi- 
lar for  the  paroxysms  of  individual  cases.  The  patient  may  complain 
either  of  slight  muscular  cramps  and  articular  pains,  or  of  dyspeptic  di.s- 
order,  or  of  an  asthmatic  seizure  ;  or  he  may  exhibit  mental  disturbance 
— irritability  of  disposition,  broken,  restless  sleep,  and  depression  of 
spirits.  In  a  small  percentage  of  instances,  just  prior  to  the  attack  the 
patient  feels  better  than  ordinarily.  It  has  been  observed  that  imme- 
diately before  and  also  during  the  early  part  of  a  paroxysm  the  daily 
amount  of  uric  and  phosphoric  acids  found  in  the  urine  is  diminished ; 
but  Klemperer  has  shown  that  no  relation  exists  between  the  amount  of 
uric  acid  present  in  the  urine  and  the  character  of  the  disease. 

The  attack  generally  develops  in  the  very  early  morning  hours.  The 
patient  awakens  sufi'ering  from  pains  in  the  metatarso-phalangeal  joint 
of  the  great  toe,  that  soon  become  excruciating,  Avhile  the  joint  feels 
as  if  it  were  tightly  compressed  in  a  vise.  The  local  signs  of  inflamma- 
tion— heat,  redness,  swelling,  and  excessive  sensitiveness — quickly  super- 
vene. The  skin  pits  on  pressure  and  becomes  shiny.  The  ho([j-tern- 
perature  rises  to  102°  or  103°  F.  (39.4°  C),  and  the  patient  manifests 
intense  irritability. 

At  the  end  of  an  hour  or  two  the  sufferings  abate,  the  fever  often 
declines,  with  free  perspiration,  and  the  patient  may  be  able  to  pursue 
his  avocation.  During  the  next  day  some  degree  of  enlargement  and 
inflammatory  edema  remains,  and  on  the  following  night  the  symptoms 
are  usually  repeated  in  all  their  violence.  The  condition  usually  pro- 
gresses in  this  manner  from  four  to  seven  or  eight  days,  though  after  a 
few  days  the  intensity  of  the  paroxysms  is  apt  to  lessen.  After  the 
attack  the  swelling  subsides  and  there  is  a  slight  desquamation  of  the 
skin,  which  resumes  its  normal  color,  and  the  general  health  is  often 
unusually  good.  These  so-called  fits  of  gout  usually  recur  from  time  to 
time,  the  duration  of  the  intervals  depending  largely  upon  the  patient's 
habits  or  routine  of  life.  On  the  whole,  the  first  interval  is  apt  to  be 
the  longest,  while  later  the  intermissions  may  not  exceed  two  or  three 
months.  With  subsequent  attacks  the  aflfection  is  apt  to  spread  to  other 
articulations.      There  is  no  tendency  to  suppuration. 

2.  Retrocedent  Gout. — This  term  implies  the  sudden  transmission  of 
the  arthritic  process  to  some  internal  organ.  During  a  paroxysm  the 
joint-inflammation  may  quickly  disappear  Avith  an  equally  sudden  de- 
velopment of  intense  pain  in  the  region  of  the  stomach,  vomiting,  diar- 
rhea, faintness,  and  a  rapid,  feeble  pulse.  Suppressive  gout  may  attack 
the  heart  and  produce  precordial  pain,  dyspnea,  cardiac  palpitation,  and 
much  anxiety  of  mind.  It  may  also  excite  pericarditis  with  a  fatal 
result.     Transmission   to   the   head,    with   the   development   of  intense 


396  CONSTITUTIONAL  DISEASES. 

cerebral  symptoms  (maniacal  excitement,  coma,  and  apoplexy),  also 
occurs.  Nervous  phenomena,  however,  are  more  commonly  due  to 
uremic  poison. 

3.  Symptoms  of  Chronic  Gout. — Chronic  gout  follows  the  acute  variety. 
The  transition  is  gradual,  the  intervals  between  attacks  shorter,  while 
the  attacks  themselves  grow  milder  and  longer.  At  last  the  local  in- 
flammation does  not  appear.  The  condition  extends  to  other  joints : 
first,  to  the  corresponding  joint  on  the  opposite  side,  then  to  the  other 
toes  and  the  ankles.  Later,  the  fingers  and  Avrists  may  be  invaded,  but 
almost  never  the  largest  joints  (hip,  shoulder).  With  the  progress  of 
the  affection  the  chalk  deposits  slowly  and  gradually  increase  until  the 
characteristic  deformity  is  produced.  The  skin  covering  the  tophi  may 
ulcerate,  exposing  the  chalk-stones,  an  unmistakable  picture.  When  the 
fingers  are  affected  we  note  a  deflection  at  the  second  or  third  joint,  con- 
stituting a  peculiar  habitus. 

Among  important  associated  conditions  are  chronic  gastric  catarrh, 
arterio-sclerosis,  cardiac  hypertrophy  Avith  considerable  functional  dis- 
turbance of  the  heart,  and  "contracted  kidney,"  forming  a  much  com- 
plicated yet  easily  recognized  clinical  picture.  If  in  cases  of  this  sort 
the  urine  of  a  gouty  person  is  carefully  examined,  and  is  found  to  con- 
tain a  small  percentajre  of  albumin  and  tube-casts,  the  Avhole  train  of 
events  becomes  easy  of  interpretation.  Tlie  cases  may  be  divided  into 
tAvo  classes:  {a)  those  in  Avhich  the  complexien  is  florid  and  the  general 
health  vigorous;  {h)  those  Avith  pale,  salloAv  facies,  emaciation,  and  en- 
feeblement.  These  groups  are  chiefly  dependent  upon  the  differences  in 
the  etiologic  factors.    Gouty  subjects  often  manifest  unusual  mental  vigor. 

The  course  of  chronic  gout  is  liable  to  be  interrupted  by  acute  exacer- 
bations Avith  fever,  during  Avhich  dangerous  complications  may  arise — 
e.  g.  uremia,  pericarditis,  pleurisy,  pneumonia. 

4.  Irregular  Gout. — Says  Sir  Dyce  Duckworth:  "Gout  manifesting 
itself  anyAvhere  but  in  a  joint  is  to  be  considered  irregular  or  incom- 
plete." Such  cases  are  confined  chiefly  to  persons  of  gouty  heritage, 
though  I  feel  confident  that  the  diathesis  may  be  also  acquired.  But 
though  the  etiologic  factors  that  produce  lithemia  also  in  time  produce 
gout,  these  tAvo  conditions  should  be  discriminated :  for,  Avhile  in  both 
Ave  usually  note  an  excess  of  uric  acid  in  the  blood,  in  lithemia  there 
are  no  tophi  present,  and  hence  no  necrotic  foci  in  the  joints  or  else- 
Avhere.  Irregular  gout,  then,  rarely  occurs  in  persons  Avho  have  had 
previous  typical  attacks,  but  should  any  of  the  conditions  described 
beloAv  as  being  dependent  upon  the  gouty  diathesis  be  associated,  or 
should  they  alternate,  Avith  acute  gout,  they  may  be  properly  ascribed 
to  the  latter.  On  the  other  hand,  Avhen  these  conditions  occur  in 
persons  Avho  are  free  from  hereditary  taint,  and  Avho  are  not  addicted 
to  the  intemperate  use  of  alcoholic  beverages,  or  excessive  indulgence  in 
the  pleasures  of  the  table,  and  are  not  possessed  of  luxury-  and  rest- 
loving  temperament,  the  diagnosis  of  irregular  gout  is  to  be  made  Avith 
extreme  caution.  It  is  perfectly  justifiable  to  apply  a  therapeutic  test 
Avhen  other  means  of  diagnosis  fail. 

The  features  of  irregular  gout  are  exceedingly  diA^ersified  ;  the  follow- 
ing are  the  more  important : 

ia)  Joint-  and  Muscle-pains. — The  muscular  pains  may  be  anywhere, 


GOVT.  397 

and  "flying"  in  nature,  but  the  muscles  of  the  back  of  the  neck,  the 
lumbar  region,  the  abductors  of  the  thigh,  and  the  gastrocnemii  are 
especially  liable  (Tyson).  These  pains  are  most  severe  in  the  early 
morning  hours  and  subside  as  the  day  grows.  Articular  pains  attended 
with  some  degree  of  swelling  and  deformity  of  the  joints  (the  latter,  how- 
ever, not  due  to  uratic  deposits)  may  be  of  gouty  origin  ;  and,  according 
to  Paget  and  Garrod,  Heberden's  nodosities  (previously  described  under 
Rheumatoid  Arthritis)  may  present  vesicular  eminences  due  to  gout. 

{h)  Gastro-i7itestinal  Disturbances. — The  symptoms  referable  to  the 
intestines  are  identical  with  those  presented  by  lithemia.  In  one  of  my 
cases  intestinal  colic  followed  by  diarrhea  put  in  an  appearance  at  long 
intervals.  Tonsillitis,  pharyngitis,  pericarditis,  and  even  parotitis,  may 
also  be  manifestations. 

(c)  Cardio-vasculm-  Si/mptorns. — Just  as  in  pure  lithemia,  so  in  atypi- 
cal gout,  the  increased  amount  of  uric  acid  usually  present  in  the  blood, 
by  increasing  the  blood-tension,  excites  arterio-sclerosis  and  chronic  in- 
terstitial nephritis — affections  w^hich  are  fully  described  in  appropriate 
sections  of  this  work. 

(d)  Nervous  Manifestations. — The  different  varieties  of  headache, 
including  migraine,  are  common.  Sciatica  and  other  forms  of  neuralgia, 
tingling,  itching,  burning  sensations,  and  even  pain  in  the  palms  of  the 
hands  and  sole§  of  the  feet,  are  of  frequent  occurrence.  Hot  and  itch- 
ing eyeballs  are,  according  to  Hutchinson,  among  frequent  manifesta- 
tions ;  apoplexy  may  arise,  secondary  to  atheroma  induced  by  gout ; 
and  rarely  meningitis  (basilar)  is  among  the  gouty  morbid  states.  The 
latter  also  include  certain  psychopathia — insomnia,  irritability  of  temper, 
and  melancholia.     The  possibility  of  gouty  neuritis  is  to  be  remembered. 

(e)  Urinary  Symptoms. — The  urine  is  highly  colored,  of  high  specific 
gravity,  often  scanty,  and  the  standing  specimen  deposits  lithic  acid. 
This  is  not  peculiar  to  gout,  however.  In  many  cases  uric  acid  is  in 
excess  only  at  intervals,  giving  rise  to  so-called  uric-acid  showers,  while 
at  other  times  it  is  diminished  in  quantity.  The  results  of  the  investi- 
gations by  Klemperer  are  to  be  recollected  here  {vide  ante).  Gouty 
persons  are  liable  to  gravel :  I  agree,  with  Tyson,  however,  in  thinking 
that  the  two  conditions  more  frequently  alternate  than  coexist.  Inter- 
mittent glycosuria  is  also  common  in  gouty  subjects,  and  may  lead  to 
true  diabetes  mellitus ;  this  glycosuria  may  alternate  with  uric-acid 
showers.  Oxaluria  has  been  noted.  Grandmaison  believes  the  associa- 
tion of  albuminuria  with  gout  to  be  a  frequent  one,  and  that  the  early 
albuminuria  is  often  intermittent.  Among  grave  secondary  affections 
chronic  interstitial  nephritis,  with  its  characteristic  features  (slight  albu- 
minuria and  later  casts),  very  commonly  develops,  sooner  or  later,  and 
cystitis  (with  gouty  hemorrhage  into  the  bladder),  urethritis,  prostatitis, 
and  orchitis,  all  may  be  dependent  upon  gout. 

(/)  Pulmonary  Disturbances. — Chronic  bronchitis,  to  which  asthma 
and  emphysema  are  frequently  secondary,  is  often  the  asthma  of  podagra. 

[g)  Cutaneous  Eruptions. — Eczema  is  frequently  a.ssocia,ted  with  the 
gouty  diathesis,  and  I  have  often  observed  eczematous  eruptions  in  gouty 
subjects  alternating  with  the  symptoms  of  bronchitis  or  gastric  catarrh. 

(A)  Onilar  Disorders. — The  chief  eye-symptoms  are  conjunctivitis 
and  keratitis  (with  tophi  in  the  cornea  and  eyelids),  iritis,  hemorrhagic 


398  CONSTITUTIONAL  DISEASES. 

retinitis,  and  glaucoma.  Gouty  involvement  of  the  ear  (external  canal 
and  the  auricle  particularly)  occurs  oftenest  late  in  life,  though  hereditary 
gout  may  rarely  cause  ear  symptoms  shortly  after  birth. 

Differential  Diagnosis. — The  distinction  between  typical  acute 
gout  and  acute  articular  rheumatism  is  a  simple  matter.  But  when,  as 
is  rarely  the  case,  the  former  manifests  itself  as  a  polyarthritis,  the  dis- 
crimination is  sometimes  difficult.  AY.  H.  Thompson  has  pointed  out 
that  in  gouty  polyarthritis,  when  the  knees,  elbows,  and  phalangeal 
finger-joints  are  affected,  the  points  of  greatest  tenderness  on  transverse 
pressure  are  over  the  condyles.  On  the  other  hand,  in  acute  rheuma- 
tism the  cutaneous  tenderness  is  greater,  while  the  points  of  maximum 
tenderness  correspond  with  the  tendons  anterior  and  posterior  to  the  joints. 
Moreover,  gout  distinguishes  itself  by  its  previous  history  (heredity,  alco- 
holism, gluttony),  by  the  tophi,  Avhich  may  be  first  detected  in  the  ears  or 
conjunctivae,  by  the  development  of  contracted  kidneys,  and  the  less  marked 
fever.  After  repeated  attacks  deformities  of  the  joints  ensue.  In  a  doubtful 
case  the  blood-serum  may  respond  to  the  uric-acid  test,  as  follows:  Add  5—6 
minims  (0.399)  of  acetic  acid  to  2  drams  (8.0)  of  blood-serum  in  a  watch- 
glass;  then  place  a  linen  thread  in  the  solution  and  after  twelve  to  twenty- 
four  hours  this  will  be  incrusted  with  crystals  of  uric  acid.  The  result 
is  not,  however,  obtained  exclusively  from  the  blood  of  gouty  subjects. 

Chronic  rheumatism  is  distinguished  from  gout  by  the  fact  that  the 
latter  disease  involves  chiefly  the  small,  and  chronic  rheumatism  chiefly 
the  large,  joints.  Moreover,  chronic  interstitial  nephritis  and  arterio- 
sclerosis, with  their  varied  and  often  serious  consequences,  are  fre- 
quently attendant  upon  gout,  but  not  upon  chronic  rheumatism. 

To  differentiate  chronic  gout  and  rheumatoid  arthritis  is  sometimes  a 
hard  problem,  but  the  following  table  will  indicate  the  main  points  of 
difference  : 

Gout.  Arthritis  Deformans. 

Frequently  hereditary.  Not  so. 

Causes  are  chiefly  dietetic.  Causes  chiefly  nervous. 

Affects  males  and  the  better  classes  most  Affects  females   and  lower  classes  most 

frequently.  frequently. 

Begins   in    the   big   toe   and  extends  to  Begins  in  the  fingers,  which  point  to  the 

other  toes.  ulnar  side. 

Attacks  are  periodic.  IMore  steadily  progressive. 

Deformity  due  to  tophaceous  deposits.  Deformity   due    to    exostosis   and    anky- 
losis, and  more  marked. 

Uric  acid  usually  in  excess.  Not  so. 

Complications  (nephritis,   arterio-sclero-  Very  rare. 

sis). 

Treatment. — (1)  Prophylaxis. — In  order  to  prevent  the  develop- 
ment of  gout,  especially  in  persons  who  have  inherited  or  acquired  a 
strong  predisposition  to  the  disease,  temperate  and  even  rigid  habits  of 
life  should  be  adopted.  Alcohol,  particularly  the  heavier  wines  (Madeira, 
port,  sherry,  champagne,  etc.)  and  heavier  malt  liquors,  must  be  eschewed, 
and  the  patient  must  eat  sparingly  of  concentrated  meat  (particularly 
red  meat).  A  residence  in  the  country  with  active  out-of-door  exercise 
is  of  paramount  importance,  but  straining  efforts,  both  mental  and  phys- 
ical, are  to  be  avoided.  The  climate  should  be  temperate  and  mode- 
rately dry.     The  sleeping  apartments  should  be  capacious,  well  venti- 


GOUT.  399 

lated,  and  free  from  draught,  and  tlie  action  of  the  skin  is  to  be  favored 
by  cleanliness,  and  if  the  patient  be  strong  by  a  cold  bath  in  the  morn- 
ins;  with  friction.  For  the  robust,  Turkish  baths  at  intervals  of  two  or 
three  weeks  constitute  an  excellent  measure.  In  the  class  of  patients 
that  are  pale  and  debilitated  warm  baths  on  retiring  are  preferable,  and 
the  chilling  of  the  skin-surface  is  to  be  carefully  guarded  against.  The 
patient  should  "wear  flannels  next  to  the  skin  in  all  seasons. 

(2)  Active  Treatment.- — {a)  Dietetic. — ••  There  is  no  diet  for  gout,  but 
there  is  a  diet  for  the  patient '"  (H.  C.  Woodj.  The  amount  of  food  must 
be  lessened  as  a  rule,  and  taken  at  regular  intervals.  On  the  other  hand, 
spare  gouty  subjects  are  met  ^^-ith.  and  in  such  I  have  found  a  rather 
generous  diet,  including  fat-producing  foods,  of  great  service.  Broadly 
speaking,  the  dietary  should  be  constituted  as  follows:  succulent  vege- 
tables (cabbage,  salads,  string-beansj  ;  fruits  (except  bananas,  tomatoes, 
and  strawberries) ;  farinacea.  as  rice,  hominy  and  the  like  (oatmeal 
to  be  avoided);  meats  should  be  restricted:  beef  and  mutton  ma^^ 
be  allowed  in  corpulent  subjects,  but  are  otherwise  to  be  interdicted, 
particularly  in  well-marked  cases  of  gout ;  oysters  and  fish  (except  those 
that  contain  too  much  protein,  salmon,  smoked  herring,  canned  sardines, 
mackerel,  halibut,  salt  codfish,  flounder),  and  fowl,  particularly  the  white 
meat  of  chicken,  are  permissible ;  fats  in  the  form  of  good  butter  may 
be  taken  freely — from  2|-  to  3i-  ounces  (TO. 0-100.0)  per  diem,  according 
to  Ebstein ;  milk  is  entirely  unobjectionable,  and  should  be  used  in  large 
quantities.  If  whole  milk  does  not  agree,  it  may  be  mixed  with  an  equal 
part  of  Vichy.  According  to  Kolisch,  eggs  are  not  objectionable,  as  the 
neucleins  contained  do  not  form  alloxins.  Stale  breads  may  be  used.  I 
have  observed  that  occasionally  patients  do  best  on  albuminoids,  while, 
on  the  other  hand,  with  about  .equal  frequency  they  improve  on  a  vege- 
table diet;  but  I  am  convinced  that  a  mixed  diet,  such  as  has  just  been 
indicated,  is  best  adapted  to  the  vast  majority  of  the  cases.  Among 
articles  to  be  avoided  are  pastry,  tea  and  coffee,  hot  bread  and  cakes, 
sweet  puddings,   cheese,   dried  meats,   and  all   highly  seasoned  dishes. 

Beverages. — Alcohol  is  ordinarily  to  be  interdicted.  Rarelv  it  becomes 
necessary  to  administer  it.  particularly  in  cases  of  suppressed  gout,  and 
when  needed  whiskey  or  gin  (diluted)  is  to  be  preferred.  Most  wines, 
and  especially  champagne.  Tokay,  Port,  and  malted  liquors  are  particu- 
larly injurious  in  their  effects. 

3Iineral  ivaters,  particularly  the  alkaline,  are  highly  advantageous, 
and  sometimes  are  even  curative.  Their  value,  like  that  of  the  Avarm 
baths  and  systematic  exercise,  is  dependent  upon  their  power  to  increase 
renal  elimination.  Whether  they  promote  solubility  of  the  uric  acid  in 
the  blood  is  questionable :  moreover,  according  to  the  observations  of 
Klemperer.  this  is  not  a  rational  indication.  The  carbonate  and  citrate 
of  lithium  are  efficient  diuretics,  but  have  no  other  claim  to  virttie  in 
this  disease.  Among  natural  waters  of  special  value  abroad  are  Yichv, 
Carlsbad,  Homburg.  Ems.  Kissingen.  Aix.  Buxton,  and  Bath,  and  in 
this  country  Saratoga  and  Bedford.  These  waters  are  to  be  taken  in 
large  quantities  and  when  the  stomach  is  empty.  It  is  highly  probable 
that  the  environment,  rigid  system  of  hygiene,  including  exercise  and 
an  appropriately  modified  dietary,  play  the  principal  role  in  producing 
the  favorable  results  obtained  at  these  noted  springs. 


400  CONSTITUTIONAL   DISEASES. 

(b)  Medicinal  Treatment. — During  an  acute  attack  the  pajn,  if  ex- 
cruciating, is  to  be  relieved  br  a  hyjDodermic  injection  of  morphin,  -which 
is  to  be  followed  by  a  purgative  dose  of  some  mercurial.  Colchicum  is 
the  specific  remedy,  and  must  be  administered,  in  the  form  either  of 
the  wine  or  the  tincture,  in  doses  of  ITLxx-xxx  (1.333-1.999)  every  four 
hours.  It  alleviates  the  inflammation  and  promptly  relieves  the  pain, 
but  its  effects  during  the  attack  should  be  carefully  noted.  After  the 
paroxysm  it  should  be  continued,  though  in  small  doses,  combined  with 
the  citrate  or  bicarbonate  of  potassium  or  lithium.  The  limb  should  be 
raised  and  the  affected  joint  or  joints  wrapped  in  flannel  or  cotton-wool. 
Warm  alkaline  solutions  or  hot  fomentations  often  afford  relief  in  the 
worst  cases,  and  anodynes  may  be  tried  locally.  The  diet  should  con- 
sist chiefly  of  milk,  animal  broths,  and  egg-white  during  the  attack, 
while  after  the  latter  rice,  eggs,  fish,  and  other  light  forms  of  meat 
may  be  added,  the  more  liberal  dietary  previously  indicated  being 
slowly  resumed. 

In  the  intervals  between  the  acute  attacks  the  prophylactic  and 
dietetic  measures  previously  mentioned  are  to  be  resorted  to  with  a 
view  to  preventing  recurrences  of  the  disease,  and  in  addition  the 
alkaline  diuretics  and  saline  laxatives,  together  with  warm  bathing,  will 
be  found  of  the  utmost  value. 

In  chronic  and  irregular  forms  of  gout  medicines  are  of  subsidiary 
importance,  and  are  in  no  wise  comparable  in  their  beneficial  efi'ects  to 
the  previous  recommendations.  Two  agents  deserve  prominent  mention, 
however.  They  are  piperazin  and  the  extract  of  thymus  gland.  The 
ingestion  of  the  latter,  as  obtained  from  the  calf,  is  followed  by  an  in- 
creased excretion  of  uric  acid.  Piperazin  has  been  warmly  advocated 
in  all  forms  of  gout  for  its  supposed  effect  as  a  solvent  of  uric  acid,  and 
clinicians  are  almost  unanimous  in  reporting  its  favorable  results.  Its 
beneficial  effects  are  probably  due  to  its  diuretic  action.  The  dose  is 
gr.  v-x  (0.324-0.648)  thrice  daily,  freely  diluted  with  water.  Some 
authors  highly  recommend  the  salicylates  for  acute  attacks  of  gout,  both 
primary  and  intercurrent,  in  the  course  of  the  chronic  form.  In  my 
own  experience  they  have  been  less  effective  in  this  disease  than  colchi- 
cum, though  ammonium  salicylate  or  salicin  may  be  tried  if  there  be 
present  marked  gastric  disturbance,  since  they  are  better  borne  under  these 
circumstances  than  colchicum.  Luff"  has  demonstrated  by  experimentation 
the  negative  value  of  the  alkalies  and  salicylates  in  the  treatment  of 
gout.  If  nephritis  or  a  failure  of  compensation  be  present,  even  the 
former  remedies  should  be  administered  with  extreme  caution. 

For  chronic  gout  potassium  iodid  has  been  much  used,  though  Avith 
slight  advantage  to  the  patient,  I  think.  The  bitter  tonics,  combined 
with  a  vegetable  salt  of  iron,  should  be  resorted  to  in  the  anemic,  debili- 
tated  class  of  gouty  patients,  and  a  change  of  climate  often  serves  to 
improve  bodily  vigor  in  the  same  category  of  cases. 


LITHEMIA. 

Definition. — A   condition   due  to  a  disturbed  cellular  metabulism. 
It  is  characterized  chemically  by  an  excess  of  uric  acid  in  the  blood,  and 


LITHEMIA.  401 

clinically  by  various  digestive,  circulatory,  genito-urinary,  and  nervous 
phenomena.  My  purpose  in  describing  lithemia  is  that  the  common 
error  may  be  avoided  of  attributing  its  symptoms  to  other  causes. 

Pathogenesis  and  Ktiology. — Lithemia  is  comparatively  a  latent 
condition.  There  is  an  excess  of  uric  acid,  which  may  be  for  a  time 
eliminated  through  the  natural  channels  (kidneys,  lungs,  skin,  etc.)  with- 
out the  occurrence  of  symptoms.  On  the  other  hand,  Avhen,  as  the  result 
of  too  little  exercise,  impaired  elimination,  high  living,  the  use  of  sweet 
wines,  combined  with  the  neurotic  temperament,  uric  acid  is  alloAved  to 
collect  in  different  parts  of  the  organism,  marked  disturbances — nervous, 
gastro-hepatic,  etc. — follow.  We  are  not  here  concerned  with  the  artic- 
ular tyjje.  C.  G.  Stockton  holds  that  lithemia  is  a  gastro-intestinal  auto- 
intoxication. Among  agencies  that  predispose  to  the  onset  of  lithemia 
are  alcoholism,  heredity,  climate  (temperate  or  cold  climates  favor 
diminished  actions  of  the  skin),  and  the  male  sex. 

Symptoms. — The  nervous,  circulatory,  respiratory,  integumentary, 
and  genito-urinary  symptoms  are  practically  the  same  as  those  described 
under  Irregular  Gout ;  but  I  would  here  emphasize  the  broad  clinical 
fact  that  the  urethral  and  genital  mucous  membranes  often  become 
inflamed  on  slight  provocation,  producing  urethritis,  cystitis,  orchitis, 
epididymitis,  vaginitis,  endometritis.    These  conditions  resist  treatment. 

Gastro-intestinal  Symptoms. — The  appetite  is  variable,  sometimes 
voracious,  and  at  other  times  it  is  impaired  or  perverted.  The  tongue 
is  coated,  and  a  metallic  taste  is  often  complained  of,  while  various  forms 
of  indigestion  attend.  There  may  be  a  delay  in  the  conversion  of  the 
albuminoids,  causing  |)?/rosis,  gastric  oppression,  fulness,  and  sometimes 
nausea  and  vomiting  soon  after  food.  These  symptoms,  together  with 
marked  flatulence,  are  manifested  at  a  later  period  after  meals  if  there 
be  failure  in  the  digestion  of  the  carbohydrates.  The  bowels  work 
irregularly,  and  there  may  be  diarrhea  attended  by  colicky  pain,  with 
frothy  and  ill-smelling  discharges.  Hemorrhoids  are  usual,  and  raelena 
may  occur  independently  of  the  hemorrhoids.  The  liver  is  some^vhat 
enlarged  and  often  tender.  A  few  prominent  cardio-vascular  symptoms 
should  be  mentioned,  such  as  paljntation,  particularly  after  eating. 
More  rarely  it  occurs  while  the  patient  is  at  rest  or  even  lying  abed. 
Increased  arterial  tension  develops  early,  but  may  not  be  constant,  and 
is  due  probably  to  the  action  of  the  iiric  acid  in  the  blood  upon  the 
vaso-motor  nerves,  exciting  universal  contraction  of  the  arteries.  This 
condition  may  be  present  for  a  long  time  before  actual  arterio-sclerosis 
is  in  evidence.  The  latter  complaint  invariably  follows,  however,  and 
sooner  or  later  the  well-known  group — chronic  gout,  arterio-sclerosis,  and 
granular  kidney — will  be  presented. 

Treatment. — (1)  Prophylaxis. — The  patient  should  be  taught  the 
lesson  of  thorough  mastication,  and  robust,  plethoric  persons  should  ex- 
ercise Avith  method  in  the  open  air,  with  a  view  to  consuming  the  fats  in 
the  body.  For  this  purpose  cycling,  horseback-riding,  rowing,  and  walk- 
ing are  all  excellent.  Nervous  persons,  however,  demand  rest  (Gray). 
The  constant  use  of  iithia-water,  more  particularly  in  the  spring  of  the 
year,  is  warmly  advocated  by  Wilcox. 

(2)  Diet. — As  in  gout,  so  in  the  preliminary  stages  of  lithemia,  no  sin- 
gle dietary  suits  all  cases,  though  I  agree  with  those  who  contend  that  a 

26 


402  CONSTITUTIONAL  DISEASES. 

diet  consisting  chiefly  of  albuminoids  is  proper  in  most  cases.  The 
lighter  forms  of  albuminous  articles  of  diet  are  to  be  preferred,  and,  if 
well  borne,  fruits  and  green  vegetables  may  be  added  ;  but  fried  meats 
of  all  sorts  and  made-over  dishes  are  to  be  eschewed.  Assuming  that 
certain  cases  are  dependent  upon  an  auto-mtoxication  from  the  gastro- 
intestinal tract,  the  object  should  be  to  limit  fermentation  by  the  use  of 
a  nitrogenous  diet ;  and  I  have  found  large  amounts  of  water  very  bene- 
ficial in  such  instances.  There  are  cases  in  which  the  gastric  digestion 
is  feeble,  and  in  such  the  carbohydrates  are  better  borne  than  the  albu- 
minoids. Cream  and  good  butter  are  the  only  forms  of  fat  to  be  allowed. 
Alcohol  should  be  interdicted. 

(3)  Medicinal  Treatment. — If  the  patient  be  robust,  it  is  well  to  begin 
with  a  saline  laxative,  such  as  Carlsbad  Spriidel  salt  (3J-ij — 4.0-8.0). 
moderately  diluted  and  taken  before  breakfast.  If  necessary,  the  hepatic 
function  may  be  stimulated  still  further  by  a  mild  mercurial  or  by  podo- 
phyllin.  On  the  other  hand,  the  neurasthenic,  delicate  sufferer  must  use 
a  milder  form  of  laxative,  such  as  Rochelle  salt  in  the  same  dose,  or 
sodium  phosphate  in  the  morning,  or  a  rhubarb  pill  at  night.  This  class 
of  lithemics  also  requires  nerve-sedatives  (sodium  bromid,  etc),  and 
diuretics  to  aid  in  the  excretion  of  uric  acid.  If  it  be  true,  as  some 
claim,  that  the  sodium  phosphate  is  for  the  greater  part  excreted  by  the 
urine,  and  that  it  holds  in  solution  more  uric  acid  than  any  other  salt, 
it  is  one  of  the  foremost  remedies  in  the  treatment  of  the  affection.  Per- 
sonally, I  have  found  it  to  be  a  most  useful  agent.  To  reduce  acidemia 
and  to  stimulate  gently  hepatic  activity  the  salts  of  lithium,  highly  di- 
luted,'may  also  be  tried.  To  aid  in  the  digestion  of  the  albuminoids 
hydrochloric  acid  may  be  needful,  and  if  the  appetite  be  impaired  it  may 
be  combined  with  a  simple  bitter  or  with  nux  vomica  (lTLx-xv — 0.666- 
0.999)  thrice  daily. 

RACHITIS. 

{Rkkets.) 

Definition. — A  constitutional  disease  of  childhood,  exhibiting  gross 
nutritive  clianges,  chiefly  in  the  bones  and  cartilages,  causing  deformities. 

Patholog^^. — A  mere  summary  of  the  anatomic  characters  can  be 
given  here.  There  is  a  derangement  of  the  nutritive  ])rocesses  which 
retards  and  otherwise  modifies  the  growth  of  the  bony  skeleton,  particu- 
larly of  the  skull,  the  ends  of  the  ribs  and  of  the  long  bones.  The 
latter  soften  or  remain  unduly  flexible  as  the  result  either  of  the  absorp- 
tion of  ossified  structures  or  of  the  greatly  diminished  deposition  of  lime- 
salts.  Longitudinal  section  of  the  long  bones  shows  the  seat  of  the  chief 
changes  to  be  at  the  junction  of  the  epiphysis  with  the  shaft.  In  health 
we  note  at  this  point  two  thin  layers,  an  outer  (next  to  the  epiphyseal 
cartilage)  proliferative  zone,  and  an  inner  layer  (of  ossification).  In 
rachitis  both  zones,  though  more  particularly  the  proliferative,  are 
greatly  thickened,  much  softened,  and  their  margins  irregularly  notched. 
The  periosteum  is  thickened  and  easily  separable  from  the  shaft. 

A  microscfrpic  examination  shows  an  increased  rate  of  proliferation 
of  the  cartilage-cells  with  a  scanty,  fibroid  matrix,  while  the  ossific  layer 
presents  disseminated  and  imperfectly  calcified  areas.     Similarly,  the 


RACHITIS.  403 

deep  (osteoblastic)  layer  of  the  periosteum  is  thickened,  and  remains 
spongoid.  It  is  highly  probable  that  absorption  of  true  bone-tissue 
rarely  occurs,  and  that  the  most  characteristic  pathogenic  change  is  a 
lack  of  development  of  the  normal  structures.  The  morbid  changes 
probably  arise,  as  Kassowitz  contends,  from  the  presence  of  hyperemia 
of  the  cartilage,  marrow,  and  periosteum — a  process  that  interferes  with 
the  deposition  of  lime  salts. 

The  cranial  bones  present  areas  of  the  so-called  craniotabes,  and 
yield  to  the  pressing  finger  in  consequence  of  delayed  ossification. 
This  may  lead  to  a  disappearance  of  the  cranium  in  certain  areas, 
causing  depressions,  while  flattened  protuberances  may  develop  over  the 
arterio-lateral  regions.  When  cases  terminate  in  recovery  the  bones 
become  hard  and  ossify,  although  the  deformities  persist.  The  chemist 
has  shown  us  that  rachitic  bones  may  contain  less  than  half  the  normal 
percentage  of  lime-salts.  The  liver  and  spleen  are  moderately  enlarged, 
and  rarely  the  mesenteric  glands  are  increased  in  size. 

Ktiology. — (1)  Rachitis  may  occur  in  the  neiv-born.  Schwartz  states 
that  among  500  new-born  children  in  Vienna,  75.8  per  cent,  show  dis- 
tinct signs  of  rachitis.  Doubtless  this  estimate  is  too  high,  and  entirely 
at  variance  with  the  experience  of  clinicians  in  general ;  but  I  believe 
that  congenital  rickets  is  by  no  means  a  rare  condition.  Many  of  the 
cases  are  still-born,  and  those  that  outlive  childhood  become  peculiarly 
dwarfed  (niicromanid).  (2)  Heredity. — The  instances  in  which  rachitis  de- 
velops at  an  early  period  of  life,  due  to  ante-partum  causes,  are  not  rare,  but 
it  must  not  be  forgotten  that  it  is  extremely  hard  to  estimate  the  influence 
of  heredity  where  both  parent  and  child  are  exposed  to  similar  unfavor- 
able hygienic  and  dietetic  conditions.  Ill-health,  malnutrition,  close  con- 
finement, lactation,  and  syphilis  may  all  act  as  predisposing  factors  dur- 
ing pregnancy.  Setting  aside  syphilis,  and  perhaps  phthisis,  the  state  of 
the  health  of  the  father  has  little  if  any  effect  in  the  causation  of  rachitis 
in  his  offspring.  (3)  GreograjjJdcal  Distribution. — The  disease  is  more 
common  by  far  in  large  cities  than  in  rural  districts,  and  in  European 
countries — Russia,  Germany,  Great  Britain,  and  Italy  more  especially — 
the  disease  prevails  more  extensively  than  in  America.  (4)  Race. — The 
colored  race  furnishes  a  preponderance  of  rachitic  subjects.  The  reason 
for  this  may  be  a  racial  need  of  warmth  that  is  not  supplied  by  the  tem- 
perature of  more  northerly  latitudes,  their  native  habitat  being  in  a  more 
southerly  climate.  The  Italian  race  also  suff'ers  inordinately.  (5)  Sta- 
tion.— It  is  especially -among  the  ranks  of  the  poor  children,  whose  en- 
vironment is  highly  unfavorable,  in  large  cities  that  rachitis  is  seen. 
Joukownski,  from  personal  observations  in  over  3000  poor  children  in 
St.  Petersburg  examined  for  rachitis,  found  that  from  the  Avorking- 
classes  come  the  greatest  number  of  cases.  Like  scurvy,  rickets  may  be 
found  in  the  families  of  the  wealthy  under  perfect  hygienic  conditions 
(Osier).  The  quarters  of  the  cities  in  which  the  poorer  classes  live  are 
densely  crowded,  the' dwellings  are  insufficiently  ventilated,  and  there  is 
a  great  lack  of  sunlight.  (6)  Diet. — The  disease  is  dependent  largely 
upon  improper  or  insufficient  food,  and  among  hand-fed  children  the  dis- 
ease is  much  more  common  than  among  those  at  the-  breast.  It  also 
occurs  in  breast-fed  infants  when  the  mother's  milk  is  poor  in  quality  as 
the  result  of  previous  ill-health  or  too  long-continued   lactation.     The 


404  CONSTITUTIONAL  DISEASES. 

view  was  at  one  time  widely  held  that  rickets  Avas  produced  bj  a  fari- 
naceous diet,  and  that  the  active  agent  was  lactic  acid,  produced  by  the 
fermentative  processes  set  up  by  the  starch.  Even  granting,  however, 
that  the  lactic  acid  forms  a  soluble  salt  by  union  with  the  lime  of  the 
bone,  thus  removing  it  from  the  system,  this  does  not  explain  the  pro- 
ductive lesions  described  under  Pathology.  According  to  another  view, 
rachitis  is  apt  to  develop  when  the  system  is  deprived  of  an  adequate 
amount  of  proteids  and  fats,  and  for  this  belief  there  is  considerable  ex- 
perimental proof.  Certain  forms  of  diet  predispose  to  rickets,  princi- 
jially  for  the  reason  that  they  do  not  supply  certain  necessary  articles  in 
adequate  proportion.  (7)  Age. — Of  903  cases,  more  than  75  per  cent, 
occurred  before  the  end  of  the  second  year ;  but  of  these  only  99  com- 
menced during  the  first  half  year  (Bruennische,  Von  Rittershain, 
Ritsche).  It  may  occur  as  late  as  the  tenth  year.  (8)  Se.v  is  Avithout 
effect.  (9)  Syphilis. — Divers  views  are  entertained  regarding  the  role 
played  by  syphilis  as  a  cause  of  this  disease.  Dou])tless  the  two  affec- 
tions are  sometimes  associated,  and  it  cannot  be  denied  that  syphilis 
brings  about  a  marked  impairment  of  nutrition  both  in  the  mother  and 
the  child,  so  that  the  disease  may  engender  a  predisposition  to  rickets. 

Bacteriology. — Mircoli  contends  that  it  is  produced  by  the  action  of 
ordinary  pyogenic  organisms  upon  the  osseous  and  nervous  systems.  He 
adduces  clinical  and  pathological  evidence  in  support  of  this  position. 

Symptoms. — The  onset  is  slow.,  and  the  symptoms  of  gastro-intes- 
tinal  catarrh,  with  their  usual  effect  upon  the  general  nutrition,  may  pre- 
cede or  accompany  the  true  rachitis  symptoms.  At  the  beginning  the 
infant  is  restless,  irritable,  and  sleeps  poorly,  and  slight  fever  is  present 
in  some  cases.  About  the  head  and  neck  the  child  perspires  freely,  espe- 
cially Avhen  asleep,  Avetting  his  pillow  Avhile  the  rest  of  the  bed  is  dry. 
It  is  also  annoyed  by  the  bed-clothes,  Avhich  it  continually  throAvs  off, 
lying  exposed  even  in  a  cool  temperature.  Among  the  earlier  symj)fomH 
is  a  tenderness  both  over  the  bony  surfaces  and  the  soft  parts,  so  that  the 
patient  Avishes  to  keep  still  and  dreads  to  be  handled.  The  child  is 
languid  and  disinclined  to  move  his  limbs  or  to  A\"alk  or  i)lay,  even  if  he 
have  done  so  previously. 

The  symptoms  are  progressive  in  their  development,  rachitis  being 
ordinarily  a  chronic  disease,  so  that  after  many  months  more  pronounced 
features,  including  various  bone-deformities,  appear.  OAving  to  the  im- 
pairment of  nutrition  of  the  muscles  the  use  of  the  limbs  may  become 
impossible,  and  these  cases  have  been  spoken  of  by  Avriters  as  "rachitic 
paralysis  ;"  this,  however,  is  a  misnomer.  Cases  have  been  reported  by 
Berg  and  others  that  resembled  spastic  paralysis,  pseudo-hypertrophic 
paralysis.  Urinary  phenomena  are  neither  constant  nor  characteristic. 
Secondary  anemia  of  mild  grade  supervenes,  and  there  may  be  a  leuko- 
cytosis. 

The  first  rachitic  osteal  changes  are  presented  by  the  cranial  bones, 
the  ribs,  the  radius,  and  the  ulna.  The  cranium  appears  enlarged,  though 
this  enlargement  is  more  apparent  than  real,  being  due  to  the  diminished 
size  of  the  facial  bones.  The  sutures  remain  ojjcn,  the  fontanels  are 
large,  and  their  closure  is  delayed,  sometimes  until  the  fifth  or  even  the 
eighth  year.  Craniotahes  is  most  fre(iuently  seen  in  infants  under  one 
year  of  age.     This  soft,  thin  condition  of  tiie  bones  is  due  to  pressure 


RACHITIS.  405 

both  from  ■\vithin  and  Avitliout ;  it  occurs  on  the  surfaces  on  which,  the 
head  of  the  child  rests  while  lying-  To  detect  the  presence  of  cranio- 
tabes  light  pressure  with  the  fingers  is  to  be  made  in  a  direction  away 
fi'om  the  sutures.  It  is  to  be  recollected  that  craniotabes  is  often  a 
syphilitic  manifestation.  Per  contra,  increased  hardness  of  certain  bones 
may  be  observed  (cranio-sclerosis).  A  rachitic  head  generally  ap- 
proaches a  square  in  outline,  or  it  may  present  marked  angularities, 
with  an  increase  in  the  antero-posterior  diameter  and  a  flattened  top. 
Hyperostosis  may  cause  prominence  of  the  parietal  and  frontal  emi- 
nences, giving  the  forehead  a  square,  broad  outline.  A  short,  round  head 
(brachycephaly)  may  rarely  be  met  (Bonnifay).  The  veins  of  the  scalp 
are  enlarged,  and  the  hairy  growth  is  usually  scanty,  being  often  re- 
moved from  the  back  of  the  head  by  rubbing.  Drs.  Whitney  and  Fisher 
first  called  attention  to  the  fact  that  the  ear  placed  over  the  anterior 
fontanel  often  detects  a  systolic  murmur.  A  considerable  patency  of 
the  anterior  fontanel  both  in  health  and  disease  allows  of  detection  of 
this  murmur,  however,  and  hence  its  diagnostic  value  is  slight.  A  prom- 
inent feature  of  the  disease  is  delayed  teething,  the  teeth  that  appear 
being  deficient  in  enamel,  ill-shapen,  and  prone  to  early  decay. 

The  ribs  become  affected  very  early.  Anteriorly,  where  they  join  the 
costal  cartilages,  swellings  occur,  causing  the  "rachitic  rosary."  This  is 
composed  of  nodules  corresponding  with  the  costo-chondral  articulations^ 
and  these  can  generally  be  seen  and  always  felt  under  the  skin.  They 
rarely  outlast  the  fourth  or  fifth  year.  The  ribs  present  two  short  curves 
— one  at  the  junction  of  the  dorsal  and  lateral  parts  of  the  thorax,  and 
the  other  in  front,  where  they  turn  sharply  inward  toward  the  sternum. 
This  deformity  is  the  result  of  the  atmospheric  pressure  upon  the  softened 
bones,  a  shallow  groove  usually  being  produced  in  the  line  of  the  costo- 
chondral  articulations  or  obliquely  from  the  second  or  third  rib  downward 
and  outward.  These  changes  lessen  the  transverse  diameter  of  the  thorax 
in  front  and  interfere  with  the  lung-expansion  in  the  antero-lateral  por- 
tions of  the  chest.  They  also  produce  bulging  of  the  sternum,  resulting 
in  the  so-called  pigeon  or  chicken  breast.  On  both  sides,  from  a  point 
corresponding  to  the  anterior  end  of  the  eighth  or  ninth  rib,  there  passes 
outward  toward  the  axilla  a  furrow  (Harrison's  groove)  which  is  caused  by 
an  eversion  of  the  lower  part  of  the  thorax,  and  is  heightened  by  atmo- 
spheric pressure,  particularly  during  inspiration.  This  thoracic  deformity 
is  not  peculiar  to  rickets,  but  is  met  with  in  all  cases  in  which  there  is 
moderate  obstruction  to  the  ingress  of  air  into  the  lungs. 

Amona;  the  first  indications  of  rickets  is  an  enlargement  of  the  lower 
end  (junction  of  the  shaft  and  epiphysis)  of  the  radius.  The  radius  and 
ulna  are  sometimes  twisted  and  deflected  outward,  owing  to  the  fact  that 
some  of  the  body-weight  is  supported  by  the  hands  when  sitting  or  crawl- 
ing. The  clavicle  may  be  thickened  and  curved  near  either  end,  and 
occasionally  the  scapulae  may  be  enlarged,  but  deformities  of  the  upper  ex- 
tremities are  rare  as  compared  with  those  of  the  lower.  Occasionally  the 
vertebrae  and  intervening  cartilages  soften,  with  a  resulting  spinal  curva- 
ture, and  in  such  instances  there  is  usually  an  antero-posterior  curvature 
with  which  lateral  deflexion  may  be  associated. 

Pelvic  defonnities  are  not  uncommon,  and  are  of  no  little  importance 
in  female  children  as  bearing  upon  the  questions  of  marriage  and  subse- 


406  CONSTITUTIONAL  DISEASES. 

quent  labor.  The  femora  may  be  curved,  often  forward  and  more  rarely  out- 
ward ;  swelling  of  the  lower  end  of  the  tibia  is,  however,  the  first  change  to 
be  observed  in  the  lower  extremities.  In  some  well-advanced  cases  the 
heads  of  the  bones  forming  the  knee-joints  are  also  enlarged,  and  outward 
curvature  of  the  femora  and  tibia  is  common,  especially  under  the  age  of  one 
year  (see  Fig.  32).  After  the  child  begins  to  walk  a  forward  bowing  of 
these  bones,  due  to  the  weight  of  the  body  and  to  muscular  action,  occurs. 
Knock-knee  is  sometimes  observed.  Those  who  have  suffered  from 
rickets  in  infancy  usually  fall  short  of  the  average  stature  on  reaching 
adolescence,  giving  rise  to  disproportion  betAveen  head  and  height — a 
most  characteristic  sign  of  rachitis. 

These  skeletal  changes  sustain  a  causal  relation  to  many,  and  some 
serious,  affections,  chiefly  nervous.  Thus,  craniotabes  is  supposed  to  in- 
duce laryngismus  stridulus,  though  this  condition  may  also  arise  in  the 
rachitic  without  cranial  softening.  In  like  manner,  rickets  predisposes 
to  tetany,  Avhich  affects  most  commonly  the  upper  extremities.  Convul- 
sions are  also  prone  to  occur  in  this  disease.  The  reflex  nervous  excita- 
bility is  unquestionably  exaggerated  in  rickets,  and  another  exciting 
cause  for  the  eclampsia  so  often  met  with  is  the  associated  gastro-intes- 
tinal  catarrh.  The  abdomen  becomes  greatly  enlarged,  chiefly  by  flatu- 
lence, though  to  a  less  extent  also  by  the  swelling  of  the  liver  and 
spleen.  Chest-complications  are  common.  Most  of  them  are  due  pri- 
marily to  a  mechanical  interference  Avith  the  cardio-pulmonary  circula- 
tion, and  with  the  respiration.  Among  these  are  atelectasis,  bronchial 
catarrh,  broncho-pneumonia,  and  emphysema.  Green-stick  fracture  of 
the  bones  often  occurs  in  the  rachitic  subject. 

Prognosis. — The  evolution  of  rickets  is  a  long  process,  accompanied 
by  a  slowly  progressive  impairment  of  the  general  nutrition ;  and  hence 
most  patients  become  weak,  anemic,  and  emaciated.  The  so-called  "  fat 
rickets,"  however,  is  not  rare.  Innately,  the  disease  tends  to  spontaneous 
cure,  which  is  attained  from  the  end  of  the  second  to  the  fifth  year ;  but 
its  course  may  be  abridged  to  a  few  months  by  appropriate  treatment. 
When  death  occurs  it  is  usually  occasioned  by  one  or  other  of  the  com- 
plications before  mentioned,  and  especially  by  laryngismus  stridulus  or 
pneumonia. 

Treatment. — Prophylaxis. — The  institution  of  preventive  measures 
is  a  matter  of  first  importance,  and  by  simple  means  directed  to  the  ante- 
partum causal  factors  in  the  mother  rickets  may  in  a  large  proportion  of 
the  cases  be  prevented.  Prophylaxis  also  embraces  appropriate  feeding 
and  other  agencies  that  tend  to  maintain  the  normal  nutrition  of  infants. 

Hygienic  Management. — As  faulty  diet  is  in  a  great  measure  responsi- 
ble for  rachitis,  proper  feeding  is  an  important  factor,  and  if  the  child 
cannot  be  satisfiictorily  nursed  by  its  mother  and  if  it  is  under  the  age 
of  six  months,  a  wet-nurse  should  be  procured.  Should  this  not  be  prac- 
ticable, it  must  be  hand-fed,  and  the  best  artificial  food  is  cow's  milk,  if 
properly  prepared.  In  cities  it  is  to  be  sterilized,  and  then  diluted  to 
suit  the  age,  and  I  have  found  that  barley-water,  when  made  in  the  man- 
ner recommended  by  J.  Lewis  Smith,  may  be  added  to  milk,  replacing 
the  water  most  advantageously.  A  heaping  teaspoonful  of  barley-flour  is 
poured  into  25  teaspoonsful  (.^iij — 96.0)  of  water,  and  when  the  mixture 
is  lukewarm  10  or  15  drops  of  diastase  (Forbes)  are  added  to  it,  the  gruel 


Fig.  32.— Outward  curvature  of  tibia  and  fibula  (Willard). 


SCORBUTUS.  407 

in  a  few  minutes  becoming  much  thinner  from  the  digestion  of  the  starch. 
The  physician  must  regulate  with  much  precision  the  frequency  of  the 
feeding,  and  the  amount  of  food  taken  according  to  the  age  of  the  child. 
The  stools  are  also  to  be  inspected.  If  they  are  green  or  if  curds  appear, 
either  digestion  is  imperfect  or  the  child  is  being  over-fed.  Older  children 
may  be  given  the  lighter  meats,  green  vegetables,  and  fruits,  but  these 
must  be  carefully  selected. 

Other  hygienic  details  are  of  little  less  importance  than  a  proper  diet. 
The  decubitus  of  the  child  must  be  changed  frequently,  so  as  to  prevent 
bony  deformities ;  moreover,  the  rickety  child  should  not  be  allowed  to 
walk,  and  to  prevent  his  doing  so  splints  extending  beyond  the  feet  have 
been  recommended.  A  tepid  bath,  warm  clothing,  and  a  prolonged  daily 
.stay  in  the  open  air  are  measures  that  should  not  be  neglected. 

Of  medicines,  those  that  rank  highest  are  phosphorus,  the  hypophos- 
phites,  iron,  and  cod-liver  oil.  The  officinal  oleum  phosphoratum  (gr.  y^^ 
— 0.0021}  is  used  by  Jacobi.  Phosphorus  is  highly  spoken  of  by  many 
writers.  It  may  be  given  either  pure  (gr.  ^^  to  y^^— 0.0003  to  0.0006) 
or  preferably  in  the  form  of  an  emulsion  with  sweet  oil  or  cod-liver  oil : 

^.  Phosphori,  gr.  ^  (0.00648)  ; 

Olei  olivse,  .lij  (64.0) ; 

M.  et  ft.   emulsio. 
Sig.  3j  three  times  a  day,  after  meals,  for  a  child  under  the  age 
of  one  year. 

Kissel  states  there  is  no  evidence  in  favor  of  the  use  of  phosphorus 
in  rickets.  Baginsky,  Leray,  Weiss,  and  others  have  found  from  its 
extensive  employment  that  it  is  of  doubtful  value  in  the  majority  of 
cases.  Kassowitz,  Swetchen,  and  others,  however,  observed  cases  with 
cure,  hence  the  remedy  deserves  a  trial. 

When  it  is  desired  to  administer  cod-liver  oil  and  it  is  not  tolerated  by 
the  stomach,  it  may  be  rubbed  gently  into  the  skin  of  the  thighs  and 
trunk.  Arsenic  in  small  doses  has  proved  to  be  a  capital  remedy  in 
selected  cases  ;  and  iron,  particularly  in  combination  Avith  arsenic,  is  in- 
dicated if  anemia  be  pronounced. 

The  numerous  complications  to  which  rachitic  subjects  are  liable  pre- 
sent special  indications  which  are  to  be  met  by  the  same  measures  as 
when  they  arise  under  other  circumstances.  The  condition  of  the  diges- 
tive organs  must  be  kept  constantly  in  mind ;  and  no  remedy,  however 
promising,  that  is  designed  to  assist  the  general  condition  should  be  con- 
tinued if  it  tends  to  aggravate  the  digestive  disturbance.  The  treat- 
ment of  the  rachitic  deformities  belongs  to  the  domain  of  the  orthopedic 
surgeon. 


SCORBUTUS. 

{Scurvy.) 


Definition. — A   constitutional   disease,   caused  by   a  lack   of  fresh 

vegetables  in  the  diet,  and  characterized  by  anemia,  excessive  weakness, 
spongy  gums,  a  tendency  to  muco-cutaneous  hemorrhages,  and  a  brawny 


408  CONSTITUTIONAL  DISEASES. 

induration  affecting  chiefly  the  muscles  of  the  calves  and  the  flexor 
muscles  of  the  thighs. 

Pathologfy. — We  know  nothing  concerning  the  pathogenesis  of 
scurvy.  Evidences  of  profound  anemia  are  found  upon  microscopic  ex- 
amination of  the  blood,  which  is  thin  and  dark,  but  there  is  no  leukocy- 
tosis. The  skin  may  show  spots  of  subcutaneous  hemorrhage  (ecchy- 
moscs),  but  the  most  characteristic  hemorrhage  is  that  under  the  periosteum 
of  the  femora.  Bleedings  into  the  articulations  and  muscles  may  also  at 
times  be  noted,  and  occasionally  the  serous  membranes  are  the  seat  of 
hemorrhages,  as  well  as  the  internal  organs.  Submucous  hemorrhages 
are  extremely  common.  The  intestinal  mucosa  may  also  present  ulcers. 
The  gums  are  swollen,  spongy,  dark  in  color,  and  sometimes  ulcer- 
ated, and  the  teeth  may  be  loose  or  missing.  The  epiphyses,  par- 
ticularly of  the  lower  end  of  the  femora,  may  be  congested,  and 
rarely  they  are  detached.  The  spleen  is  soft  and  swollen.  The  heart, 
liver,  and  kidneys  sometimes  show  fatty  and  usually  parenchymatous 
degeneration. 

Ktiology. —  In  former  times  scurvy  was  very  prevalent  among 
sailors  at  sea  and  soldiers  in  the  field,  and  epidemics  were  com- 
mon. Doubtless,  however,  it  has  declined  in  importance  as  a  disease 
incident  both  to  sea-life  and  to  armies ;  but,  as  pointed  out  by  Wise, 
it  would  seem  that  changing  physiological  and  economical  conditions 
may  cause  it  to  be  dreaded  on  the  land  as  it  has  hitherto  been  on 
the  sea.  Osier  states  that  the  disease  is  not  infre<[uent  among  Hun- 
garians, Bohemians,  and  Italian  miners  in  Pennsylvania.  It  is  rarely 
epidemic  at  the  present  day.  F.  A.  McGrew  records  an  epidemic 
(with  a  total  of  42  cases)  in  Chicago,  in  1894.  Endemie  appearances 
of  scurvy  are  still  common,  particularly  in  portions  of  Russia  (Hoff- 
man) and  elsewhere  also,  sweeping  through  prisons,  barracks,  alms- 
houses, and  other  institutions  of  like  kind.  While  the  majority  of 
cases  met  with  are  sporadic,  the  above  facts  point  to  the  infectious 
character  of  scurvy. 

Bacteriology. — Testi  and  Beri  have  isolated  a  micro-organism  which 
has  been  cultivated  and  inoculated  into  guinea-pigs  and  rabbits,  pro- 
ducing in  the  latter  ])atliologic  lesions  and  symptoms  simulating  closely 
those  of  scurvy.  The  microbe  is  perfectly  round  and  is  a  diplococcus. 
These  experiments  require  confirmation. 

Predisposing  Causes. — The  chief  factor  is  the  long-continued  use  of  a 
dietary  deficient  in  fresh  vegetables.  Precisely  what  there  is  in  the  lat- 
ter, the  absence  of  which  in  the  system  produces  scurvy,  is  not  known 
to  a  certainty,  but  it  is  probable  that  it  consists  of  the  organic  (potas- 
sium) salts  present  in  the  fresh  vegetables,  which  elements  are  recjuisite 
to  normal  histogenesis.  Albertoni  has  recently  shown  that  in  scurvy  of 
a  protracted  course  free  hydrochloric  acid  is  absent  from  the  gastric  juice, 
and  that  the  total  acidity  is  much  reduced,  but  this  is  neither  so  in  every 
case  nor  at  all  stages  of  the  disease.  He  found  no  deficiency  of  chlorids 
in  the  body.     Peptonization  is  feeble. 

Dehilitatinfi  i)iflNenees,  as  unhygienic  surroundings,  excessive  mus- 
cular exercise,  humidity,  and  cold,  often  play  no  mean  role  in  causing 
scurvy.  Mental  anxiety  and  depression  seem  to  have  etiologic  signif- 
icance.    The  old  are  very  susceptible,  and  all  ages  are  liable  to  the  dis- 


SCORBUTUS.  409 

ease.  Sex  has  no  special  influence  upon  scorbutus.  Starvation  does  not 
predispose  to  the  disease. 

Symptoms. — Scurvy  has  a  sloiv  onset.  The  earliest  symptoms  are 
generally  a  swelling  around  the  eyes,  over  which  the  skin  has  the  color 
of  a  bruise,  and  a  pale  face,  which  looks  bloated  and  wears  an  apathetic 
expression.  There  is  noticeable  almost  from  the  start  a  gradually  in- 
creasing debility,  emaciation,  an  inability  to  perform  mental  or  physical 
labor,  and  despondency.  The  patient  experiences  arthritic  and  muscular 
rheumatoid  pains  and  dyspnea  on  slight  exertion. 

With  rare  exceptions  the  gums  swell,  sometimes  enormously,  and  be- 
come spongy,  bleeding  most  readily.  They  may  become  ulcerated,  and 
may  be,  though  rarely,  fungoid  in  appearance.  The  teeth  often  become 
loose,  and  in  rare  cases  drop  out.  The  breath  emits  an  oifensive  odor, 
that  is  sometimes  due  to  necrosis  of  the  jaw.  The  tongue  swells,  though 
it  is  usually  clean  and  often  pale.  In  the  mouth  may  be  observed  sub- 
mucous hemorrhages  in  many  cases.  There  is  loss  of  appetite,  but  the 
digestion  is  usually  good  ;  there  may,  however,  be  constipation  or  diar- 
rhea, more  frequently  the  former.  Seorhutic  dysentery  has  been  de- 
scribed by  certain  Avriters.  The  sMn  is  dry  and  of  a  muddy  color, 
blended  occasionally  with  a  greenish  or  greenish-yellow  tinge.  At  the 
end  of  a  week  or  ten  days  petechke  and  ecchymoses  appear  upon  the  legs, 
arranging  themselves  about  the  hair-follicles.  These  may  also  come  out 
later  on  the  trunk  and  upper  extremities.  Submucous  hemorrhages  may 
give  rise  to  circumscribed  swellings,  and  subperiosteal  hemorrhages  may 
occur  and  engender  node-like  protuberances.  There  may  be  frequently 
noticed  a  peculiar  brawny  induration,  due  to  extensive  hemorrhagic  infil- 
tration of  the  muscles  and  subcutaneous  tissues,  most  marked  in  the  hams 
and  calves.  The  condition  is  not  without  considerable  pain^  particularly 
if  the  parts  be  touched,  and  in  severe  cases  bull^  and  vibices  may  be  seen, 
as  in  a  recent  case  of  my  own.  Hemorrhages  from  the  mucous  channels 
of  the  body  occur,  and  epistaxis  is  frequent.  In  bad  cases  hematuria, 
also  melena  and  rarely  hematemesis,  may  be  observed.  Blood  may  be 
efiused  into  the  serous  membranes,  accompanied  sometimes  by  inflamma- 
tory changes  in  the  latter ;  also  into  the  lungs,  which  are  rarely  the  seat 
of  secondary  pneumonia.  Pulmonary  infarction  occurs,  but  is  a  rare 
event.  Hemoptysis  may  be  a  symptom  of  the  lung-complications  or  may 
occur  as  an  independent  phenomenon. 

The  heart  may  present  symptoms,  such  as  palpitations,  feeble  impulse, 
arrhythmia,  and  sometimes  a  basic  blood-murmur,  but  these  are  without 
diagnostic  importance.  The  pulse  is  soft,  small,  and  on  exertiop  much 
accelerated.  The  temperature  is  sometimes  subnormal,  and  the  presence 
of  fever  is  a  certain  indication  of  the  existence  of  some  complication. 

The  nervous  symptoms,  aside  from  the  profound  mental  depression,  are 
not  prominent.  Insomnia  may  be  a  distressing  symptom.  Delirium  (late) 
is  sometimes  witnessed.  Meningeal  hemorrhage  may  supervene.  Both 
night-blindness  and  day-blindness  are  among  the  rarer  and  extraordinary 
ocular  features. 

The  urinary  symptoms  vary  in  diff"erent  cases.  Albuminuria  is,  how- 
ever, common.  The  specific  gravity  of  the  urine  is  increased,  the  color 
high,  and  the  solid  constituents  diminished,  except  the  phosphates,  which 
are  abundant.     Albertoni  found  the  proportion  of  chlorids  less  than  the 


410  CONSTITUTIONAL  DISEASES. 

normal,  Avhile  other  investigators  claim  that  the  percentage  is  high. 
Nephritis  may  occur  as  a  complication.  The  bones  in  long-standing 
cases  may  be  congested  and  sometimes  necrotic,  and  the  epiphyses 
may  separate  from  the  shafts.  In  one  of  my  cases  an  old  cicatrix 
reopened. 

Diagnosis. — This  rests  upon  the  following  points :  the  history,  the 
peculiar  facies,  the  spongy  and  swollen  gums,  the  gingival  and  deep- 
seated  cutaneous  hemorrhages,  the  progressive  loss  of  strength  and 
energy,  great  mental  depression,  and  the  speedy  recovery  after  an  appro- 
priate regimen.  Scurvy  Avill  be  distinguished  from  purpura  under  the 
description  of  the  latter  disease. 

Prognosis. — Unless  far  advanced,  the  prognosis  generally  becomes 
good  ui)ou  the  institution  of  correct  dietetic  principles.  If  the  disease 
have  made  extensive  inroads,  the  danger  to  life  is  considerable.  The 
gravity  of  the  internal  symptoms  (particularly  pulmonary)  is  far  greater 
than  of  the  external,  and,  indeed,  the  presence  of  the  latter  is  a  favor- 
able omen.  Certain  complications  augur  a  serious  termination,  such  as 
pneumonia,  hemorrhagic  infarctions  of  the  lung,  pleurisy  with  bloody 
effusion,  dysentery,  acute  nephritis,  etc. 

Treatment. — Prophylaxis. —  By  carrying  out  the  known  means 
of  prevention  the  disease  has  been  diminished  more  than  90  per  cent, 
among  mariners  and  soldiers.  This  change  has  been  brought  about  by 
the  enforcement  of  governmental  regulations  which  demand  that  an  ade- 
quate  supply  of  antiscorbutic  articles  of  food  must  be  provided  for  military 
campaigns  and  for  long  sea-voyages.  Fresh  fruits  and  vegetables  can 
be  readily  transported  in  hermetically  sealed  jars  or  cans. 

Treatment  of  the  Attack. — The  chief  indication  is  to  be  met  by 
the  use  of  fruits  and  fresh  vegetables.  Of  the  former,  two  or  three 
lemons  daily  or  oranges  and  other  fruits  suffice  to  work  a  surprising  de- 
gree of  improvement  in  a  short  space  of  time.  Antiscorbutic  vegetables 
(potatoes,  water-cresses,  raw  cabbage,  lettuce,  saur-kraut)  in  liberal  quan- 
tity should  also  be  given.  Meats,  eggs,  milk,  and  farinaceous  dishes  are 
not  to  be  prohibited,  since  the  patients  require  all  forms  of  food  to  invig- 
orate the  system  and  to  render  normal  the  constitution  of  the  blood ;  but 
if  the  digestive  power  be  feeble,  it  is  advisable  to  begin  with  the  juice  of 
oranges  or  lemons,  conjoined  with  meat-juice,  egg-white,  milk,  and  light 
farinaceous  articles,  adding  the  stronger  forms  of  animal  food  and  fresh 
vegetables  when  improvement  is  noted.  We  may  assist  the  digestive 
function  in  bad  cases  by  the  use  of  simple  bitters,  strychnin,  and  hydro- 
chloric acid  (after  meals) ;  hematinics  are  sometimes  indicated. 

Special  symptoms  may  call  for  appropriate  measures.  Constipation 
requires  simply  an  enema.  On  the  other  hand,  diarrhea  presents  an  in- 
dication for  intestinal  antiseptic  and  astringent  remedies.  The  oral  con- 
dition varies,  hence  the  measures  to  relieve  it  vary  also ;  but  if  ulcers  be 
present,  the  solution  of  potassium  chlorate  is  best.  For  swelling  of  the 
gums  the  application  by  means  of  a  cotton  swab  of  tannic  acid  (2  per 
cent.)  or  a  solution  of  silver  nitrate  (2-5  per  cent.)  is  serviceable.  A 
combination  of  boric  and  carbolic  acids  in  a  solution  of  suitable  strength 
may  be  used  as  a  mouth-wash.  If  copious  hemorrhages  occur,  hemostatics 
are  eminently  useful.  The  various  complications  must  be  met  by  the 
usual  measures,  according  to  their  nature. 


SCORBUTUS.  411 


Infantile  Scorbutus. 


Definition. — A  constitutional  disease,  characterized  by  the  same 
symptoms  as  scurvy  in  adults,  except  that  in  many  instances  undoubted 
evidences  of  rachitis  are  associated. 

Pathology. — The  bones  are  thickened  and  excessively  sensitive, 
owing  to  a  marked  subperiosteal  hemorrhage,  with  more  or  less  macera- 
tion, and  want  of  firmness  between  the  epiphysis  and  shaft.  The  muscles 
may  also  be  the  seat  of  eifusion.  The  characteristic  lesions  of  rickets  are 
often  associated. 

The  nature  of  the  affection  is  unsettled.  Originally  looked  upon  by 
most  observers  as  acute  rickets,  it  was  subsequently  described  by  Cheadle 
(from  the  clinical  side)  and  Barlow  (from  the  anatomo-pathologic  side)  as 
infantile  scurvy.  On  the  other  hand,  Ashby  of  Manchester,  Fiirst  and 
other  German  writers,  are  inclined  to  the  view  that  the  affection  should 
be  considered  a  hemorrhagic  form  of  rachitis.  The  belief  that  rickets 
predisposes  to  scurvy,  but  that  the  two  diseases  have  not  the  same  patho- 
genesis, is  probably  the  correct  one. 

^Etiology. — Scurvy  is  almost  solely  confined  to  hand-fed  infants, 
especially  those  reared  upon  the  numerous  infant-foods  which  have  been 
foisted  upon  the  market,  including  condensed  milk,  etc.  Louis  Starr, 
Jacobi,  and  others  have  shown  that  it  sometimes  folloAVS  the  prolonged 
use  of  sterilized  milk,  either  exclusively  or  in  combination  with  artificially 
prepared  foods.  An  investigation  by  a  committee  of  the  American  Pedi- 
atric Society  ^  showed  that  of  379  cases  the  majority  occurred  between 
the  ages  of  7  and  14  months,  inclusive,  and  that  the  disease  has  a  greater 
tendency  to  occur  among  the  rich  or  well-to-do.  This  committe's  report 
also  embraces  the  following  among  other  justifiable  conclusions :  "  The 
farther  a  food  is  removed  in  character  from  the  natural  food  of  a  child 
the  more  likely  its  use  is  to  be  followed  by  the  development  of  scurvy." 

Symptoms. — The  skin  presents  the  muddy  color  peculiar  to  the  dis- 
ease in  adults.  The  patient  may  be  well  nourished,  but  more  often  there 
is  a  tendency  to  ivasting,  and  other  symptoms  of  impaired  nutrition  appear, 
particularly  irritability  and  disinclination  to  exertion.  The  more  cha- 
racteristic features  appear  after  one  or  two  months,  and  the  child  cries 
when  handled,  especially  on  touching  the  lower  limbs.  About  the  same 
time  there  is  an  irregularly  cylindrical  swelling;  of  one  of  the  thighs,  due 
to  subperiosteal  efi"usion.  Soon  the  other  limb  is  similarly  involved, 
though  not  always  to  a  like  degree.  At  first  the  legs  are  flexed,  but  later 
they  become  straightened  and  slightly  everted  on  account  of  the  progres- 
sive hemorrhage  or  separation  of  the  epiphyses.  The  bones  in  other  por- 
tions of  the  body  may  be  involved  secondarily  in  more  or  less  rapid  suc- 
cession, but  the  swellings  are  less  mai'ked  than  in  the  lower  limbs.  Later, 
if  teeth  be  present,  the  gums  may  swell  and  become  spongy.  Ecchymoses 
in  the  form  of  petechige  appear  upon  the  skin-surface,  and  particularly 
about  the  eyes.  Barlow  describes  a  remarkable  ocular  phenomenon : 
"  There  develops  a  rather  sudden  swelling  of  one  eyebrow.  Avith  puffiness 
and  very  slight  staining  of  the  upper  lid.  Within  a  day  or  two  the  other 
lid  presents  similar  appearances,  though  they  may  be  of  less  severity.  The 
ocular  conjunctivae  may  show  a  little  ecchymosis  or  may  be  quite  free." 
1  Medical  Record,  July  2,  1898. 


412  CONSTITUTIONAL  DISEASES. 

Hemorrhages  from  the  mucous  surfaces  may  finally  put  in  an  appearance. 
To  complete  the  statement  of  characteristic  features,  it  should  be  men- 
tioned that  rapid  improvement  invariably  follows  an  antiscorbutic  regimen. 

Diagnosis. — To  distinguish  rickets  from  infantile  scurvy  Barlow's 
brief  though  clear  agffregation  of  the  characteristics  of  the  latter  disease 
may  be  quoted:  "(1)  Predominance  of  lower-limb  affection,  in  which 
there  is  immobility  going  on  to  pseudo-paralysis ;  excessive  tenderness ; 
general  swelling  of  the  lower  limbs;  skin  shiny  and  tense,  but  seldom 
pitting,  and  not  characterized  by  undue  local  heat ;  on  subsidence  reveal- 
ing a  deep  thickening  of  the  shafts,  also  liability  to  fracture  near  the 
epiphysis.  (2)  Swelling  of  the  gums  about  erupted  teeth  only,  varying 
from  definite  sponginess  to  a  minute,  transient  ecchymosis." 

Prognosis. — Favorable,  even  in  well-established  instances,  if  brought 
under  the  proper  regimen. 

Treatment. — An  antiscorbutic  dietary — mother's  milk  or  fresh  cows' 
milk,  meat-juice,  and  orange-  or  lemon-juice — meets  the  main  indication. 
If  there  be  systemic  exhaustion — a  condition  that  is  not  infrequent — 
gentle  stimulation  with  brandy  (highly  diluted)  and  an  abundance  of  fresh 
air  are  pre-eminent  among  the  measures  to  be  employed.  Iron,  arsenic, 
and  cod-liver  oil  may  be  needful  to  complete  the  cure,  but  usually  the 
simple  means  already  mentioned  will  prove  effective.  The  limbs,  espe- 
cially the  lower,  may  claim  attention.  Local  treatment,  however,  is  rarely 
necessary,  except  tliere  be  separation  of  the  epiphyses,  when  suitable 
splints  are  to  be  applied. 


PURPURA. 


Two  main  groups  are  to  be  distinguished  :  (1)  Secondary  purpura, 
which  occurs  from  a  great  variety  of  causes  and  in  numerous  affections, 
in  which  its  clinical  significance  has  been  pointed  out  in  appropriate  sec- 
tions of  this  work.  It  seems  pertinent,  however,  to  enumerate  the  chief 
among  the  diseases  and  conditions  under  which  it  mav  arise,  as  follows: 
{a)  scurvy  ;  (h)  acute,  infectious  diseases  (eerebro-spinal  meningitis,  vari- 
ola, measles,  septicemia,  ulcerative  endocarditis);  {e)  hemophilia;  (<7) 
numerous  chronic  affections,  as  nephritis,  leukemia,  pernicious  anemia, 
jaundice,  Hodgkins  disease,  and  tuberculosis;  (e)  malignant  sarcomata: 
(,f )  nervous  affections,  as  locomotor  ataxia,  acute  and  transverse  myelitis, 
and  hysteria;  (</)  mechanical  causes,  straining  efforts,  intense  paroxysms 
of  Avhooping-cough.  and  violent  convulsions  :  (It)  certain  drugs  may  pro- 
duce a  petechial  eruption — quinin,  copaiba,  belladonna,  ergot,  mercury, 
and  the  iodids  ;  {i)  snake-poisons  produce  rapid  and  extensive  hemorrhagic 
extravasations,  as  shown  by  the  careful  studies  of  S.  Weir  Mitchell. 

(2)  Primary  or  idiopathic  purpura  forms  the  second  group.  It  is  di- 
visible into  (rt)  simple  purpura  [purpura  simplex)  ;  {h)  arthritic  purpura, 
of  which  two  varieties  may  be  recognized  :  (1)  peliosis  rheumatica.  and 
(2)  Henoch's  purpura  ;  [c)  hemorrhagic  purpura  {purpura  hcemor- 
rhaqiea). 

(a)  Simple  Purpura. — The  cause  is  unknown.     Among   predisposing 


PURPURA.  413 

influences,  however,  is  age,  the  condition  being  most  common  in  children 
about  the  time  of  puberty.  It  may  be  a  sequel  of  the  acute,  infectious 
diseases,  and  in  not  a  few  cases  develops  in  seemingly  healthy  subjects. 

Symptoms. — This  is  the  mildest  variety  of  primary  purpura.  The 
hemorrhages  into  the  skin  take  the  form  of  petechia,  vibices,  or  ecchy- 
moses.  The  first  are  exti'avasations  of  blood  in  the  form  of  minute 
points,  that  appear,  as  a  rule,  in  the  hair-follicles,  and,  unlike  the  ery- 
themas, do  not  disappear  upon  pressure.  The  vibices  receive  their  name 
from  the  fact  that  the  hemorrhages  occur  as  streaks,  w^hile  the  ecchymoses 
are  larger,  but  similar  in  nature  and  behavior  to  the  petechise.  They 
may  exceed  in  size  that  of  a  split  pea,  and  their  hue  ranges  from  a  deep 
red  to  a  livid  bluish  tint.  As  they  fade  away  they  assume  at  first  a  yel- 
lowish-brown, then  a  yellow  color,  and  finally  disappear.  The  eruption 
appears  in  a  series  of  crops,  and  its  seat  of  election,  often  favored  by 
the  erect  posture,  is  the  legs.  Bloody  serum  may  be  effused  into  bullpe 
or  large  blebs.  Shepherd  and  others  have  reported  cases  in  w^hich  the 
purpuric  eruption  ended  in  gangi'ene,  though  in  Shepherd's  case  the  gan- 
grene was  believed  to  be  due  to  the  use  of  sodium  salicylate. 

{h)  Arthritic  Purpura. — (1)  Peliosis  Rheumatica  (SchonleiJi' s  Disease). 
— The  cause  of  this  remarkable  disease  is  unknown.  Formerly  many 
writers  inclined  to  the  view  that  it  is  of  rheumatic  origin,  and  since  en- 
docarditis and  pericarditis  are  occasionally  observed  in  association  with 
peliosis  rheumatica,  considerable  coloring  is  given  to  this  belief.  On  the 
other  hand,  the  fact  that  the  cardiac  complications  are  rare  in  arthritic 
purpura  shows  that  not  all  cases  of  the  latter  disease  are  genuinely  rheu- 
matic. It  occurs  chiefly  in  males  from  the  twentieth  to  the  thirtieth 
year  of  age.  Among  the  p)'^'odromata  are  angina,  slight  articular  pains, 
headache,  loss  of  appetite,  and  fever  ranging  from.  100°  to  102°  F. 
(37.7°-38.8°  C).  The  affection  is  especially  characterized,  however,  by 
polyarthritis.,  the  joints  being  swollen,  painful,  and  very  tender;  also  by 
purpura,  associated  or  not  with  urticarial  wheals  or  erythema  exudativum ; 
and  by  subcutaneous  edema.  The  purpuric  eruption  is  the  only  symp- 
tom that  has  pathognomonic  significance,  and  in  this  afi"ection  it  shows  a 
strong  preference,  as  regards  distribution,  for  the  affected  joints  and  the 
legs.  The  eruption,  as  already  intimated,  does  not  display  constant  cha- 
racteristics. It  may  not  differ  from  that  of  simple  purpura,  and  the  rash 
consists  of  petechi?e,  ecchymoses,  streaks,  and  rarely  of  bullae  [pemphi- 
goid purpura)  ;  or  it  may  be  made  up  of  wheals  of  urticaria,  attended 
with  intense  itching  ;  and,  finally,  it  may  be  identical  with  erythema 
nodosum.     These  forms  of  eruptions  may  be  variously  combined. 

IIe7no7'rhages  from  the  mucous  surfaces  rarely  occur,  though  epistaxis 
is  the  most  common.  The  extent  of  the  edema  varies  greatly,  in  rare  cases 
being  quite  extensive  and  overshadowing  all  other  symptoms  (febrile  pur- 
puric edema).  Albuminuria  may  be  noted,  and  accompanying  the  pur- 
puric eruption  there  will  be  a  mild  febrile  movement.  Convalescence  is 
usually  protracted  (even  into  years),  and  is  often  interrupted  by  recur- 
rence of  the  characteristic  features. 

The  diagnosis  is  made  from  the  presence  of  three  characteristic  symp- 
toms— polyarthritis,  a  purpuric  rash,  and  edema.  The  combination  of 
purpura  and  urticaria  is  one  of  the  chief  distinguishing  features.  It  is 
not  always  possible  to  eliminate  rheumatism,  but  the  non-rheumatic  cha- 


414  CONSTITUTIONAL  DISEASES. 

racter  of  some  of  the  cases  may  be  clearly  shown  by  the  therapeutic  test, 
as  happened  in  one  of  my  own  patients. 

Prognosis. — This  type  of  the  disease  is  generally  benign,  death  being 
very  rare.  Complications,  however,  may  prove  serious,  especially  the 
cardiac.  The  throat-condition  may  outlast  the  attack,  and  terminate  in 
gangrene  of  the  uvula  or  tonsils. 

(2)  Henoclis  Purpura — Henoch  and  Couty  have  described  a  form  of 
rheumatic  purpura  occurring  chiefly  in  children,  and  characterized  by 
painful  and  sometimes  swollen  joints ;  by  a  purpuric  eruption,  plus  ery- 
thema multiforme ;  by  vomiting,  diarrhea,  and  intestinal  pain  ;  by  local- 
ized edema  of  the  skin  ;  and  by  hemorrhages  from  the  mucous  membranes 
and  sometimes  into  the  kidneys. 

The  diagnosis  is  difficult  in  proportion  to  the  scanty  development  of 
the  purpuric  symptoms,  some  of  which  are  often  wanting. 

The  prognosis  is  favorable,  though  complications  of  more  or  less  seri- 
ous import  may  arise.  One  of  Osier's  cases  proved  fatal  Avith  the  symp- 
toms of  acute  hemorrhagic  Bright's  disease. 

(3)  Factitious  Purpura. — Bruce  and  Galloway  ^  report  a  case  in  which 
any  irritation  of  the  skin,  such  as  might  be  caused  by  drawing  the  blunt 
end  of  a  pencil  over  it,  produced  a  white  line,  which  presently  became 
pink  and  then  intensely  purpuric.  In  this  Avay  letters,  figures,  and  the 
like  could  be  shown  as  hemorrhagic  outlines. 

[c)  Purpura  Haemorrhagica  {3Io7-bus  WerUiofii). — This  is  the  severest 
form  of  purpura,  and  its  apparent  etiologic  connection  with  certain  infec- 
tious diseases,  particularly  rheumatism,  malaria,  etc.,  is  interesting,  but 
not  well  understood.  The  disease  is  perhaps  most  common  in  young 
females,  particularly  if  they  have  fallen  into  general  ill-health  ;  but  all 
persons  are  liable,  and  post-mortem  anatomo-pathologic  pictures  of  the 
disease  leave  little  room  for  doubt  that  it  is  an  infectious  complaint. 

Symptoms. — Prodromal  symptoms,  (malaise,  headache,  depression, 
anorexia)  may  appear,  and  last  one  or  two  days.  The  invasion  is  moder- 
ately abrupt,  with  fever,  and  soon  cutaneous  ccchymoses  appear  upon 
the  skin,  (quickly  increasing  in  size  and  numbers.  Slight  hemorrhages 
from  the  mucous  membranes  into  the  internal  organs  occur.  Epistaxis 
generally  comes  first ;  it  tends  to  persist  and  to  recur,  and  the  same  pecu- 
liarities pertain  to  bleedings  from  other  points.  Prostration  now  becomes 
rather  marked,  the  patient  complaining  of  pains  in  the  limbs,  loins,  abdo- 
men, and  chest,  and  the  latter  often  presage  a  fresh  hemorrhage.  There 
is  moderate  fever,  as  a  rule,  the  temperature  during  the  height  of  the 
attack  ranging  from  101°  to  103°  F.  (38.3°-39.4°  C.),  or  it  may  reach 
104°  to  105°  F.  (40.5°  C),  though  rarely.  The/;?//.sr  is  accelerated  (120 
to  130  per  minute),  but  full  and  regular,  though  in  the  worst  cases  it 
becomes  small  and  very  rapid.  The  mind  is  usually  clear.  Hematuria 
followed  by  nephritis  may  occur. 

There  is  anemia  varying  in  intensity  with  the  extent  of  the  hemor- 
rhage and  the  severity  of  the  type,  and  showing  the  characteristics  of 
symptomatic  anemia.  The  face  may  be  exceedingly  pale  and  anxious. 
The  course  is  run  in  from  seven  to  ten  days  in  mild  cases,  while  the  severer 
attacks  pursue  a  longer  course.  It  is  to  be  recollected,  however,  that  the 
malignant  form  {^purpura  fulminans)  has  a  speedily  fatal  termination. 
^  Briiish  Jour,  of  Dermatology,  Jan.,  1898. 


HEMOPHILIA .  415 

The  diagnosis  of  purpura  hsemorrhagica  rarely  presents  any  difficulty. 
Scurvy  may  simulate  it  in  some  particulars,  but  is  distinguished  by  its 
chief  etiologic  factor — a  diet  deficient  in  fresh  vegetables  and  fruits — by 
the  spongy,  swollen  condition  of  the  gums,  the  loosened  teeth,  and  brawny 
induration  of  the  limbs.  Moreover,  in  purpura  hsemorrhagica  the  hair- 
follicles  do  not  occupy  the  centers  of  the  ecchymotic  spots,  and  the  hemor- 
rhages from  the  mucous  membranes  are  more  copious  than  in  scurvy. 
Malignant  types  of  the  eruptive  fevers  distinguish  themselves  by  the  his- 
tory of  the  prevailing  epidemic,  by  the  characteristic  prodromes  and  in- 
vasion, and  by  the  high  temperature.  It  must  be  remembered,  however, 
that  variola  purpura  often  pursues  an  afebrile  course. 

Prognosis. — Grave,  except  in  mild  cases.  In  the  malignant  type  death 
may  come  before  hemorrhages  from  the  mucosa  appear.  Certain  com- 
plications may  prove  fatal — cerebral  hemorrhage,  inundation  of  the  lungs 
with  blood,  Bright's  disease,  and  shock  from  rapid,  profuse  bleedings. 
Death  may  also  be  the  result  of  exhaustion  due  to  protracted  bleedings. 

Treatment. — (a)  The  nianagement  of  secondary  jncrpura  is  em- 
braced, in  other  portions  of  this  volume,  in  connection  with  the  treatment 
of  the  diseases  and  conditions  which  it  accompanies. 

[b)  Simple  purpura  demands  arsenic,  first  in  moderate  doses,  and  then 
increased  until  slight  toxic  effects  are  noticeable.  Legroux  speaks  in 
warm  terms  of  the  iron  compounds,  and  especially  of  iron  perchlorid  in 
doses  of  3SS-J  (2.0-4.0)  daily,  and  if  the  child  is  somewhat  anemic,  the 
inhalation  of  oxygen  will  promote  hematosis.  The  disease  also  requires 
fresh  air  in  abundance  and  a  generous  diet. 

((?)  In  peliosis  rheumatica,  in  addition  to  the  measures  recommended 
in  purpura  simplex,  the  salicylates  should  be  tried. 

(d)  Purpura  Hcemorrhagiea. — In  all  kinds  of  purpura  the  patient 
should  be  confined  to  bed.  An  abundance  of  nourishment,  by  support- 
ing the  patient's  power,  is  of  the  greatest  service.  Internally,  ergot, 
turpentine,  tincture  of  the  chlorid  of  iron,  acetate  of  lead,  and  dilute 
sulphuric  acid  enjoy  the  widest  reputation.  Calcium  chlorid,  suggested 
by  Wright,  should  be  tried  when  other  remedies  fail.  The  following 
combination,  recommended  by  Hardaway,   I  have  found  useful : 

^.  Ext.  ergotae  fl., 

Tr.  ferri  chlorid.,  ad  f.^ij  (64.0).— M. 

Sig.   Three  to  ten  drops  in  water,  t.  i.  d. 


HEMOPHILIA. 

[Bleeder  s  Disease.) 

Definition. — An  hereditary  afi"ection,  transmitted  by  females  who 
are  themselves  not  aff"ected  (Nasse's  law).  It  is  characterized  by  fre- 
quent uncontrollable  hemorrhages  that  are  either  spontaneous  or  due  to 
slight  traumatism. 

Pathology. — The  constitutional  changes  or  peculiarities  on  which 
the  disease  depends  are  to  be  found  in  the  blood-vessels  rather  than  in 
the  blood  itself  (Henry) ;  microscopic  changes  have  been  found  in  the 


416  CONSTITUTIONAL  DISEASES. 

arterioles,  the  middle  muscular  tunic  being  either  absent  or  much  atro- 
phied. Vaso-motor  influences  also  play  an  important  part  in  causing  an 
attack,  as  is  shown  by  the  frequent  flushings  of  the  face  preceding  an 
attack,  and  also  by  the  fact  that  bleeding  may  follow  emotional  excite- 
ment (Henry).  Synovitis  with  hemorrhages  into  the  joints  may  some- 
times be  observed.      The  blood  presents  slight  change. 

Ktiologfy. — Hemophilia  is  more  distinctly  hereditary  than  any  other 
known  disease,  but  Nasse's  law  is  not  of  such  universal  application  as 
is  generally  supposed,  R.  Kolster  found  that  of  50  hemophilic  families, 
18  cases  followed  this  law,  16  others  with  some  exceptions  to  its  provis- 
ions, and  12  without  anv  regard  to  it.  The  law  embraces  the  followins; 
points  :  The  daughter  (not  herself  affected)  of  a  bleeder  transmits  the 
tendency  to  her  sons,  who  become  bleeders  ;  her  daughters  do  not  suffer, 
but  in  turn  transmit  the  disease  to  their  sons.  Females,  however,  may 
be  bleeders,  and,  according  to  Virchow,  one  woman  is  affected  to  every 
seven  men.     The  disease  has  been  traced  for  centuries  in  a  few  families. 

The  disposition  may  be  acquired,  but  of  the  conditions  that  may  lead 
to  its  development  we  are  entirely  ignorant.  It  is  observed  in  all  classes 
of  society,  and  is  most  frequent  in  families  whose  members  are  large, 
vigorous,  and  have  delicate  complexions,  the  complaint  usually  manifest- 
ing itself  before  the  end  of  the  second  year  of  life,  though  exceptionally 
as  late  as  puberty. 

Symptoms. — The  occurrence  of  profuse  and  persistent  bleedings 
that  are  either  spontaneous  or  the  result  of  slight  injury  characterizes 
hemophilia.  The  character  of  the  injuries  that  lead  to  dangerous  bleed- 
ings is  often  exceedingly  trivial ;  thus  a  slight  scratch,  cut,  blow,  the  ex- 
traction of  a  tooth,  and  other  minor  surgical  operations  [e.  g.  circumcis- 
ion) may  be  followed  by  severe  hemorrhage. 

If  we  include  spontaneous  hemorrhages,  bleedings  take  place  most 
frequently  from  the  nose.  Legg  has  made  three  clinical  groups,  based 
on  the  intensity  of  the  symptoms,  as  folloAvs  :  (1)  Seen  most  frequently 
in  men,  and  characterized  by  external  and  internal  bleedings  of  all  kinds 
and  by  joint-aff"ections  ;  (2)  most  frequent  in  women,  and  distinguished 
by  spontaneous  hemorrhages  from  mucous  membranes  only  ;  and  (3)  cha- 
racterized simply  by  ecchyraoses. 

The  capillaries  ooze  blood — a  process  that  may  vary  in  duration 
from  a  few  hours  to  as  many  weeks.  A  fatal  result  may  thus  occur  in 
a  few  hours,  while,  on  the  other  hand,  recovery  may  follow  a  slow  ooz- 
ing of  blood  that  has  continued  for  many  days.  In  the  latter  instances 
profound  anemia  follows,  the  blood,  however,  being  rapidly  replaced. 
Extensive  blood-extravasations  (hematomata)  usually  follow  contusions. 
Petechiie,  when  they  occur,  are  apt  to  be  spontaneous.  The  blood 
coagulates,  except  in  long-standing  hemorrhages,  when  it  becomes  thin 
and  watery  (late).  Fussell  made  blood  examinations  in  two  cases,  and 
found  the  leukocytes  slightly  increased  (14,000  and  15,000  per  c.mm.), 
while  the  red  cells  were  moderately  diminished. 

Arthritic  symptoms  are  common,  the  larger  joints,  and  especially  the 
knees,  being  most  frequently  aff"ected  and  showing  swelling  that  is  due 
chiefly  to  hemorrhages  into  the  joints.  In  other  instances  febrile  syno- 
vitis may  be  present,  resembling  rheumatism.  The  joint-symptoms  may 
either  announce  an  approaching  hemorrhage  or  pain  alone  may  be  ex- 


HEMOPHILIA .  417 

perienced.      The   attacks   are  liable  to   recur,  especially  in   cold,  damp 
Aveather,  and  may  result  in  stiffened,  deformed  joints  (Musser). 

DiagfnosiS. — When  persistent  capillary  oozing  occurs  in  a  person 
with  a  clear,  hereditary  disposition  the  diagnosis  is  clear.  Without  an 
inherited  tendency  we  cannot  be  certain  of  the  diagnosis  unless  pro- 
tracted hemorrhages  from  insufficient  causes  are  repeatedly  manifested. 
The  presence  of  joint-involvement  is  very  helpful. 

Differential  Diagnosis. — Peliosis  i^lieumatiea  is  an  affection  which,  as 
Osier  remarks,  touches  hemophilia  very  closely,  particularly  in  the  re- 
lation of  the  joint-swelling.  It  is  true  that  the  former  may  also  show 
itself  in  several  members  of  a  family,  but  the  presence  in  this  affection 
of  more  or  less  edema,  and  often  of  wheals  of  urticaria,  accompanied 
by  intense  itching,  aids  greatly  in  its  elimination. 

Prognosis. — In  undeveloped  forms  the  outlook  is  not  particularly 
grave,  since  in  these  the  tendency  may  either  lessen  or  become  alto- 
gether arrested  after  childhood.  In  the  majority  of  well-marked  cases 
the  children  do  not  survive  this  period.  On  the  other  hand,  thosr  who 
live  to  become  full-grown  show  a  diminished,  and  in  a  small  class  of 
cases  an  absolute,  disappearance  of  the  tendency.  The  first  hemor- 
rhage rarely  proves  fatal.  Boys  suffer  from  a  more  serious  form  than 
girls.  Moreover,  menstruation,  though  sometimes  very  copious,  does 
not  to  any  great  extent  endanger  the  life  of  a  hemophilic  woman.  Of 
130  cases  of  pregnancy  and  labor,  the  death  of  the  mother  occurred  in 
only  3,  and  abortion  in  16  cases  (Kolster). 

Treattnent. — The  physician  can  do  most  in  the  direction  of  pro- 
phylaxis. All  surgical  operations  that  are  not  absolutely  necessary 
must  be  avoided  ;  neither  should  the  teeth  be  erupted  nor  the  operation 
of  circumcision  be  permitted.  Leeches  are  not  permissible.  Females 
who  belong  to  bleeder  families,  as  well  as  males  who  have  had  hemo- 
philia,  should  not  marry. 

During  the  attack  absolute  rest — mental  and  bodily — must  be  en- 
joined, and  light  compression,  and  if  this  fail  strong  pressure  or  styp- 
tics, should  be  tried.  In  epistaxis  ice,  tannin,  and  turpentine  should 
be  tried  before  using  nasal  plugs;  and  if  the  latter  prove  indispensable, 
the  lightest  only  should  be  employed.  J.  Greig  Smith  regards  lint 
saturated  with  spirit  of  turpentine  as  the  best  local  application  in  epis- 
taxis. The  application  of  normal  human  blood  to  the  bleeding  surface 
is  warmly  recommended.  Gelatin  has  recently  been  used  topically 
with  a  successful  result.^  Internal  medicines  are  of  secondary  import- 
ance, though  they  may  be  tried,  and  opium  is  unquestionably  of  signal 
value,  since  it  tends  to  quiet  the  patient,  thus  favoring  repose.  The 
remedies  that  have  been  given  are  various.  Delafield.  Furth,  and 
others  have  used  successfully  the  fluid  extract  of  hydrastis  canadensis, 
the  dose  being  from  20  to  40  drops  daily ;  among  other  hemostatics, 
gallic  acid,  turpentine,  and  iron  perchlorid  produce  the  best  results.  The 
dose  of  the  latter  should  be  3ss  (2.0)  every  two  hours,  with  a  purge  of  sul- 
phate of  soda  (Legg).  The  use  of  calcium  salts  has  produced  good  results 
in  some  cases  and  merits  a  trial.  Thyroid  extract  and  inhalations  of 
oxygen  have  also  been  advocated.  During  convalescence  arsenic,  iron, 
and  the  bitter  tonics,  together  with  a  liberal  dietary,  will  aid  recovery. 
»  J.  B.  Nichols,  M.  D.,  Medical  Neivs,  Dec.  2,  1899.. 
27 


418  CONSTITUTIONAL  DISEASES. 


HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

(a)  Epidemic  Hemoglobinuria  (  WincheVs  Disease). — This  affection, 
which  is  septic  in  nature,  is  occasionally  met  with  in  lying-in  hospitals, 
and  occurs  in  children  from  one  to  ten  days  after  birth.  The  infants  re- 
fuse the  breast  and  show  hematogenous  (?)  icterus;  gastro-enteric  catarrh 
is  an  attendant  of  the  disease.  The  stools  are  meconic  ;  the  urine  is 
scanty,  dark-colored  (from  the  presence  of  methemoglobin),  often  albu- 
minous, and  may  contain  casts.  Hemorrhages  occur  into  organs  other 
than  the  kidney  and  into  the  mucous  membranes,  there  also  being  mild 
fever,  rapid  emaciation,  and  often  mild  convulsions.  It  is  a  very  fatal 
disease.  Bacteriologic  experiments  have  shown  that  the  disease  may 
be  produced  by  the  growth  of  the  colon  bacillus  in  the  buccal  epithelium 
of  infants.  Kilham  and  Mercelis '  report  an  epidemic  of  10  cases  oc- 
curring in  the  NeAV  York  Infirmary ;  complete  bacteriologic  studies 
were  made  in  all,  and  the  organism  discovered  suggested  the  diplo- 
coccus  of  pneumonia  or  the  pneumococcus  group.  There  is,  however, 
great  confusion  in  regard  to  the  possible  specific  micro-organism  of 
this  disease. 

(h)  Acute  Fatty  Degeneration  of  the  New-born  (^BuliVs  Disease). — 
This  disease  may  be  similar  to  Winckels  in  nature.  It  was  first  de- 
scribed b}^  Hecker  and  Buhl  as  an  infectious  disease  of  the  new-born, 
characterized  by  cyanosis,  jaundice,  and  copious  visceral  hemorrhages. 
The  chief  pathologic  change  is  an  acute  fatty  degeneration  of  the  inter- 
nal organs. 

(<-)  Syphilis  Haemorrhagica  Neonatorum. — Either  at  birth  or  soon 
thereafter  bleedings  take  place  into  the  skin  (ecchymoses)  and  from 
the  mucous  surfaces  and  the  navel.  Jaundice  may  be  associated.  The 
viscera  are  found  upon  post-mortem  examination  to  be  the  seat  of  syphi- 
litic lesions. 

(d)  Morbus  Maculosus  Neonatorum. — Hemorrhage  from  the  gastro- 
intestinal mucosa  of  the  new-born  (meh^na  neonatorum)  occurs,  and 
may  be  due  to  intracranial  lesions  during  birth :  it  may  also  take  place 
independently  of  the  latter.  Preuschen  has  collected  the  reports 
of  37  cases,  in  5  of  which  the  brain  was  examined,  and  all  of  these 
showed  cerebral  hemorrhages.  The  latter  may  occur  in  spontaneous 
births  and  give  rise  to  meljena  neonatorum.  Gartner  believes  the  dis- 
ease to  be  an  infectious  one,  and  claims  that  in  2  cases  he  was  able  to 
identify  a  bacillus  for  which  the  navel  is  believed  to  be  the  entrance- 
point.  The  blood  may  also  come  from  the  mouth,  nose,  navel,  etc. 
Townsend  found  morbus  maculosus  neonatorum  in  45  cases  in  6700 
deliveries,  and  in  most  of  these  instances  the  bleeding  was  general.  The 
hemorrhage  usually  sets  in  during  the  first  Aveek,  rarely  later,  and  the  du- 
ration of  the  disease  is  between  one  and  seven  days,  the  mortality  being 
a  little  over  50  per  cent.  Vomiting  of  the  blood  which  the  child  has 
drawn  from  the  breast  must  not  be  confounded  with  true  melena.  The 
treatment  is  by  gallic  acid  and  ergotin.  the  latter  hypodermically  ;  stim- 
ulants may  also  be  required,  and  warmth  to  the  extremities  if  the  per- 
ipheral circulation  be  feeble. 

'  Archives  of  Pediatrics,  March,  1899. 


PART  III. 

DISEASES   OF  THE   BLOOD  AND  THE 
DUCTLESS  GLANDS. 


ANEMIA. 

Definition. — A  pathologic  condition,  characterized  either  by  a 
diminution  in  the  quantity  of  blood  or  by  a  deficiency  in  one  or  more 
of  its  constituents.  Anemias  may  be  subdivided  into — I.  Primary  or 
Essential  (simple,  chlorotic,  and  pernicious) ;  II.  Secondary  (symptom- 
atic) ;  III.  Leukocytosis ;  TV.  Leukocythemia  (splenic,  myelogenic,  and 
lymphatic). 

Pattiologfy. — Anemia,  in  its  different  forms,  is  characteristic  of  dis- 
eases of  the  blood  or  of  the  blood-making  organs.  It  may  be  manifest, 
on  examination,  as  a  diminution  of  the  total  quantity  or  body  of  the 
blood  [oligemia) ;  of  the  number  of  red  corpuscles  {oligocythemia) ;  of 
the  hemoglobin  (oligochromemia) ;  and  of  other  constituents,  as  albumin 
{anliydremia).  The  diminution  of  hemoglobin  gives  rise  to  the  most 
obvious  sign  of  anemia  or  impoverished  blood — namely,  the  pallor  of  the 
cutaneous  surface — but  it  is  important  to  point  out  here  that  the  quan- 
tity of  hemoglobin  in  the  blood  is  not  necessarily  proportionate  to  the 
number  of  red  corpuscles.  Thus  the  percentage  of  hemoglobin  con- 
tained by  the  red  corpuscles  may  vary  in  disease,  so  that  a  reduction  in 
its  amount  does  not  necessarily  involve  a  corresponding  decrease  in  the 
number  of  red  corpuscles.  Conversely,  a  diminution  in  the  number  of 
the  latter  may  not  be  accompanied  by  a  proportionate  diminution  in  the 
amount  of  hemoglobin,  the  corpuscular  richness  in  coloring-matter  being 
quite  normal.  As  a  matter  of  fact  it  frequently  happens  that  oligo- 
chromemia is  associated  with  a  certain  degree  of  oligocythemia,  and 
vice  versa,  though  where  they  coexist  the  degrees  of  reduction  may 
neither  be  relatively  nor  proportionately  equal. 

Anemia  can  be  positively  ascertained  only  by  an  adequate  examina- 
tion of  the  blood.  It  may  be  inferred  from  the  presence  of  pallor, 
languor,  dyspnea,  palpitation,  etc.  ;  but  it  should  be  borne  in  mind  that 
not  every  pale  person  has  anemia,  since  pallor  of  the  face  may  be  hered- 
itary, and,  at  the  same  time,  perfectly  consistent  with  good  health,  a 
normal  number  of  corpuscles,  and  a  normal  percentage  of  hemoglobin. 
Conversely,  a  person  with  marked  vascularity  of  the  face,  and  a  rosy 
complexion  even,  may  have  anemia. 

The  anemias  embrace  those  conditions,  also,  in  which  there  are 
changes  in  the  shape  of  the  red  corpuscles  {poikilocytosis),  and  in  their 
size  {inicro-,  macro-,  or  jnegalocytosis). 

419 


420     DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 


I.  THE  PRIMARY    OR  ESSENTIAL   ANEMIAS. 

Primary  anemias  constitute  those  forms  in  which,  so  far  as  our  pres- 
ent knowledge  of  their  etiology  and  pathology  goes,  no  other  tissues  or 
organs  than  the  blood  and  the  blood-making  organs  are  either  at  fault 
or  are  directly  affected.  Future  investigations  of  the  life-history  of  the 
blood  may  reveal  the  exact  causation  of  what  are  now  regarded  as  pri- 
mary or  essential  anemias,  and  thus  permit  of  a  clearer  discrimination 
and  a  more  accurate  classification. 


SIMPLE    OB  BENIGN    ANEMIA. 

This  form  is  not  infrequently  met  with  as  a  congenital,  constitutional 
affection,  without  any  assignable  cause,  and  is  entirely  free  from  per- 
nicious manifestations  or  tendencies.  There  is  no  discoverable  element 
of  relationship  between  simple  benign  anemia  and  chlorosis,  nor  is  the 
former  symptomatic  of  any  disease  in  whicli  anemia  is  common,  such  as 
tuberculosis,  carcinoma,  and  nephritis. 

Htiology. — Simple  constitutional  anemia  is  often  met  with  among 
the  poorer  classes,  and  from  this  fact  it  is  probable  that  living  or  work- 
ing in  a  vitiated  atmosphere,  as  well  as  deficient  sunlight  and  nutriment, 
is  primarily  active  in  reducing  the  general  health.  In  this  way  is  often 
caused  a  lifelong  pallor,  due  to  an  interference  with  the  normal  process 
of  blood-making  (hemogenesis).  There  are  also  certain  individuals  in 
whom  sliglit  pallor  and  systemic  feebleness  have  existed  from  infancy 
(thus  probably  congenital),  and  whose  modes  of  life  and  environment 
have  been  more  or  less  uniformly  hygienic  and  provident.  In  such  cases 
we  may  assume  that  there  is  some  innate  imperfection — anatomic  or 
physiologic,  or  both — in  the  blood-forming  organs. 

Finally,  in  the  later  manifestations  of  slight  general  anemia  a  devel- 
opmental strain  or  abnormality  may  start  a  disorder  of  hematopoiesis  in 
organs  congenitally  insufficient  for  new  and  greater  demands  for  blood 
made  by  the  system. 

Symptoms. — There  is  some  pallor,  often  with  languor,  slight  pal- 
pitation, and  dyspnea,  occasional  headache,  and  a  tendency  to  fatigue. 
The  general  healtli  is  not  otherwise  disturbed,  and  an  active  life  may  be 
enjoyed  for  many  years.  Examination  of  the  blood  shows  a  slight  re- 
duction in  the  number  of  the  red  cells  and  of  the  hemoglobin  (rela- 
tive). This  degree  of  anemia  persists  without  aggravation  or  amelio- 
ration. It  may  be  found  to  aff'ect  males  and  females,  and  is  observed 
principally  in  adult  life. 

The  diagnosis  of  simple,  benign,  or  constitutional  anemia  should 
be  made  with  considerable  caution  and  reserve,  and  it  sliould  be  arrived 
at  only  after  the  closest  scrutiny  of  all  the  symptoms  and  signs,  the 
most  careful  study  and  judicious  balancing  of  the  data  entering  into 
the  previous  history  of  the  patient.  If  there  be  a  latent  or  incipient 
tuberculosis,  carcinoma,  or  nephritis,  a  previous  attack  of  some  infec- 
tious fever,  rheumatism,  etc.,  this  fact  clearly  bears  upon  the  case,  and 
the  diagnosis  of  simple  anemia  is  precluded. 

The  prognosis  is  usually  favorable.  On  account  of  the  possible 
existence  of  one  of  the  above-mentioiieil  diseases,  or  from  the  fact  that 


CHLOROSIS.  421 

a  grave   variety  of  anemia   may  be   superadded,  however,  it   should  be 
guarded  in  the  mind  of  the  physician,  at  least. 

The  treatment  of  simple,  benign  anemia  is  an  expectant  one  in 
most  instances.  Hematinics  (iron,  arsenic,  etc.)  are  seldom  required, 
as  they  have  little  if  any  influence  upon  the  blood  or  upon  the  pallor  or 
other  symptoms.  A  rigid  system  of  hygiene,  together  with  attention 
to  proper  food  and  drink  and  to  the  manner  of  eating  and  drinking, 
will  probably  ensure  to  the  patient  all  the  benefit  that  may  be  obtained. 
Cardiac  tonics  (digitalis,  strophanthus)  may  be  useful  in  controlling  the 
palpitation.  It  is  worse  than  futile  to  attempt  to  eradicate  any  con- 
genital defect  of  the  blood-vessel  system   or  hematopoietic  organs. 

CHLOROSIS. 

{Green  Sickness.) 

Definition. — A  blood-disease,  occurring  chiefly  in  adolescent  fe- 
males, and  characterized  principally  by  a  deficiency  of  hemoglobin  in 
the  red  corpuscles.  It  runs  a  mild  course,  though  with  a  tendency  to 
relapse. 

Pathology. — It  is  so  seldom  that  death  occurs  in  cases  of  chlorosis 
that  autopsies  of  this  disease  have  not  been  frequent  enough  to  determine 
definitely  the  nature  of  the  findings.  There  is  no  loss  of  fat  in  the 
body,  but  signs  of  physical  degeneration  and  disorders  of  development 
are  quite  common,  hypoplasia  of  the  vascular  system  and  of  the  genital 
organs  seeming  to  be  the  most  prominent.  Incurable  cases  of  chlorosis 
are  nearly  always  characterized  by  anomalies  of  the  blood-vessels  and 
genitalia  (Rokitansky).  Yirchow  has  also  shown  that  congenital  arrest 
of  development  of  the  aorta  and  larger  arteries,  as  indicated  by  their 
small  size,  their  soft  and  elastic  walls,  is  quite  constant  in  chlorotics. 
The  uterus  (especially)  and  adnexa  manifest  the  hypoplasia,  and  yellow- 
ish spots  and  streaks  of  fatty  degeneration  are  sometimes  seen  in  the 
intima  of  the  arteries.  The  cardiac  muscle  is  softened,  the  whole  heart 
is  dilated,  and  the  left  ventricle  is  usually  somewhat  hypertrophied. 

Ktiologfy. — Chlorosis  occurs  most  frequently  in  girls  at  or  near 
puberty,  and  also  may  appear  between  that  period  and  twenty  or 
twenty-five  years  of  age.  It  usually  happens  that  the  condition  dates 
from  a  scanty  menstruation,  beginning  late  in  the  "teens,"  but  it  should 
be  recollected  that  amenorrhea  is  not,  as  formerly  supposed,  a  cause, 
being  rather  an  effect  of  the  underlying  blood-disorder.  Blondes  are 
oftener  affected  than  brunettes.  In  males  the  disease  is  rare,  though 
cases  may  develop  at  puberty  or  during  adolescence. 

The  influence  of  heredity  in  the  causation  of  chlorosis  is  undoubted 
in  those  cases  described  by  Virchow,  in  Avhich  congenital  hypoplasia  of  the 
blood-vessels  and  genitalia  is  found  to  exist.  Other  cases,  moreover,  in 
which  such  anatomic  evidence  is  wanting,  also  bear  the  stamp  of  hered- 
ity, in  that  their  mothers  have  been,  and  their  sisters  are,  chlorotic.  A 
family  tuberculous  taint  may  predispose  to  chlorosis  (Jolly).  Such  un- 
hygienic conditions  as  bad  air.  dimly-lighted  rooms,  a  lack  of  nutritious 
food  and  out-door  exercise,  a  sedentary  occupation,  hasty  and  irregular 
eating,  excessive  tea-  and  coffee-drinking,  irregular  and  insufficient  hours 
of  rest  and  sleep ;  bodily  fatigue,  as  from  stair-climbing  and  standing  in 


422     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

constrained  positions  without  intervals  of  rest, — all  these  predispose  to 
the  disease.  And  yet  girls  living  amid  the  most  luxurious  and  favor- 
able surroundings  have  had  chlorosis.  It  is  not  at  all  improbable  that, 
as  the  late  Sir  Andrew  Clarke  believed,  copremia — the  absorption  of  the 
toxic  ptomains  and  leucomains  from  the  colon  in  constipation — is  often 
the  cause  of  chlorotic  symptoms  and  signs,  though  physiological  chemists 
fail  to  find  in  the  urine  the  evidences  of  intestinal  putrefaction  {i.  e.  an 
increase  of  the  aromatic  sulphates).  Sometimes  a  previously  existing 
simple  constitutional  anemia  appears  to  be  an  underlying  cause  for  an 
exacerbation  of  genuine  chlorosis.  In  such  instances,  however,  I  be- 
lieve additional  exciting  causes  to  be  operative. 

Sudden  emotional  excitement  and  prolonged  mental  over-exertion 
operate  as  causative  agencies.  Shock  from  bad  news,  such  as  loss  of 
relatives,  crosses  of  various  kinds,  home-sickness,  disappointment  in 
love,  rankling  grievances,  and  perhaps  ungratified  sexual  desires  or 
masturbation,  may  contribute  to  the  "•  neuropathic  "  origin  of  chlorosis. 
A  change  of  climate  seems  to  operate  as  a  cause,  and  is  manifested 
especially  in  the  case  of  girls  emigrating  from  Ireland  to  enter  domestic 
service  here  (Townsend). 

S3^inptoins. — A  brief  outline  of  the  more  frequent  and  prominent 
general  manifestations  of  chlorosis — or  "green  sickness" — ma}'  be  nar- 
rated at  the  outset.  The  gradual  onset  is  usually  marked  by  languor, 
indisposition  to  either  physical  or  mental  exertion,  motor  weakness, 
irritability  or  inertia  of  mind,  depression  of  energy,  and  a  more  or  less 
constant  fatigue.  Palpitation  of  the  heart  and  di/spnea  on  slight  exer- 
tion are  much  complained  of  in  most  cases ;  headache  is  also  an  early 
symptom,  and  may  be  accompanied  by  vertigo  in  some  cases ;  and  di/s- 
pepsia  and  constipation  occur  in  65  per  cent,  of  cases  (Townsend). 
Probably  in  one-half  of  all  cases  cessation  of,  or  scanty  and  irregular, 
menses  may  form  the  burden  of  complaint. 

Gastro-intestinal  Symptoms. — The  appetite  is  either  poor  or  perverted, 
and  a  capricious  desire  for  such  iunutritious  substances  as  chalk,  slate- 
pencils,  and  even  bits  of  earth  (pica),  or  for  sour,  highly  spiced,  and 
unwholesome  articles  of  food  (^inalacia),  is  not  uncommon.  Morning 
vomiting  or  regurgitation  of  food  and  eructations  occur,  in  some  cases, 
pain  after  eating  may  be  noticed,  and  dilatation  of  the  stomach  and 
high  position  of  the  diaphragm  are  found  in  many  instances.  The  tongue 
is  pale,  flabby,  often  dry,  and  the  edges  show  indentations. 

"Constipation  is  usually  present,  though  sometimes  diarrhea,  lasting 
for  a  day  or  two,  may  alternate,  as  after  the  ingestion  of  some  unwhole- 
some article  that  has  been  eaten  to  satisfy  the  perverted  appetite. 

General  Appearance. — The  subcutaneous  fat  is  not  only  well  re- 
tained, but  in  many  cases  is  even  increased,  and  the  rotundity  of  the 
body  and  members  preserved.  The  peculiar  fireenish-yelloxv  tint  of 
the  complexion  is,  however,  the  most  striking  manifestation  to  the  eye. 
It  differs  thus  from  the  muddy  pallor  of  cancerous  anemia,  from  the 
lemon-yellow  tint  of  pernicious  anemia,  from  the  saffron  hue  of  jaundice, 
and  from  the  blanched  pallor  after  severe  hemorrhages.  The  sclerce 
are  often  pearly-  or  bluish-white  ("cerulean  hue"),  and,  though  this  is 
considered  by  many  the  earliest  positive  indication  of  anemia,  when  the 
skin-tint  is  not  characteristic,  yet,  according  to  Townsend's  analysis  of  87 


CHLOROSIS. 


423 


cases  of  chlorosis,  it  is  not  the  most  constant.  The  nails  sho^ved  pallor 
in  95  per  cent,  of  the  cases ;  the  cheeks,  tongue,  and  lips  were  paled  in 
89,  84,  and  76  per  cent,  respectively,  -n-hile  the  scleras  were  pale  in  but 
64  per  cent.  On  exertion  the  cheeks  and  lips  may  become  (|uite  ruddy 
in  cases  of  moderate  anemia  [chlorosis  rubra). 

Circulatory  symptoms  arebreathlessness,  palpitation,  and  the  tendency 
to  vertigo  and  syncope  complained  of  in  the  majority  of  cases ;  other 
circulatory  disturbances  ma}^  occur.  The  slcin  and  the  extremities  are 
frequently  cold,  owing  to  sluggish  heart-action.  The  pulse  is  usually 
full  and  easily  compressible,  and,  owing  to  its  excitability,  it  may  be 
accelerated  for  the  time  being  by  various  external  influences  (see  Fig, 
33).     Visible  undulating  pulsations  of  the  carotid  vessels  are  frequent, 


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Fig.  33.— Pulse-  and  temperature-chart  of  a  case  of  chlorosis,  sho^sing  the  eflfect  exerted  upon  the 
pulse  by  eating,  exertion,  and  excitement. 


and  a  pulsation  at  the  base  of  the  heart  and  in  the  peripheral  veins  is 
also  observed  at  times.  Physical  examination  shows  the  Jieart  to  be 
slightly  dilated.  Systolic  murmurs,  soft  and  "  whifEng  "  in  character, 
are  heard  at  the  base,  though  in  severe  cases  they  may  be  heard  at  the^ 
apex  of  the  heart  also.  Systolic  blowing  murmurs  of  hemic  origin  are 
not  infrequently  heard  over  the  carotid  arteries.  More  common  and 
characteristic,  however,  is  the  venous  hum  or  bruit  de  diable — the  soft 
continuous  murmur  heard  over  the  large  cervical  veins.  Thrombosis  of 
the  larger  veins  or  of  a  cranial  sinus  may  occur,  and  is  always  of  serious 
import. 

Of  the  nervous  mcmifestations  that  are  often  present,  neuralgias  of 
the  head,  mental  depression,  hyperesthesia  of  the  skin,  particularly  of 
the  abdomen,  gastralgic  attacks,  and  hysteria,  are  most  frequently  met 
with.    Tinnitus  aurium  and  anemic  amaurosis  have  been  known  to  occur. 

Edema  of  the  ankles  is  found  in  perhaps  one-third  of  the  cases.  The 
uriiie  is  generally  pale,  free  in  quantity,  and  its  specific  gravity  is  some- 
what lowered ;  and  according  to  recent  studies  there  is  a  diminished 


424     mSEASE.S  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

excretion  of  nitrogen  in  the  form  of  urea,  despite  the  abnormal  destruc- 
tion of  albuminoids. 

Blood-examination. — The  blood  flowing  from  a  punctured  finger-pulp 
or  ear-lobule  is  pale,  though  seldom  thin  or  hydremic,  and  the  paleness 
is  due  to  a  qualitative  rather  than  a  quantitative  change.  There  is  a 
disproportionate  reduction  of  the  hemoglobin  as  compared  with  the 
number  of  the  red  cells.  The  hemoglobin  may  range  from.  50  per  cent, 
to  as  low  as  16  or  17  per  cent,  in  severe  cases,  the  average  quantity  being 
about  38  or  40  per  cent.  On  the  other  hand,  the  number  of  red  corpus- 
cles is  not  greatly  reduced,  and  may  even  be  normal.  The  moderate 
oligocythemia  and  marked  oligochromemia  are  almost  distinctive  of 
chlo^'osis :  these  features,  however,  may  be  closely  simulated  by  the 
chloroanemia  of  syphilis  or  early  tuberculosis.  The  average  number 
of  red  corpusles  is  from  3,700,000  to  4,100,000  per  cubic  millimeter  of 
blood,  but  the  count  in  very  severe  cases  may  be  as  low  as  1,900,000. 
Approximately,  the  number  of  red  corpuscles  is  from  70  to  85  per  cent, 
of  the  normal,  while  the  leukocytes  are  only  slightly  increased  in  num- 
ber (8000  to  8500  per  c.mra.).  Microscopical/)/,  the  red  cells  are  seen 
to  be  paler  than  normal,  and  somewhat  altered  in  size  and  shape.  Some 
are  distinctively  larger  than  is  usual  (macrocytes),  but  the  majority  are 
slightly  undersized  (microcytes).  Irregularity  in  shape  (pokilocytosis) 
is  seen  in  quite  a  number  of  the  red  cells  in  the  severe  cases,  and  an 
occasional  normoblast  (small  nucleated  red  corpuscle)   may  be   noted. 

Diagnosis. — When  the  greenish  pallor  of  the  face  is  marked  this 
can  often  be  correctly  made  at  a  glance.  The  blood-examination  must 
be  made,  however,  to  completely  establish  the  diagnosis,  even  when  dis- 
tinctive symptoms  are  present,  such  as  the  shortness  of  breath,  palpita- 
tion, weakness  and  languor,  faintness,  amenorrhea,  capricious  appetite, 
together  with  a  well-nourished  appearance  of  the  body.  The  bluish- 
white  sclerae  and  pallid  nails  are  confirmatory  when  observed,  and  the 
physical  signs  should  also  be  sought  for. 

The  primary  character  of  the  anemia  may  be  determined  in  doubtful 
cases,  or  in  those  in  which  incipient  tuberculosis  or  Bright's  disease  may 
be  suspected,  by  exclusion.  Here  the  physical  examination  of  the  chest 
and  urinalysis  should  supplement  the  blood-examination.  Organic  dis- 
ease of  the  heart  may  be  simulated  by  the  breathlessness,  palpitation, 
vertigo,  and  edema.  According  to  F.  P.  Henry,  the  following  blood- 
variations  may  be  considered  in  the  diagnosis  of  chlorosis :  (1)  the  red 
corpuscles  may  be  normal  in  number  and  in  size,  the  only  change  being 
a  deficiency  of  the  hemoglobin ;  (2)  the  corpuscles  may  be  normal  in 
number,  but  diminished  in  size,  while  the  percentage  of  hemoglobin 
is  normal ;  (3)  the  corpuscles  may  be  diminished  in  number,  with 
either  a  diminished,  normal,  or  perhaps  an  increased  percentage  of 
hemoglobin. 

Prognosis. — This  is  always  favorable,  except  in  those  cases  in 
which  congenital  or  developmental  anomalies  of  the  vascular  system  are 
associated.  The  discontinuance  of  proper  treatment  before  a  substan- 
tial cure  is  eff'ected  is  often  followed  by  a  relapse,  and  even  after  appar- 
ent cure  one  or  more  recurrences  may  be  witnessed  before  the  age  of 
thirty.  The  average  duration  of  a  case  of  chlorosis  is  from  two  to 
three  months.     In  cases  of  very  severe  type,  in  which  the  dividing-line 


CHLOROSIS. 


425 


between  this  disease  and  pernicious  anemia  may  not  be  marked  clearly, 
the  prognosis  should  be  made  Avith  due  reserve. 

Treatment. — "While  the  treatment  of  chlorosis  by  the  administra- 
tion of  iron  is  wellnigh  specific,  the  hygienic  measures  are  also  import- 
ant, and  particularly  in  order  that  relapses  may  be  avoided. 

Hygienic. — Pure  air,  wholesome  food,  and  plenty  of  rest  and  sleep, 
with  regular  habits,  are  prime  requisites.  Sometimes  a  change  of  occu- 
pation, even  temporary,  where  confinement  may  be  replaced  by  an  out- 
door life  and  sunshine,  as  in  the  case  of  store-girls  and  mill-operatives, 
is  of  great  value  in  bringing  about  a  rapid  improvement.  Patients  in 
better  circumstances  may  be  sent  to  rural  districts,  the  mountains,  or 
sea-shore.  In  cases  marked  by  much  palpitation,  dizziness,  and  dyspnea, 
rest  in  bed  for  a  week  or  so  is  often  imperative  at  the  outset.  As  im- 
provement goes  on,  however,  light  and  then  moderate  exercise  mav  be 
permitted  out  of  doors,  and  the  increasing  appetite  should  be  gratified 
by  a  generous,   easily  assimilable  diet  (milk,  meat,  eggs,  fish,  purees  of 


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Fig.  34.— Chart  of  a  case  of  chlorosis,  showing  the  improvement  following  the  administration 
of  iron.  Convalescence  almost  complete ;  relapse.  Black,  red  corpuscles ;  red,  hemoglobin ; 
blue,  white  corpuscles. 

green  vegetables,  stewed  fruit).  Fats  and  carbohydrates  should  generally 
be  avoided.  Coffee,  tea,  and  alcoholics  do  harm.  Hot  baths  continued 
for  fifteen  or  twenty  minutes,  thrice  weekly,  have  been  recommended. 

Medicinal. — The  one  remedy,  par  excellence,  on  both  rational  and 
empirical  grounds,  is  a  good  preparation  of  iro7i.  This  should  be 
given    methodically    and   persistently  until    the   percentage    of  heme- 


426    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

globin  is  90,  and  then  maintained  there  by  continuing  the  adminis- 
tration of  the  iron  for  several  weeks  to  prevent  a  recurrence  (Fig.  34). 
Exactly  how  the  iron  acts  in  curing  chlorosis  has  not  been  definitely 
proved,  but  its  almost  specific  action  is  indubitable.  Not  all  prepara- 
tions of  iron  are  equally  well  borne  by  the  stomach,  however,  and  sev- 
eral changes  may  be  necessary  during  the  course  of  a  given  case.  Prob- 
ably the  best  form  for  general  use  is  the  dried  sulphate,  usually  given 
together  with  potassium  carbonate  in  the  Avell-known  Blaud's  pills — 2 
grains  (0.129)  of  each  to  the  pill.  Starting  with  one  pill  thrice  daily 
for  a  week  or  ten  days,  the  daily  dosage  is  increased  until  nine  pills  daily 
are  administered  in  the  third  week,  and  continued  for  several  weeks  or 
as  long  as  the  case  ma}''  require.  It  is  very  important,  meanwhile,  that 
the  bowels  should  be  kept  soluble  by  the  use  of  cascara  sagrada.  salines, 
and  the  like.  A  preliminary  course  of  intestinal  antiseptics  for  a  week 
or  so  is  strongly  advised  by  some  authorities,  and  is  worthy  of  recom- 
mendation. Beta-naphtol,  thymol,  guaiacol,  and  salol  are  used  for  this 
purpose.  The  hematinic  eifect  of  the  iron  seems  to  be  produced  earlier 
and  better  when  this  plan  is  followed  :  and  this  fact  seems  to  give  cor- 
roborative evidence  to  Bunge's  theory  of  the  absorption  of  the  iron  in 
chlorosis — in  a  certain  class  of  cases  at  least.  Other  iron  preparations 
of  value  in  this  disease  are  the  citrate,  protoxalate,  lactate,  carbonate, 
the  succinate,  and  the  reduced  iron.  The  albuminates  of  iron,  so  much 
vaunted  for  a  time,  are  pi'actically  worthless.  In  severe  cases  Quincke 
uses  at  first  a  5  per  cent,  solution  of  the  ferric  citi-ate,  hypodermically 
(TTLvijss-oijss — 0.5-10.0,  daily).  The  preparation  known  as  ferratin  is 
also  highly  recommended  by  some,  and  the  therapeutic  efficacy  of  gly- 
cerin extract  of  bone-marrow  in  chlorosis  is  as  yet  doubtful.  Bitter 
tonics  and  dilute  hydrochloric  acid  are  indicated  in  a  certain  number 
of  cases  in  which  indigestion  is  troublesome.  The  acid  tincture  of  iron 
chlorid  is  sometimes  used  in  such  cases.  Mild  cases  often  yield  to  the 
simple  use  of  remedies  for  the  cure  of  gastro-intestinal  derangement. 
Adjuvants  in  the  treatment  of  chlorosis  that  may  be  of  use  are  arsenic, 
manganese,  mercuric  chlorid,  and  arsenite  of  copper  in  minute  doses. 

PROGRESSIVE   PERNICIOUS   ANEMIA. 
{Idiopathic  Anemia:  Bermier's  Anemia.) 

Definition. — A  grave  blood-disease  characterized  by  a  great  de- 
struction of  red  corpuscles,  and  a  persistent  tendency  from  a  bad  to 
a  worse  condition.  It  usually  ends  in  death,  and  seldom  exhibits  causal 
lesions  other  than  those  of  the  blood  or  blood-making  organs. 

The  term  "idiopathic  anemia"  applied  to  this  disease  by  Addison, 
whose  first  clear  description  of  its  clinical  history  has  become  classical, 
is  applicable  to  a  proportionately  smaller  number  of  cases  to-dav  than 
during  his  time.  This  is  owing  to  the  later  discovery  (post-mortem)  of 
adequate  causes  for  the  pernicious  anemia  that  during  life  could  not 
be  found.  Thus,  while  still  a  primary  essential  anemia  in  most  cases, 
for  descriptive  purposes  it  will  nevertheless  be  convenient  to  classify 
both  groups  under  the  title  oi  progressive  pernicious  anemia  in  order  to 
describe  the  invariable  tendency  of  both.  Under  Diagnosis  {vide  infra), 
however,  will  be  found  some  differential  clinical  features. 


PROGRESSIVE  PERNICIOUS  ANEMIA.  427 

Pathology. — The  subcutaneous  fat  is  rarely  diminished,  so  that 
emaciation  is  exceptional.  The  skin  is  pale  and  of  a  lemon-yellow 
tint,  and  most  of  the  tissues  and  organs  are  anemic,  except  the 
muscles,  which  are  often  decidedly  red  in  color.  The  fat  is  usu- 
ally pale  and  yellowish,  and  fatty  degeneration  is  one  of  the  most 
striking  changes  in  this  affection.  The  heart  is  usually  large  and  flabby, 
and  on  section  of  the  ventricular  walls  there  is  a  marked  pallor,  as  well 
as  a  friability,  and  a  fatty  change  shown  by  the  yellow  tint.  Micro- 
scopically, the  fibers  or  columns  of  heart-muscle  are  seen  to  be  distinctly 
fatty.  The  heart-cavities  contain  little  light-colored  blood.  Other 
organs  showing  the  fatty  degeneration  (of  the  epithelium)  are  the  liver, 
kidneys,  gastric  and  intestinal  walls,  and  the  intima  of  many  of  the 
smaller  blood-vessels  (in  patches).  This  general  fatty  change  is  prob- 
ably due  to  the  deficient  oxygenation  of  the  tissues  and  to  the  anemic 
blood-supply. 

Owing  to  the  above  degenerative  change,  and  consequent  Aveakening 
in  the  vessel-walls,  small  extravasations  of  blood  are  found  in  dif- 
ferent parts.  Most  frequently  these  punctiform  hemorrhages  are  seen 
in  the  retina  and  on  serous  membranes,  as  on  the  inner  surface  of  the 
dura  mater,  the  pericardium,  and  the  pleura.  Ecchymoses  are  also  ob- 
served occasionally  on  the  mucous  membranes  and  on  the  skin.  More 
or  less  general  edema  and  dropsical  accumulations  in  the  serous  cavities 
are  not  uncommon.  The  spleen  and  liver  are  seldom  and  only  very 
slightly  enlarged.  The  Ij^mph-glands  are  often  somewhat  swollen  and 
intensely  red  in  color,  owing  to  the  unusual  number  of  red  corpuscles. 

A  marked  and  important  pathologic  feature  of  pernicious  anemia  is 
the  presence  of  abundant  deposits  of  iron-pigment,  especially  in  the 
liver,  but  also  in  the  spleen,  kidneys,  pancreas,  and  other  organs.  The 
fact  that  the  abnormal  quantity  of  iron  in  the  liver  is  peculiarly  distrib- 
uted about  the  periphery  and  middle  zone  of  the  lobules  is  particularly 
noteworthy,  and  quite  characteristic  of  pernicious  anemia.  The  origin 
of  this  iron  is  doubtless  the  enormous  destruction  of  red  corpuscles,  and 
that  the  pigment  in  the  hepatic  lobules  is  ferruginous  may  be  determined 
by  a  micro-chemic  test  with  ammonium  sulphid,  granules  of  black  sul- 
phid  of  iron  being  formed. 

Of  special  interest  are  the  lesions  found  in  the  bone-marrow  on 
account  of  its  hematopoietic  function.  This  is  virtually  hypertrophied, 
and  is  in  many  cases  deep-red  instead  of  yellow,  and  more  like  the 
hemoblastic  marrow  of  childhood  (H.  C.  Wood).  While  formerly  held  to 
be  causative,  this  change  is  now  regarded  as  being  secondary  to  the  severe 
anemia.  Cellular  hyperplasia  may  be  seen  microscopically  in  the 
great  number  of  large  and  small  granular  medullary  cells,  and  also  in 
the  nucleated  red  cells. 

An  atrophied  condition  of  the  gastric  and  duodenal  mucosa  is  noticed 
in  some  cases.  The  sympathetic  ganglion  cells  may  also  show  changes. 
More  constant,  however,  is  the  sclerosis  of  the  posterior  columns  and, 
to  some  extent,  of  the  lateral  columns  of  the  spinal  cord :  this  is 
especially  marked,  according  to  Burr,  in  the  cervical  swelling.  Patveu 
examined  9  cases  ;  in  4  he  found  hyaline  degeneration  of  the  vessels  of 
the  white  substance,  and  in  5  small  hemorrhages.  These  changes  are 
probably  due  to  a  toxic  agent. 


428      DISEASES  OF  THE  BLOOD  AXD   THE  DUCTLESS  GLANDS. 

Htiology. — There  are  three  etiologic  categories  into  -which  cases  of 
pernicious  anemia  may  be  grouped :  (1)  those  cases  in  which  no  discov- 
erable cause  for  the  hemolysis  (blood-destruction)  is  ascertained,  either 
during  life  or  after  death — i.  e.  the  idiopathic  variety  of  Addison  ;  (2) 
those  in  which  an  adequate  cause  is  found  post-tnortem  only  ;  (3)  those 
that  are  plainly  traceable,  ante-mortem,  to  some  sufficient  primary  causal 
condition  acting  directly  or  indirectly. 

(1)  As  regards  the  obscure  cases  of  idiopathic  anemia — or  cachexia — 
the  essential  cause  of  the  symptomatic  condition  is  evidently  an  actively 
increased  hemolysis.  The  blood-generation  (hemogenesis)  may  be  nor- 
mal in  power  of  there  may  be  a  congenital  or  acquired  underlying  de- 
ficiency in  hemogenetic  power.  Stengel  believes  that  the  hemolysis 
originates  in  the  gastro-intestinal  capillaries,  and  depends  upon  poisons 
generated  or  absorbed  from  that  tract — an  auto-intoxication. 

(2)  Apparently  causeless  cases  of  progressive  pernicious  anemia  may 
be  found  post-mortem  to  have  been  caused  by  {a)  obscure  malignant  dis- 
ease ;  {b)  parasites,  especially  the  Anchylostoma  duodenalis,  and  rarely 
by  the  Bothriocephalus.  Not  infrequently,  by  a  careful  study  of  the 
anamnesis  of  a  patient,  aided  by  modern  methods  of  examination,  the 
cause  of  pernicious  anemia  may  be  detected  during  life  Atrophy  of 
the  stomach  and  chronic  gastritis,  with  polypoid  growths  of  the  mucosa, 
were  formerly  included  in  this  category.  It  is  now  held  that  this 
atrophy  of  ventricular  and  intestinal  glands  is  an  effect  rather  than  the 
cause  of  the  anemia  (Grawitz).  Wm.  Hunter  ^  concludes  that  the  dis- 
ease is  of  infectious  (streptococcal)  nature  dependent  primarily  upon 
caries  of  the  teeth. 

(3)  Certain  exhausting  causes,  operating  directly  or  indirectly,  may 
precede  this  affection,  as  severe  or  prolonged  hemorrhages,  or  diarrhea, 
fevers,  mental  shock,  profound  chlorosis,  pregnancy,  and  parturition. 

Unfavorable  hygienic  surroundings  and  insufficient  nourishment, 
habitually  kept  up,  may  also  favor  the  development  of  the  disease  ;  but, 
as  in  chlorosis,  the  most  favorable  environment  is  not  by  any  means 
preventive  of  its  development.  Males  are  more  frequently  affected  than 
females,  and  especially  does  it  occur  during  middle  life.  Griffith  has 
collected  several  cases  occurring  under  twelve  years  of  age.  The  disease 
is  widely  distributed,  and  it  has  been  observed  to  behave  almost 
endemically  at  times,  as  in  Switzerland  and  Leipsic  Changes  left  in 
the  tissues  (bones  ?)  after  syphilis  may  be  the  pathologic  basis,  and 
osteosarcoma  may  act  similarly. 

Symptoms. — Idiopathic  pernicious  anemia  develops  so  slowly  and 
insidiously  that  it  is  hardly  ever  possible  to  fix  upon  any  precise  date  as 
the  commencement  of  the  disease.  The  transition  from  health  to  pro- 
gressive pernicious  anemia,  particularly  in  persons  previously  feeble  and 
pale,  is  usually  too  gradual  to  be  demonstrable  :  though  a  rapid  and 
acute  onset  is  rare,  it  may  occur  in  pregnant  or  puerperal  women. 

Pallor  is  soon  noticed  and  gradually  increases,  or  when  there  has 
been  a  previous  pallor,  this  becomes  more  marked.  Shortness  of  breath 
SLud  palpitation  of  the  heart,  especially  on  exertion,  are  complained  of; 
the  patient  is  also  easily  fatigued,  and  becomes  quite  languid.      Occa- 

^  Lancet,  Jan.  27,  1900 


PROGRESSIVE  PERNICIOUS  ANEMIA.  429 

sional  nausea  may  come  on  early  in  those  cases  in  which  a  previous 
gastro-intestinal  disturbance  has  been  noted,  and  headache,  vertigo,  tin- 
nitus aurium,  and  anorexia  ensue  and  grow  progressively  worse.  Gen- 
eral weakness  increases,  and  occasional  attacks  of  faintness  and  vomit- 
ing supervene.  Meanwhile,  the  skin  takes  on  a  bloodless,  Avaxy  appear- 
ance, and  soon  the  characteristic  lemon-yelloiv  tint  appears.  The  mucous 
membranes  (lips,  gums)  are  likewise  pale  and  colorless.  Prostration  in 
bed  gradually  becomes  almost  absolute  as  the  feebleness  and  flabbiness 
of  the  tissue  increase.  Malleolar  edema  is  sometimes  noticeable,  and 
ecchymoses — mucous  and  cutaneous — are  seen  in  profound  cases  of 
anemia.  Although  the  intellect  is  not  impaired,  except  that  mental  ex- 
ertion becomes  irksome,  the  tone  and  manner  of  speech  are  feeble.  As 
the  debility  becomes  severe  the  mind  wanders,  and,  to  use  Addison's 
words,  the  patient  "  falls  into  a  prostrate  and  half-torpid  state,  and  at 
length  expires." 

Emaciation  is  rare,  the  fat  being  preserved  and  sometimes  increased 
in  quantity.  Pulsation  in  the  large  arteries  is  abnormally  visible,  and 
a  diffuse,  exaggerated  cardiac  impulse  is  felt.  The  pulse  early  in  the 
case  may  be  strong,  and  generally  it  is  rapid  (100-120),  soft,  and  com- 
pressible, and  as  full  and  quick,  often,  as  the  Avater-hammer  pulse  of 
aortic  regurgitation.  Auscultation  reveals  the  constant  and  character- 
istic hemic  murmurs.,  best  heard  at  the  base  of  the  heart,  and  the  bruit 
de  diable  in  the  veins  of  the  neck.  There  may  also  be  visible  pulsations 
in  the  latter. 

G-astro-intestinal  symptoms  may  be  the  most  prominent  signs  in  cases 
Avhere  gastritis  polyposa  and  gastritis  atrophica  are  causal.  Diarrhea, 
dyspepsia,  nausea,  and  vomiting  are  then  present  throughout  the  long 
course ;  otherAvise,  constipation,  eructations,  and  simple  anorexia  are 
most  common. 

An  ophthalmoscopic  examination  shoAvs  the  cause  of  the  anemic 
amaurosis,  in  the  profound  cases  of  anemia,  to  be  one  or  more  retinal 
hemorrhages.  The  Avhites  of  the  eyes  become  pearly,  the  conjunctivae 
pale.  The  liver  and  spleen  are  rarely  palpable.  The  bones,  and  especi- 
ally the  sternum,  are  sometimes  sensitive  to  pressure. 

Respiratory  Symptoms. — The  breathing  is  accelerated,  and  the  anemic 
dyspnea  may  become  very  pronounced  and  stertorous,  accompanied  by 
a  sense  of  oppression  in  the  chest  and  a  "hunger  for  air."  Near  the 
end  pleural  and  pericardial  serous  effusions  and  pulmonary  edema  tend 
to  appear. 

The  urine  is  of  Ioav  specific  gravity,  and,  on  account  of  its  pigmenta- 
tion Avith  pathologic  urobilin,  dark  in  color.  The  urobilin  is  detected 
both  by  chemic  and  spectroscopic  examination.  In  the  former  the  addi- 
tion of  a  foAV  droj)s  of  an  alcoholic  solution  of  zinc  chlorid  to  the  urine 
gives  a  green  fluorescence.  The  presence  of  indican  in  the  urine 
points  to  albuminous  decomposition  in  the  intestines.  Albumin  and 
glucose  are  absent,  but  uric  acid  and  urea  are  both  increased  in  amount, 
the  former  occasionally  and  the  latter  usually. 

Fever  of  a  moderate  degree  is  commonly,  though  not  invariably, 
present,  the  evening  temperature  sometimes  reaching  102°  F.  (38.8°  C). 
Previous  to  death  the  temperature  may  be  subnormal. 

Nervous  Symptoms. — Paresthesia,  spastic  paralysis  of  the  limbs,  and 


430     DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 

a  loss  of  control  of  the  sphincters  indicate  the  paralytic  tendency  of 
those  cases  in  which  sclerosis  of  the  cord  occurs.  Tabetic  symptoms 
are  sometimes  marked. 

Blood-examination. — The  blood  is  usually  pale,  though  sometimes  dark 
and  watery,  and  the  oligocythemia  is  distinctive  of  pernicious  anemia. 
The  number  of  red  corpuscles  may  be  reduced  to  less  than  200,000  per 
c.mm.,  and  is  seldom  more  than  1,000,000.  There  is  ordinai-ily  no 
increase  in  the  number  of  leukocytes  ;  on  the  contrary,  they  may  be 
somewhat  diminished.  This  diminution  usually  affects  the  polynuclear 
cells  most.  The  percentage  of  hemoglobin  may  be  approximately  pro- 
portionate to  the  number  of  red  corpuscles,  but  more  often  it  is  relatively 
increased,  so  that  the  individual  corpuscles  are  rich  in  hemoglobin.  In 
other  words,  although  there  is  a  reduction  in  the  total  amount  of  hemo- 
globin, it  is  usuall}'  not  so  great  as  the  reduction  in  the  number  of  ery- 
throcytes ;  therefore,  the  percentage  of  hemoglobin  is  nearly  always 
relatively  higher  than  that  of  the  red  globules  (see  Fig.  35),  a  condition 


IOOt. 
90,5 

60-? 
\0% 

MONTH 

JUNE 

JULY 

AUGUST 

SEPT. 

MONTH 

lOOr 
30-' 
60$; 

50-; 

30^ 
20^ 

DAY 

-  z  s  s  g 

- 

« 

-  £ 

; 

-|S 

s 

^ 

s 

< 

- 

£ 

=  ,; 

t.^z 

- 

" 

- 

O 

« 

DAY 

5,000,000 

5,000.000 

4,000,000 

4,000,000 

1 

3,000,000 

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U 

1 

2,000,000 

2,000,000 

■<i.l 

1  V^ 

•• 

- 

i\. 

... 

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1,000,000 

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1    |N. 

-' 

■+- 

• 

500,000 

i    1 

^ 

J 

500.000 

1 

-■ 

— 

1 

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1 

Fig.  35.— Blood-chart  of  a  case  of  progressive  pernicious  anemia.    Black,  red  corpuscles  ;  red, 

hemoglobin. 

in  marked  contrast  with  chlorosis.  Macrocytes,  microcytes,  and  poi- 
kilocytes  are  abundant,  and  the  macrocytes  are  supposed  to  give  rise  to 
the  relatively  larger  percentage  of  hemoglobin.  The  presence  of  nu- 
cleated red  corpuscles  is  also  a  striking  characteristic  of  pernicious 
anemia.  When  normal  in  size  they  are  known  as  normoblasts  :  when 
very  large,  as  gigantohlasts.  In  the  former,  according  to  Ehrlich,  the 
eccentrically-placed  nuclei  stain  deeply ;  in  the  latter  the  large  nuclei 
stain  faintly.  The  former  are  typical  of  those  nucleated  red  globules 
found  in  the  hematopoietic  organ  of  adults  ;  the  hitter,  of  those  found 
in  the  blood-development  of  embryonic  life.  The  gigantohlasts  are 
numerous  in  this  disease.  There  are  other  and  various  forms  of  degen- 
eration of  the  red  cells,  but  these  are  of  minor  import.  There  may  be 
an  increase  in  the  small  lymphocytes  at  the  expense  of  the  polynuclear 
cells;  and,  according  to  Cabot,  there  was  always  a  marked  leucopenia, 
in  a  series  of  110  cases.'  The  blood-phites  are  generally  fewer  than 
normal.  The  relative  proportion  of  the  proteids  in  the  blood-plasma  is 
altered  (Adami). 

Diagntiosis. — The  clinical   characteristics,  particularly  steady  pro- 
»  Cabot :   Medical  Nms,  May  o,  1900. 


PROGRESSIVE  PERNICIOUS  ANEMIA.  431 

gression  ^vith  remissions,  are  quite  as  important  as  microscopic  study  of 
the  blood.  The  possibility  of  hidden  carcinoma,  gastric  atrophy,  the 
anchylostoma  or  other  parasite,  and  incipient  tuberculosis  should  be 
borne  m  mind  also.  Intestinal  parasites  may  be  inferred  from  the 
microscopical  examination  of  the  feces  after  a  brisk  purge  if  the  eggs 
of  the  parasites  or  the  parasites  themselves  be  found.  Atrophic 
gastritis  may  be  discriminated  by  examining  the  viscus  and  gastric 
juice  by  modern  methods.  The  following  table  will  permit  the  elimina- 
tion of  obscure  gastric  carcinoma: 

Progressive  Perxiciol'S  Anemia.  Obscure  Gastric  Carcinoma. 

The  biood  shows  characteristic  changes,       Blood  shows  characteristics  of  secondary 
and  the  red  corpuscle  count  falls  to  or  anemia,  and  the  count  does  not  fall  to 

below  1.000,000  per  c.mm.  1,000.000,  as  a  rule. 

Found  earlier  in  life.  Occurs  after  middle  life. 

Gastric  symptoms  not  so  prominent.  Gastric  symptoms  more  sugcrestive. 

Lemon-tinted  skin  common.  Skin    of  a   pale,    muddy-color,    or    only 

slightly  jaundiced  (saffron-yellow). 
Adipose  tissue  fairly  well  preserved.  Progressive  emaciation. 

No  glandular  enlargements  palpable.  Supraclavicular  or  inguinal  glands  may 

be  palpable. 
No  physical  signs  over  stomach.  There  may  be   an   area   of  increased  re- 

sistance over  the  stomach. 
Examination    of    gastric    contents    after      Examination  of   gastric  contents   shows 
test-meal  usually  negative.  deficiency  or   absence   of  free   hydro- 

chloric acid  and  presence  of  lactic  acid. 
Some  improvement  may  be  brought  about       Condition   becomes  steadily  worse  until 
— even  cure,  though  very  rarely.  death  ends  the  case. 

FrOm  chlorosis  the  affection  may  be  differentiated  easily  by  the  blood- 
examination.  The  relative  increase  in  hemoglobin,  the  presence  of  gi- 
gantoblasts  and  many  macrocytes,  and  the  severe  oligocythemia  are 
pathognomonic  of  pernicious  anemia,  and  are  in  marked  contrast  to  the 
oligochromemia,  and  slight,  if  any,  reduction  in  the  number  of  red 
globules  of  chlorosis.  Again,  the  progressive  pernicious  character  of 
the  former  and  the  tendency  to  hemorrhage  should  be  remembered,  as 
well  as  the  contrasting  factors  of  age  and  sex  in  the  two  affections. 

Prognosis. — The  disease,  as  a  rule,  terminates  fatally,  though  not 
so  frequently  noAv  as  at  one  time,  for  obvious  reasons.  The  course  of 
pernicious  anemia  is  usually  sIoav  and  gradual,  and  may  be  interrupted 
by  improvement  or  apparent  recovery.  Recurrences,  however,  invari- 
ably occur.  Idiopathic  anemia  is  therefore  almost  hopeless,  although  a 
few  apparently  substantial  recoveries  have  been  reported.  The  dura- 
tion of  the  disease  is  seldom  more  than  a  year,  and  may  not  be  more 
than  two  or  three  months.  The  nucleated  red  corpuscles  usually  become 
much  more  numerous  shortly  before  death  (^Billings).  Death  may  be 
caused  either  by  syncope,  cerebral  hemorrhage  (most  commonly),  or  by 
slow  asthenia. 

Treatment. — Hygienic  measures  must  be  regarded  as  of  signal  im- 
portance, and  rest  in  bed,  together  with  light  nutritious  food  given  at 
short  regular  intervals,  is  indicated  first  of  all.  Salt-water  baths  and 
gentle  and  systemic  massage  when  the  patient  is  at  absolute  rest  and  is 
not  too  w^eak,  are  useful  adjuvants. 

The  value  of  arsenic  in  this  disease  is,  I  think,  analogous  to 
that   of   iron   in   chlorosis.      The  best  action  of  the  drug  will  be   ob- 


432     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

tained  by  the  administration  of  gradually  ascending  doses  of  Fowler's 
solution  or  of  arsenous  acid.  Beginning  with  four  or  five  drops  of  the 
former,  three  times  daily  during  the  first  week,  and  thereafter  adding 
one  drop  to  the  dose  every  day  or  two  up  to  the  point  of  tolerance,  as 
much  as  twenty  or  thirty  drops,  well  diluted,  may  be  taken  (see  Fig. 
36).     Evidences  of  gastro-intestinal  irritation  should  be  watched  for, 


9C% 
80;; 
70j 

40-. 

'0> 

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SEPT. 

OCTOBER 

NOVEMBER 

DECEMBER 

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_L 

M  1  1  1  1  M  1 

'  M  1  1  M  M 

1  M  r 

Pig.  36.— Chart  of  a  case  of  progressive  pernicious  anemia,  showing  the  improvement  foUowing 
the  administration  of  arsenic.     Black,  red  corpuscles  ;  red,  hemoglobin. 

and  the  arsenic  either  discontinued  or  the  daily  dose  reduced  should 
they  appear.  Sometimes  it  is  advisable  to  use  the  remedy  hypodermic- 
ally.  Arsenous  acid  is  given  in  pill  form,  commencing  with  ^  or  ijlj 
gr.  (0.0021-0.0032). 

The  introduction  by  Fraser  of  Edinburgh  of  bone-marrow  in  the 
treatment  of  pernicious  anemia  has  been  followed  by  various  results  : 
some  cases  have  been  reported  in  Great  Britain  and  in  the  United  States 
in  which  it  has  seemed  to  do  good,  while  in  others  it  was  found  to  be 
useless.  While  the  glycerin  extract  is  the  preparation  generally  used, 
it  is  not  so  reliable  as  the  raw  red  bone-marrow,  or  that  freshly  prepared 
each  day  by  mixing  with  it  an  equal  quantity  of  glycerin  :  an  ounce  or 
two  may  be  administered  daily.  Hunter  suggests  the  use  of  anti-strep- 
tocccus  serum  coupled  with  the  antiseptic  care  of  the  mouth  and 
gastro-intestinal  antisepsis. 

Near  the  end  of  the  disease  the  danger  often  greatlv  increases,  owing 
to  the  marked  reduction  in  the  quantity  of  the  blood  {oligemia).  This 
may  be  combated  by  the  injection  of  warm  water  or  a  weak  saline  solu- 
tion into  the  colon  (enteroclysis)  and  also  into  the  subcutaneous  tissue 
(hypodermoclysis).  Both  the  former  procedure  and  gastric  lavage  are 
of  value  in  preventing  and  ameliorating  the  gastro-intestinal  disturbance 
from  fermentation  and  putrefaction.  Intestinal  antiseptics  (thymol,  guai- 
acol  carbonate,  salol,  beta-naphtol,  and  hydro-naphtol)  should  be  given 
by  the  mouth  in  conjunction  with  the  injections,  and  lavage  of  the 
tract  should  be  employed   for  the  same  purpose. 

Anthelmintics  must  be  used  in  those  cases  of  pernicious  anemia  in 
which  intestinal  parasites  are  associated.  Dilute  hydrochloric  acid,  nux 
vomica,  and  bitter  tonics  are  serviceable  in  cases  in  which  gastric  diges- 
tion is  impaired. 


THE  SECONDARY  ANEMIAS.  433 

During  the  convalescence  in  favorable  cases  iron  seems  to  be  pecu- 
liarly valuable,  sometimes  alone  and  frequently  in  conjunction  with 
arsenic.  Thus,  arsenious  acid  and  either  the  carbonate  of  iron  or  re- 
duced iron  may  be  combined  in  pill  form,  or  Fowler's  solution  and  the 
tincture  of  the  chlorid  of  iron,  or  Blaud's  pill,  may  be  used  with  satis- 
factory results.  Recurrences  Avill  yield  to  the  same  treatment,  if  they 
yield  at  all,  except  that  the  doses  may  have  to  be  increased  according  to 
the  tolerance  of  the  individual  case. 

II.  THE   SECONDARY  ANEMIAS. 

The  secondary  anemias  are  symptomatic  of  abnormal  processes  or  of 
existing  disease,  whether  acute  or  chronic,  and  their  causes  are  numer- 
ous and  various.  I  have  already  stated  that  secondary  anemia  may 
occur  when  the  true  primary  form  cannot  readily  be  determined  and 
when  the  course  of  the  anemia  is  progressive  and  pernicious.  Further- 
more, several  possible  causes  may  exist  in  a  given  case  of  symptomatic 
anemia,  and  it  may  be  quite  difficult  to  discover  which  of  these  is  the 
active  factor  in  the  condition. 

In  certain  secondary  anemias,  also,  the  associated  impairment  of  the 
blood-making  organs  is  so  evident  that  the  anemia  may  assume  almost 
a  primary  importance.  This  was  exemplified  in  StrlimpelFs  case  of 
carcinoma  and  anemia,  with  secondary  implication  of  the  bone-marrow. 
The  variety  and  uncertainty  of  the  causes  of  secondary  •  anemias  thus 
prevent  a  satisfactory   classification. 

The  Blood. — In  most  cases  this  distinctly  differs  in  character  from  the 
blood  of  the  primary  or  essential  anemias.  There  is  oligocythemia, 
usually  of  a  moderate  degree,  about  3,000,000  red  corpuscles  per  cubic 
millimeter  being  noted,  though  in  cases  of  severe  hemorrhage  the  reduc- 
tion may  be  as  great  for  a  time  as  in  pernicious  anemia.  There  is  also 
a  relative  decrease  in  the  amount  of  hemoglobin,  and  sometimes  the  per- 
centage may  be  relatively  lower  even  than  is  compatible  with  the  de- 
crease in  the  number  of  the  red  corpuscles.  There  is  a  relative,  and 
often  an  absolute,  increase  in  the  number  of  leukocytes  {vide  Fig.  37). 
Either  a  few  or  many  poikilocytes,  a  few  macrocytes,  microcytes,  and 
nucleated  red  cells,  some  shoAving  fragmented  nuclei,  are  found.  Free 
nuclei  may  occur,  Gigantoblasts  are  not  seen,  and  the  relative  increase 
in  the  percentage  of  hemoglobin  is  also  absent. 

The  most  important  etiologic  groups  of  secondary  anemias  are  as 
follows  :  (1)  Hemorrhage.— Hemorrhages  occur  under  a  great  variety  of 
circumstances,  and  if  copious  result  in  an  acute  secondary  anemia. 
Thus  there  may  be  the  rupture  of  an  aneurysm,  monorrhagia,  post- 
partum hemorrhage,  hemoptysis,  gastrorrhagia,  enterorrhagia,  etc.,  all 
of  Avhich  produce  the  same  general  effect  upon  the  system.  Repeated 
small  hemorrhages  may  finally  produce  the  same  result  as  a  single  large 
one,  and  spontaneous  hemorrhages  or  epistaxes,  such  as  occur  in  persons 
of  a  hemorrhagic  diathesis  (hemophilia)  or  in  purpura  and  scurvy,  may 
cause  profound  secondary  anemia.  Females  are  most  tolerant  of  losses 
of  blood,  but  infants  of  both  sexes  bear  depletion  very  badly.  The 
total  mass  of  blood  may  be  much  diminished  (oligemia),  and  the  sudden 
loss  of  a  great  volume  of  blood  may  prove  fatal  in  a  few  moments ;  but 

28 


434     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

it  is  often  surprising  how  recovery  can  take  place,  and  often  does,  after 
the  rapid  loss  of  several  pounds  of  blood — e.  g.  in  hemoptysis,  hematem- 
esis,  or  menorrhagia.  Sometimes  the  source  of  bleeding  is  obscure, 
as  in  cases  of  intestinal  parasites,  hepatic  cii'rhosis,  or  duodenal  ulcer ; 
or  it  may  be  intentionally  kept  suh  rosa  by  females  having  uterine  dis- 
order or  bleeding  hemorrhoids.  The  (juick  blanching  of  the  counte- 
nance, the  Aveakness,  the  coldness  of  the  skin,  faintness,  dimness  of  vision, 
tinnitus  aurium,  sighing  respiration,  and  feeble,  rapid  pulse  are  charac- 
teristic symptoms  of  acute  anemia.      Unconsciousne.^s  and  epileptiform 


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Fig.  37.— Blood-chart  of  a  case  of  symptomatic  anemia.    Black,  red  corpuscles;  red,  hemoglobin; 

blue,  white  corpuscles. 


co7ivulsions  precede  death  in  cases  in  which  the  total  volume  of  blood 
lost  is  sufficiently  large.  When  recovery  takes  place  the  blood-regen- 
eration goes  on  rapidly,  so  that  within  from  one  to  three  weeks  restitu- 
tion is  complete.  The  normal  volume  is  soon  restored — first  by  the 
absorption  of  Avater,  hydremia  existing  for  several  days  before  the  saline 
and  albuminous  elements  are  renewed.  The  white  corpuscles  are  earlier 
restored  than  the  red,  so  that  there  is  a  temporary  relative  leukocytosis. 
The  hemoglobin  is  restored  still  more  slowly  than  the  red  corpuscles. 

(2)  Inanition. — Anemia  from  inanition  may  be  caused  by  a  food- 
supply  that  is  insufficient  either  in  (juantity  or  quality,  or  both;  or, 
even  with  abundant  food  of  sufficient  nutritive  qualities  the  digestive 
power  may  be  so  im|);iired  as  to  cause  defective  assimilation.    Esophageal 


THE  SECONDARY  ANEMIAS.  435 

carcinoma  and  chronic  gastritis,  especially  of  the  atrophic  variety,  may 
thus  cause  anemia  from  inanition.  The  reduction  of  the  blood-plasma 
forms  a  feature,  while  the  corpuscles  may  be  affected  but  slightly. 

(3)  Excessive  albuminous  discharges,  as  in  chronic  Bright's  disease, 
prolonged  suppuration,  long-continued  lactation,  chronic  dysentery,  etc., 
drain  the  system  so  that  marked  anemia  may  be  produced. 

(4)  Toxic  Agents. — The  poisons  may  either  be  organic  or  inorganic, 
though  toxic  anemias  are  most  common  from  the  absorption  of  lead, 
arsenic,  mercury,  and  phosphorus.  The  poisoning  is  usually  chronic, 
and  affects  principally  the  corpuscles.  Anemia  due  to  the  poisons  of 
acute  or  chronic  infectious  diseases  is  also  frequently  met  with,  and  may 
thus  be  observed  after  typhoid  fever,  diphtheria,  yellow  fever,  and  in- 
flammatory (articular)  rheumatism  among  the  acute  diseases,  and  during 
chronic  malaria,  tuberculosis,  and  syphilis  ("syphilitic  chlorosis"). 
There  is  considerable  destruction  of  the  red  corpuscles  in  some  of  these 
diseases,  either  directly  or  indirectly,  and  the  greater  the  pyrexia  the 
greater  the  action  upon  the  blood  or  blood-making  organs. 

Symptoms. — The  common  indications  of  secondary  anemia  are  the 
pallor  of  the  face  and  mucosae,  muscular  and  mental  weakness,  loss  of 
nerve-function,  neuralgias,  coolness  of  the  skin,  dyspnea  on  exertion, 
cardiac  palpitation,  impaired  appetite  and  digestion,  and  a  weak  pulse. 
The  physical  signs  are  those  of  the  primary  or  essential  anemias. 

Diagfliosis. — Here  may  be  advantageously  contrasted  the  distin- 
guishing features  naturally  grouping  themselves  under  symptomatic  and 
essential  anemias,  respectively  : 

Symptomatic  or  Secondary  Anemia.  Idiopathic  or  Essential  Anemia. 

A  symptomatic  blood-condition  secondary      A    primary    disease   of   the   blood   and 
to  disease  elsewhere.  blood-making  organs. 

Occurs  at  any  age.  Occurs    principally   during    adolescence 

and  early  middle  life. 

Previous   or   associated   history  of  trau-      Previous  history  negative  in  its  bearings 
matic     or     spontaneous    hemorrhage,  upon  the  disease, 

chronic  suppuration,  prolonged  lacta- 
tion, chronic  Bright's  disease,  carci- 
noma, chronic  lead-poisoning,  chronic 
malaria,  etc. 

Blood-changes  not  so  marked  and  more      Distinctive      blood-characteristics,      and 
variable.  often    profound   changes,   both    as   to 

blood-cells  and  hemoglobin. 

Moderate    reduction  in  both,  merely  the       Marked   reduction    in    either  the  hemo- 
relative  proportion  being  maintained.  globin  percentage  or  in  the  number  of 

red  corpuscles. 

General  symptoms  and  signs  usually  sub-      General  symptoms  and   signs  also  more 
ordinate  in   manifestation  to  those  of  characteristic  of  the    respective   form 

the  primary  disease  or  lesion.  of  anemia  in  the  case. 

Gravity  of  anemia  depends  on  that  of  the       Gravity     depends     on     type   of    blood- 
primary  disease.  changes    and   progressiveness   of  dis- 
ease. 

Often  responds  to  treatment,  depending       One  variety  (chlorotic)  quite  curable,  the 
on  the  cause  ;  in  a  few  instances,  as  other    (progressive     pernicious)    com- 

in  hemorrhage,  it  is  short  in  duration.  monly  fatal. 

The  prognosis  depends  upon  the  cause  of  the  anemia. 
Treatment. — Symptomatic  anemia  is  amenable  to  treatment  accord- 


436     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

ing  to  the  cause.  The  traumatic  acute  variety  does  well  under  simple 
hygienic  measures  after  the  urgent  indications  have  been  met.  Plenty 
of  pure  air,  Avholesome  food,  and  graduated  rest  and  exercise  may  suf- 
fice, and  drugs  not  be  needed.  Cases  in  Avhich  it  is  difficult  or  -wellnigh 
impossible  to  remove  the  cause  of  the  anemia  of  course  do  not  improve 
under  any  treatment  other  than  that  which  may  favorably  influence  the 
primary  affection.  Nutritious  aliment,  iron  in  some  form,  a  judicious 
hygienic  regimen  calculated  to  increase  the  assimilation,  and  stomachic 
and  general  tonics  are  required  in  the  majority  of  cases.  Toxic  sub- 
stances must  be  eliminated,  their  re-introduction  into  the  body  prevented, 
and  the  repair  of  the  blood  and  tissue  actively  promoted. 

LEUKOCYTOSIS. 

Definition. — A  temporary  increase  in  the  number  of  polymorpho- 
nuclear leukocytes  in  the  blood  though  rarely  in  the  mononuclear  ele- 
ments. Leukocytosis,  however,  may  be  continuous.  The  number  of 
white  corpuscles  in  a  moderate  leukocytosis  would  be  about  10,000 
per  cubic  millimeter ;  in  marked  leukocytosis  there  might  be  as 
many  as  from  20,000  to  40,000 ;  a  count  of  50,000  leukocytes  to  the 
c.mm.  may,  however,  usually  be  considered  to  indicate  leukemia.  Von 
Limbeck,  notwithstanding,  reported  a  case  of  leukocytosis  accompany- 
ing carcinoma  of  the  kidney  with  metastasis,  in  which  there  were 
80,000  white  corpuscles  per  cubic  millimeter. 

Physlolnjfic  leukori/fnsis  occurs  in  infants  during  the  first  few  davs 
after  birth,  in  pregnancy,  during  digestion,  and  after  exercise.  Accord- 
ing to  Carter,  the  ''  digestion  leukocytosis  is  present  after  a  meal  of 
proteids  or  hydrocarbons,  but  not  after  a  meal  of  carbohydrates."  * 
Massage  and  cold  baths  also  produce  leukocytosis,  probably  by  stimula- 
ting the  circulation,  and  not  by  increasing  the  actual  number  of  leuko- 
cytes, some  of  which  have  simply  become  stagnated. 

Pathologic  leukocytosis  is  secondary  to  various  aff"ections.  It  may 
be  temporary,  as  in  the  curable  primary  diseases,  or  permanent,  as  in 
those  that  do  not  permit  of  recovery.  It  is  also  found  to  be  well 
marked  in  acute  inflammations  and  in  infectious  febrile  diseases  aecom- 
panied  with  exudation,  such  as  pneumonia,  pertussis,  and  diphtheria. 
In  pleuritis.  peritonitis,  pericarditis,  erysijielas,  and  in  all  snjijuirative 
processes  there  is  an  excess  in  the  number  of  polynuclear  neutropliiles. 
Inflammations  of  the  serous  membranes,  Avhen  not  tuberculous,  causes 
leukocytosis,  so  that  a  purulent  meningitis  may  be  differentiated  from 
tuberculous  meningitis  by  the  pronounced  leukocytosis  in  the  former 
and  its  absence  in  the  latter.  As  a  rule,  the  greater  the  local  reaction 
and  the  stronger  the  resistance  to  severe  infections  the  greater  the  leuko- 
cytosis. As  IS  well  known,  the  pus-cells  of  an  abscess  consist  almost 
wholly  of  dead  white  corpuscles — phagocytes — that  have  been  overcome 
or  exhausted,  directly  or  indirectly,  in  the  struggle  against  the  toxin  of 
the  infection.  Cac/tectic  states,  as  in  cases  of  malignant  tumors,  are 
often  attended  with  an  increase  in  the  number  of  mononuclear  cells  in 
the  blood,  especially  in  the  region  of  the  tumor  and  where  the  lymph- 
glands  are  involved.      Leukocytosis  may  be  very  marked  in  carcinoma, 

'  Univ.  Med.  Magazine,  vols,  vii  and  viii,  p.  181,  Dec  ,  1894. 


LEUKOCYTHEMIA.  437. 

and  near  the  close  in  any  marantic  condition.  Chemical  irritants, 
such  as  turpentine,  may  also  produce  leukocytosis,  and  whatever  the 
substance  causing  the  condition  it  is  spoken  of  as  positively  chemotactic 
— attractive  to  the  white  blood-corpuscles — in  contradistinction  to 
negatively  chemotactic  substances,  which  repel  the  white  corpuscles. 

In  non-leukocytotic  infectious  diseases  (typhoid  fever,  influenza, 
malaria,  and  acute  miliary  tuberculosis),  the  diagnosis  of  a  complicating 
pleuritis,  for  example,  may  be  confirmed  by  the  detection  of  the  leu- 
kocytosis. Leukocytosis  under  such  circumstances  has  prognostic  im- 
portance. Diminishing  leukocytosis  during  the  height  of  a  grave  dis- 
ease may  be  significant  of  lessening  powers  of  resistance,  though  this  is 
not  an  invariable  rule,  since  just  before  the  crisis  of  a  pneumonia  a 
diminution  of  the  leukocytes  is  apt  to  occur. 

The  object  of  the  leukocytosis  is  naturally  protective,  beneficent,  and 
reparative.  It  is  accomplished  either  by  direct  antagonism  or  by  the 
formation  of  substances  that  enter  the  fluids  and  tissues  of  the  body, 
and  counteract  the  influence  of  the  toxic  substances  causing  the  disease. 
The  existence  of  leukocytosis  can  best  be  determined  by  the  examination 
of  stained  specimens  of  the  blood.  Physiologic  digestion  leukocytosis 
is  to  be  discriminated  from  the  pathologic  variety  by  making  the  ex- 
amination several  hours  after  the   last  meal  has  been  taken. 

LEUKOCYTHEMIA. 
{True  Leukemia.) 

Definition. — A  blood-disease,  usually  chronic,  characterized  by  a 
peculiarly  marked  and  persistent  increase  in  the  number  of  leukocytes, 
associated  with  lesions  occurring  either  respectively  or  unitedly  in  the 
spleen,  bone-marrow,  and  Ij^mphatic  glands. 

Pathology. — Bodily  emaciation  and  pallor  are  pronounced,  and 
edema,  Avith  dropsical  efl"usions  in  the  serous  cavities,  is  by  no  means 
uncommon.  The  cardiac  chambers  and  principal  veins  are  distended 
with  large  blood-clots  of  a  greenish-yellow  or,  in  extreme  cases,  yellow- 
ish-white, purulent  appearance.  Subserous  ecehymoses  of  the  pericar- 
dium and  endocardium  are  frequent,  and  the  myocardium  is  often  found 
to  have  undergone  a  moderate  degree  of  fatty  degeneration.  Various 
abnormal  substances  have  been  found  in  leukemic  blood,  and  among  them 
the  following  may  be  mentioned :  hypoxanthin,  leucin,  tyrosin,  acetic, 
formic,  and  lactic  acids,  and  certain  albuminous  substances  (deutero- 
albumose  and  nucleo-albumin)  resulting  probably  from  the  destruction 
of  blood-corpuscles.  The  alkalinity  and  specific  gravity  of  the  blood  are 
both  diminished.  The  minute,  colorless,  octahedral,  so-called  Charcot's, 
crystals  are  found  most  abundantly  in  settled  leukemic  blood,  and  have 
also  been  detected  in  the  spleen,  bone-marrow,  and  liver,  as  well  as  in 
other  affections.     Their  composition  is  not  clearly  known. 

Although  the  spleen,  bone-marrow,  or  the  lymph-glands  may  alone 
show  the  pronounced  pathologic  changes  of  leukemia,  it  is  usual  to 
find  all  more  or  less  afl'ected.  Purely  splenic  or  myelogenic  leukemia, 
and  the  latter  especially,  are  rarer  than  the  lymphatic  type,  so  that  it  is 
customary  to  speak  of  two  principal  groups:  (1)  splenic-myelogenous  (or 
spleno -medullary)  leukemia,  the  most  frequent  variety ;  and  (2)  lym- 
phatic leukemia. 


438    DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 

There  is  nearly  always  some  splenic  enlargement,  and  in  many 
cases  the  enlargement  is  considerable,  as  in  spleno-medullary  leukemia. 
Leukemic  spleens  sometimes  weigh  as  much  as  from  two  to  eighteen 
pounds,  and  their  lengths  may  vary  from  six  to  twelve  inches.  The 
enlargement  is  generally  uniform,  and  the  notches  upon  the  anterior 
border  may  be  much  exaggerated.  White  patches  of  perisplenitis  and 
a  thickened  capsule  adhering  to  the  surrounding  organs  and  the  abdom- 
inal wall  may  also  be  noticed.  The  consistence  of  the  spleen  is  firm 
and  resistant  to  the  knife,  though  in  the  earlier  stages  it  may  be  quite 
soft  and  pulpy.  The  cut  surface  is  either  of  a  uniformly  brown  color 
or  mottled  by  the  presence  of  grayish-  or  yellowish-white  circumscribed 
lymphoid  tumors,  or  by  deep-red  or  brownish-yellow  hemorrhagic  in- 
farcts. The  Malpighian  bodies  may  or  may  not  be  visible.  The  blood- 
vessels at  the  hilum  are  enlarged.  Microscopic  examination  shows 
hyperplasia  of  the  organ,  although  most  pathologists  regard  the  change 
as  lymphadenomatous  in  nature  rather  than  a  simple  hyperplasia.  The 
cells  of  the  pulp  sometimes  show  granular  and  fatty  degeneration,  and 
in  advanced  cases  the  trabecuhe  may  be  thickened  by  a  considerable 
amount  of  firm  connective  tissue. 

In  the  majority  of  cases  the  bone-marrow  is  affected  as  well  as  the 
spleen,  and  a  purely  myelogenous  leukemia  is  extremely  rare.  Indeed, 
the  few  reported  cases  of  the  latter  may  be  doubted.  The  medullary 
substance,  instead  of  being  fatty,  is  rich  in  lymphoid  and  blood-cells  in 
various  stages  of  development,  and  is  either  reddish-brown  or  greenish- 
yellow  in  color.  Neuman  regarded  the  marrow-change  as  a  constant 
and  essential  lesion  of  leukemia,  and  called  the  former  transformation 
"lymph-adenoid,"  and  the  latter  "pyoid."  The  pus-like  marrow  and  the 
dark-red  may  exist  side  by  side,  although  the  former  is  more  common. 

A  fine  reticulum  may  be  seen  between  the  cells,  especially  in  the 
dark-red  variety,  and  small  hemorrhagic  infarcts  may  also  be  noted 
occasionally.  Microscopically ^  the  medulla  contains  an  abundance  of 
lymphoid  cells  and  nucleated  red  corpuscles.  Eosinophilic,  mononuclear, 
and  polynuclear  leukocytes  are  also  present,  the  first-named  being  quite 
numerous,  as  are  also  certain  myelo-plaques  and  cells  showing  karyo- 
kinetic  figures.  The  li/mphatic  glands  are  more  or  less  enlarged  in  the 
splenic  and  medullary  forms  of  leukemia. 

In  the  lymphatic  variety,  especially  when  acute,  an  early  and  marked 
hyperplasia  of  all  the  glands  takes  place.  The  cervical,  axillary,  in- 
guinal, and  mesenteric  glands  are  usually  involved,  and  may  form  dis- 
tinct, soft,  and  movable  tumors,  their  color  being  a  reddish-gray. 
Rarely,  the  primary  lesions  may  be  in  the  lymphadenoid  tissues  of  the 
gastro-intestinal  tract. 

The  histological  examination  shows  an  increase  in  the  cellular  ele- 
ments. A  similar  hyperplasia  occurs  in  those  glandular  tissues  that  are 
allied  to  the  lymphatic  glands,  such  as  the  tonsils,  lymph-follicles,  the 
tongue,  mouth  and  pharynx,  thymus  gland,  and  the  solitary  and 
Peyer's  agminated  intestinal  glands. 

The  liver  may  be  greatly  enlarged  ;  indeed,  some  of  the  instances  of 
greatest  enlargement  of  this  organ  have  been  those  due  to  leukemia,  the 
Aveight  being  as  much  as  fourteen  pounds.  The  enlargement  is  uniform 
and  due  to  a  diffuse  leukemic  infiltration.  The  capillaries  and  inter- 
lobular tissue  are  distended  with  leukocytes,  and  disseminated  whitish 


LEUKOCYTHEMIA.  439 

or  grayish  nodules,  usually  quite  small,  consisting  of  lymphoid  cells 
undergoing  indirect  division  of  their  nuclei,  are  frequently  found. 
Sometimes  these  leukemic  nodules  appear  as  definite  growths,  with  an 
adenoid  reticulum  between  the  cells,  on  account  of  which  they  have 
been  called  lymphomata  or  lymph-adenomata. 

Similar  changes  are  observed  in  the  kidneys,  enlargement,  paleness, 
and  diffuse  and  circumscribed  leukemic  infiltration  of  the  capillaries  and 
intertubular  tissue  all  being  noted.  Leukemic  nodules  may  also  be 
found  in  other  parts  of  the  body,  such  as  the  retina,  brain,  serous  mem- 
branes, lungs,  testicles,  and  skin.  Karyokinetic  figures  are  numerous 
in  the  cells  accompanying  these  leukemic  growths. 

Ktiology. — The  primary  cause  of  leukemia  is  unknown ;  that  it 
directly  affects  the  blood-forming  organs,  however,  is  most  probable, 
though  with  differences  of  selection  and  co-ordination  and  with  different 
degrees  of  intensity.  The  combination  of  lesions  in  the  spleen,  lymph- 
glands,  and  bone-marrow,  along  with  the  histologic  similarity  of  the 
leukemic  growths  to  the  infectious  granulomata,  and  the  clinical  history 
of  cases  of  acute  leukemia,  would  seem  to  point  strongly  to  the  microMc 
origin  of  the  disease.  Moreover,  various  cocci  and  bacilli  have  been 
found,  but  not  one  of  them  has  been  definitely  proved  to  be  the  specific 
cause  of  the  disease.  Auto-intoxicatio7i  by  toxic  albuminoids  from  the 
digestive  tract  is  believed  by  Vehsemeyer,^  who  analyzed  600  cases,  to 
be  the  important  point  of  departure  of  the  disease.  It  is  likely  that  the 
direct  cause  of  the  leukocythemia  is  a  simple  increase  of  the  cytogenic 
function  of  one  or  more  of  the  hematopoietic  organs.  Kottnitz  held 
leukocythemia  to  be  a  reactive  condition  following  auto-intoxication 
with  peptones,  and  consequently  a  leukolysis,  the  over-action  of  the 
hematopoietic  organs  leading  to  hypertrophy.  Whether  the  reduction 
of  the  erythrocytes  is  due  to  diminished  production  or  to  increased 
destruction  is  not  positively  known,  although  the  former  factor  is  more 
probably  operative. 

The  disease  has  often  been  preceded  by  an  injury  or  a  blow  in  the 
splenic  region,  but  its  direct  traumatic  origin  is  hypothetic  only.  In- 
testinal ulceration  has  been  a  frequent  feature  prior  to  leukemia,  and 
undoubtedly  affords  a  source  of  possible  infection  from  the  tract. 
Stomatitis  also  may  furnish  a  means  of  entrance  for  the  infectious  agent. 
The  causal  relation  of  pseudo-leukemia  and  true  leukemia  is  uncertain, 
although  a  few  cases  of  the  one  have  been  observed  to  pass  into  the  other. 

In  a  considerable  proportion  of  cases  leukemic  patients  have  had 
malaria  of  some  form.  Syphilis  may  be  associated  with  the  disease,  but 
it  is  not  probable  that  it  acts  in  a  causative  manner. 

Hereditary  influences  undoubtedly  play  a  part;  a  "lymphogenous 
diathesis  "  may  thus  be  transmitted,  and  several  generations  may  be 
affected  by  the  disease.  Adverse  hygienic  and  social  conditions  may  also 
predispose  to  leukemia.  It  may  also  develop  after  pregnancy,  or  more 
commonly  at  the  climacteric.  Anxiety,  worry,  and  mental  depression 
have  been  mentioned  as  predisposing  causes,  with  doubtful  justification. 

Leukemia  occurs  most  frequently  in  males  during  the  middle  period 
of  life,  and  is  apt  to  attack  young  persons.  It  has  occurred  during  in- 
fancy, and  as  late  also  as  the  seventieth  year,  but  the  average  age  ranges 
^  International  klin.  Rundseh.,  Vienna,  Nov.  25,  1894. 


440    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

from  twenty-five  to  forty-five  years.  .  Sometimes  the  previous  condition 
■was  one  of  apparently  perfect  health. 

Symptoms. — Acute  leukemia,  although  comparatively  rare,  may  be 
described  briefly  first.  It  usually  occurs  in  an  adolescent  who  may  have 
enjoyed  previous  good  health.  Fussel  and  Taylor  collected  56  cases 
from  the  literature.  Its  onset  is  sudden,  and  usually  begins  with  pros- 
tration, hemorrhage  of  the  mucous  membranes,  and  high  fever.  Acute 
splenic  tumor  rapidly  develops  ;  the  lymphatic  glands  may  enlarge ;  and 
palpitation,  dyspnea,  and  gastro-intestinal  symptoms  of  a  severe  type 
appear.  The  skin  becomes  anemic,  and  edema  of  the  feet  is  common. 
The  blood  shows  a  marked  increase  in  the  number  of  leukocytes,  the 
ratio  to  the  red  corpuscles  being  1  to  30  or  1  to  50,  instead  of  the  nor- 
mal 1  to  350  or  1  to  600.  In  acute  lymphatic  leukemia  the  lympho- 
cytes are  very  numerous.  Large  mononuclear  leukocytes  and  myelo- 
cytes are  also  numerous,  while  the  eosinophilic  cells  are  few  in  number 
compared  Avith  those  found  in  the  blood  of  chronic  leukemia.  The  case 
grows  progressively  worse ;  hematemesis,  cerebral  or  retinal  hemor- 
rhages, and  petechije  supervene  perhaps,  and  the  clinical  features  may 
then  resemble  an  infectious  disease  with  hemorrhagic  and  purpuric 
manifestations.     Death  occurs  in  from  two  to  three  months. 

In  chronic  leukemia  the  onset  is  generally  slow  and  insidious  and  its 
development  imperceptible,  and  for  many  months  the  earlier  symptoms 
may  not  differ  from  those  of  simple  anemia.  Languor,  a  deranged 
appetite,  dizziness,  noises  in  the  ears,  faintness,  breathlessness  on  exer- 
tion, and  palpitation  may  all  appear.  Sometimes,  however,  not  even 
these  symptoms  are  present,  common  as  they  are  to  most  anemic  cases, 
and  the  patient  may  first  consult  the  physician,  because  of  a  swelling  or 
distress  in  the  left  side  of  the  abdomen — the  enlarged  spleen.  Early 
manifestations  may  be  hemorrhagic  in  some  cases  (epistaxis,  hematem- 
esis, enterorrhagia).  with  nausea,  vomiting,  and  diarrhea ;  or  increas- 
ing pallor  of  the  countenance,  yet  at  times  a  patient  may  appear  to  be 
plethoric  ;  or  troublesome  priapism  may  be  the  first  indication.  As  the 
disease  progresses  the  anemia  becomes  more  marked,  edema  of  the  de- 
pendent portions  of  the  body  may  appear,  and  fever,  though  slight  at 
first  (99.5°  F.— 37.5^  C),  may  gradually  rise  to  102°  or  103°  F  (39.4° 
C),  either  remaining  constant  or  alternating  with  periods  of  apyrexia. 

The  pulse-rate  is  increased  ;  in  quality  it  is  soft  and  compressible, 
though  sometimes  full  in  volume.  The  dyspnea  may  be  aggravated  by 
the  hydvothorax  of  a  general  dropsy  in  advanced  cases,  or  by  the  up- 
ward displacement  of  the  diaphragm  owing  to  the  increasing  splenic  and 
hepatic  enlargement.  Epistaxis  may  become  obstinate.  Retinal  hemor- 
rhage is  common,  and  there  may  be  aggregations  of  leukocytes  (leukemic 
growths).  Hemorrhages  from  mucous  membranes  are  common,  and 
localized  gangrent^  may  occur,  in  which  case  the  symptoms  of  infection 
appear.      Hemic  murmurs  are  quite  constant. 

Ulcerative  processes  in  the  bowels  may  give  rise  to  severe  dysenteric 
diarrhea.  Ascites  is  usually  present  in  advanced  cases  on  account  of 
the  splenic  tumor,  or  owing  to  pressure  upon  the  portal  vein  by  enlarged 
glands.  Jaundice  is  an  occasional  event.  Leukemic  peritonitis  may 
occur  from  the  presence  of  lymphomatous  growths  in  the  membrane. 

Nervous  symptoms,  such  as  headache,  vertigo,  and  syncopal  attacks, 


LEUKOCYTHEMIA.  441 

are  liable  to  recur  as  the  anemia  and  prostration  increase  and  the  lia- 
bility to  hemorrhage  becomes  more  frequent.  Sudden  coma  and  hemi- 
plegia following  upon  the  rupture  of  a  cerebral  vessel  (apoplexy)  may 
be  the  immediate  cause  of  death.  Minute  brain-hemorrhages,  which 
may  occur  at  any  period  of  the  disease,  probably  account  for  deafness. 
Priapism  may  be  very  troublesome.  Peripheral  paralysis  of  several  cra- 
nial nerves,  due  to  hemorrhages  into  their  sheaths,  has  been  reported. 

Cutaneous  ecchymoses  are  sometimes  observed,  and  sometimes  there 
is  a  troublesome  pruritus.  The  urine  contains  an  excess  of  uric  acid, 
but  albuminuria  does  not  occur,  except  as  a  complication. 

Along  with  the  anemia  and  debility  are  the  signs  of  splenic  and 
lymphatic  involvement,  and  rarely  of  the  bone-marrow.  The  liver  may 
also  become  enlarged. 

Leading  Symptoms  in  Detail. —  The  Spleeii. — This  organ  is  generally 
enlarged  in  all  forms  of  leukemia,  but  especially  in  the  spleno-medullary, 
the  most  frequent  form.  It  is  a  prominent  feature,  both  on  account 
of  its  being  the  first  subject  of  complaint,  and  because  of  the  huge 
size  it  frequently  attains.  The  enlargement  is  gradual,  and  there  may 
be  neither  pain  nor  tenderness  over  it.  The  tumor  may  cause  a  visible 
projection  below  the  ribs,  and  in  marked  cases  great  abdominal  disten- 
tion may  be  produced,  pushing  up  the  diaphragm  and  thoracic  organs, 
and  extending  to  the  navel  in  tne  median  line  and  to  the  pelvis  below, 
in  which  case  the  cardiac  pulsation  is  seen  at  the  second  or  third  inter- 
space. The  edge  and  notch  or  notches  may  be  felt  easily  in  such  in- 
stances, while  the  surface  is  smooth  and  the  consistence  firm.  A  friction- 
fremitus  is  felt  sometimes  during  respiratory  movement.  The  tumor  may 
vary  in  size,  and  after  severe  hemorrhage  or  diarrhea  it  may  become 
swollen.  Gastric  distress  after  eating  and  obstructive  constipation  are 
usually  complained  of  in  cases  of  great  splenic  enlargement.  Jaundice 
may  also  be  present.  Pulsation  has  been  noted  and  a  systolic  murmur — 
"splenic  souffle  " — has  been  heard  at  times  over  the  tumor.  The  percus- 
sion-note is  dull  over  the  tumor,  and  areas  of  movable  dulness,  due  to  fluid 
occupying  the  peritoneal  cavity,  are  not  infrequent.  A  wave  of  fluctu- 
ation may  be  detected  over  the  abdomen.      The  liver  is  often  enlarged. 

Lymphatic  Glands. — In  the  splenic-lymphatic  variety,  which  is  less 
common  than  the  splenic-myelogenous,  and  in  the  still  rarer  purely 
lymphatic  leukemia,  the  superficial  lymph-glands  may  be  both  visibly 
and  palpably  enlarged,  though  not  in  bunches  as  in  Hodgkin's  disease. 
They  are  soft,  resilient,  and  movable. 

The  Bones. — Purely  myelogenous  leukemia  is  very  rare,  and  local 
bone-symptoms  are  scarcely  ever  manifested.  There  may  be  some  ten- 
derness on  immediate  percussion  over  the  sternum  or  some  of  the  long 
bones,  and  slight  swelling,  irregularity,  or  deformity  of  the  ribs,  the 
sternum,  or  other  bones  may  result  from  leukemic  hyperplasia. 

Tlie  Blood. — It  is  by  the  blood-examination  alone  that  the  pathog- 
nomonic features  of  leukemia  are  determined.  The  blood  is  paler  than 
normal,  and  sometimes  has  a  brownish-red  or  chocolate  color.  Upon  a 
microscopic  examination  of  the  blood  in  the  spleno-medullary  form  of 
the  aff"ection  the  striking  increase  in  the  number  of  leukocytes  is  ob- 
served at  once.  The  count  shows  usually  from  85,000  to  500,000  white 
corpuscles  per  cubic  millimeter,  and  the  ratio  of  the  Avhite  to  the  red 


442    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

cells  may  thus  vary  from  1  to  150  down  to  1  to  10  or  1  to  5  in  the  aver- 
age case,  instead  of  the  normal,  1  to  500  (see  Fig.  38).  In  extreme 
cases  the  number  of  leukocytes  may  be  equal  to,  or  even  slightly  greater 
than,  that  of  the  erythrocytes,  and  such  an  instance  has  been  recorded 
by  Sorensen,  in  which  the  proportion  of  whites  to  reds  was  3  to  2. 

Stained  specimens  of  the  blood  enable  us  to  recognize  the  variety  of 
leukemia  (see  Fig.  39).  Thus,  in  the  ordinary  splenic-myelogenous  form 
the  characteristic  change  is  the  presence  of  the  abnormal  myelocytes — 
large,  mononuclear  leukocytes  with  the  protoplasm  filled  with  fine  neu- 
trophilic or  occasionally  eosinophilic  granules.  These  may  make  up  25 
per  cent,  of  the  white  cells,  whereas  they  do  not  occur  in  normal  blood, 
and  very  rarely,  and  only  in  small  numbers,  in  leukocytosis.  They 
probably  correspond  to  the  cells  found  in  the  bone-marrow,  the  large, 


100% 
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Fig.  38.— Blood-tracing  of  a  case  of  leukemia.    Black,  red  corpuscles ;   red,  hemoglobin ;  blue, 

white  corpuscles. 

oval,  and  eccentrically-placed  nuclei  of  both  blood-  and  marrow-cells 
showing  karyokinetic  figures.  The  polynuclear  leukocytes  may  be  nor- 
mal in  number,  but  usually  they  are  relatively  diminished  to  about  '6b 
per  cent,  instead  of  75  per  cent.,  as  in  normal  blood.  The  polynuclear 
cells  showing  coarse  basophilic  granules  are  increased,  and  may  equal  in 
number  the  eosinophiles.  When  Ehrlich's  triacid  stain  is  used  these 
cells  appear  as  non-granular  polynuclear  bodies.  Tlie  lymphocytes  are 
also  relatively  less  in  number,  making  up  but  1  or  2  per  cent.,  instead 
of  the  normal  15-30  per  cent.  The  bright,  acid-stained  eosinophiles, 
though  absolutely  increased,  are  not  always  relatively  so,  though  this 
relative  increase  may  occur. 

Moderate  oligocythemia  is  noted,  the  reduction  being  seldom  lower 


Fig  39  —A  Fresh  preparation  from  the  blood  of  a  case  of  leukemia  (X  550) ;  large  mononu- 
clear leukbevtes  of  immature  form;  B.  Preparation  of  a  ease  of  the  lieno-myelogenetie  variety 
(Ehrlich's  triple  stain) ;  numerous  eosinophile  and  immature  leukocytes,  myelocytes,  and  nucle- 
ated red  blood-cells  (Grawitz). 


LEUKOCYTHEMIA.  443 

than  to  2,000,000  per  c.mm.  The  percentage  of  hemoglobin  may  also 
be  reduced  relatively  or  in  slightly  greater  proportion.  Nucleated  red 
corpuscles,  chiefly  normoblasts,  are  frequently  found  in  considerable 
numbers.  Cells  with  large,  pale  nuclei  are  occasionally  found,  and 
cells  with  fragmented  nuclei  are  common.  Gigantoblasts  may  be  pres- 
ent. Osier  asserts  that  blood  of  the  type  of  pernicious  anemia  has  sub- 
sequently developed  a  true  leukemia.  Litten  and  Musser  have  also  de- 
scribed such  cases. 

In  lympliatic  leukemia,  which  is  rarer  and  more  quickly  fatal  than 
the  preceding  variety,  the  blood-changes  are  also  different.  The  lym- 
phocytes are  the  ones  increased,  all  other  leukocytes  being  relatively 
much  diminished  in  number.  Instead  of  the  normal  percentage  (15  to 
30  per  cent.),  the  lymphocytes  may  number  from  90  to  97  per  cent,  of 
all  the  leukocytes.  This  increase  affects  the  small  forms  in  most  cases, 
however.  Cabot  has  shown  that  in  some  instances  this  increase  affects 
the  larger  lymphocytes — cells  of  the  size  of  polynuclear  leukocytes. 
Nucleated  red  corpuscles  and  myelocytes  are  absent  as  a  rule,  unless 
the  bone-marrow  happens  to  be  diseased  at  the  same  time.  Eosinophiles 
are  rare.  Mixed  forms  of  leukemia  are,  however,  not  at  all  uncommon, 
so  that  the  proportions  of  the  various  types  of  normal  and  abnormal 
cells  are  quite  variable. 

The  blood-plates  may  be  quite  abundant  in  many  leukemic  cases,  and 
Charcot's  octahedral  crystals  appear  in  specimens  of  the  blood  if  allowed 
to  stand  for  any  length  of  time.  An  unusually  dense  and  thick  fibrous 
network  is  also  often  found. 

Complications. — Fatal  hemorrhages  may  occur  at  any  time,  and 
pulmonary  tuberculosis,  pleuritis,  pneumonia,  septico-pyemia,  renal  dis- 
ease, severe  diarrhea,  and  edema  msLj  complicate  leukemia  and  cause  death. 

Diagnosis. — This  can  be  made  easily  and  accurately  by  the  blood- 
examination  alone,  the  distinguishing  characteristics  of  the  blood  having 
been  enumerated  above,  both  as  to  the  existence  of  leukemia  and  the  dif- 
ferentiation of  its  several  varieties.  It  may  be  necessary  in  doubtful  cases 
to  examine  the  blood  by  Ehrlich's  staining  methods,  since  the  mere  ex- 
cess of  leukocytes  alone  is  not  proof  of  leukemia,  and  also  because  the 
disease  may  exist  without  an  excess,  owing  either  to  previous  medicinal 
treatment  or  to  natural  temporary  improvement. 

Leukemia  is  differentiated  from  a  marked  leukocytosis  by  the  fact  that 
in  the  latter  there  is  usually  a  more  moderate  increase  in  the  number  of 
leukocytes,  and  this  increase,  as  a  rule,  is  principally  of  the  polynuclear 
neutrophiles. 

Hodghins  disease  may  be  simulated  by  the  purely  lymphatic  leu- 
kemia on  account  of  the  enlarged  glands ;  but  in  leukemia  the  lymph- 
glands  are  not  found  in  such  large  bunches,  and  the  blood-examination 
will  show  the  characteristic  changes  of  lymphatic  leukemia  if  that  dis- 
ease be  present.      Simply  a  leukocytosis  is  present  in  pseudo-leukemia. 

Malignant  growths  of  the  spleen  and  lymphatic  glands,  and  also  a 
malarial  and  passively  congested  spleen  with  anemia,  may  simulate  leu- 
kemia.    The  simple  leukocytosis  here  Avill  exclude  leukemia. 

Prognosis. — Many  cases  are  mild  and  gradual  in  their  progress ; 
children,  however,  when  affected,  succumb  more  rapidly  than  do  adults. 
Lymphatic  leukemia  is  always  fatal  earlier  than  the  spleno-medullary 


444     DISEASES  OF  THE  BLOOD   AND   THE   DUCTLESS  GLANDS. 

variety.  Although  recovery  does  occur  occasionally,  most  cases  of  leu- 
kemia, of  whatever  form,  prove  fatal  certainly  within  five  years,  gener- 
ally in  two  or  three  years,  and  sometimes  in  seven  or  eight  months  or 
even  less  (from  two  weeks  to  two  or  more  months)  in  acute  leukemia. 
In  an  advanced  case  the  prognosis  is  hopeless.  It  should  be  borne  in 
mind  that  apparent  improvement  is  usually  only  temporary,  and  that  a 
fresh  exacerbation  is  apt  to  folloAv.  Grave  symptoms  heralding  an  earlv 
termination  are  profound  debility,  anemia,  emaciation  or  edema,  severe 
and  obstinate  hemorrhages,  cerebral  apoplexy,  persistent  diarrhea,  and 
high  fever.  Intercurrent  affections  not  infre(iuently  cause  death,  while, 
on  the  other  hand,  cases  are  recorded  in  which  the  appearance  of  inter- 
current infectious  diseases  has  favorably  aifected  the  course  of  leukemia. 

Treatment. — At  present  no  remedies  are  known  to  have  any  per- 
manent curative  effect,  although  several  agents  are  used  for  their  favor- 
able influence.  The  aim  should  be  to  improve  the  general  condition  of 
the  patient  and  endeavor  to  prolong  life  by  hygienic  and  medicinal 
means. 

The  environment  should  be  made  as  favorable  as  possible — physically, 
mentally,  socially,  and  morally.  (Jut-of-door  life  in  a  mild,  dry  climate, 
an  abundance  of  nutritious  and  easily  digestible  and  assimilable  food, 
calm  and  moderate  exercise  of  mind  (depending  upon  the  strength  and 
endurance  of  the  patient),  should  all  be  advised  and  encouraged.  On 
the  other  hand,  traumatism  and  inflammation,  irregular  habits  of  body, 
worry,  excitement,  and  passionate  emotions  and  appetites  should  be 
regulated  and  avoided. 

Arsenic  gives  the  best  results  in  most  cases,  and  should  be  pushed  to 
the  limit  of  tolerance,  as  in  pernicious  anemia.  It  should  be  given  con- 
tinuously, regardless  of  apparent  improvement  under  its  use,  as  the  lat- 
ter may  be  only  the  natural  remission — a  not  uncommon  incident  in  the 
disease.  Quinin,  iron,  and  the  oil  of  eucalyptus  have  been  recommended 
in  those  leukemic  cases  in  which  a  clear  history  of  malaria  has  been 
obtained.  Bone-marrow,  either  raw  and  spread  upon  bread  or  in  the 
form  of  a  glycerin  extract,  may  be  tried  when  arsenic  fails.  Oxygen- 
inhalations  and  blood-transfusion  have  been  susTgested.  The  so-called 
"splenic  remedies,"  whether  systemic  or  local,  have  no  controlling  in- 
fluences upon  the  disease.  Electricity  may  aff'ord  some  local  comfort  or 
contribute  to  psychic  ease.  Complications  and  intercurrent  affections 
may  often  be  greatly  relieved  by  appropriate  treatment. 

PSEUDO-LEUKEMIA. 

{Hodgkiri's  Disease;  Adenia ;   General  Lymphadenoma ;  Multiple  Malignant 

Lymphoma ;  Malignant  Lymphosarcoma.) 

Definition. — An  anemic  disease  characterized  by  the  anatomical 
peculiarities  resembling  those  of  lymphatic  leukemia — viz.  progressive 
hyperplasia  of  the  lym])h-glands,  occasional  secondary  lymphoid  growths 
of  other  organs  (liver,  spleen) ;  and  by  the  absence  of  the  destructive 
blood-changes  of  true  leukemia. 

Varieties. — Although  the  disease  that  bears  his  name  was  first  de- 
scribed by  Ilodgkin  of  Guy's  Hospital  in  1832  as  an  affection  of  the 
lymphatic  glands  and  spleen,  two  varieties  are  included  under  the  title 


PSEUDO-LEUKEMIA.  445 

of  pseudo-leukemia  (or  Hodgkin's  disease),  as  follows  :  (1)  that  which 
presents  simply  an  enlarged  spleen  (the  less  frequent  one) ;  and  (2)  that 
in  which  the  lymphatic  glands  are  chiefly  involved. 

Pathology. — The  lymph-glands  shoAv  different  degrees  of  hyperplas- 
tic enlargement  and  consistency.  In  the  earlier  stages  they  are  small, 
isolated,  and  movable,  while  in  advanced  and  well-developed  cases  of 
the  disease  they  are  larger,  fused  together  into  great  bunches,  and  more 
or  less  fixed  by  fibrous  investment.  As  a  rule,  the  glands  are  soft  and 
elastic,  though  sometimes  they  are  hard  and  dense,  and  masses  as  large 
as  an  orange  or  pineapple  may  be  seen.  Single  glands  may  be  as  large 
as  a  hen's  egg,  and  the  gland-capsules  may  show  connective-tissue  pro- 
liferation and  a  thickening  periadenitis.  Extension  of  the  lymphatic 
growth  into  the  surrounding  tissues  by  perforation  of  the  capsule  may 
occur.  As  a  rule,  the  overlying  skin  is  freely  movable,  though  it  may 
rarely  be  adherent.  On  section  the  tumors  display  a  smooth  white  or 
reddish-gray  surface  in  the  case  of  the  soft  and  almost  fluctuating  glands, 
and  a  grayish  or  a  yellowish-white  color  if  they  are  fii-m.  The  fusion  of 
the  swollen  glands  into  nodular  masses  is  also  seen,  and  when  ulceration 
through  the  skin  has  taken  place  suppuration  of  the  glands  may  be  re- 
vealed. In  the  harder  tumors  areas  of  necrosis  having  the  appearance 
of  caseation  may  be  visible,  and  shining,  more  or  less  hyaline  masses  of 
fibroid  tissue  may  also  be  detected. 

Microscopically,  there  is  a  typical  hyperplasia  of  the  lymph-cells, 
often  obscuring  completely  the  reticulum  of  the  gland,  except  in  the 
harder  enlargements,  where  the  fibrous  proliferation  shows  a  very  dis- 
tinct network.  The  change  is  a  lymphadenoma  of  the  lymphatic 
glands. 

The  cervical  glands  are  most  prominently  involved.  The  superficial 
chains  of  glands — axillary,  mediastinal,  scapular,  and  pectoral — especi- 
ally along  the  great  vessels,  are  often  found  connected,  and  the  inguinal, 
bronchial,  and  lumbar  glands  are  also  affected,  though  less  frequently. 
The  retroperitoneal  glands  are  more  frequently  affected  than  the  mesen- 
teric, and  sometimes  the  thoracic  vessels  are  completely  surrounded  by 
enlarged  lymph-glands;  they  have  occasionally  projected  externally  by 
perforation  through  the  sternum.  The  abdominal  vessels,  nerves  and 
nerve-plexues,  and  ducts  may  be  compressed  also  by  huge  groups  of  en- 
larged glands. 

The  spleen  is  enlarged  in  about  four-fifths  of  the  cases,  but  only 
slightly.  In  the  majority  of  cases  there  are  disseminated  throughout 
the  organ  whitish,  lymphomatous  growths  or  nodules  from  the"  size  of  a 
pea  to  that  of  a  nut.  Their  histologic  structure  is  like  that  of  the  lymph- 
glands  (lymphadenoma).      Occasionally  the  spleen  alone  is  hyperplastic. 

Lymphomata  may  also  develop  in  the  tonsils,  lingual  follicles,  intes- 
tinal lymphatics,  liver,  kidneys,  lungs,  brain,  heart,  testicles,  retina, 
and  skin.  Invasion  of  the  spinal  cord  may  occur  by  erosion  of  the  ver- 
tebrae or  through  the  blood-current  by  metastasis.  The  bone-marrow 
often  has  the  same  appearance  as  in  pernicious  anemia. 

Htiology. — There  are  'no  well-established  predisposing  conditions 
to  which  Hodgkin's  disease  is  referable.  In  75  per  cent,  of  cases 
males  are  affected,  and  young  and  middle-aged  persons — between  the 
ages  of  ten   and  forty  years.     In   an   analysis  of  100   cases  BO  were 


446    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

under  twenty  years,  34  between  twenty  and  forty,  and  36  after  forty 
(Gowers).  Heredity  may  possibly  be  a  cause.  Neither  has  an  exeit- 
ing  cause  been  discovered  as  yet.  The  disease  would  seem  to  belong 
to  the  group  of  infectious  granulomata,  but  the  infectious  agent  is  not 
known.  Flexner  thinks  that  certain  protoplasmic  foreign  bodies  (found 
in  the  larger  nodules  of  two  cases)  may  possibly  have  a  causal  relation 
to  the  disease.  Malaria,  syphilis,  chronic  skin-diseases,  and  various 
irritative  conditions,  especially  of  the  mouth,  giving  rise  to  local  gland- 
ular swellings,  have  also  been  assigned  as  causes.  In  undoubted  in- 
stances of  Hodgkin's  disease  the  lymphatic  glands  frequently  harbor 
tubercle  bacilli ;  hence  it  has  been  thought  that  the  latter  exercise  a  dis- 
tinct causative  influence.  It  must  be  remembered,  however,  that  some 
of  these  may  be  examples  of  secondary  accidental  infection ;  others  of 


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primary  diffuse  lymphatic  tuberculosis,  indistinguishable  from  or  mis- 
taken for  Hodgkin's  disease.  It  is  not  uncommon  to  find  pseudo-leu- 
kemia developing  in  a  ])erson  who  immediately  preceding  the  beginning 
of  the  disease  was  apparently  in  perfect  health. 

Symptoms. — Usually  the  first  thing  to  attract  attention  is  the  en- 
largement of  the  submaxillary  and  cervical  glands,  often  on  one  side  of 
the  neck  alone.  These  grow  gradually  until  they  may  finally  appear  on 
both  sides  as  large  as  a  fist,  and  produce  considerable  disfigurement. 
Sometimes  several  years  may  elapse  before  other  glandular  groups  are 
affected,  but,  as  a  rule,  it  is  a  matter  of  months  only  before  the  axillary, 
then  the  inguinal,  and  ])erliaps  the  internal,  glands  are  invaded.  The 
changes  vary  greatly  in  rapidity  and  extent. 

At  first  the  general  health  may  be  but  slightly  affected.  A  little 
constitutional  disturbance  and  some  pallor  may  be  complained  of,  though 


PSEUDO-LEUKEMIA.  447 

seldom  before  the  glandular  swellings  are  noticed.  Then  as  the  disease 
progresses  the  paleness  increases  and  all  the  symptoms  of  a  marked 
anemia  appear — languor,  failure  of  physical  strength,  beginning  emacia- 
tion, gastro-intestinal  derangement,  headache,  giddiness,  palpitation, 
dyspnea,  and  edema  of  the  legs.  Later,  the  serous  cavities  contain 
effusion  and  there  is  a  tendency  to  hemorrhages.  Epistaxis  and  metror- 
rhagia may  occur,  and  petechial  spots,  especially  on  the  lower  extrem- 
ities, are  not  infrequent.  The phi/sieal  signs  of  anemia — hemic  murmurs 
— are  also  present.  An  irregular  slight  or  moderate  pyrexia  is  common 
to  most  cases.  Fever  of  a  peculiar  intermittent  type  has  been  ob- 
served, the  intermissions  and  paroxysms  each  lasting  for  several  days 
or  weeks  (see  Fig.  40),  and  the  term  "  chronic  relapsing  fever " 
has  been  applied  in  consequence.  When  these  pyrexial  exacerbations 
occur  the  cases  generally  run  a  more  acute  course.  Ague-like  paroxysms 
may  persist  for  even  months,  as  described  by  Pel,  of  Amsterdam. 

The  symptoms  due  to  mechanical  compression  by  the  lymphomata 
are  varied  and  numerous,  depending  upon  the  number,  size,  and  distri- 
bution of  the  tumors.  Hundreds  of  tumors  may  be  present  through'- 
out  the  body,  but,  unless  they  press  upon  the  adjacent  nerves,  the  glands 
are  not  usually  painful.  Enlargement  of  the  tracheal  and  bronchial 
glands  may  cause  dysphagia,  dyspnea,  thoracic  pain,  disturbed  phonation, 
and  venous  congestion,  by  pressure  respectively  upon  the  esophagus, 
trachea,  bronchi,  thoracic  nerves,  recurrent  laryngeal  nerves,  superior 
vena  cava,  and  the  jugular  veins.  The  obstruction  to  respiration  may 
become  so  great  as  to  produce  death  by  suffocation. 

Circulatory  Symptoms. — Congestion  of  the  head  and  upper  extremities 
may  be  quite  marked,  and  in  such  cases  compensatory  dilatation  of  the 
superficial  veins  is  observed.  Edema  of  the  hand  and  arm  may  result 
from  venous  obstruction  due  to  the  pressure  of  very  large  axillary  glands. 
The  heart's  action  may  be  disturbed  by  pressure  on  the  pneumogastric, 
and  the  heart  itself  may  be  dislocated  by  great  gland-tumors  within  the 
chest.  Under  such  circumstances  the  latter  may  be  detected  by  dulness 
on  percussion  over  the  anterior  mediastinal  space. 

Edema  of  the  feet  and  legs  may  be  an  early  indication  of  enlarged 
abdominal  glands  pressing  upon  the  femoral  veins.  Albuminuria  is  not 
uncommon ;  ascites  and  hydrothorax  are  late  conditions  Jaundice  is 
sometimes  attributed  to  pressure  upon  the  bile-duct.  Cr astro-intestinal 
disturbances  may  be  troublesome,  and  are  usually  symptomatic  of  lymphoid 
growths  in  the  stomach  and  bowels.  In  thin  individuals  gland-masses 
may  be  palpable  over  the  abdomen.  Deafness  may  be  caused  by  growths 
in  the  pharynx. 

Nervous  Symptoms. — Inequality  of  the  pupils  and  unilateral  sweating 
of  the  face,  owing  to  glandular  pressure  upon  the  cervical  sympathetic, 
may  be  noticed  in  some  cases.  Sharp  lancinating  pains  along  the  nerves 
may  also  be  felt.  Pressure-paraplegia,  and  neuralgic  pains  variously 
distributed  throughout  the  body  should  also  be  mentioned  among  the 
nervous  manifestations. 

Cutaneous  Symptoms. — It  has  been  suggested  that  the  bronzing  of 
the  skin  sometimes  seen  in  Hodgkin's  disease  may  be  due  to  the  pressure 
of  enlarged  glands  upon  the  suprarenal  capsules.  An  intense  pruritus 
has  been  complained  of,  and  the  skin  may  be  erythematous.  Occasion- 
ally the  thyroid  and  thymus  glands  are  involved. 


448    DISEASES  OF  THE  BLOOD  AND  THE  DUCTLESS  GLANDS. 

Spleen. — The  slightly  or  moderately  enlarged  spleen  can  usually  be 
felt  just  below  the  ribs,  projecting  toAvard  the  navel.  Tenderness  over 
the  spleen  and  bones  may  be  elicited.  The  characteristic  feature  in 
splenic  pseudo-leukemia  is  the  decided  enlargement  of  the  spleen  with- 
out involvement  of  the  lymphatics. 

The  hlood  shows  a  moderate  diminution  in  the  number  of  red  cor- 
puscles, and  a  corresponding  diminution  in  the  hemoglobin,  the  former 
in  most  instances  numbering  from  2.000,000  to  4,000,000  per  cubic 
millimeter.  There  may  be  more  or  less  leukocytosis,  and  sometimes 
the  lymphocytes  may  preponderate  relatively  ;  if  the  latter  be  present 
in  great  numbers,  the  blood  may  show  great  similarity  to  that  of  lym- 
phatic leukemia.     An  occasional  normoblast  may  be  seen. 

Diagfnosis. — Pseudo-leukemia  is  more  readily  confused  with  tuhercu- 
lous  adenitift  than  any  other  disease,  particularly  at  the  outset.  Although 
an  acute  tuberculous  adenitis  may  very  closely  simulate  Hodgkin's  dis- 
ease and  render  a  diagnosis  almost  impossible,  more  often  the  glands  of 
tuberculous  adenitis  are  slower  in  enlarging  and  extending  than  in  this 
disease.  In  fact,  extension  of  the  lymjjhatic  enlargements  of  tuberculo- 
sis is  rarely  seen  as  compared  Avith  pseudo-leukemia.  Again,  tuberculous 
adenitis  is  most  common  in  the  young,  is  unilateral  rather  than  circumfer- 
ential in  the  neck,  and  attacks  the  submaxillary  glands  oftener  than  the 
cervical  chains  along  the  sterno-cleido-mastoid.  Again,  periadenitis, 
adhesion,  and  suppuration  of  the  glands  occur  in  tuberculosis.  Tubercu- 
lous foci  in  other  organs  may  also  be  found.  Intermittent  attacks  of 
pyrexia  are  an  indication  favoring  Hodgkin's  disease.  In  doubtful 
cases  a  gland  may  be  removed  for  microscopic  examination. 

The  blood  should  be  examined  in  order  to  differentiate  from  leukemia. 

Syphilis  must  be  carefully  excluded  by  the  history,  symptoms,  and 
therapeutic  test.  Neoplasvis  of  the  lymph-glands  may  sometimes  be 
difficult  to   distinguish  from  pseudo-leukemia. 

The  diagnosis  of  splenic  pseudo-leukemia  is  to  be  made  on  the  decided 
splenic  enlargement  without  involvement  of  the  lymphatics.  The  fol- 
lowing conditions,  however,  must  be  distinguished:  (a)  Pernicious 
anemia  with  enlargement  of  the  spleen  ;  this  is  readily  done  by  a  blood- 
examination  :  [b)  Cirrhosis  of  the  liver,  in  which  there  is  splenic  en- 
largement ;  {e)  The  splenic  tumor  of  chronic  malarial  poisoning.  Here 
the  blood  should  be  repeatedly  examined  for  the  organism  of  Laveran, 
if  the  patient  resides  in  a  malarial  region ;  ('7)  Idiopathic  enlargement 
of  the  spleen  without  any  anemia. 

Prognosis. — This  affection  runs  an  almost  invariably  fatal  course. 
The  remissions  and  exacerbations  of  the  disease  are,  however, 
notable.  In  some  cases  the  termination  may  occur  in  a  few  months, 
but  usually  death  ensues  after  the  lapse  of  two  or  three  years. 
It  should  be  remembered  that  some  instances  of  Hodgkin's  disease 
seem  to  merge  into  a  true  lymphatic  leukemia. 

Grave  indications  are  the  rapid  extension  of  the  glandular  enlarge- 
ments, great  debility,  anemia,  emaciation,  steadily  increasing  and  con- 
tinuous pyrexia,  thoracic  pressure-symptoms,  hemorrhages,  and  marked 
anasarca.'  Sometimes  the  tumors  diminish  greatly  before  death.  In 
certain  cases  general  streptococcus  infection,  intercurrent  diseases,  or 
such  complications  as  empyema  or  nephritis,  may  be  the  immediate 
cause  of  death. 


A:^MMIA   infantum  PSEUDO-LEUKjEMICA.  449 

Treatment. — Local  or  surgical  treatment  is  of  no  avail.  Hygienic 
measures  and  the  use  of  all  possible  agencies  to  support  the  strength  of 
the  patient  should  be  resorted  to,  and  the  administration  of  arsenic  in 
gradually  ascending  doses,  as  for  pernicious  anemia  and  leukemia, 
should  be  begun  as  soon  as  the  diagnosis  of  pseudo-leukemia  is  made. 
The  value  of  arsenic  is  undoubted  in  many  cases,  and  Fowler's  solution 
is  very  generally  used.  Phosphorus  has  also  be'en  recommended.  In- 
unctions of  ichthyol,  iodoform,  or  green  soap  may  be  tried  for  their 
psychic  effect,  and  the  galvanic  current  may  also  be  applied  topically. 
Tonics  and  nutrients  may  be  of  temporary  service. 

ANEMIA  INFANTUM   PSEUDO-LEUK^MICA. 

Definition. — The  above  title  was  given  by  von  Jaksch  to  a  form  of 
anemia  occurring  in  childhood  that  bears  certain  similarities  to  leu- 
kemia, but  is  Avithout  the  tendency  to  a  fatal  end.  It  is  probably  the 
same  class  of  cases  that  Italian  writers  have  classified  under  the  name 
of  ancemia  splenica  infettiva  dei  bambini. 

Pathology. — Splenic  enlargement  is  the  most  striking  lesion.  The 
organ  is  hard  and  dark  red,  and  perisplenitis  may  be  observed.  The 
histologic  examination  shows  a  uniform  hyperplasia  of  the  tissue,  such 
as  is  witnessed  in  ordinary  splenic  hypertrophy  due  to  various  conditions. 
The  liver  is  enlarged  in  most  cases,  but  presents  practically  normal  ap- 
pearances on  section  ;  slight  enlargement  of  the  lymphatic  glands  may 
also  occur,  though  never  lymphomatous  tumors.  Diffuse  reddening  of 
marrow  has  been  described. 

etiology. — Children  under  the  age  of  four,  and  particularly  during 
the  second  half  year  of  life,  are  especially  prone  to  this  condition.  It 
is  equally  common  in  the  two  sexes,  and  is  most  often  met  with  in 
rachitic  infants,  16  of  20  cases  collected  by  Monti  and  Berggriin  having 
exhibited  this  etiological  factor.  Hereditary  syphilis,  intestinal  dis- 
turbances, and  other  diseases  doubtless  play  a  part  in  the  etiology.  The 
disease  is  a  rare  affection,  occurring  very  seldom  even  in  the  largest 
children's  clinics. 

Symptoms. — The  onset  is  gradual.  The  child  becomes  pale,  Aveak, 
and  often  emaciated,  and  enlargement  of  the  spleen  is  the  most  strik- 
ing feature.  Sometimes  this  reaches  such  a  grade  that  the  left  half 
of  the  abdomen  is  practically  filled,  variations  in  its  size  being  observed 
from  time  to  time.  Hepatic  enlargement  is  frequently  present,  but  does 
not  correspond  to  that  of  the  spleen,  and  the  loAver  border  of  the  organ 
is  found  to  be  sharp  instead  of  rounded,  as  is  the  case  in  leukemia. 
Gastro-intestinal  disturbances  may  occur  in  the  course  of  the  disease, 
and  gradually  increasing  weakness  may  lead  to  a  fatal  end ;  death  may 
also  occur  from  peritonitis,  bronchitis,  or  pneumonia. 

Blood. — An  examination  of  the  blood  will  in  many  cases  show  an  in- 
ordinate reduction  in  the  number  of  red  corpuscles.  Nearly  ahvays  the 
number  is  below  3,000,000.  Degeneration  of  the  corpuscles,  poly- 
chromatophilia.  and  poikilocytosis  are  seen  in  the  severer  cases.  Large 
numbers  of  nucleated  erythrocytes,  especially  the  normoblasts,  may  be 
found,  and  karyokinetic  figures  are  frequently  observed  in  the  nuclei. 
A  marked  increase  in  the  number  of  leukocytes  is  one  of  the  characteris- 
tics, the  number  ranging  from  40,000  to  over  100,000,  and  the  proportion 

29 


450      DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

of  the  red  to  the  white  at  times  being  as  low  as  12  to  1.  Considerable 
fluctuations  in  the  number  of  leukocytes  may  occur  from  time  to  time. 
Von  Jaksch  insisted  that  the  different  forms  of  leukocytes  occur  in  their 
usual  relative  proportions,  or  that  the  polymorphous  forms  are  specially 
increased.  Cases  have,  however,  been  described  in  which  the  mononu- 
clear elements  were  particularly  increased. 

The  nature  of  the  disease  is  difficult  to  determine,  though  the  favor- 
able termination  of  many  cases,  the  lesser  grade  of  hepatic  enlargement, 
and  the  character  of  the  leukocvtosis  distinguish  these  cases  from  leukemia. 
It  is  not  even  certain  that  it  is  a  special  disease-entity,  and  the  evidence 
is  in  favor  of  its  be-ing  a  type  of  secondary  anemia  with  peculiar  features, 
due  perhaps  to  an  infectious  state  and  the  age  of  the  patient. 

Diagnosis. — Some  points  of  distinction  from  leukemia  have  been 
referred  to  above.  In  addition  I  would  say  that  the  absence  of  hemor- 
rhages, purpura,  and  lymphomatous  enlargements,  and  the  presence  of 
abundant  nucleated  corpuscles  showing  karyokinesis,  together  with  the 
existence  of  rickets,  point  to  a  non-leukemic  affection. 

Prognosis. — The  disease  tends  to  a  progressive  increase  of  the 
anemia,  but  under  treatment  the  majority  of  cases  terminate  favorably. 

Treatment. — Hygienic  measures  together  with  the  administration 
of  remedies  directed  to  the  anemia  constitute  the  treatment. 

SPLENIC    ANEMIA. 

Definition. — A  condition  described  by  H.  C.  Wood  in  1871 ;  it  is 
looked  upon  by  most  authors  as  a  splenic  form  of  Hodgkin's  disease. 
Striimpell,  Banti,  and  Bruhl  also  regard  it  as  a  distinct  variety  of  anemia 
(vide  p.  448).  Some  of  the  cases  are,  I  am  inclined  to  believe,  instances  of 
pernicious  anemia,  others  of  secondary  anemia  with  splenic  enlargement. 

Pathology. — Among  pathologic  characters,  splenic  enlargement  is 
to  be  specially  noted.  It  is  an  idiopathic  enlargement  of  the  spleen 
with  anemia  and  without  lymphatic  involvement  (Osier). 

Ktiology. — So-called  splenic  anemia  is  not  rare  in  persons  who 
have  resided  in  malarial  districts  for  a  long  period  of  time  (although 
cases  are  recorded  in  which  no  previous  history  of  malaria  existed),  and 
in  rachitic  persons. 

Symptoms. — The  affection  is  characterized  by  three  stages  :  ^  (1)  The 
initial  stage,  which  shows  extreme  anemia,  with  marked  loss  of  power 
and  muscular  wasting,  emaciation,  however,  being  usually  slight,  not- 
withstanding. 

(2)  The  second  stage  is  characterized  by  progressive  enlargement  of, 
and  pain  in  the  region  of  the  spleen.  Anemia  is  now  profound,  loss  of 
strength  extreme,  and  attacks  of  epistaxis  or  other  mucus  bleedings  are 
common.  Hemorrhages  of  the  skin  are  also  noted.  The  fever  is  apt  to 
be  hectic  in  type  (ranging  from  100°  to  102°,  and  rarely  even  higher). 

(3)  The  condition  is  that  of  progressive  asthenia,  ending  in  death. 
The  Blood  Character. — The  anemia  is  of  the  chlorotic  type.     The 

red  cells  are  usually  near  the  normal  count  (8,700,000  to  4,000,000), 
while  the  hemoglobin  is  greatly  reduced  (40  per  cent,  or  lower).  Poikilo- 
cytosis  may  exist.  The  treatment  coincides  with  that  of  the  graver  forms 
of  anemia. 

^  S.  West,  in  AUbutt's  System  of  Medicine. 


CHLOBOMA— ADDISON'S  DISEASE.  451 


CHLOROMA. 

Owing  to  its  clinical  resemblance  to  leukemia  and  pseudo-leukemia  a 
brief  reference  to  this  comparatively  new  and  rare  aifection  may  be  made 
here.  Pathologically,  it  consists  of  a  sarcomatous  growth,  the  pri- 
mary seat  of  which  is  in  the  periosteum  and  bone  in  and  about  the  orbit. 
The  growth  shows  a  pea-green  pigmentation.  Secondary  growths  may 
be  widespread,  the  metastatic  nodules  being  also  green  in  color,  but 
more  circumscribed  than  are  the  lymphatic  infiltrations  of  ordinary 
leukemia.  In  2  cases  reported  recently,  1  by  Dock  and  the  other  by 
Ayers,^  the  ages  were  fifteen  and  seven  years  respectively. 

Pain  in  the  orbital  region,  exophthalmos,  and  deafness  were  noted 
early,  and  severe  conjunctival  hemorrhages  and  epistaxis  occurred. 
Rounded  elastic  swellings  were  observed  in  the  temporal  and  parotid,  as 
well  as  in  the  orbital  regions,  corresponding  to  the  chloromata.  The 
blood  was  pale  and  Avatery,  and  leukocytosis  was  present,  multinuclear 
leukocytes  being  noted.     The  eosinophiles  were  slightly  reduced. 

The  course  of  the  disease — spoken  of  by  .French  writers  as  "  green 
cancer  " — is  rapid,  and  death  usually  comes  on  within  a  few  months. 


DISEASES  OF  THE  DUCTLESS  GLANDS. 

DISEASE      OF      THE      SUPRARENAL     CAPSULES. 
ADDISON'S   DISEASE. 

Definition. — A  constitutional  disease,  characterized  by  a  degenera- 
tion of  the  suprarenal  capsules  or  semilunar  ganglia,  a  bronzed  or  pig- 
mented skin,  great  bodily  and  mental  asthenia,  feeble  circulation,  and 
gastro-intestinal  irritability. 

This  affection  is  named  in  honor  of  its  discoverer,  Thomas  Addison 
of  Guy's  Hospital,  London,  who  first  described  it  in  a  monograph  pub- 
lished in  1855,  entitled  "  The  Constitutional  and  Local  Effects  of  Dis- 
ease of  the  Suprarenal  Capsules. 

Pathology. — Addison  emphasized  the  fact  that  while  the  supra- 
renal bodies  were  affected  with  a  fibro-caseous  alteration  in  many  cases, 
the  anatomical  changes  were  by  no  means  always  the  same.  Both  supra- 
renal capsules  are  usually  diseased  at  the  same  time.  Tuberculosis  is 
the  commonest  condition,  and  is  often  associated  with  tuberculous  lesions 
in  other  parts  of  the  body,  as  in  the  lungs,  bones,  and  other  glands. 
Rarely,  it  seems  to  be  primary,  no  other  evidences  of  tuberculous  infiltra- 
tion being  found.  The  capsules  are  enlarged,  firm  in  places,  and  nodu- 
lated on  the  surface,  owing  to  the  caseous  masses  surrounded  by  fibrous 
tissue.  Sometimes  there  is  marked  cicatricial  contraction  of  the  adrenals, 
and  the  adjacent  structures  may  be  found  matted  together  with  the  cap- 
sules. Microscopic  examination  shows  a  reticulum  of  connective  tis- 
sue surrounding  a  soft  cheesy,  granular,  and  fatty  detritus,  lymphoid 

^  Jour.  Amer.  Med.  Assoc,  Xov.  7,  1896. 


452    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

cells,  and  some  giant  cells.  Other  morbid  processes  in  the  adrenals  that 
are  non-tuberculous  in  nature  have  also  been  found  associated  with  Ad- 
dison's disease,  such  as  ati'ophy  of  one  or  both  glands  from  interstitial 
cirrhosis,  carcinoma  or  sarcoma,  and  chronic  inflammation. 

Especial  attention  has  recently  been  given  to  the  condition  of  the 
solar  plexits  and  semilunar  ganglia  of  the  abdominal  sympathetic,  and 
implication  of  these  nervous  structures  by  compression,  cicatricial  con- 
traction, entangled  in  the  cicatricial  tissue  surrounding  the  suprarenal 
bodies  or  by  chronic  inflammation,  is  not  infrequently  discovered,  to- 
gether with  a  degeneration  and  deep  pigmentation  of  the  semilunar 
ganglion-cells. 

Enlargement  of  the  solitary  and  agminated  follicles  of  the  intestine, 
and  slight  enlargement  and  some  softening  of  the  spleen  are  noted  at 
times ;  parenchymatous  or  fatty  degeneration  of  the  heart,  liver,  and 
kidneys  has  also  been  noted  in  some  instances.  The  thymus  gland  may 
be  found  to  have  remained  normal,  or  even  to  have  enlarged,  perhaps. 
The  deposition  of  pigment  is  in  the  same  anatomic  elements  as  in  tht 
negro — in  the  lower  layers  of  the  rete  Malpighii. 

The  pathological  connection  between  the  symptomatic  phenomena  of 
Addison's  disease  and  the  anatomical  lesions  has  not  been  satisfactorily 
made  out.  The  experimental  evidence  regarding  the  functions  of  the 
adrenals  is  imperfect ;  but  it  seems  quite  probable  that  some  essential 
"internal  secretion,"  influencing  the  normal  metabolism  of  the  skin  and 
muscles,  is  diminished  or  absent  in  Addison's  disease.  On  the  contrary, 
cases  exhibiting  the  clinical  phenomena  of  this  affection  have  occurred 
in  which  no  suprarenal  morbid  processes  could  be  found  jjost  mortem. 
Again,  marked  changes  have  been  observed  in  these  glands,  while  dur- 
ing life  no  symptoms  of  the  disease  had  been  noted.  Hence,  it  is 
maintained  by  some  that  the  abdominal  sympathetic  nerves  and  ganglia 
are  directly  concerned  in,  producing  the  clinical  manifestations,  either 
by  an  independent  morbid  process  or  by  extension  from  some  adjacent 
organ.  Others  hold  that  both  the  adrenals  and  the  sympathetic 
ganglia  are  the  seat  of  pathologic  changes.  The  data  are  not  sufficient, 
however,  to  determine  whether  the  principal  involvement  is  nervous  or 
secretory. 

Ktiology. — This  is  obscure.  It  has  been  held  that  some  infection 
of  the  blood  from  Avithout  precedes  the  suprarenal  and  nervous  lesions 
of  Addison's  disease.  A  tuberculous  diathesis  or  infection  has  also  been 
emphasized  by  some  investigators,  and  Fleming  and  Miller^  have  re- 
ported a  family  with  probable  Addison's  disease.  A  history  of  injury 
to  the  trunk  has  been  noted  in  several  cases.  The  disease  is  more 
common  in  Europe  than  in  America,  though  it  is  rare  everywhere. 
Analysis  of  183  cases  showed  119  males  and  64  females  (Greenhow). 
While  the  disease  may  affect  all  ages  (it  may  even  be  congenital),  it  is 
usuallv  found  in  early  or  middle  life — between  fifteen  and  forty  yeai'S  of 
age.  That  Addison's  disease  is  due  either  to  a  general  neurosis  or  to  dis- 
turbed hematopoiesis  is  merely  hypothetic. 

Symptoms. — While  it  does  not  seldom  happen  that  tuberculosis 
or  carcinoma  affects  the  adrenals,  the  purest  and  most  typical  symp- 
toms of  Addison's  disease  are  apparently  primary  in  their  develop- 
1  British  Medical  Journal,  April  28,  1900. 


ADDISON'S  DISEASE.  453 

mentj  and  not  those  that  usually  attend  the  course  of  the  former 
diseases. 

Cutaneoics  Symi^toms. — The  gradual  pigmentation  of  the  skin  of 
various  parts  of  the  body  may  be  one  of  the  first  evidences  of  the  affec- 
tion. This  pigmentation  may  have  either  a  dusky-yellow,  bronze  or 
yellowish-brown,  olive,  deep  or  greenish-brown,  or  even  black  color. 
Althoug-h  sometimes  diifuse,  the  discoloration  is  not  uniform  over  all 
parts  of  the  body,  but  commences  earlier,  and  becomes  deeper  especially 
on  the  exposed  parts  and  where  the  normal  pigmentation  is  marked,  as 
the  face,  neck,  backs  of  the  hands,  the  axillae,  abdomen,  groins,  genital 
regions,  and  the  areolae  of  the  nipples.  Pigment-spots,  often  somewhat 
bluish  in  color,  are  also  found  on  the  mucous  membranes  of  the  mouth, 
lips,  conjunctiva,  and  vagina.  On  the  lips  the  discoloration  takes  the 
form  of  a  dark  streak,  running  lengthwise,  near  the  junction  of  the 
skin  and  mucous  membrane ;  or  broAvnish  patches  or  streaks  cor- 
responding to  the  points  of  pressure  by  the  teeth  may  be  noticed. 
Irregular  stains  with  ill-defined  borders  may  also  be  shown  on  the 
skin,  corresponding  to  the  lines  of  pressure  exerted  by  garments, 
strings,  suspenders,  garters,  etc.  (Greenhow).  White  patches  of  leu- 
koderma may  be  seen  here  and  there,  in  marked  contrast  to  the 
pigment-deposits. 

G-eneval  Symptoms. — The  constitutional  symptoms  may  exist  in 
a  slight  degree  before  the  pigmentation  first  attracts  the  patient's 
attention.  There  is  gradual  and  progressive  asthenia  without  ap- 
parent cause,  great  lassitude  and  loss  of  physical  and  mental  energy, 
breathlessness,  headache,  dizziness,  tinnitus  aurium,  sighing,  and 
fatigue.  The  hlood-examination,  however,  rarely  shows  any  marked 
reduction  of  the  erythrocytes  or  hemoglobin ;  nor  is  there  any 
leukocytosis.  The  fat,  particularly  of  the  abdomen,  may  be  well 
preserved. 

Circulatory  Symptoms. — The  heart's  action  is  weak  and  the  pulse 
small  and  feeble ;  attacks  of  faintness  and  palpitation  on  exertion  are 
common,  as  are  functional  murmurs  and  coldness  and  clamminess  of  the 
extremities.    The  blood  pressure  is  greatly  reduced  before  death  (Turner). 

Grastro-intestinal  symptoms  are  usually  prominent.  There  is  a  loss 
of  appetite,  and  nausea  and  vomiting  may  occur  early  and  either  be 
paroxysmal  or  persistent.  The  tongue  may  be  clean,  and  the  gastric 
disturbances  do  not  seem  to  follow  errors  in  diet.  Diarrhea  may  be 
troublesome  in  the  latter  stao;e,  and  is  often  associated  with  intractable 
vomiting.  Neuralgic  attacks  of  either  sharp  or  dull,  aching  pain  are 
referred  to  the  epigastric,  hypochondriac,  and  lumbar  regions  in  about 
one-third  of  the  cases.  The  mind  is  usually  clear  until  near  the  last, 
but  mental  weariness  is  constant,  and,  as  the  later  stages  of  the  disease 
come  on,  the  patient  often  lies  in  a  somnolent,  semi-comatose  state.  The 
physiognomy  expresses  fatigue,  dejection,  and  apathy;  the  speech  be- 
comes slow  and  incoherent,  and  in  many  cases  the  patient  passes  into 
delirium.  Prostration  is  profound,  the  weakness  being  disproportionate 
to  the  general  condition. 

Renal  Symptoms. — Polyuria  is  sometimes  evident,  but  albumin  is 
seldom  present.  The  amount  of  indican  is  increased,  as  it  is  in  the  urine 
of  all  of  the  cachectic  diseases  associated  with  destruction  of  albuminoids. 


454    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

There  is  usually  a  diminished  excretion  of  urea,  but  urobilin  and  uro- 
melanin  may  be  present  in  abnormal  quantity.  Tubercle  bacilli  may  be 
found  in  the  sputum. 

Diagnosis. — The  principal  error  in  diagnosis  is  in  the  assumption 
that  the  case  is  one  of  Addison's  disease,  simply  from  the  presence  of 
patches  of  pigmented  skin.  Other  conditions  in  which  the  discoloration 
may  simulate  that  of  Addison's  disease  are  the  following:  (1)  Carcinom- 
atous and  tuberculous  disease,  particularly  when  seated  in  the  abdomen 
and  when  involving  the  peritoneum  ;  (2)  Hepatic  disease,  such  as  the 
cirrhosis  of  diabetes,  protracted  jaundice,  chronic  congestion,  and  lith- 
emia  ("liver-spots  ")  ;  (3)  Pregnancy,  and  uterine  disease,  in  which  the 
patchy  discolorations  (chloasmata)  appear  principally  upon  the  face ; 
(4)  Irritation  of  lice  and  dirt  and  exposure,  as  in  the  case  of  tramps  and 
vagrants  ("vagabond's  disease");  (5)  Tinea  versicolor;  (6)  Melanotic 
sarcoma ;  (T)  Exophthalmic  goiter ;  (8)  Post-eruptive  staining  of 
syphilitic  eruptions ;  (9)  The  administration  of  silver  nitrate  for  a 
long  time  (argyria) ;  (10)  Marked  brunette  complexions  and  racial 
admixture. 

AYhen  the  pigmentation  is  scanty,  of  course  the  diagnosis  is  more 
difficult ;  but  in  all  cases  of  pigmentation  in  which  other  causes  may  be 
excluded  the  progressive  asthenia,  unaccountable  vomiting  and  diarrhea, 
easily  compressible  pulse,  great  bodily  weakness,  mental  hebetude,  and 
lumbar  and  epigastric  pain  render  the  diagnosis  of  morbus  Addisonii, 
or  melasma  suprarenale,  justifiable.  It  is  to  be  remembered  that  the 
bronzing  of  the  skin  may  precede  as  well  as  follow  the  constitutional 
symptoms. 

In  the  negro  the  diagnosis  of  this  affection  is  extremely  difficult, 
both  on  account  of  the  naturally  dark  skin  and  because  of  the  dark  dis- 
colorations of  the  oral  mucous  membrane,  found  even  in  health  in  many 
individuals. 

Prognosis. — The  course  of  Addison's  disease  is  almost  always 
chronic,  though  cases  have  been  reported  occasionally  in  which  the  on- 
set has  been  sudden,  with  febrile  phenomena  and  a  comparatively  acute 
course  of  a  few  months,  or  Aveeks  even.  Usually  the  disease  lasts  about 
one  year,  although  some  cases  may  continue  over  five  or  even  ten  years. 
Temporary  remissions  may  be  observed,  but  death  is  inevitable  in  by 
far  the  majority  of  instances.  The  termination  is  gradual,  and  by 
profound  asthenia,  or  sometimes  by  coma,  delirium,  or  convulsions 
(epileptiform). 

Treatment. — The  hygienic  and  medicinal  treatment  must  have  vir- 
tually the  same  objects  in  view  as  in  the  other  grave  cachectic  diseases, 
and  is  both  sustentative  and  symptomatic.  As  (juiet  a  life  as  possible 
should  be  strictly  enjoined,  owing  to  the  dangers  of  a  sudden  and  fatal  syn- 
copal attack.  Rest  in  bed  is  necessary  in  moderate  and  advanced  cases 
during  a  part  of  the  day  for  the  former  and  constantly  for  the  latter. 
The  diet  should  be  restricted  to  light  nutritive,  concentrated,  and  easily 
assimilable  food,  and  particularly  to  the  nitrogenous  or  proteid  sub- 
stances.    An  absolute  milk  diet  may  be  necessary  in  some  cases. 

Iron  and  arsenic  may  be  administered  in  the  anemic  cases,  and 
strychnin,  guaiacol  carbonate,  phosphorus,  and  the  nuclein  preparations 
may  also  be  given,  along  with  bitter  tonics.     Bismuth  and  salol  may  be 


DISEASES   OF  THE  THYROID   GLAND.  455 

of  great  service  in  controlling  the  diarrhea  that  often  occurs.  The 
nausea  and  vomiting  may  be  relieved  by  unfermented  grape-juice, 
albumin-water,  champagne,  cracked  ice,  cerium  oxalate,  creasote,  and 
the  like.  Electricity  is  often  a  valuable  adjunct  in  the  treatment  of 
the  muscular  Aveakness  and  nervous  exhaustion,  and  even  in  reducing 
the  pigmentation. 

It  seems  quite  probable  that  the  administration  of  the  extract  of 
suprarenal  capsules  Avill  prove  to  be  of  considerable  value  in  causing 
marked  improvement,  if  not  a  permanent  cure,  in  a  certain  percentage 
of  cases.  In  one  instance  mentioned  by  Osier,  in  which  a  glycerin  ex- 
tract of  a  pig's  suprarenal  was  given  at  first  in  doses  of  half  a  glass 
three  times  a  day,  improvement  was  noted  in  the  temperature,  pulse, 
weight,  and  physical  and  mental  vigor  from  the  first  week  of  the 
treatment,  which  was  continued  for  three  months  and  a  half.  Eight 
months  after  the  treatment  was  begun  the  patient  appeared  to  be  Avell 
and  strong,  and  attended  to  business  ;  the  pigmentation,  however,  was 
not  removed.  In  a  recent  case  of  my  own  this  remedy  produced  like 
results.  Robin  mentions  a  case  treated  by  the  administration  of  supra- 
renal gland  that  has  shown  persistent  good  health  for  three  years. 
For  the  present,  however,  too  positive  a  value  should  not  be  attributed 
to  the  suprarenal  extract,  and  results  contrary  to  the  above  are  to  be 
found  in  the  literature. 

DISEASES   OP   THE   THYROID   GLAND. 
THYROIDITIS. 

Definition. — Acute  inflammation  of  the  thyroid  gland.  The  gland 
may  either  have  been  previously  healthy  or  the  seat  of  a  goitrous  en- 
largement ;  when  inflammation  attacks  previously  diseased  or  enlarged 
thyroid  tissue  the  term  strumitis  is  often  used. 

Pathology. — The  gland  is  swollen,  boggy,  and  the  seat  either  of  a 
single  large  or  of  multiple  small  abscesses ;  the  numerous  large  blood- 
vessels are  engorged ;  and  hemorrhages,  thrombi,  and  areas  of  tissue- 
necrosis  are  frequently  found. 

!^tiology. — Thyroiditis  is  seldom  primary  in  origin.  It  may  be 
caused  by  traumatism ;  but  usually  it  is  secondary  to  one  of  the  in- 
fectious diseases,  such  as  small-pox,  typhus,  typhoid  fever,  or  ma- 
laria. Rheumatism  has  also  been  given  as  a  cause.  Hemorrhages 
into  the  substance  of  a  goiter,  whether  apoplectic  or  traumatic,  may 
predispose  to  a  strumitis  that  may  be  excited  by  the  introduction  of 
streptococci  by  an  unclean  needle,  etc.  Repeated  congestions  of 
the  thyroid  or  a  simple  acute  congestion  may  also  dispose  to  thy- 
roiditis. 

Symptoms. — There  are  fever,  pain,  swelling,  and  suppuration  in 
one  or  the  other  lobe  of  the  gland.  Venous  obstruction  may  be  serious 
and  give  rise  to  vertigo,  headache,  cyanosis,  and  epistaxis  ;  and  compres- 
sion of  the  windpipe  by  the  great  swelling  may  cause  death  before  the 
abscess  bursts.  Resolution  occurs  infrequently,  especially  in  the  "  strum- 
ous "  cases.  Indeed,  the  symptoms  of  a  strumitis  are  usually  more 
severe,  owing  to  the  greater  size  of  the  thyroid,  a  tendency  to  metas- 


456    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

tasis,  and  to  the  burrowing  of  pus  into  adjacent  tissues  leading  to  per- 
foration and  rupture  of  the  abscess  into  the  trachea  or  esophagus. 

Diagnosis. — Thyroiditis  must  be  differentiated  from  the  laryngeal 
perichondritis  that  is  also  seen  in  the  course  of  infectious  diseases,  as 
typhoid  fever  and  small-pox.  The  higher  and  more  median  position 
and  the   smaller  swelling  of  laryngo-chondritis  are  distinctive  points. 

Prognosis. — The  outcome  is  usually  favorable  in  all  cases  in  which 
spontaneous  rupture  occurs  externally  or  when  evacuation  of  the  pus  is 
effected.  Strumitis  runs  a  less  favorable  course  for  the  reasons  men- 
tioned above. 

Treatment. — This  is  antiphlogistic  and  surgical.  The  pus  must  be 
evacuated,  and  tracheotomy  or  thyroidectomy  may  become  necessary. 

GOITER. 
(Bronchocele.) 

Definition. — A  chronic  hypertrophy  and  hyperplasia  of  a  portion 
or  the  whole  of  the  thyroid  gland.  It  is  of  obscure  origin,  involving 
one  or  more  of  the  structural  tissues,  and  is  subject  to  various  degen- 
erative changes. 

Pathology. — Several  different  varieties  are  described.  In  the  simple 
hypertrophic  or  parenchymatous  form  there  is  a  hyperplasia  of  all  the 
original  tissue-elements.  The  follicular  form  shows  an  increase  of  the 
true  glandular  elements  alone. 

Fibrous  goiter  is  that  variety  in  which  the  interstitial  tissue  or  stroma 
is  increased  out  of  all  proportion  to  the  hyperplasia  of  the  follicles, 
which  are  also  involved  in  a  much  slighter  degree.  This  variety  of  goiter 
may  have  an  inflammatory  origin  (thyroiditis).  In  old  cases  marked 
sclerosis  may  be  assumed.  There  is  also  a  vascular  variety,  in  which  the 
blood-vessels  are  enormously  dilated.  More  commonly  the  veins  are 
affected ;  but  in  the  so-called  aneurysmal  variety  the  arteries  are  chiefly 
involved.  The  intense  venous  variety  of  vascular  goiter  has  been  de- 
nominated "cancerous  tumor  of  the  thyroid,"  and  the  Avhole  gland  may 
in  such  cases  be  quite  elastic  and  like  spongy  erectile  tissue.  Follicular 
hyperplasia  is  often  associated  with  vascular  enlargement. 

The  special  varieties  of  goiter  due  to  degenerative  changes  are  the 
cystic,  amyloid,  colloid,  and  calcareous,  and  of  these  the  first  named  is 
the  most  common.  It  consists  in  the  development  in  a  large  goiter  of 
one  or  more  large  or  small  cysts  filled  with  different  kinds  of  fluid  of 
varying  consistency.  Sometimes  the  liquid  is  colloid  or  mucinous  in 
nature,  and  it  may  be  chocolate-colored  and  contain  the  residue  of  hemor- 
rhages (cholesterin,  fatt}^  products,  and  albumin).  Amyloid  changes 
affect  principally  the  vessels ;  colloid  changes  are  also  frecjuent,  while 
calcareous  infiltration  is  seen  in  very  old  fibrous  goiters.  Inflammation 
and  suppuration  of  the  goitrous  gland  may  ensue. 

Ktiology. — Goiter  may  occur  anywhere  sporadically.  Endemically 
and  in  its  worst  forms  it  occurs  in  the  mountainous  districts  of  Europe, 
Asia,  Mexico,  and  South  America,  particularly  in  the  Alps,  Pyrenees, 
and  Andes.  It  has  also  appeared  in  certain  limestone  regions,  such  as 
New  England  and  Ontario,  Canada,  where  the  habitual  use  of  limestone- 
water  for  drinking  purposes  seems  to   induce  the  disease.     Heredity 


GOITER.  457 

undoubtedly  plays  a  part  in  its  causation,  certain  children  having  been 
born  with  goiter.  Occasionally  it  has  become  epidemic  in  certain  sec- 
tions of  the  goitrous  districts  in  Europe  where  military  garrisons  have 
been  stationed,  thus  indicating  the  possibility  of  some  infectious  influ- 
ence. Women  are  more  liable  to  goiter  than  men,  and  it  is  more  com- 
mon to  find  it  after  ten  or  twenty  years  of  age.  It  has  been  alleged 
that  pregnancy  also  influences  the  development  of  this  condition. 

.Symptoms. — The  enlarged  thyroid  is  readily  recognized  and  felt, 
though  the  patient  may  complain  of  nothing  but  the  disfigurement,  ex- 
cept when  the  tumor  is  of  sufficient  size  to  cause  symptoms  of  compres- 
sion. The  goiter  develops  very  gradually,  and  may  vary  in  dimensions 
from  the  merest  perceptible  enlargement  to  a  growth  that  overhangs 
the  chest  and  greatly  hinders  the  movements  of  the  head.  It  may  or 
may  not  be  uniform  in  its  development,  and  is  often  more  enlarged  on 
the  right  side  and  in  front  than  on  the  left  side.  It  is  not  infrequently 
observed  to  increase  in  size  with  each  succeeding  pregnancy  and  during 
or  after  each  menstrual  flux. 

The  tumor  is  painless,  is  not  adherent  to  the  overlying  skin  or  to 
any  of  the  neighboring  bones,  and  rises  and  falls  during  the  act  of 
swallowing,  moving  with  the  larynx.  The  veins  covering  it  are  swollen 
and  prominent.  It  interferes  with  respiration  oftener  than  with  deglu- 
tition, causing  dyspnea ;  alteration  or  loss  of  the  voice  may  also  ensue. 
Displacement  and  distortion  of  the  trachea,  the  vessels,  and  other  cer- 
vical tissues  may  be  produced.  Large  pendulous  growths  usually  cause 
less  serious  discomfort  than  the  small  encircling  tumors  that  extend 
downward  into  the  thorax.  Headache,  somnolence,  and  marked  cere- 
bral symptoms,  such  as  tetany  and  convulsions,  have  been  described  as 
due  to  compression  of  the  carotids. 

The  general  health  or  nutrition  seldom  fails  unless  inflammation  and 
suppuration  (strumitis)  attack  the  goiter  during  the  course  of  some  in- 
fectious disease,  as  not  infrequently  happens,  or  in  cases  in  which  the 
thyroid  function  is  abolished,  leading  to  the  profound  nutritional  and 
cerebral  disorders  of  cretinism  in  children  or  myxedema  in  adults. 

Dettrich  and  Osier  have  each  reported  an  instance  of  a  goitrous 
growth  aff"ecting  aberrant  portions  of  thyroid  found  in  the  upper  region 
of  the  pleural  cavity,  one  on  the  right  and  one  on  the  left  side. 

Sudden  death  may  ensue  in  a  few  cases,  either  from  pressure  on  the 
vagi,  from  a  severe  intraglandular  hemorrhage,  or  from  a  hemorrhage 
into  the  adjacent  cellular  tissues. 

Auscultation  often  reveals  a  loud  blowing  murmur,  especially  marked 
in  the  vascular  bronchoceles.  Palpation  over  the  tumor  often  shows 
the  bossellated  surface  present  in  cystic  goiter ;  fluctuation  may  also 
be  detected  in  such  cases,  as  well  as  over  the  abscess  of  a  strumitis. 

Diagnosis. — Goiter  is  easily  differentiated  from  other  enlargements. 
The  constant  location  and  the  character  and  course  of  growth  of  the 
bronchocele  are  distinctive.  If  both  lobes  of  the  thyroid  are  aff"ected, 
making  a  symmetric  swelling,  the  diagnosis  is  almost  assured.  Bron- 
chocele is  not  easily  confounded  with  other  cervical  tumors,  such  as 
lymphadenoma.,  glandular  tuberculosis,  carcinoma  or  abscess  of  the  thy- 
roid, or  sebaceous  cysts.  A  characteristic  feature  of  tumors  of  the  thy- 
roid is  their  vertical  movement  during  the  act  of  deglutition. 


458     DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

ProgftlOSiS. — This  is  guardedly  favorable  as  to  life,  but  unfavorable 
as  to  cure.  The  course  is  chronic,  but  the  possibility  of  a  sudden  fatal 
termination  should  be  borne  in  mind. 

Treatment. — Prophylaxis  should  be  practised  in  goitrous  districts 
by  the  drinking  of  boiled  water  only,  and  removal  to  a  non-goitrous  region 
is  advisable.  The  majority  of  drugs  recommended  for  internal  and  ex- 
ternal use  have  been  proved  valueless,  though  in  the  parenchymatous 
and  follicular  forms  potassium  iodid  by  the  mouth  and  the  vigorous  and 
methodic  use  of  iodin  over  the  tumor  have  been  much  lauded.  Mer- 
curial ointment — the  red  or  biniodid  especially — has  also  been  recom- 
mended for  local  application.  Ergot  or  belladonna  in  progressively 
increasing  doses  may  do  good  in  vascular  goiters.  The  younger  and 
softer  goiters  may  also  be  benefited  by  electrolysis,  needles  attached  to 
the  negative  pole  being  inserted  into  the  substance  of  the  tumor  Avhile  a 
large  sponge  or  clay  positive  electrode  is  placed  in  the  vicinity. 

In  the  older,  fibrous,  and  degenerated  goiters  surgical  treatment 
alone  may  be  of  service.  Injections  of  iodin,  tapping  of  cysts,  incisions 
of  the  isthmus,  and  ligature  of  the  thyroid  arteries  have  been  practised 
among  the  lesser  operations.  Thyroidectomy,  or  a  partial  extirpation 
of  the  thyroid,  is  the  radical  and  final  operation. 

Recently,  the  fresh,  chopped  thymus  gland  of  the  sheep,  spread  on 
bread,  was  given  in  20  cases  of  follicular  and  parenchymatous  goiter 
Avith  gratifying  results.  The  pressure-symptoms  were  relieved  and  a 
perceptible  diminution  in  the  size  of  the  goiter  was  demonstrated  by 
actual  measurements.  Complete  recovery,  in  an  anatomical  sense,  how- 
ever, was  realized  in  two  cases  only. 

EXOPHTHALMIC   GOITER. 
(Graves's  Disease;  Basedoio's  Disease.) 

Definition  and  Nature. — Although  the  view  cannot  be  unreservedly 

accepted,  exophthalmic  goiter  is  probably  of  thyroid  origin  and  is  de- 
pendent upon  an  abnormal  action  (or  over-action)  of  the  thyroid  gland ; 
it  is  characterized  clinically  by  tachycardia,  tremors,  enlarged  thyroid, 
and  exophthalmos.  Among  other  leading  theories  the  following  may 
be  briefly  stated :  (1)  that  it  is  due  to  disturbed  innervation  (Buschan) ; 
(2)  that  the  seat  of  the  disease  resides  in  the  medulla  oblongata ;  (3)  that 
it  is  an  aff'ection  of  the  sympathetic  nerves  ;  and  (4)  that  it  is  a  disease  of 
the  central  nervous  system  associated  with  a  chronic  intoxication. 

The  theory  held  by  Mobius,  that  exophthalmic  goiter  is  attributable 
primarily  to  a  disturbance  of  the  function  of  the  thyroid  ("  hyperthyroid- 
ation  "),  a  condition  directly  opposed  to  the  lack  of  thyroid  function,  as 
in  myxedema,  is  amply  supported  by  clinical  evidence,  the  complex  symp- 
tom-group of  the  former  being  directly  antagonistic  to  that  of  the  latter 
disease.  Thyroid-feeding,  moreover,  Avhile  it  sometimes  causes  paren- 
chymatous goiters  to  disappear  rapidly,  usually  aggravates  the  symptoms 
of  Basedow's  disease.  Regarding  the  pathologic  changes  in  the  thyroid 
little  is  known.  Brissaud  ^  found  in  25  cases  of  various  chronic  diseases 
changes  in  the  thyroid,  and,  although  the  glands  in  exophthalmic  goiter 
showed  no  changes  peculiar  to  that  disease,  yet  quantitatively  the  lesions 
'  Mercredi  mcd.,  No.  34,  1895. 


EXOPHTHALMIC  GOITER.  459 

were  always  such  as  to  make  "  liyperthyroidation  "  possible.  Persist- 
ence of  the  thymus  gland  is  common  (Hector  MacKenzie).  Muscular 
changes,  probably  resulting  from  toxemia,  explain  the  profound  muscular 
weakness  (Askanazy). 

Ktiology. — It  is  more  common  in  women  than  in  men.  A  table  of 
200  cases  showed  161  females  and  39  males  (Eshner) ;  and,  although  it 
has  been  met  with  at  both  extremes  of  life,  it  is  seen  usually  in  adults. 
The  influence  of  heredity  is  undoubted,  and  several  members  of  a  family 
may  suffer,  persons  that  possess  a  sensitive  nervous  organization  being 
especially  prone  to  the  disease. 

Among  direct  causes  are  emotional  disturbance,  worry,  severe  acute  dis- 
ease (noted  in  two  of  my  cases),  and  prolonged  mental  or  physical  strain. 

The  disease  may  also  occur  as  a  secondary  complication  in  the  course 
of  simple  goiter,  affections  of  the  nose,  and  pregnancy ;  this  variety, 
however,  is  to  be  distinguished  from  the  primary  or  essential  form. 

Symptoms. — The  development  of  the  characteristic  symptoms  is 
generally  gradual,  though  it  may  rarely  be  rapid.  In  the  so-called  abor- 
tive form  the  symptoms  arise  somewhat  rapidly,  but  early  subside. 

In  acute  Basedow's  disease  the  symptoms  consist  of  an  excessively 
rapid  action  of  the  heart,  incessant  vomiting,  purging,  and  marked 
exophthalmos,  with  or  without  pronounced  cerebral  symptoms.  J.  H. 
Lloyd's   case  proved  fatal  after  an  illness  of  three  days. 

In  the  chronic  form  heart-hurry  is  almost  constantly  a  conspicuous 
early  symptom,  and  not  seldom  have  I  found  that  it  precedes  for  a  long 
period  of  time  the  appearance  of  the  remaining  characteristic  features 
(enlargement  of  the  thyroid,  exophthalmos,  and  tremor).  The  pulse 
remains  at  or  over  100  beats  per  minute,  and  upon  unusual  exertion -or 
excitement  the  heart's  action  becomes  violent  and  irregular,  the  pulse 
even  reaching  160  or  over.  Palpitation,  often  with  breathlessness,  is  a 
distressing  symptom. 

Cardiac  Physical  Signs. — Inspection  reveals  a  forcible  impulse  that  is 
not  displaced,  though  late  in  the  affection  it  may  be  much  extended  in 
superficial  area.  The  carotids  and  the  abdominal  aorta  beat  more  or  less 
violently,  and  the  capillaries  and  veins  of  the  hands  may  also  pulsate 
visibly.  Palpation  detects  an  increased  force  of  the  cardiac  impulse. 
The  area  of  percus%ion-dulness  may  be  somewhat  increased,  as  hyper- 
trophy and  secondary  dilatation  supervene.  On  auscultation,  blowing 
murmurs  over  the  heart  and  the  great  vessels,  as  well  as  an  increased 
accentuation  of  the  valvular  sounds,  may  be  audible  even  for  some 
distance  from  the  patient.  Distinct  b?niits  may  be  heard  over  the  base 
and  manubrium. 

Exophthalmos. — Protrusion  of  the  eyeballs  is  usually  present.  The 
degree  of  exophthalmos  varies  greatly  from  time  to  time  in  the  same 
case — a  fact  that  points  to  an  increased  amount  of  blood  or  lymph  in  the 
orbit  as  its  cause.  In  advanced  cases  permanent  prominence  of  the  balls 
may  be  attributable  to  augmentation  of  the  orbital  adipose  tissue.  On 
closing  the  eyes  a  rim  of  white  is  visible  above  and  below  the  cornea,  and 
Graefe's  sign,  immobility  of  the  upper  lid  when  the  eye  is  turned  down- 
ward, are  two  symptoms  of  great  diagnostic  importance.  Mobius  has 
called  attention  to  the  inability  to  converge  the  eyes  upon  near  objects; 
and  Stellwag,  to  an  apparent  separation  of  the  eyelids,  due  to  spasm  or 
retraction  of  the  upper  lid.     The  pupils  and  the  vision  are  unaffected 


460    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS   GLANDS. 

while  the  patient  winks  less  often  than  in  health.  Abnormalities  are 
rarely  presented  by  the  optic  nerves,  and  ulceration  of  the  cornea  may 
supervene.     The  retinal  arteries  pulsate. 

Thyroid  enlargement  may  either  accompany  or  follow  the  exophthal- 
mos, and  has  for  its  cause  the  great  dilatation  of  the  vessels,  particu- 
larly of  the  arteries.  The  enlargement  is  usually  moderate,  and  may 
be  general  or  partial,  the  size  of  the  gland  exhibiting  sudden  variations, 
since  it  is  dependent  upon  the  circulatory  disturbance.  Inspection  may 
also  show  visible  pulsation ;  palpation  feels  a  thrill,  and  auscultation 
renders  audible  a  double  systolic  murmur.  The  latter  sign  is  probably 
present  in  most  instances,  though  not  constantly. 

Nervous  Symptoms. — 3Iuscular  tremors  form  an  early  symptom ; 
they  are  involuntary,  and  fine  in  character,  numbering  about  eight 
to  the  second  (Osier).  The  characteristic  features  of  neurasthenia 
appear  and  gradually  increase  in  intensity.  Mental  disturbances,  par- 
ticularly marked  depression  or  great  excitability,  are  common,  and 
even  mania  (which  may  prove  speedily  fatal)  or  melancholia  may  be 
observed. 

Cutaneous  Symptoms. — The  temperature  may  at  intervals  be  moderately 
elevated,  and  this  symptom  may  be  associated  with  profuse  sweatings. 
Among  other  cutaneous  phenomena,  though  these  are  for  the  greater  part 
occasional,  are  pigmentation  (which,  in  the  case  of  a  physician  whom  I 
recently  saw  suffering  from  Basedow's  disease,  was  as  pronounced  as  in 
typical  Addison's  disease),  scleroderma,  urticaria,  pruritus,  and  circum- 
scribed solid  edema.  In  the  advanced  stage  malleolar  edema  sets  in  and 
may  become  general.  A  marked  diminution  in  the  cutaneous  resistance 
to  the  electric  current  lias  been  noted  by  Charcot.  The  forehead  is  not 
wrinkled  as  in  health. 

General  Symptoms. — Muscular  weakness,  either  local  or  general,  is 
pronounced ;  the  patient  becomes  anemic  and  is  at  last  extremely 
emaciated.  Vomiting  and  purging  may  appear  at  different  times  and 
assume  great  gravity,  and  in  some  cases  hemorrhages  (epistaxis,  he- 
moptysis, hematemesis)  tend  to  supervene.  Albuminuria  and  an  in- 
creased amount  of  urine,  with  glycosuria,  are  among  the  commoner 
complications.  Louise  Bryson  has  maintained  that  diminution  in  the 
chest-expansion  is  a  characteristic  sign  of  exophthalmic  goiter ;  and 
Patrick,^  who  examined  40  cases,  found  that  there  was  an  average 
diminution,  but  believed  it  to  be  proportionate  to  the  amount  of 
the  general  muscular  weakness.  Rarely  a  myxedematous  condition 
is  associated;  probably  the  disease  is  also  remotely  related  to  sclero- 
derma. 

Diagnosis. — The  diagnosis  of  Graves's  disease  may  be  made  when 
tachycardia  or  delirium  cordis  and  fine,  general  muscular  tremors  are 
present.  Exophthalmos  and  enlargement  of  the  thyroid  are  often  late- 
appearing  symptoms,  and  are  as  often  temporarily  lacking  even  in  fully- 
developed  cases.  Rarely,  either  or  both  of  these  signs  may  be  permanently 
absent.  On  the  other  hand,  in  a  few  cases  exophthalmos  is  the  sole  cha- 
racteristic feature  for  a  long  time,  though  it  is  eventually  followed  by  an 
unmistakable  symptom-group.  Parenchymatous  goiter  presents  a  non- 
pulsating  tumor,   and  hence  is  easily  distinguishable  from  the   thyroid 

1  Deutsche  med.  Woch.,  Dec.  20,  1894. 


EXOPHTHALMIC  GOITER.  4^1 

enlargement  of  Basedow's  disease  Avith  its  additional  unequivocal  symp- 
toms. 

Course  and  Prognosis. — The  chronic  form  of  the  disease  endures, 
as  a  rule,  for  a  few  years.  A  gradual  subsidence  of  the  cardinal  symp- 
toms for  a  long  period  has  been  noted,  and  in  such  cases  complete  recov- 
ery may  be  claimed.  In  fully-developed  cases  the  prognosis  formerly  was 
almost  hopeless,  but  since  the  introduction  of  the  operative  treatment 
many  cases  have  been  greatly  benefited,  and  others,  though  constituting 
a  smaller  number,  have  been  entirely  cured. 

Treatment. — This  is  {a)  Hygienic,  [b)  Medicinal,  and  (c)  Operative. 

(a)  Hygienic. — The  environment,  both  physical  and  mental,  should  be 
made  as  favorable  as  possible.  A  change  of  climate,  and  especially  mod- 
erate elevation,  in  cases  not  too  far  advanced,  bring  about  beneficial  re- 
sults. Such  elevation  (3250  feet)  produces  a  sedative  effect  upon  the 
nervous  state  that  reacts  most  favorably  upon  the  circulatory  organs, 
while  the  purity  and  tonic  quality  of  the  air  have  a  general  strengthening 
and  restorative  effect  (Yeo).  Among  other  promising  measures  may  be 
mentioned  the  wet-pack,  methodical  hydrotherapy  with  massage,  and  a 
continuous  galvanic  current.  The  electric  treatment  should  be  given  a 
thorough  trial  over  three  or  four  months  (Osier).  The  local  use  of  an  ice- 
bag  to  the  precordium  has  acted  admirably  in  reducing  the  heart-hurry  in 
a  few  cases  of  my  own.  I  have  also  observed  favorable  results  from  care- 
fully graduated  physical  exercise.  Rest  in  bed  for  a  few  weeks  at  a  time, 
at  intervals,  is  often  followed  by  improvement,  though  I  have  never  seen 
complete  cure  follow  this  plan  of  treatment. 

(b)  Medicinal  Treatment. — This  is  probably  secondary  to  the  hygenic 
and  operative  measures.  In  two  cases  of  my  own,  however,  recovery  fol- 
lowed the  persistent  use,  for  about  six  months,  of  the  following  prescrip- 
tion : 

^.  Extr.  digitalis,  gr.  iv  (0.259)  ; 

Extr.  ergotse  (Squibb),  3ss       (2.0) ; 

Strychninas  sulph.,  gr.  ss  (0.032)  ; 

Ferri  arsenias,  gr.  ij  (0.129). 
M.  et  ft.  capsul{»  No.  xxiv. 
Sig.   One  t.  i.  d.  after  meals. 

In  2  other  cases  (one,  a  trained  nurse)  the  use  of  sodium  salicylate  (gr.  x- 
0.648 — four  times  a  day)  was  followed  by  almost  total  relief.  L.  Webster 
Fox  also  warmly  advocates  the  latter  remedy  in  this  affection.  Trachewsky, 
in  Kocher's  clinic,  found  that  sodium  glycerophosphate  (gr.  xx — 1.296 — 
three  or  four  times  a  day),  had  the  effect  of  diminishing  the  size  of  the 
enlarged  thyroid  glands,  and  Starr  ^  has  also  found  this  remedy  of  great 
service  in  several  cases.  Other  therapeutic  agents  that  have  been  exten- 
sively employed,  but  with  doubtful  advantage,  are  aconite,  veratrum  viride, 
and  belladonna.  From  all  of  the  clinical  testimony  at  hand  I  feel  con- 
vinced that  thyroid-feeding  is  contraindicated  in  the  treatment  of  Basedow's 
disease,  unless  a  myxedematous  condition  be  associated,  when  it  may  prove 
efficient-  S.  Solis-Cohen  and  others  have  used  extract  of  suprarenal 
gland  with  good  results. 

(c)  Operative  Treatment. — Starr  ^  has  collected  190    cases  in  which 

1  Medical  Sews,  April  18,  1896,  ^  Loc.  cit. 


4^2    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

some  form  of  operation  was  performed.  Of  these,  74  are  reported  as  com- 
pletely cured,  many  of  them  having  been  Avatched  two  to  four  years 
before  the  result  was  published ;  45  of  the  cases  w^ere  improved,  and 
23  died  immediately  after  operation.  The  symptoms  preceding  the 
fatal  result  are  sudden  hyperpyrexia,  with  rapid  pulse,  nervous  dis- 
tress, sweating,  cardiac  failure,  and  collapse.  The  statistics  of  Kinni- 
cutt  and  of  Abram  ^  (particularly  the  latter)  show  less  encouraging  re- 
sults from  operation.  It  is  to  be  remembered  that  under  the  most  fa- 
vorable circumstances  a  complete  cure  Avill  not  be  attained  immediately, 
and  frequently  not  for  several  years.  I  am  convinced  that  removal  of 
the  entire  gland  is  not  to  be  advised,  since  myxedema  will  likely  result. 
Whether  partial  removal — one-half  to  three-fourths  of  the  gland — is  to 
be  effected,  or  mere  ligation  of  the  thyroid  arteries,  must  be  decided  by 
the  surgeon.  Bilateral  resection  of  the  sympathetic  nerve  has  been 
done  by  Schwartz  and  others  with  marked  amelioration  of  the  symptoms. 

MYXEDEMA. 

( Sporadic  Cretinism.) 

Definition. — A  general  nutritional  disorder,  consequent  upon  atro- 
phy and  loss  of  function  of  the  thyroid  gland,  and  characterized  by  a 
myxedematous  infiltration  of  the  subcutaneous  tissue  and  a  cretinoid 
cachexia. 

Three  varieties  occur,  as  follows  :  (1)  True  myxedema ;  (2)  Cretinism 
(the  absence  of  thyroid  function — congenital,  or  lost  during  childhood)  ; 
(3)  Operative  myxedema,  due  to  total  removal  of  the  glands  for  surgical 
reasons  or  in  experiments  upon  lower  animals. 

Nature  of  Myxedema  Proper  of  Adults. — Charcot,  who  gave  the  name 
of  cachexie  pachydermique  to  this  disease,  believed  it  to  be  of  tropho- 
neurotic origin.  Atrophy  of  the  thyroid  is  pretty  constantly  present, 
and  the  gland  may  either  be  converted  into  a  small  fibrous  mass  or  be 
entirely  absent,  so  that  the  causal  relation  between  myxedema  and 
functional  and  structural  alterations  of  the  thyroid  seems  to  be  conclu- 
sive. Moreover,  the  therapeutic  test  of  improvement  under  the  admin- 
istration of  thyroid  extract  sustains  this  view.  It  is  probable  that  the 
active  thyroid  supplies  some  essential  secretion  which  maintains  normal 
metabolism,  though  this  product  has  not  been  isolated.  Its  existence 
being  inferred,  however,  it  has  been  called  tliyroidin.'^  Ponfick  has 
pointed  out  that  the  hypophysis  sometimes  shows  changes  resembling 
those  in  the  thyroid  gland.  The  fact  that  in  a  good  many  cases  of 
myxedema  a  considerable  portion  of  the  thyroid  gland  is  unaltered  and 
partly  capable  of  functionating  arouses  a  suspicion  that  the  hypophysis 
may  share  in  the  production  of  this  disease. 

Ktiology. — The  thyroid  was  destroyed  by  actinom//cosis  in  a  case 
of  myxedema  reported  recently.  Myxedema  may  also  be  secondary  to 
exophthalmic  f/oiter,  but  it  is  then,  as  in  the  case  of  a  simple  acute  goiter, 
only  a  transient  condition.  Women  are  much  more  frequently  affected 
than  men,  and  a  neurotic  condition  may  precede  some  cases.  The  dis- 
ease may  affect  several  members  of  a  family,  and  hereditary  transmission 

*  American  Year-Book  of  Medicine  and  Surgery,  1897. 

'^The  term  "  thyroidin "  lias  also  been  i^iven  to  a  substance  possessing  specific 
therapeutic  activities  that  has  been  obtained  from  the  thyroid  gland  of  the  sheep. 


MYXEDEMA.  463 

through  the  mother  has  been  observed.  Sisters  may  suffer,  one  from 
myxedema  and  the  other  from  exophthalmic  goiter.  Pregnancy  may 
cause  a  disappearance  of  the  myxedematous  symptoms  (Osier).  The 
symptoms  may  reappear   after  delivery. 

Symptoms. — The  myxedematous  condition  is  most  plainly  noted  in 
the  face,  the  skin  being  swollen,  but  inelastic,  rough,  dry,  and  firm. 
The  lines  of  facial  expression  are  obliterated,  and  the  features  are 
broad,  coarse,  immobile,  and  bulky.  The  physiognomy  is  stupid,  dull, 
and  phlegmatic,  and  simulates  imbecility.  The  hair  falls  out,  owing  to 
deficient  nutrition,  and  the  general  bulk  of  the  body  is  markedly  in- 
creased. Pressure  does  not  produce  pitting,  as  in  true  edema.  Accord- 
ing to  Ord,  the  local  tumefaction  of  the  skin  and  subcutaneous  tissue  is 
most  frequently  prominent  in  the  supraclavicular  regions.  The  mucous 
membranes  are  also  infiltrated,  and  the  teeth  may  become  loosened.  The 
tongue,  lips,  and  nose  are  thickened,  and  the  voice  is  monotonous,  slow, 
and  has  a  "leathery  tone,"  "  with  curious  nasal  explosions  at  short  in- 
tervals during  speaking."  Bodily  movements  are  slow,  and  the  gait  is 
heavy  and  uncertain  on  account  of  disturbed  co-ordination. 

Nervous  Symptoms. — Mental  perception  and  thought  are  also  slow, 
and  the  memory  is  defective  and  slow  to  respond.  jSTot  infrequently 
there  may  be  considerable  irritability,  or  hebetude  alternating  with 
sudden  excitability.  The  patient  may  become  suspicious,  and  later  is 
subject  to  delusions  and  hallucinations  ;  or  the  apathy  may  pass  into  a 
melancholia,  ending  at  last  in  dementia.  Ord  mentions  "the  aggrava- 
tion  of  all  symptoms  during  low  climatic  temperatures;  "  and  "among 
the  minor  or  accessory  signs  may  be  quoted  abnormal  subjective  sensa- 
tions, belonging  particularly  to  taste  and  smell;  occipital  headache; 
marked  alterations  of  temper  ;  and  a  curious  persistence  of  thought  and 
action,  overriding  all  attempts  at  interruption  by  friends  or  observers." 

The  temperature  in  myxedema  is  usually  either- normal  or  subnormal. 
Albumin  and  sugar  are  occasionally  found  in  the  urine,  but  the  quantity 
of  nitrogen  excreted  is  small,  owing  to  the  diminished  metabolism  of 
proteids.  Hemorrhages  from  the  nose,  gums,  and  bowels  sometimes 
occur.  Ascites  also  may  be  present  in  some  cases,  and  may  simulate 
ovarian  tumor.  The  thyroid  is  not  palpable,  partly  because  of  its 
atrophy,  and  partly  because  of  the  thickened  myxedematous  tissues  of 
the  neck. 

The  diagnosis  is  not  difiicult  if  one  bears  in  mind  the  character- 
istic manifestations  described  above.  Mxedema  could  hardly  be  mistaken 
for  acute  or  chronic  nephritis  in  the  absence  of  pitting,  etc..  as  some  have 
supposed. 

The  prognosis  is  guardedly  favorable  in  a  majority  of  the  cases 
since  the  introduction  in  the  treatment  of  thyroid-feedinc.  The 
course  of  the  disease  is  slow  and  progressive,  however,  often  lastino^ 
from  five  to  fifteen  years,  and  death  from  intercurrent  disease  is  not 
uncommon. 

Treatment. — Until  the  advent  of  thyroid-feeding  the  treatment  of 
myxedema  was  palliative,  and  usually  unsuccessful. 

A  warm  and  equable  climate  is  very  desirable,  owing  to  the  sub- 
normal temperature  from  which  the  patients  frequently  suffer.  The 
various  warm  baths — as  the  Turkish,  Russian,  and  electric — should  be 


464    DISEASES  OF  THE  BLOOD  AND   THE  DUCTLESS  GLANDS. 

employed  for  the  same  reason.  Pilocarpin  has  been  recommended,  and 
strychnin  and  arsenic  have  been  administered  for  their  tonic  effect. 

Since  the  brilliant  results  obtained  by  Murray,  however,  the  internal 
use  of  the  thyroid  gland  of  sheep  or  calves  has  come  into  a  well- 
deserved  favor  in  the  treatment  of  all  cases  of  myxedema,  whether  of 
the  so-called  true  form,  of  sporadic  cretinism,  or  of  the  cachexia 
strumipriva.  The  gland  may  be  given  raw  or  cooked,  in  the  form  of 
the  glycerin  extract,  or  in  the  dried  and  powdered  extract ;  the  last 
named  is  sometimes  put  into  tabloid  form.  If  cooked,  the  gland  should 
be  only  partially  "done."  The  fresh  thyroid  is  minced  and  often 
spread  on  bread,  and  from  one  quarter  to  half  a  gland  may  be  taken 
daily. 

The  glycerin  extract  is  readily  made.  "  Several  dozens  of  thyroids 
of  young  sheep  or  calves  are  carefully  separated  from  the  connective 
tissue,  cut  into  small  pieces  about  the  size  of  a  bean,  and  then  put  into 
a  jar  and  covered  Avith  glycerin  of  the  beSt  quality,  allowing  2  c.cm. 
of  glycerin  for  each  lobe  of  the  thyroid  used.  The  mixture  is  permitted 
to  stand  for  twenty -four  or  thirty-six  hours,  and  is  then  squeezed  through 
a  cloth,  so  as  to  get  out  as  much  liquid  as  possible.  Of  this,  2  c.cm., 
corresponding  to  about  half  a  gland,  may  be  given  at  a  dose.  If  used 
for  hyjjodermic  injection,  to  a  dram  (4.0)  of  the  glycerin  extract  is  added 
half  a  dram  (2.0)  of  a  1  per  cent,  solution  of  carbolic  acid  in  distilled 
water,  of  which  mixture  from  10  to  15  minims  (0.66-1.0)  may  be  in- 
jected three  or  four  times  a  week."^ 

It  is  safest — for  reasons  that  will  be  pointed  out  below — to  begin 
with  quite  small  doses,  and  gradually  increase,  especially  if  there  is 
much  gastric  irritation.  Not  more  than  5  minims  (0.333)  of  the  glycerin 
extract  should  be  given  at  the  start.  This  dose  may  be  increased  grad- 
ually until  15  or  20  minims  (1.0-1.33)  are  taken  three  times  daily. 
From  3  to  5  grains  (0.194-0.324)  of  the  powdered  gland  or  tabloid  form 
will  be  a  safe  commencing  dose  in  adult  myxedema :  a  caution,  however, 
is  necessary  regarding  the  various  manufactured  preparations  of  the 
thyroid  gland,  some  of  which  are  impure  and  even  dangerous,  owing  to 
the  careless  handling  or  fraudulent  substitution  in  order  to  meet  the 
demand  for  thyroid  extracts  on  trial  in  other  affections. 

The  toleration  of  thyroid-feeding  does  not  depend  upon  the  volume, 
but  upon  the  functional  activity,  of  the  gland,  and  this  fact,  together 
with  the  evidences  of  toxic  action  reported  in  some  instances  of  the 
administration  of  thyroids  to  a  maximum  degree,  make  it  important  to 
urge  again — as  intimated  above — the  necessity  of  small  dosage  at  the 
beginning  of  treatment,  and  the  most  careful  and  judicious  increase  in 
the  quantity  given.  The  additional  fact  of  an  occasional  cumulative 
action  should  also  be  emphasized.  Should  vomiting,  renal  pain,  tachy- 
cardia, suffusion  of  the  face,  syncope,  vertigo,  or  marked  headache 
supervene,  the  remedy  should  be  stopped  at  once.  The  treatment 
may  be  resumed  again  cautiously,  alternating  with  intervals  of  cessa- 
tion. I  have  observed  that  by  combining  arsenic  Avith  any  of  the 
preparations  of  thyroid  the  toxic  effects  of  the  latter  can  be  in 
great  measure  obviated.  Good  results  are  obtained  usually  within  a 
month,  though  it  is  probable  that  even  after  all  the  symptoms  have 

^  Osier,  in  tlie  Amer.  Text-hook  of  Therapeutics,  pp.  936,  927. 


MYXEDEMA.  465 

subsided  the  treatment  may  have  to   be  continued  off  and  on  if  the 
thyroid  gland  seems  to  be  permanently  atrophied. 

Cretinism,  Sporadic  and  Endemic. — Here  there  is  a  congenital  atrophy 
or  absence  of  the  thyroid  gland,  or  an  enlargement  by  the  groTvth  of 
fibrous  tissue  at  the  expense  of  the  glandular  elements.  Cretinism  may 
also  develop  in  early  infancy.  The  patients  are  often  the  children  of 
parents  noted  for  violent  emotion  and  having  various  neuroses  and 
goiter,  and  syphilis  has  also  been  supposed  to  have  a  causative  influence. 
Congenital  myxedema  is  quite  common  only  in  regions  Avhere  goiter  is 
endemic,  and  hence  it  is  rare  in  America.  A  marked  sporadic  case  has, 
however,  been  in  the  Philadelphia  Hospital  for  many  years. 

Symptoms. — Cretins  are  dwarfs  Avith  large  heads  and  faces,  thick 
lips,  thick  protruding  tongues,  broad  bodies  and  members,  and  promi- 
nent abdomens.  The  subcutaneous  tissues  are  myxedematous.  Umbili- 
cal hernia  has  been  noted.  The  mental  condition  is  that  of  idiocy,  and 
physical  growth  is  retarded  and  slow.  Speech  is  unintelligible  or  nearly 
so,  and  the  voice  harsh.  Walking  may  never  be  accomplished,  and  is 
always  slowly  developed.  There  is  anemia,  the  blood  being  of  a  fetal 
type.     Rheumatic  symptoms  sometimes  occur. 

Prognosis. — The  disease  is  progressive  until  about  the  fifteenth 
year  in  those  cases  developing  during  early  childhood.  Congenital 
cases  usually  die  shortly  after  birth.  At  the  twentieth  or  thirtieth 
year   "the  mental  and  physical  characters  are  those  of  childhood." 

Treatment. — Thyroid-feeding  has  been  followed  by  beneficial  results, 
the  checked  growth  having  recommenced  and  the  cretinic  aspect  having 
been  largely  lost.  S.  Kuh  ^  has  employed  iodothyrin  in  one  case  with 
quite  as  satisfactory  results  as  those  from  the  dried  thyroid,  while  it 
caused  no  disturbance  of  the  stomach  or  other  disagreeable  effects. 

Operative  Myxedema,  or  Cachexia  Strumipriva. — Extirpation  of  the 
thyroid  for  surgical  reasons  has  given  rise  to  the  gradual  production  of 
symptoms  and  conditions  identical  either  with  true  myxedema  or  with 
the  cretinoid  state.  Partial  removal  of  the  gland  is  not  followed  by 
cachexia  strumipriva,  nor  is  complete  thyroidectomy  when  accessory 
glands  are  present  elsewhere. 

The  administration  of  raw  or  broiled  thyroids,  or  of  their  various 
extracts  or  preparations,  must  also  be  employed  in  this  form  of  myx- 
edema, and  should  be  continued  throughout  the  rest  of  the  patient's 
life,  perhaps  with  intervals  of  withdrawal  of  the  feeding  until  the  im- 
provement gained  begins  to  lapse. 

^  Philadelphia  Medical  Journal,  April  8,  1899. 
30 


PART  IV. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


DISEASES  OF  THE  NOSE. 


ACUTE  RHINITIS. 

(Acute  Nasal  Catarrh;  Acute  Coryza) 

Definition. — An  acute  catarrh  of  the  Schneiderian  membrane,  some- 
times tending  to  involve  the  adjacent  sinuses  and  passages.  It  is  knoAvn 
to  the  laity  as  "  cold  in  the  head." 

il^tiology. — Its  most  conspicuous  cause  is  exposure  to  draughts  of 
air  and  to  the  influence  of  the  atmospheric  vicissitudes  that  are  espe- 
cially prevalent  during  the  winter  and  spring  seasons.  It  often  results 
from  the  inhalation  of  irritants  (physical,  chemical,  or  biological).  It 
may  also  display  epidemic  behavior,  and  this  fact  seems  to  point  strongly 
to  its  microbic  origin.  Hence  local  disturbances  of  the  circulation  due 
to  exposure  are  to  be  regarded  as  the  accidental  means  of  preparing  the 
soil  for  bacterial  invasion.  Acute  rhinitis  may  be  also  secondary  to,  or 
propagated  from,  inflammations  of  the  faucial  mucosa  by  contiguity. 

Symptoms. — Sensations  of  cliiUiness,  succeeded  by  feverishness 
(the  temperature  reaching  100°  to  101°  F.  ;  37.7°-38.3°  C.),  frequent 
sneezing,  headache,  and  a  feeling  of  general  ill-health  are  among  the 
prominent  features  that  attend  the  development  of  coryza.  Pains  in 
the  extremities  and  back  tend  to  appear  only  in  severe  cases.  The  pulse 
is  frequent,  the  skin  dry  and  unduly  warm,  thirst  is  increased,  while  the 
appetite  is  impaired,  and  constipation  often  attends.  The  nasal  mucosa 
is  swollen,  and  thus  interferes  both  with  the  nasal  respiration  and  the 
senses  of  smell  and  taste ;  its  color  is  deepened,  its  surface  covered  at  first 
with  opaque  mucus,  and  later  with  a  muco-purulent  secretion.  Among 
early  symptoms  is  the  discharge  of  a  watery,  irritating  secretion  from  the 
nares  and  a  maceration  of  the  epidermis,  with  resulting  abrasions.  On 
account  of  the  swelling  of  the  mucosa  of  the  lacrymal  ducts  the  tears 
flow  down  over  the  cheeks.  Adjacent  mucous  surfaces  then  become  in- 
volved, giving  rise  to  conjunctivitis,  catarrhal  pharyngitis,  laryngitis, 
and  finally,  in  the  severer  types,  bronchitis.  Naso-labial  herpes  is  not 
uncommon.  As  the  afi^ection  progresses  the  secretion  becomes  more 
abundant  and  turbid  and  more  or  less  pyoid.  The  symptoms  due  to 
extension  of  the  catarrhal  inflammation  vary  with  the  organs  or  struc- 
tures involved.     The  disease  runs  its  course  within  five  or  six  days,  but 

467 


468  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  nasal  discharge,  which  gradually  diminishes,  usually  persists  for  a 
few  days  longer. 

Diagnosis. — In  the  presence  of  the  above-mentioned  symptoms  the 
disease  is  readily  recognized.  In  Avell-marked  cases,  however,  the  pos- 
sibility that  an  infectious  disease  may  be  developing,  the  beginning  of 
which  is  characterized  by  nasal  catarrh  (measles,  influenza,  etc.),  is  to 
be  recollected. 

Prognosis. — Except  in  neglected  cases,  which  result  in  bronchitis, 
and  occur  at  one  or  other  extreme  of  life,  the  disease  is  free  from  dan- 
ger.     The  nursing  infant  may  have  to  be  fed  with  a  spoon  temporarily. 

Treatment. — At  the  outset  a  purge,  consisting  of  calomel  (gr.  ij — 
0.129),  or  a  pill  of  blue  mass  (gr.  v — 0.324)  at  night,  followed  by  a 
Seidlitz  powder  in  the  morning,  is  advisable.  To  children  a  dose  of 
castor  oil  may  be  given.  The  early  administration  of  a  diaphoretic, 
such  as  Dover's  powder  (gr.  v-x — 0.324-0.648)  at  night  may  arrest  the 
complaint,  and  (juinin  in  a  large  dose  (gr.  xij-xv — 0.777-0.972)  at  night 
may  cut  short  the  course  of  the  disease.  When  the  above-mentioned 
abortive  measures  fail,  the  following  tablet  produces  good  results : 

I^.   Quinin.  sulphat.,  gr.  ijss  (0.162) 

Extr.  belladonnte  fl.,     mjss      (0.099) 
Sodii  salicylatis,  gr.  xxx  (1.944) 

Camphorse,  gr.  ijss  (0.162). 

M.  et  ft.  tablet  No.  x. 
Sig.   One  tablet  every  hour  or  two. 

For  the  fever  aconite  may  be  employed,  and,  if  the  throat  be  involved, 
bryonia  may  be  given  in  conjunction. 

Local  Treatment. — This  aims  at  soothing  as  well  as  at  reducing  the 
swelling  of  the  Schneiderian  membrane.  The  compound  tincture  of 
benzoin  forms  a  soothing  inhalation  (^ij  to  a  pint — 8.0  per  half  liter — 
of  water)  when  raised  nearly  to  the  boiling-point ;  the  vapor  is  inhaled 
for  ten  or  fifteen  minutes  at  a  time.  With  a  view  to  reducing  the  swell- 
ing a  solution  of  cocain  (strength  2  to  4  per  cent.)  may  be  temporarily 
used ;  Mackenzie  recommends  this  admirable  combination  : 

Menthol,  gr.v  (0.324); 

Pinol  mv    (0.324); 

Benzoinol,  f.5J      (32.0). 

In  severe  cases  the  patient  should  be  kept  in-doors  and  in  an  atmosphere 
of  even  temperature. 


CHRONIC  RHINITIS. 

(Chronic  Nasal  Catarrh.) 

Two  forms  are  recognized,  the  hypertrophic  and  atrophic,  and  these, 
though,  as  a  rule,  occurring  separately,  may  be  found  in  combination. 

Pathology. — The  morbid  changes  in  hypertrophic  rhinitis  consist 
in  an  enlargement  of  the  loAver  turbinated  processes,  together  with  red- 
ness and  swelling  of  the  nasal  mucosa  that  may  be  general  or  limited 


CEROSIC  RHiyiTIS. 


469 


eit-lier  to  the  anterior  or  posterior  nares.  As  the  disease  progresses  the 
thickening  of  the  membrane  increases,  until  it  finally  encroaches  upon 
the  nasal  chambers  at  every  point.  In  addition  to  the  nasal  obstruction 
there  is  a  hypersecretion  of  mucus.  Opposite  changes  occur  in  atrophic 
rhinitis,  such  as  thinning  or  atrophy  of  all  the  structures,  Tfith  enlarge- 
ment of  the  nasal  cavities.  The  nasal  mucosa  is  coated  with  thick,  yel- 
lowish-green, decomposing  crusts,  which  emit  a  characteristically  fetid 
odor,  and  the  frontal,  ethmoid,  or  other  accessory  sinuses  may,  by  an 
extension  of  the  inflammation  from  the  nasal  chambers,  be  invaded  by 
mucopurulent  inflammation.  The  atrophic  process  does  not  affect  the 
glandular  structures  of  the  upper  third  of  the  nose,  and  this  fact  ex- 
plains the  most  unpleasant  feature  of  the  affection — namely,  the  hor- 
rible secretion. 

etiology. — Frequently  occurring  attacks  of  acute  rhinitis  may  pro- 
duce the  chronic  form,  and  syphilis  and,  less  commonly,  tuberculosis 
are  also  among  its  causes.  Abel  ^  regards  atrophic  rhinitis  as  infectious, 
claiming  that  the  cause  is  the  bacillus  mucosis  ozence,  which  resembles 
closely  the  pneumobacillus,  but  is  distinguishable  from  it. 

Symptoms. — («)  In  the  hypertrophic  form  nasal  respiration  is  im- 
peded, owing  to  the  hypertrophy  of  the  turbinated  bodies.  The  sense 
of  smell  is  impaired,  and  there  is  a  discharge  of  secretion  from  the 
nares.  particularly  the  posterior, 
inducing  '•  hawking. "  The  diag;- 
nosis  is  set  at  rest  by  a  rhino- 
scopic  inspection  of  the  parts. 
While  this  is  a  common  affec- 
tion everywhere,  it  is  wellnigh 
universal  in  this   country. 

(5)  In  chronic  atrophic  ca- 
tarrh there  is  some  degree  of 
nasal  obstruction,  occasioned  by 
the  presence  of  the  thick  crust, 
but  the  most  conspicuous  symp- 
tom is  the  diso-ustino:  odor, 
which  makes  the  patient  re- 
pellent in  society.  The  sense 
of  smell  is  lacking.  After 
cleansing  the  membrane  the  rhinoscope  will  show  the  nasal  chambers 
to  be  unduly  capacious. 

Treatment. — (1)  Chronic  Hypertropliie  RMnitis. — The  treatment  is 
divisible  into  general  and  local.  The  physician  should  procure  an  envi- 
ronment for  his  charge  most  favorable  for  promoting  the  general  nutrition, 
which  is  often  below  the  health-standard.  The  selection  of  a  suitable 
climate,  then,  forms  an  important  part  of  the  management,  and  a  resi- 
dence in  a  locality  that  possesses  a  mild,  equable,  comparatively  dry 
and  pure  atmosphere  is  to  be  advised  and  encouraged.  Various  tonics 
may  then  be  demanded  by  the  general  condition  of  the  patient,  and 
strychnin  and  electricity  are  useful  in  restoring  the  loss  of  power  in  the 
contractile  elements  of  the  intercellular  walls. 

Local  measures  are  employed  to  facilitate  thorough   cleanliness  and 

^  Zeit.  f.  Hyg.  u.  Infefctiomkrank.,  Bd.  xxi.  H.  1. 


Fig.  41. — Apparatus  for  cleansing  the  nasal  passages 
in  chronic  rhinitis. 


470  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

disinfection  of  the  affected  parts,  though  in  incipient  and  mild  cases 
energetic  treatment  is  scarcely  needful.  The  best  method  of  cleansing 
the  nasal  passages  is  by  means  of  the  coarse  spray  (Fig.  41).  The 
apparatus  of  Lefferts  is  also  to  be  employed  when  the  secretion  is  in- 
spissated or  tightly  adherent.  An  excellent  combination  for  use  in 
this  manner  is  the  following  : 

!^.   Sodii  biborat., 

Sodii  bicarb.,  da.  3j  (4.0) ; 

Acid,  carbolici,  gr-  viij  (0.518); 

Listerin.,  sj  (32.0) ; 

Aquse  destillat.,       q.  s.  ad  siv  (128.0). — M. 
Sig.   Use  as  a  spray  three  times  daily. 

It  is  often  desirable  to  use  warm  or  even  hot  liquids,  in  which  case 
the  application  is  made  by  the  use  of  the  anterior  and  posterior  nasal 
syringe.  Powders  are  har:mful,  and,  as  the  nasal  douche  is  dangerous 
in  unskilled  hands,  these  should  both  be  abandoned. 

In  hypertrophic  rhinitis  the  obstruction  to  nasal  breathing  is  to  be 
removed,  and  to  accomplish  this  caustics  (chromic,  glacial  acetic,  and 
nitric  acids)  are  used,  of  which  the  most  efficacious  is  chromic  acid. 
This  should  be  applied  by  means  of  a  pointed  glass  rod,  the  application 
being  followed  by  a  sloughing  away  of  the  diseased  tissues.  Among 
other  modes  of  removing  the  nasal  obstruction  that  may  be  mentioned 
are  the  galvano-cautery,  the  thermo-cautery,  and  the  cold- wire  snare ; 
these  modes,  however,  are  practised  chiefly  by  the  specialist. 

(2)  In  atrophic  rhinitis  a  cure  is  to  be  despaired  of,  but  the  patient 
can  be  rendered  free  from  the  offensive  discharge,  and  hence  to  a  great 
degree  comfortable.  As  this  is  often  but  an  advanced  stage  of  hyper- 
trophic nasal  catarrh,  the  general  treatment  is  similarly  directed :  it  is 
therefore  well  to  overcome,  as  far  as  possible,  by  a  mental  stimulus,  the 
depressed  mental  state  due  to  the  fetor.  If  the  diathesis  be  tuberculous, 
cod-liver  oil,  iron,  arsenic,  and  strychnin,  together  with  a  generous  diet, 
are  to  be  advised.  If  syphilis  is  associated,  appropriate  measures  must 
be  instituted.  Moreover,  since  a  subject  of  atrophic  rhinitis  is  a  fertile 
source  of  atmospheric  contamination,  his  living  and  sleeping  apartments 
must  be  highly  ventilated. 

Local  Measures. — An  antiseptic  spray  of  Seller's  or  Dobell's  solu- 
tion, and  oiling  the  nasal  cavities,  are  measures  to  be  first  tried. 
If  they  prove  non-efficacious,  the  crusts  may  then  be  removed  with  a 
cotton  applicator  coated  with  a  solution  of  hydrogen  peroxid.  We  may 
then  use  a  spray  of  li(|uid  albolene  and  menthol ;  this  serves  not  only 
to  lubricate,  but  to  supply  moisture,  both  of  which  are  important  thera- 
peutic indications.  Small  ulcerations  occur  in  this  affection  and  induce 
oft-repeated  epistaxis ;  consequently,  an  attempt  should  be  made  to  heal 
the  latter  and  to  obtain  an  even,  moist  surface.  To  accomplish  this  the 
method  of  Clarence  C.  Kice  may  be  followed — /.  e.  to  rub  the  ulcer- 
ations thoroughly  by  means  of  a  cotton-carrier  Avith  a  small  hard 
pledget  of  cotton  moistened  with  listerin  or  borolyptol  for  a  few  sec- 
onds at  a  time.  These  antiseptic  frictions  are  made  at  intervals  of  two 
or  three  days  for  two  or  three  weeks. 


AUTUMNAL   CATARRH.  471 

AUTUMNAL   CATARRH. 

{Hay  Asthma;  Hay  Fever.) 

By  this  term  is  meant  a  form  of  asthma  that  occurs  exclusively 
during  the  -warm  season  (spring  and  late  summer,   particularly). 

Htiology. — The  direct  causes  are  the  odorous  principles  given  off 
from  certain  plants  (the  pollen  of  the  Antlioxanthum  odoratwn,  of  the  rose, 
etc.),  and  inorganic  dusts  of  various  sorts.  In  some  instances  it  appears 
to  arise  without  obvious  exposure  to  a  special  irritant — for  example,  it 
may  be  excited  by  strong  emotional  disturbance. 

Predisposing  Factors. — The  male  sex  suffers  more  frequently  than  the 
female.  Age  has  a  slight  though  decisive  influence,  more  than  33  per 
cent,  of  the  cases  occurring  before  the  twentieth  year.  Often  some 
ahnormality  of  the  nasal  passages  {e.  g.  a  polypoid  tumor,  hypertrophy 
of  the  mucosa,  a  deflected  septum)  acts  as  a  source  of  reflex  irritation. 
Heredity  is  among  the  potent  contributing  causes.  The  inhabitants  of 
cities  are  more  liable  than  those  in  rural  districts,  though  the  air  of  agri- 
cultural regions  intensifies  the  condition.  Perfect  immunity  is  enjoyed 
by  the  dwellers  in  certain  climates — chiefly  mountainous  and  marine. 

Symptoms. — The  symptoms  are  {a)  local  and  {h)  general. 

(a)  Local. — Hay  fever  has  an  abrupt  onset,  and  the  attacks  return 
annually  at  or  about  the  same  time.  The  invasion  is  marked  by  pro- 
nounced coryzal  symptoms,  with  much  sneezing,  stoppage  of  the  nasal 
passages,  copious  rhinorrhea,  the  discharge  being  thin  and  watery  as  a 
rule,  and  rarely  mucopurulent.  Suffusion  of  the  eyes,  with  itching  of 
the  lids  and  free  lacrymation  are  constant  features ;  the  decided  itch- 
ing sensation  of  the  palate  and  pharynx  is  also  at  times  a  very  distress- 
ing svmptom.  The  sense  of  smell  may  be  lost,  and  taste  and  hearing 
are  often  impaired. 

The  cour.%e  as  regards  the  local  symptoms  is  marked  by  alternate 
amelioration  and  aggravation  of  the  symptoms,  the  exacerbations  being 
due  to  exposure  to  the  open  air,  especially  in  changeable  weather. 
Later  the  catarrhal  process  invades  the  bronchi,  and  cough  and 
asthmatic  seizures  appear,  these  often  becoming  very  distressing. 

(h)  G-eneral  disturbances  are  varied,  and  comprise  subjective  sensa- 
tions, such  as  anorexia,  insomnia,  lassitude,  and  chilliness  alternating 
with  slight  feverishness. 

The  course  is  from  four  to  six  weeks,  and  cases  that  develop  in 
August  are  terminated  by  the  occurrence  of  a  decided  frost.  Wyman 
also  describes  the  "rose  cold,"  which  comes  on  in  the  spring. 

Diagnosis. — The  recognition  of  hay  asthma  is  unattended  with 
difficultv,  provided  that  such  facts  as  the  time  of  its  occurrence  and 
its  annual  periodicity  are  carefully  noted.  The  sudden  onset  of  severe 
coryza-like  symptoms  in  a  manifestly  neurotic  person,  particularly  in 
the  month  of  August,  should  always  direct  the  attention  to  this  disease. 

Prognosis. — This  is  favorable  both  as  to  life  and  length  of  days, 
though  a  permanent  cure  is  a  rare  event  unless  permanent  removal  from 
the  influence  of  the  specific  causes  can  be  effected. 

Treatment. — Whenever  possible  the  patient  should  travel  till  he 
finds  a  locality  in  which  he  ceases  to  suff"er,  and  subsequently  he  should 
there  spend  the  period  of  annual  attack,  and  by  these  means  escape  the 
excitino-  causes.     The  Adirondacks  and  AYhite  Mountains  usually  bestow 


472  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

immunity.  If  the  patient  cannot  make  the  necessary  change,  the  gen- 
eral nutrition  is  to  be  improved  by  the  use  of  such  measures  as  phos- 
phorus, strychnin,  quinin,  and  arsenic.  Much  is  to  be  gained,  more- 
over, by  hygienic  means,  especially  avoidance  of  physical  and  mental 
overwork  and  the  adoption  of  a  proper  mode  of  life. 

The  local  symptoms  demand  the  topical  application  of  various  agents 
to  the  nasal  chambers,  such  as  cocain  hydrochlorate  solution  (1  per  cent.), 
applied  on  cotton  with  a  probe,  followed  by  a  4  per  cent,  solution  of 
antipyrin,  prolong  the  palliative  effect  (Gleason).  HoUopeter  has  had 
uniformly  good  success,  in  over  200  cases,  by  daily  sterilizing  the  nasal 
chambers  by  means  of  the  ordinary  Dobell's  solution  used  first  with  an 
atomizer;  then  swabbed  thoroughly  over  the  whole  naso-pharynx.  The 
membrane  is  then  dried  and  the  nose  loosely  plugged  for  a  short  time 
with  cotton  saturated  with  a  mild  solution  of  menthol  in  albolene.  The 
local  symptoms  are  also  greatly  benefited  by  the  internal  use  of  atropin, 
which  allays  the  irritability  of  the  mucous  membrane  involved  and 
diminislies  the  rhinorrhea,  thus  indirectly  mitigating  the  constitutional 
disturbances  and  sometimes  directly  relieving  the  asthmatic  paroxysms. 
When  given  internally  the  dose  should  not  exceed  gr.  3-^  (0.0002),  to 
be  repeated  every  hour  till  dryness  of  the  throat  appears. 

My  own  best  results  have  been  derived  from  the  hypodermic  use  of 
this  drug  (gr.  ^wo — 0.0003)  at  intervals  of  tliree  to  four  hours  till  the 
desired  effect  is  produced.  Thorough  destruction  of  the  vessels  and 
sinuses  is  also  advised  (Osier).  Recently  the  internal  use  of  5  grain 
tabloids  of  suprarenal  extract  has  met  with  fair  success  in  the  treatment 
of  hay  fever  in  the  hands  of  S.  Solis-Cohen  and  others. 


EPISTAXIS. 

(Nose-bleed.) 


i^tiologfy. — The  causes  of  nose-bleed  are  various,  and  a  convenient 
grouping  is  the  following  :  (a)  Affections  of  the  nasal  mucosa  {e.  g.  ulcer, 
polypi,  intense  hyperemia).  {h)  Injuries,  either  external,  as  from  a 
blow,  or  internal,  as  from  plugging  with  a  foreign  body,  nose-picking, 
etc.  In  this  category  may  also  be  included  epistaxis  due  to  fracture  at 
the  base  of  the  skull,  (c)  xlcute  infectious  fevers,  particularly  typhoid 
(at  the  onset)  and  influenza,  (c^)  Chronic  afiections,  such  as  pernicious 
anemia,  leukemia,  and  the  hemorrhagic  diathesis  or  hemophilia,  [e) 
Vicarious  menstruation.  (/)Ilarefaction  of  the  air.  (</)  Plethora ;  here 
may  be  mentioned  cerebro-congestion  with  intense  headache.  (A) 
Severe  over-exertion.  («')  Frequent  epistaxis  may  be  caused  by  arterio- 
sclerosis even  in  the  earlier  stage  while  yet  amenable  to  treatment. 

Symptoms. — Except  when  due  to  traumatism  the  blood  usually 
drops  slowly  from  one  and  occasionally  from  both  nostrils.  Rarely,  the 
blood  may  flow  as  a  continuous  stream  or  the  nares  may  present  a  pro- 
jecting coagulum.  The  blood  may  also  gravitate  into  the  pharynx  and 
be  coughed  up,  or  it  may  be  swallowed  and  vomited.  A  rhinoscopic 
examination  often  reveals  the  source  in  cases  in  which  a  previous  diag- 
nosis of  hemoptysis  or  hematemesis  has  been  made. 


DISEASES  OF  THE  LARYNX.  473 

The  immediate  results  of  nose-bleed  are  weakness  and  a  moderate 
anemia,  but  these  are  not  prolonged  unless  the  epistaxis  be  oft  re- 
peated. Cases  arising  from  fracture  at  the  base  of  the  skull  will  gen- 
erally prove  fatal. 

Treatment. — A  careful  search  for  a  local  cause  is  especially  de- 
manded in  cases  in  which  there  are  frequently  recurring  attacks.  In 
most  cases  a  spontaneous  arrest  occurs,  but  if  not,  a  resort  to  simple 
household  measures,  such  as  the  application  of  ice  to  the  nose  or  to  the 
back  of  the  neck,  holding  the  hands  up,  or  the  injection  of  very  cold  or 
very  hot  Avater  into  the  nares,  are  to  be  encouraged.  Various  astrin- 
gents (tannic  acid,  acetate  of  lead,  alum,  zinc)  may  be  employed,  and 
a  saturated  solution  of  antipyrin  is  also  highly  praised.  When  an 
ulcerated  bleeding  point  can  be  reached,  there  may  be  applied  to  it  a 
solution  of  chromic  acid  or  it  may  be  cauterized  by  solid  silver  nitrate. 
Prolonged  pressure  applied  upon  the  facial  artery  as  it  passes  over  the 
inferior  maxilla  may  be  efficacious.  The  late  D.  Hayes  Agnew  success- 
fully employed  a  bougie  made  of  a  long  strip  of  the  rind  of  bacon, 
"  passing  it  through  the  nostril  and  allowing  it  to  stay  there  some  time." 
A  solution  of  gelatin  may  be  injected  into  the  nostril.  I  have  little 
confidence  in  internal  astringent  remedies.  The  oil  of  origanum,  ad- 
ministered in  large  doses,  has  seemed  to  do  good  in  a  few  of  my  own  cases, 
but  when  the  epistaxis  tends  to  prove  obstinate,  the  posterior  nares 
should  be  plugged. 


II.  DISEASES  OF  THE  LARYNX. 
ACUTE  CATARRHAL  LARYNGITIS. 

(Acute  Endolaryngitis.) 

Definition. — An  acute  catarrhal  inflammation  of  the  larynx,  cha- 
racterized by  cough,  hoarseness,  and  painful  deglutition. 

Patholog^y. — The  anatomic  changes  present  during  life  are  all 
lacking  ijost  mortem.  The  laryngoscopic  appearances  will  be  given 
below. 

Btiology. — Acute  laryngitis  may  be  a  primary  affection — and  par- 
ticularly laryngitis  sicca  (Molinie) — but  oftener  it  is  associated  with  and 
secondary  to  catarrh  of  the  nose  and  nasopharynx.  Wright  attributes 
laryngitis  sicca  to  the  coccus  of  Lowenburg. 

Catarrhal  laryngitis  has  for  its  chief  direct  causes  traumatism,  ex- 
posure to  cold  and  dampness,  the  inhalation  of  irritating  vapors  or 
gases,  rheumatism  (rarely),  and  the  corrosive  effect  of  certain  poisons 
and  hot  fluids.  A  certain  degree  of  predisposition  is  engendered  by 
immoderate  smoking,  particularly  by  the  cigaret-habit,  and  by  the  use 
of  concentrated  alcoholic  drinks.  These  agencies  induce  hyperemia  of 
the  laryngeal  mucosa,  which  is  easily  converted  into  active  inflammation. 
Acute  laryngitis  is  often  associated  with  acute  infectious  diseases. 

Symptoms. — There  are  two  conspicuous  symptoms — alteration  in 
the  voice  (hoarseness)  and  cough.     At  first  there  is  merely  a  huskiness 


474 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


of  the  voice,  but  later  there  may  be  pronounced  hoarseness  or  even  com- 
plete aphonia.  The  cough  is  dry  and  characteristically  painful  until 
secretion  is  free.  In  the  early  stages  the  patient  complains  of  sensa- 
tions of  tickling  or  the  presence  of  some  small  object  in  the  larynx, 
causing  a  frequent  desire  to  clear  the  throat.  In  severe  instances  deg- 
lutition is  painful.  Edema  of  the  larynx  may  tend  to  supervene  and 
cause  intense  dyspnea,  with  a  feeling  of  distressing  oppression.  There 
is,  as  a  rule,  a  slightly  elevated  temperature. 


Fig.  42.— Method  of  making  a  laryngoscopic  examination. 


The  patient  is  placed  in  front  of  the  operator,  on  an  arni-cliair,  with  the  back  of  the  chair 
higli  enough  to  afford  his  head  a  comfortable  rest,  and  with  the  .>;ouri'e  of  the  light  over  tlie  right 
shoulder.  The  (iperator  then  adjusts  the  head-mirror  (the  lixed  apparatus),  warms  the  throat- 
mirror  over  a  light  sullii-iently  to  prevent  the  moisture  of  the  breath  from  being  deposited  upon 
it,  and  touches  the  liaud  with  the  mirror  before  passing  it  into  tlie  mouth,  so  as  not  to  use  it  too 
hot.  The  iiaticnt's  tongue  is  then  protruded,  and  by  means  of  a  napkin  is  seized  between  the 
tluinib  and  the  fore-finger  and  drawn  well  forward  to  lay  the  fauces  open  to  observation.  The 
throat-mirror  is  then  held  in  the  right  hand  in  the  same  way  as  one  holds  a  pen.  "  Jlnally,  it  is 
intr<iduced  into  the  moutli.  its  handle  being  inclined  downward  and  outward,  its  base  being 
parallel  with  the  dorsum  of  the  tongue:  it  is  then  passed  backward  without  altering  this  relation 
until  the  edge  of  the  mirr(jr  nearly  touches  the  soft  iialate,  the  shaft  of  the  mirror  in  this  move- 
ment striking  the  angle  of  the  mouth  as  a  resting- jilace  and  fulcrum.  The  subsequent  movement 
consists  in  turning  the  mirror  by  twisting  its  shaft  between  the  lingers  until  it  is  inclined  at  an 
angle  of  45  degrees  to  the  line  of  vision  ;  then  it  is  carried  backward  and  downward  until  the 
uvula  rests  upon  its  i)osterior  surface,  when  it  is  lifted  boldly  upward  and  backward  until  its 
lower  edge  conies  entirely  into  view  again  and  rests  firmly  against  the  posterior  wall  of  tlie  pha- 
rynx. The  patient  should  then  be  directed  to  sound  in  a  somewhat  high  key  '«,'  which  lifts  the 
larynx  and  at  the  same  time  the  epiglottis,  and  exposes  and  brings  into  view  the  laryngeal 
cavity"  (Bosworth). 

It  is  important  that  the  mirror  itself  should  be  kept  in  the  median  line,  with  its  plane  always 
at  right  angles  with  the  field  of  vision,  as  shown  in  the  illustration.  In  making  a  laryngoscop'ic 
examination  we  note  any  abnormalities  of  color-ai)pearance  (the  natural  being  a  rose-pinkish  tint), 
of  the  outline  of  the  dill'erent  i)arts,  and  the  deviations  from  the  symmetrical  movements  of  cords, 
if  any,  etc. 

The  laryngeal  mirror  brings  to  view  a  characteristic  picture — a 
swollen,  tumefied,  and  reddened  mucosa.  These  changes  affect  the 
vocal  cords  (whose  pearly-white  appearance  is  now  lacking)  and  the  ary- 
epiglottidean  folds.  It  is  usual  to  note  also  redness  and  swelling  of  the 
epiglottis  above  and  of  the  trachea  below.  After  secretion  has  occurred 
a  mucoid  covering  in  streaks  or  patches  is  noticeable. 


CHRONIC  LARYNGITIS.  475 

Diagnosis. — This  is  easy  in  the  presence  of  marked  hoarseness, 
dry  cough,  and  the  image  aiforded  by  the  laryngeal  mirror  (Fig.  42).  In 
very  early  life  the  larynx  cannot  be  successfully  examined  ;  still,  laryngis- 
mus stridulus  (oAving  to  the  absence  of  fever,  coryza,  etc.)  could  hardly 
be  mistaken,  as  has  been  supposed,  for  acute  catarrhal  laryngitis.  The 
same  is  true  of  membranous  laryngitis,  if  we  bear  in  mind  the  charac- 
teristic local  features  and  the  more  intense  constitutional  disturbances 
of  the  affection. 

Treatment. — The  physician  must  enjoin  against  the  use  of  the  voice. 
The  very  young  and  the  aged  should,  in  severe  or  even  moderate  cases,  be 
kept  in  bed,  and  should  occupy  a  single  apartment  in  which  the  at- 
mosphere is  uniformly  moist  and  Avarm,  the  temperature  ranging  from 
75°  to  80°  F.  (23.8°-26.6°  C).  Inhalations  of  moist  air  or  steam  are 
of  great  service,  and  I  have  long  been  in  the  habit  of  recommending 
the  following  simple  apparatus  and  method  of  carrying  out  this  mode 
of  treatment :  An  ordinary  tin  cup,  small  pitcher,  or  other  vessel  is 
filled  with  boiling  water  to  which  1  or  2  drams  (4.0-8.0)  of  the  com- 
pound tincture  of  benzoin  have  been  added ;  the  steam  is  then  collected 
by  inverting  over  the  vessel  an  ordinary  funnel.  The  patient  is 
allowed  to  inhale  the  steam  by  placing  the  mouth  over  the  narrow  neck 
of  the  funnel  above,  or  a  piece  of  rubber  tubing  may  be  attached  to  the 
end  of  the  funnel  that  is  uppermost. 

Steam  atomizers  admirably  meet  the  necessities  of  the  case ;  and  in 
the  case  of  children  the  vapor  of  benzoin,  eucalyptol,  and  other  equally 
sedative  and  stimulating  substances  may  be  diffused  in  the  air  of  the 
sick-room.  Concentrated  solutions  or  insufflations  of  powders  are  not 
without  harmful  influence,  and  neither  the  cotton-carrier  nor  the  mop 
should  be  allowed  to  enter  the  larynx  in  this  affection.  The  external 
application  of  the  ice-bag  or  cold  compress  tends  to  mitigate  the  inflam- 
matory process  and  to  obviate  spasm. 

The  general  treatment  differs  with  the  special  stages  of  the  com- 
plaint. If  the  case  is  seen  early,  a  full  dose  of  quinin  (gr.  xij-xvj — 
0.777-1.036)  may  serve  to  successfully  abort  the  attack,  and,  in  con- 
junction Dover's  powder  (gr.  v-x — 0.324-0.648)  may  be  prescribed. 
Codein  sulphate  may  be  given  at  prolonged  intervals  during  the  attack, 
and  frequently  at  night,  to  allay  cough  ;  this  remedy  may  be  combined 
with  ipecac,  aconite,  and  liquor  ammonii  acetatis  to  facilitate  secretion 
and  render  the  cough  humid.  If  we  except  the  abortive  measures,  the 
constitutional  is  wholly  inferior  to  the  topical  treatment  of  this  variety, 
though  the  existence  of  any  particular  diathesis  may  require  special  in- 
ternal remedies. 


CHRONIC  LARYNGITIS. 

( Chronic  Endolaryngitis.) 

Pathology. — The  laryngeal  mucosa  is  thickened  and  somewhat 
reddened,  and  erosions  amounting  to  superficial  ulcerations  are  rarely 
seen.  A  prominence  of  the  mucous  glands,  especially  of  the  ventricles 
and  epiglottis,  is   noticeable.     Fine  villous  projections  from,   and  nod- 


476  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ular  swellings  in,  the    vocal  cords  are  among  the  rarer  morbid  changes. 
Minute  vesicles  may  arise  upon   the  surface  (Jierpetic  laryngitis). 

l^tiology. — Oft-repeated  acute  attacks  frequently  cause  chronic 
laryngitis,  and  the  long-continued  use  of  the  voice  (as  in  public  speak- 
ing or  singing),  the  inhalation  of  an  atmosphere  laden  Tvith  mildly  irri- 
tating impurities  (tobacco  smoke,  etc.),  and  an  immoderate  indulgence 
in  alcoholic  stimulants,  respectively  or  unitedly,  predispose  to,  if  they 
do  not  excite,  the  disorder. 

Symptoms. — As  in  the  acute  form,  hoarseness  and  cough  are  the 
two  especially  prominent  symptoms.  The  former  may  be  so  slight  as  to 
present  merely  a  rough  tone,  or  it  may  involve  an  almost  total  loss  of 
voice.  The  cough  shows  similar  variations  in  severity,  sometimes  con- 
sisting of  a  short  hack,  and  again  occurring  in  spasmodic  and  ringing 
paroxysms,  due  to  a  sense  of  tickling  in  the  larynx.  There  may  be  a 
small  amount  of  mucous  or  muco-purulent  expectoration,  but  for  pro- 
longed periods  the  cough  may  be  dry  and  ineft'ectual.  Local  pain  and 
discomfort  sometimes  supervene,  and  are  excited  generally  by  attempts 
at  speaking  or  singing — events  that  aggravate  all  the  other  symptoms. 
To  complete  the  diagnosis,  the  laryngeal  mirror  is  required  to  show  a 
swollen  and  slightly  red  membrane,  Avith  a  distention  of  the  mucous 
glands  in  the  immediate  vicinity  of  the  epiglottis  and  ventricles,  and 
occasionally  superficial  erosions. 

Prognosis. — This  is  unpromising  as  to  complete  recovery,  although 
it  presents  no  grave  dangers.  It  is  incurable  in  those  instances  in 
which  the  causal  influences  cannot  be  removed,  and  in  all  cases  in 
which  the  patient  fails  to  lend  hearty  co-operation. 

Treatment. — This  is  (a)  hygienic  and  {b)  medicinal,  (a)  The  sani- 
tary measures  embrace  preventives  that  are  directed  to  the  removal  of 
all  the  etiologic  factors,  whether  merely  predisposing  or  exciting.  The 
voice  demands  rest  and  the  prohibition  of  smoking  and  the  use  of  alco-. 
holies  in  excess,  and  the  patient  must  also  avoid  the  close,  contaminated 
air  of  the  croAvded  hall,  theatre,  and  like  places.  In  addition,  a  tonic 
regimen,  with  a  view  to  energizing  the  nutritive  processes,  is  to  be  en- 
couraged. In  many  instances  the  environment  is  best  arranged  with 
reference  to  the  commonly  associated  conditions — especially  the  morbid 
processes  in  the  nasal  and  naso-pharyngeal  cavities.  "  A  sea-voyage  or 
residence  at  the  sea-shore  is,  in  the  large  majority  of  instances,  pro- 
ductive of  good,  and  the  eifects  of  surf-bathino;  are  often  magic " 
(Mackenzie).  My  own  practice  has  been  to  send  subjects  of  chronic 
laryngitis  to  pine-forest  resorts  at  low  elevations  that  aftbrd  a  pure, 
equable,  and  somewhat  stimulating  atmosphere,  and  I  have  found  that 
in  many  cases  the  selection  of  a  proper  climate  constitutes  the  most  im- 
portant part  of  the  treatment,  {h)  The  medicinal  treatment  is  both 
local  and  general.  The  latter  should  include  creasote,  cod-liver  oil.  and 
other  tonics.  Expectorants  are  of  little  if  any  value.  The  local  meas- 
ures, however,  are  important.  Moderate  exposure  of  the  neck  and  daily 
ablution  with  cold  water  are  to  be  advised,  and  attention  to  the  nose  and 
naso-pharyngeal  cavity  is  of  prime  impoi'tance.^ 

A  long  list  of  applications  to  the  larynx  from  Avithin,  including  local 
astringents,  disinfectants,    and   alcoholics,    might   be   enumerated.      Of 

^  J.  C.  Wilson's  American  Text-hook  of  Applied  Therapeutics,  p.  791. 


SPASMODIC  LARYNGITIS.  All 

astringent  solutions,  however,  the  best  are  tannic  acid  (1-2  per  cent.) 
or  alum  (.5-1  per  cent.)  and  zinc  sulphate  (3-5  per  cent.).  These  may 
be  sprayed  into  the  larynx  by  means  of  a  compressed-air  machine  with 
spraying-tubes,  although  all  of  the  different  kinds  of  inhaling  apparatus 
more  commonly  used  will  answer  the  purpose.  If  the  ordinary  hand- 
atomizer  be  used,  the  patient  should  be  taught  to  draw  the  vapor  into 
the  larynx  by  gentle  and  frequent  acts  of  respiration.  Disinfectants, 
such  as  creasote,  potassium  chlorate  (the  latter  if  ulcerations  be  present) 
in  solutions  of  suitable  strength,  may  be  used  in  like  manner.  I  can 
confidently  advise  as  useful  alteratives  both  iodin  and  silver  nitrate, 
commencing  with  a  weak  solution  of  the  latter  (gr.  v-3j — 0.324-4.0), 
and  the  strength  being  gradually  increased  until  the  maximum  strength 
that  can  be  endured  without  distress  is  reached  (gr.  xx-^ij — 1.296-8.0). 
These  topical  applications  should  be  made  directly  with  a  cotton-carrier 
or  brush  at  intervals  of  three  or  four  days,  preceded  by  the  use  of  a 
cleansing  spray.  Many  astringent  and  sedative  lozenges  are  to  be  found 
in  the  market,  but  they  are  only  slightly  palliative  in  their  effects,  and 
their  prolonged  use  tends  to  excite  gastric  disturbance.  I  am  unalter- 
ably opposed  to  the  insufflation  of  powders,  believing  that  they  are 
capable  of  augmenting  the  laryngeal  irritation  and  of  adding  fresh 
irritation  in  adjacent  parts,  particularly  in  the  tracheo-bronchial  tract. 


SPASMODIC  LARYNGITIS. 

{Laryngismus  Stridulus;  False  Croup'.) 

Definition. — An  affection  peculiar  to  children,  chiefly  of  nervous 
origin,  though  also,  according  to  Strlimpell  and  others,  often  associated 
with  acute  catarrhal  laryngitis. 

Htiology. — The  affection  is  almost  solely  limited  to  children  be- 
tween six  months  and  five  or  more  years  of  age.  It  is  sometimes  ex- 
cited by  strong  passion  or  emotion,  and  it  may  be  associated  with  tetany. 
Rachitic  subjects  are  peculiarly  liable.  The  causes  of  spasmodic  croup 
are  in  great  part  those  of  acute  laryngitis. 

The  mode  of  action  of  the  direct  causes  is  unknown,  but  the  spasm  of 
the  adductors  that  causes  the  urgent  dyspnea  is  probably  reflex  and  due 
to  peripheral  irritation. 

Symptoms. — Two  clinical  varieties  are  to  be  distinguished :  (1) 
that  in  which  the  larynx  is  free  from  catarrhal  inflammation,  or  the 
"purely  nervous  type.  This  is  especially  characterized  by  sudden  brief 
attacks  of  dyspnea,  either  by  day  or  night  (often  on  awakening),  that 
terminate  in  a  high-pitched  crowing  inspiration  ("child-crowing"). 
The  face  during  the  spasm  is  cyanotic.  General  convulsions  have  been 
noted,  but  there  is  neither  cough,  fever,  nor  hoarseness.  The  attacks 
may  be  frequently  repeated  within  a  single  day. 

(2)  Spasm  of  the  larynx,  associated  with  mild  catarrhal  laryngitis. 
The  attacks  generally  begin  suddenly,  about  midnight  or  toward  morn- 
ing on  awakening  from  a  sound  sleep.  Positive  evidence  of  the  affection 
is  afforded  by  the  croupy,  ringing  cough,  combined  with  the  hard,  strid- 
ulous  breathing.     An  approaching  spasm  may  be  announced  by  a  harsh 


478 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


cough  and  slightly  stridulous  breathing  in  the  sleeping  child.  During 
the  attack  the  countenance  may  be  cyanotic  and  the  breathing  most  dis- 
tressing, but  these  and  the  above-mentioned  severer  symptoms  generally 
cease  abruptly  in  an  hour  or  two,  and  the  child  resumes  its  slumber.  In 
my  experience  the  attacks  have  been  repeated  for  two  or  three  nights  in 
succession,  and  rarely  oftener  except  in  the  severest  cases.  Not  infre- 
quently the  child  manifests  the  symptoms  of  mild  catarrhal  laryngitis 
between  the  attacks.     A  brassy,  croupy  cough  may  also  attend. 

Diagnosis. — Membranous  laryngitis  may  be  mistaken  for  spasmodic 
croup.  The  development  of  the  dyspnea,  however,  is  more  gradual,  is 
without  intermission,  and  without  relation  to  the  period  of  the  day. 
Albuminuria  and  a  false  membrane  in  the  throat  or  nares  are  usually 
present  in  laryngeal  diphtheria. 

Prognosis. — Although  the  appearance  of  a  paroxysm  is  alarming, 
the  disease  is  practically  free  from  danger. 

Treatment. — 1.  The  treatment  of  laryngismus  stridulus  is  quite 
similar  to  that  of  infantile  convulsions.     A  warm  bath  at  a  temperature 


Four  upright  rods  (5.7  inches  in  length)  are  fastened  to  the  legs  of  the  bedstead  by  a  wire  or 
string.  Two  side-rods  are  tied  on  the  uprights,  and  two  end-rods  (length  dependent  on  width  of 
bed)  rest  upon  the  side-rods,  These  rods  form  a  complete  framework  for  the  sheets  to  hang  upon. 
Four  sheets  are  reijuired  (11-1  size) — three  to  cover  the  ends  and  sides,  and  one  to  be  placed  on  top. 
One  side  should  be  completely  closed,  while  the  opposite  is  to  be  left  open  for  ventilation  or  to  be 
adjusted  according  to  circumstances. 


of  98°  to  105°  F.  (36.4°-40.5°  C.)  is  the  best  means  of  breaking  up  the 
spasm.  While  in  the  bath  cold  sponging  of  the  back  and  chest  is  ser- 
viceable. The  finger  may  be  passed  into  the  fauces,  and  should  the 
epiglottis  "  become  wedged  in  the  chink  of  the  glottis,  it  must  be  re- 
leased by  the  finger."  After  the  attack  active  treatment  should  be  di- 
rected at  the  discoverable  causes,  and  I  have  been  in  the  habit  of  giving 


TUMORS  OF  THE  LARYNX.  479 

small  doses  of  the  bromids  thrice  daily,  together  with  warm  cod-liver 
oil  inunctions,   with  striking  eifect. 

2.  In  spasmodic  croup  an  emetic  is  to  be  given  at  once,  the  best  be- 
ing a  mixture  of  alum  and  syrup  of  ipecac,  of  which  the  dose  is  3j 
(4.0),  to  be  followed  by  irritation  of  the  fauces  Avith  the  finger  in  order 
to  facilitate  emesis.  In  severe  paroxysms  a  hot  bath  may  be  given  to 
aid  the  emetic.  In  case  the  dyspnea  is  not  checked  by  the  above  meas- 
ures, chloral  hydrate  may  be  exhibited  by  enema  (gr.  ij— v;  0.129— 
0.324)  or  a  Avhiff  of  chloroform  may  be  given.  The  local  application  of 
cold  (ice-collar,  ice-water  cloths)  is  useful,  and  sinapisms  placed  around 
the  throat  and  over  the  chest  also  tend  to  arrest  the  spasm.  I  am  con- 
vinced that  the  use  of  steam-inhalations  from  the  so-called  croup-kettle 
(Fig.  43)  is  of  signal  service,  and  should  be  more  widely  employed, 
particularly  when  it  is  inconvenient  to   use  the   hot-bath. 

Between  the  paroxysms  the  patient  should  receive  a  mild  laxative, 
such  as  calomel  or  castor  oil,  and,  in  addition,  the  treatment  appro- 
priate in  acute  catarrhal  laryngitis.  To  prevent  recurrences  an  envi- 
ronment calculated  to  increase  the  nervous  tone  of  the  child  is  to  be  pro- 
cured, and  it  is  especially  advisable  to  accustom  him  to  the  outer  air, 
though  protected  by  suitable  dress  and  Avithout  undue  exposure  to 
draughts. 

EDEMATOUS  LARYNGITIS. 

Definition. — An  infiltration  of  the  mucous  membrane  of  the  larynx 
with  serum.     In  most  cases  it  is  a  true  inflammatory  edema. 

Htiology. — Two  chief  classes  of  causes  are  operative  :  (1)  Those 
that  excite  inflammation.  The  condition  may  complicate  acute  laryn- 
gitis, though  oftener  it  appears  in  chronic  aff"ections  of  the  larynx,  and 
particularly  if  ulceration  be  associated  (e.  g.  tuberculosis,  syphilis) ;  it 
may  also  appear  in  connection  with  certain  infectious  diseases  (erysipe- 
las, diphtheria,  typhoid  fever).  The  inflammation  inducing  the  edema 
may  extend  from  adjacent  parts,  as  the  neck,  pharynx,  and  other  organs. 
(2)  Factors  that  tend  to  excite  dropsical  effusion.  These  may  be  gen- 
eral, as  Bright's  disease,  heart-aff"ections,  etc. ;  or  they  may  be  local. 
Among  the  latter  are  enlargements  of  the  cervical  and  mediastinal  lym- 
phatics, aneurysm  of  the  arch  of  the  aorta,  thyroid  tumors,  etc. — i.  e. 
conditions  that  exercise  pressure  upon  the  jugular  veins.  Rice,  who 
studied  41  cases,  thinks  it  doubtful  whether  edema  of  the  larynx  ever 
occurs  from  simple  catarrhal  inflammation. 

Symptoms. — In  acute  cases  the  initial  disturbance  is  both  sudden 
and  severe.  There  is  dyspnea  that  tends  to  increase  rapidly,  accompa- 
nied by  a  husky,  suppressed  voice,  with  augmenting  obstruction.  The 
respirations  may  become  stridulous,  but  there  is  no  cough.  The  laryn- 
goscope reveals  marked  swelling  of  the  epiglottis  and  of  the  ary-epi- 
glottic  folds,  and  rarely  the  SAvelling  occurs  in  or  even  wholly  below  the 
vocal  cords.  The  inserted  finger  may  detect  the  swollen  epiglottis, 
which  may  also  be  seen  if  the  tongue-depressor  be  used. 

Diagnosis. — This  can  be  made  with  ease  from  the  rapidly  develop- 
ing dyspnea  soon  reaching  the  climax,  the  absence  of  cough  and  hoarse- 
ness, and  by  the  use  of  the  laryngoscope.  In  cases  in  which  the  epi- 
glottis can  be  felt  or  seen  a  laryngoscopic  examination  is  superfluous. 


480  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  prognosis  is  decidedly  unfavorable  except  in  the  event  of  early 
opei-ative  interference. 

Treatment. — If  of  inflammatory  origin,  the  ice-bag  should  be  ap- 
plied to  the  larynx,  and  ice  should  be  allowed  to  constantly  dissolve  in 
the  patient's  mouth.  Local  depletion,  preferably  by  leeching  the  front 
of  the  neck,  is  also  to  be  tried,  and  Levy  and  Laurens^  record  a  case  in 
which  a  cure  followed  this  measure.  If  intense  dyspnea  tends  to  per- 
sist, scarification  of  the  edematous  parts  with  a  curved  bistoury,  the 
point  of  which  is  covered  with  adhesive  plaster,  must  be  promptly  insti- 
tuted, and,  if  asphyxia  threatens,  tracheotomy  must  immediately  be  per- 
formed. Dropsical  edema  demands  scarification,  and,  if  relief  does  not 
follow,  tracheotomy. 


TUMORS  OP  THE  LARYNX. 

These  may  be  either  benign  (fibroma,  myxoma,  lipoma,  chondroma, 
adenoma,  angioma,  cyst)  or  malignant  (sarcoma,  carcinoma).  Of  these, 
papillomata  or  papillomatous  fibromata  occur  most  frequentlj^,  especially 
in  infancy.  Xavratil  ^  records  42  cases  of  multiple  laryngeal  papillomata 
in  children  whose  larynges  were  extensively  filled.  These  growths  may 
also  occur  in  chronic  laryngitis,  and,  like  other  tumors  of  the  larynx,  they 
commonly  spring  from  the  vocal  cords.  Their  shape,  size,  and  tendency 
to  peduuculation  do  not  differ  from  their  characteristics  when  noted 
elsewhere  in  the  body. 

Symptoms. — Small  tumors  may  occupy  the  larynx  without  produ- 
cing symptoms.  The  first  feature  then  noted  is  hoarseness,  which  gradu- 
ally grows  worse  and  may  end  in  complete  aphonia.  If  situated  in  the 
upper  larynx,  eoiigh  is  common,  and  when  the  tumor  causes  obstruction 
of  the  larynx  dyspnea  supervenes  and  tends  to  increase  in  severity.  A 
mobile  growth  may  cause  sudden  occlusion  of  the  glottis,  exciting 
orthopnea  and  threatening  asphyxiation.  To  confirm  the  diagnosis  a 
laryngoscopic  examination  is  required. 

The  prognosis  is  favorable  in  the  benign,  but  unfavorable  in  the 
malignant  forms. 

Treatment. — This  is  altogether  surgical,  though  Delavan  states 
that  3  cases  of  papilloma  have  been  cured  by  frequently  repeated  sprays 
of  absolute  alcohol.  Curetting  is  often  followed  by  a  recurrence,  while 
laryngo-fissure  and  thorough  removal  of  the  growths  restore  speech  and 
prevent  recurrence. 


III.  DISEASES  OF  THE  BRONCHI. 
CATARRHAL  BRONCHITIS. 

( Tracheo-hronchitis.) 

Definition. — A  catarrhal  inflammation  of  a  part  or  the  whole  of 
the  mucous   membrane  of   the  bronchial   tubes.     The  mucosa  of  the 

^  Arch.  gen.  de.  Med.,  Dec,  1895. 
•^  Bed.  klin.,  Woch.,  Mar.  9,  1896. 


ACUTE  BRONCHITIS.  481 

trachea  is  also  involved  to  a  greater  or  lesser  extent,  and  hence  the  term 
tracheo-bronchitis  is  quite  appropriate,  being  descriptive  of  the  seat  and 
character  of  the  disease.  Involvement  of  the  bronchioles  may  also  take 
place,  but  this  does  not  occur  -without  an  involvement  of  the  correspond- 
ing alveolar  structure,  the  condition  being  then.  TNith  propriety,  termed 
"broncho-pneumonia."  Hence  the  term  "  capillary  bronchitis,"  which 
is' still  often  employed  to  describe  the  latter  condition,  is  not  pertinent. 
A  certain  class  of  cases  is  met  with.  hoAvever.  in  which  the  catarrhal 
inflammation,  as  the  result  of  downward  extension,  implicates  the  smaller 
bronchial  tubes  without  involving  the  bronchioles  ;  to  such  the  term 
"  capillary  bronchitis  "  might  be  appropriately  given. 

The  disease  may  be  acute  or  chronic,  both  of  these  forms  occurring 
either  as  a  primary  or  secondary  affection. 

ACUTE   BRONCHITIS. 

Pathology. — The  portions  of  the  mucous  membrane  of  the  trachea 
and  bronchi  that  are  implicated  become  reddened  and  swollen ;  they  are 
covered  with  mucus  and  mingled  with  epithelial  cells,  and  later  muco- 
pus.  Some  of  the  smaller  bronchial  tubes  are  dilated.  The  mucous 
glands  are  swollen. 

The  histological  changes  may  be  briefly  stated  as  follows  :  desquama- 
tion of  the  ciliated  epithelium,  edema  and  swelling  of  the  submucosa^ 
and.  in  the  severer  grades,  infiltration  of  the  latter  with  leukocytes. 

Ktiology. — "With  rare  exceptions  tracheo-bronchitis  is  produced  by 
the  direct  extension  of  a  catarrhal  inflammation  from  the  nares,  phar- 
ynx, and  larynx.  Rarely  the  bronchi  are  the  seat  of  primary  acute 
catarrh,  and  in  some  of  the  latter  instances  the  upper  air-passages  are 
implicated  secondarily,  constituting  a  reversal  of  the  usual  direction  of 
extension  above  referred  to. 

The  immediate  causes  are  mechanical,  chemical,  and  biological  irri- 
tants, which  act  directly  upon  the  tracheo-bronchial  mucosa;  and  that 
bronchitis  is  frequently  due  to  infection  at  a  time  when  the  resisting 
power  of  the  system  is  reduced  there  can  be  little  doubt.  The  circum- 
stances disposing  to  bronchitis  are  numerous,  those  pertaining  to  the  in- 
dividual being — (1)  Age,  the  old  and  very  young  being  most  liable  ;  (2) 
Debility;  (3)  Occupation,  as  in  certain  trades  that  expose  to  irritating 
vapors  and  sedentary  pursuits.     Among  the  external  conditions  are — 

(1)  Climatic  factors,  particularly  variability  of  temperature  and  humidity : 

(2)  Seasons  of  the  year.  '■  Catching  cold  "  often  results  from  exposure 
durino-  the  spring  and  autumn  months.  These  two  conditions  depend 
substantially  upon  the  same  factors.  (3)  Epidemic  influence,  w^hich 
may  be  independent  of  influenza. 

Acute  tracheo-bronchitis  arises  as  a  secondary  condition  in  a  great 
variety  of  diseases,  as,  for  example,  the  exanthemata  and  other  acute 
infectious  diseases  (typhoid  fever,  measles,  whooping-cough,  influenza, 
etc.).  As  shown  elsewhere,  among  this  class  of  diseases  the  bronchitis 
mav  be  dependent  upon  the  primary  infectious  process ;  but  in  many 
others  it  is  due  either  to  the  inhalation  of  pathogenic  irritants  or  to  the 
retention  of  bronchial  secretions  that  are  apt  to  accumulate  and  decom- 
pose with  resulting  bronchitis.      The  accidental  inhalation  of  particles 

31 


482  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  food  and  saliva  may  also  lead  to  secondary  bronchitis,  or  the  condi- 
tion may  be  secondary  to  chronic  affections  {e.  g.  Pott's  disease,  Bright's 
disease).     Amonor  the  toxic  causes  the  poison  of  uremia  must  be  embraced. 

Symptoms. — Bronchitis  of  the  larger  tubes,  which  extends  down 
to  about  the  second  division  of  the  bronchi,  is  spoken  of  usually  as  a 
"cold."  In  such  cases  the  onset  is  marked  by  recurring  sensations  of 
cMUiness,  and  by  coryza,  slight  wre  throat,  and  Iioarsoiess  :  while  in  young 
and  feeble  children  convulsions  may  occur  early.  Mild  febrile  symp- 
toms may  appear,  the  temperature  ranging  from  101°  to  103°  F.  (o8.3° 
to  39.4°  C),  with  slight  acceleration  of  the  pulse;  and  there  may  be 
langour  and  aching  in  the  limbs  and  lumbar  region.  With  the  fully-devel- 
oped attack  .substernal  soreness,  sometimes  even  pain,  is  experienced, 
especially  on  coughing,  and  the  pain  may  be  referred  to  the  intercostal 
muscles  and  the  line  of  insertion  of  the  diaphragm.  The  respirations 
are  increased  in  frequency,  but  there  is  no  dyspnea.  There  may  be 
thoracic  oppression  and  discomfort  until  the  bronchial  secretions  become 
free,  and  there  is  a  cough  which  is  at  first  dry  and  hard.  It  often  man- 
ifests itself  in  longer  or  shorter  paroxysms,  particularly  on  lying  down 
and  on  rising  after  a  full  night's  sleep.  At  the  end  of  one.  two,  or 
more  days  the  cough  is  moist  and  attended  with  an  expectoration  which 
is  at  first  mucoid  and  scanty,  often  viscid,  then  muco-purulent  and  free; 
later  still  it  is  sometimes  distinctly  purulent.  With  free  expectoration 
comes  relief  to  the  patient.  Histologically,  the  sputum  consists  mainly 
of  pus-corpuscles  with  large  cells,  in  which  may  be  seen  the  so-called 
myelin  droplets  of  Virchow  and  carbon  particles. 

Physical  Signs. — Upon  laryngoscopic  examination  the  mucous  mem- 
brane of  the  larynx  and  trachea  may  be  seen  to  be  reddened  and  cov- 
ered by  more  or  less  secretion. 

Inspection  and  palpation  of  the  chest  are  negative,  except  when  the 
finer  tubes  become  implicated  or  fever  is  present,  in  which  case  the  res- 
pirations may  be  observed  to  be  slightly  accelerated.  In  children  the 
increased  rapidity  of  the  respirations  is  more  common  and  reaches  a 
higher  degree.  Bronchial  fremitus  may  sometimes  be  felt.  Percussion 
yields  negative  results,  save  in  very  rare  instances,  in  which  there 
occurs  a  decided  accumulation  of  secretion  in  the  tubes,  when  there 
may  be  found  impairment  of  resonance  posteriorly  below  the  scapulae. 
Auscultation  usually  renders  audible  a  harsh  respiratory  murmur,  and 
less  frequently  piping,  sibilant,  and  sonorous  rales.  In  the  advanced 
stage  (with  relaxation  of  the  mucosa)  laj'ge  and  medium-sized  mucous 
rales  are  frequently  jtresent,  but  are  by  no  means  always  discernible. 
The  ra.les  appear  in  diff'erent  seats  from  time  to  time,  and  after  coughing 
may  altogether  disappear,  but  only  to  reappear  later. 

The  prognosis  varies  with  the  previous  constitutional  state  of  the 
individual.  In  healthy  adults,  after  a  period  ranging  fi-om  a  few  davs 
to  two  weeks,  the  fever  subsides,  but  the  coucrh,  though  less  marked, 
and  the  expectoration  usually  continue  for  a  variable  length  of  time. 
In  old  persons,  in  those  greatly  debilitated,  and  in  those  of  a  gouty  or 
tuberculous  diathesis  the  cases  pursue  a  more  protracted  course.  There 
is  also  in  these  subjects  a  tendency  on  the  part  of  the  catarrhal  process 
to  extend  downward  until  the  finer  tubes  are  implicated.  Under  these 
circumstances  life  may  be  endangered,  and  even,  rarely,  terminated.     In 


ACUTE  BRONCHITIS.  483 

the  old  the  secretions  are  imperfectly  expectorated :  they  gravitate  to 
the  most  dependent  parts  and  induce  bronchiectasis.  In  young  children 
this  downward  extension  of  the  affection,  with  resulting  broncho-pneu- 
monia and  areas  of  collapse  in  consequence  of  dilatation  and  occlusion 
of  the  bronchioles  by  muco-pus,  is  a  not  uncommon  and  serious  event 
(e.  g.  in  measles,  whooping-cough,  vide  Bi'oncJio-jjneumonia). 

The  diagnosis  is  reached  without  difficulty  through  the  symptoms 
(slight  fever,  cough,  and  expectoration),  the  acute  course,  and  the  physi- 
cal signs  (harsh  respiratory  murmur,  dry  followed  by  moist  rales,  heard 
on  both  sides  of  the  chest).  The  recognition  of  the  long  list  of  cases 
that  constitute  the  secondary  forms  will  be  made  easily  possible  by 
noting  the  circumstances  under  which  they  arise. 

Differential  Diagnosis. — Bronchitis  can  readily  be  separated  from 
pneumonia  and  from  pleurisy  ivith  effusion  by  its  history,  by  its  lighter 
course,  and  by  the  different  character  and  general  distribution  of  the 
physical  signs,  especially  by  the  absence  of  the  signs  of  effusion  and 
consolidation. 

When  bi-oncho-jmeumonia  develops  in  the  course  of  bronchitis,  dys- 
pnea and  fever  are  increased,  cyanosis  is  present,  and  the  general  con- 
dition becomes  much  more  grave.  There  are  small  patches  that  yield 
dulness  on  percussion,  and  broncho-vesicular  breathing  with  moist  rales 
can  be  detected  on  auscultation. 

Bronchitis  cannot  be  separated  from  the  early  stage  of  whooping- 
cough,  but  when  the  characteristic  cough  of  the  latter  is  heard  all  doubt 
vanishes. 

The  bronchitis  of  measles  before  the  characteristic  eruption  appears 
is  distinguished  by  the  red  spots  upon  the  anterior  half-arches  of  the 
soft  palate. 

Localized  tuberculosis  of  the  lung  and  acute  miliary  tuberculosis  are 
apt  to  be  confounded  with  bronchitis.  The  points  of  difference  have 
been  given  in  the  discussion  of  the  former  diseases. 

Treatment. — Xot  infrequently  a  "cold  "  passes  through  its  several 
stages  without  rendering  the  patient  ill  enough  to  cause  him  to  seek  the 
advice  of  a  physician,  and  there  are  many  instances  in  which  but  little 
treatment  is  required,  apart  from  the  usual  household  measures  and  pro- 
tection against  cold  and  damp.  If  seen  early,  while  the  coryza  is  pres- 
ent, the  attack  may  often  be  aborted  by  the  use  at  bedtime  of  a  Dover's 
powder  in  combination  Avith  quinin  (gr.  iv-viij — 0.259-0.518);  this 
may  be  seconded  by  a  glass  of  hot  lemonade,  with  or  vrithout  a  portion 
of  whiskey,  and  either  a- hot  bath  or  a  mustard  foot-bath.  The  follow- 
ing morning  a  saline  laxative  should  be  taken.  To  children  a  mild 
calomel  purge  followed  by  a  dose  of  castor  oil  may  be  administered 
The  patient  should  be  kept  in  a  warm,  moist,  equable  atmosphere — 
preferably  in-doors — and  during  this  period  he  should  take  divided 
doses  of  quinin  for  a  day  or  two.  If  the  above  mode  of  treatment  fail 
or  if  the  patient  does  not  come  under  observation  early,  the  main 
objects  of  treatment  should  be  {a)  to  render  the  secretions  free,  and  {b) 
to  hasten  the  expulsion  of  the  sputum  after  it  has  been  loosened.  The 
first  leading  indication  is  to  be  met  by  the  use  of  diaphoretics,  diuretics, 
and  relaxants.  The  subjoined  formula  combines  these  classes  of  agents, 
and  will  be  found  to  be  hio-hly  serviceable : 


484  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

]^.   Potassii  citrat.,  3vj    (23.3) ; 

Liq.  ammonii  acetat.,  5v     (148.0) ; 

Spt.  seth.  nit.,  ^j      (30.0); 

Vini  ipecac,  3ij     (2.0); 

Syr.  pruni  virg.,  q.  s.  ad  5viij  (236.0). — M. 

Sig.  5SS  (2.0)  in  water  every  two  hours  until  the  secretions 
are  loosened. 

If  the  temperature  in  any  given  case  be  maintained  at  a  consid- 
erable elevation,  such  as  102°-103°  F.  (38.8°-39.4°  C.)  or  over,  tinc- 
ture of  aconite  (tlt-xvj — 1.065)  may  be  added  to  the  above  mixture;  and 
if  there  be  present  much  tickling  with  distressing  cough,  due  to  irrita- 
bility of  the  affected  mucosa,  codein  (gr.  ij-iij — 0.129-0.194)  may  be 
added  to  the  same.  For  the  incessant  irritative  cough  which  is  present 
in  severe  forms  of  catarrh  opium  alone  is  really  effective.  AVhen  the 
above  prescription  is  not  productive  of  free  secretion  and  troublesome 
cough  continues,  I  employ  the  folloAving  : 

It.  Ammon.  muriat.,  3v  (20.0) ; 

Codeim^,  gr.  iv-\-j  (0.259-0.388) ; 

Spt.  junip.  CO.,  5SS  (16.0) ; 

Mist,  glycyrrh.  comp.,      .liiss  (80.0) ; 

Syr.  pruni  virg.,    q.  s.  ad  siv  (120.0). — M. 

Sig.   3J  {■^•^)  every  two  hours. 

Apomorphin  is  also  excellent  as  a  soothing  relaxant  in  doses  of  gr. 
glj-  to  yL_  (0.003  to  0.006)  every  tAvo  hours.  Mild  counter-irritation  by 
means  of  mustard-paste,  followed  by  the  application  of  iodin  once  daily, 
is  also  helpful.  The  patient  should  keep  to  his  room,  in  Avhich  the  at- 
mosphere should  be  kept  moist  and  of  even  temperature.  The  expul- 
sion of  the  sputum  may  demand  stimulating  expectorants,  though  rarely. 
It  is  to  be  recollected  that  when  the  tracheal  secretion  becomes  copious 
the  period  of  convalescence  is  usually  reached,  and  stimulating  expec- 
torants are  then  entirely  unnecessary.  When,  on  the  other  hand,  the 
cough  is  no  longer  dry,  and  on  auscultation  the  rales  are  found  to  be 
moist,  and  whilst,  at  the  same  time,  the  expectoration  is  expelled  with 
difficulty,  or  if  the  bronchitis  tends  to  become  chronic,  then  such  stim- 
ulating expectorants  as  senega,  squills,  and  ammonium  muriate  are  to 
be  employed.  In  cases  in  which  expectoration  continues  to  be  too 
abundant  terebene,  tar  syrup,  and  oil  of  sandal  are  to  be  resorted  to. 

Debility  and  secondary  anemia  must  be  speedily  overcome  by  exhib- 
iting quinin,  bitter  tonics,  iron,  and  arsenic ;  and  a  suitable  change  of 
air  often  yields  prompt  and  excellent  results  in  protracted  cases.  The 
treatment  of  the  various  forms  of  secondary  bronchitis  will  be  consid- 
ered in  their  a])propriate  connections  in  this  work.  In  the  aged  the 
general  strength  must  be  maintained  ;  the  patient's  position  must  be 
changed  at  short  intervals  and  stimulants  are  usually  needed. 

Apart  from  the  method  above  given,  of  attempting  to  abort  the 
attack  in  children,  acute  bronchitis  is  in  the  main  to  be  treated  in  the 
same  manner  as  when  it  occurs  in  the  adult.  Opium,  however,  is  to  be 
used  very  sparingly,  and  generally  in  the  form  of  paregoric.  If  the 
secretion  is  abundant  and  imperfectly  raised,  it  is  well  to  administer  an 


CHRONIC  BRONCHITIS.  485 

emetic,  such  as  the  wine  of  ipecac  (3ss-j — 2.0-4.0),  and  repeat  in  ten 
minutes  if  necessary.  If  dyspnea  be  urgent  and  cyanosis  be  marked 
in  the  lips  and  finger-tips,  a  prompt  emetic  is  then  imperative  in  order 
to  save  life.  A  child  suffering  from  acute  bronchitis  should  be  kept  in 
bed  until  the  fever  subsides. 

The  diet  during  the  dry  stage  should  consist  of  liquid  forms  of  nour- 
ishment, which  should,  for  the  greater  part,  be  taken  hot.  After  the 
"cold"  has  been  loosened  solid  food  should  be  resumed. 

CHRONIC   BRONCHITIS. 

Pathology. — The  lesions  of  chronic  bronchitis  manifest  considerable 
variety  both  as  regards  their  nature  and  extent.  The  epithelial  layer 
is,  in  great  part,  missing,  and  sometimes  the  mucous  membrane  is  quite 
thin.  In  consequence  the  longitudinal  elastic  fibers  appear  unduly 
prominent.  The  mucous  glands  and  the  muscular  coat  undergo  atro- 
phy in  long-standing  cases,  and  the  bronchial  tubes  are  dilated  {bron- 
chiectasis). 

In  another  large  group  of  cases  the  mucosa  is  irregularly  thickened 
or  infiltrated  and  granular.  Small  ulcers  corresponding  to  the  mucous 
follicles  are  common,  and  almost  constantly  emphysema  develops  in 
consequence  of  secondary  changes  in  the  vesicular  structure. 

etiology. — Chronic  bronchitis  may  either  \)e  jjrimary  or  secondary. 
The  affection  is,  however,  almost  always  a  secondary  one,  and,  though 
sometimes  the  result  of  repeated  attacks  of  acute  bronchitis,  it  is  oftener 
caused  by  certain  chronic  complaints  and  certain  diatheses,  as  chronic 
alcoholism,  rheumatism,  gout,  syphilis,  pulmonary  tuberculosis,  and 
pulmonary  emphysema.  Organic  valvular  affections  of  the  heart  and 
chronic  Bright's  disease  cause  hypostatic  bronchitis.  The  primary  form, 
which  is  rare,  is  the  result  of  exposure  to  wet  or  cold  or  to  the  daily  in- 
halation of  some  irritant  that  produces  and  maintains  a  low  grade  of 
catarrhal  inflammation  (dust,  vapors).  When  chronic  bronchitis  follows 
the  acute  form  we  are  often  able  to  detect  the  operation  of  some  favor- 
ing cause,  as  age,  climate,  or  season.  It  is  most  common  in  the  aged, 
though  younger  persons  occasionally  suffer,  and  it  occurs  by  preference 
during  the  cold  season,  often  recurring  regularly  in  the  cold  and  varia- 
ble weather  of  autumn,  winter,  and  spring,  and  disappearing  in  summer. 

Symptoms. — The  symptoms  are  similar  to  those  of  acute  bron- 
chitis, though  rather  less  severe.  Pain  is  rarely  present,  the  patient 
complaining  merely  of  a  feeling  of  substernal  constriction.  There  may 
be  soreness  at  the  base  of  the  chest  if  the  cough  be  frequent  and  severe, 
and  occasionally  in  the  epigastrium  as  a  result  of  traction  of  the  dia- 
phragm on  the  ribs.  Cough  is  not  a  constant  accompaniment,  however, 
but  is  paroxysmal  and  varies  in  severity  and  frequency.  The  degree 
of  the  violence  of  the  paroxysm  depends  upon  two  factors — the  charac- 
ter of  the  bronchial  secretion  and  the  seat  of  the  catarrhal  inflammation. 
Thus  when  the  expectoration  is  tenacious  and  small  in  quantity,  and 
when  the  small-sized  tubes  are  affected,  cough  is  most  violent.  It  also 
varies  both  with  the  weather  and  the  season,  as  is  evident  from  the  fact 
that  there  is  often  an  absence  of  cough  in  summer,  while  it  returns  un- 
failingly with  each  winter. 


486  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  expectoration  diifers  -widely  in  different  cases.  It  is  sometimes 
abundant  and  sero-mucous  in  character.  On  the  other  hand,  there  are 
cases  of  dry  cough  jn  which  there  is  little  or  no  expectoration.  As  a 
rule,  however,  it  is  rather  copious,  and  either  vmco-purulent  or  dis- 
tinctly purulent  in  character.  Fever  is  usually  absent,  though  rarely 
a  slight  rise  of  temperature  occurs  at  night.  The  appetite  is  good  as  a 
rule;  the  bodily  weight  and  nutrition  arc  also  Avell  maintained. 

Physical  Signs. — On  inspection  we  usually  note  undue  enlargement 
of  the  thorax,  with  a  decrease  in  expansile  movements  that  is  due  to 
the  associated  emphysema.     Hence  dyspnea  is  commonly  observed. 

Percussion  yields  a  clear  or  hyperresonant  note.  Dulness  or  im- 
paired resonance  is  sometimes  met  with,  however,  during  acute  exacer- 
bations, and  especially  over  the  bases,  and  is  due  to  congestion  and  edema 
(Fox).  On  auscultation  rhonchi  of  various  forms  and  moist  rales  are 
heard,  their  number  and  size  being  in  proportion  to  the  extent  of  the 
swelling  of  the  mucous  membrane  and  the  amount  and  fluidity  of  the 
secretory  products.  The  respiratory  murmur  is  enfeebled,  though 
roughened,  and  the  expiratory  sound  is  prolonged  and  Avheezy.  The 
right  heart  may  be  dilated  from  increased  tension  in  the  pulmonary  cir- 
cuit. 

Clinical  Varieties. — Special  forms,  depending  largely  upon  spe- 
cific causal  factors,  remain  to  be  described  : 

1.  The  commonest  variety  of  chronic  bronchitis  has  been  called  the 
"  winter  cough  of  the  aged,"  and,  as  before  intimated,  is  usually  accom- 
panied by  emphysema  and  cardiac  disease.  For  this  form  the  gouty 
diathesis  is  often  responsible.  The  cough  occurs  in  paroxysms  that  are 
most  severe  at  night,  and  during  the  early  morning  hours  it  is  attended 
Avith  free  expectoration  of  the  secretion  that  has  accumulated  during 
the  night. 

2.  Bronchorrhea. — In  this  form  there  may  be  an  abundant  bronchial 
secretion,  composed  largely  of  serum  {bronehorrhoea  serosa),  but  more 
frec[uently  perhaps  the  expectoration  is  purulent  and  thin,  containing 
greenish  or  greenish-yellow  masses.  It  may  at  times  be  thick  and  puru- 
lent. Dilatation  of  the  tubes  and  resulting  fetid  bronchitis  may  be  de- 
veloped as  secondary  conditions. 

3.  Fetid  Bronchitis. — In  this  variety  the  expectoration  emits  the 
characteristic  odor  of  decomposing  animal  substances.  The  fetor  may 
indicate  gangrene  of  the  lungs,  abscesses,  bronchiectasis,  decomposition 
of  matter  within  phthisical  cavities,  or  empyema  with  perforation  of  the 
lung.  It  may,  however,  occur  independently  of  the  above-mentioned 
conditions,  and  hence  these  must  be  carefully  excluded  before  the  diag- 
nosis of  true  fetid  bronchitis  is  made.  In  the  latter  disease  the  expec- 
toration is  usually  copious,  and  on  standing  separates  into  three  layers, 
of  which  the  uppermost  is  composed  of  frothy  mucus,  the  intermediate 
of  a  serous  liquid,  and  the  lowest  of  a  thick  sediment,  that  presents  a 
granular  appearance  and  is  made  up  chiefly  of  small  yellow  masses — the 
characteristic  Dittrich's  plugs.  Microscopically,  the  Dittrich's  plugs 
are  seen  to  be  composed  of  microorganisms,  chief  among  which  is  the 
Leptotlirix  pulmonalis ;  they  may  also  contain  pus-corpuscles,  fat- 
granules,  and  crystals  of  margarin.  Demetre  found  the  colon  bacillus 
and  ascribes  the  fetor  to  its  presence. 


CHRONIC  BRONCHITIS.  487 

The  condition  may  be  a  grave  one,  and  associated  with  it  may  be 
observed  ulceration  of  the  bronchial  tubes,  with  dilatation,  pneumonia, 
abscess,  gangrene,  and  rarely  metastatic  cerebral  abscesses.  When 
putrefactive  changes  take  place  in  the  bronchial  secretion  in  the  course 
of  chronic  bronchitis  a  new  group  of  symptoms,  as  a  rule,  immediately 
appears.  This  comprises  rigors  that  occur  at  irregular  intervals  and  are 
associated  Avith  high  fever  and  increased  prostration.  Cough  and  pain  in 
the  chest  also  become  aggravated,  but  these  acute  symptoms  may  shortly 
subside  and  the  usual  course  of  chronic  bronchitis  be  resumed.  Even 
under  the  latter  conditions  fetor  of  the  breath  and  sputum  may  persist. 

4.  Dry  Catarrh. — The  cough  is  both  severe  and  paroxysmal,  and 
there  is  little  or  no  expectoration.  When  expectoration  is  present  the 
sputum  is  very  tenacious  and  is  expelled  with  great  difficulty.  An 
asthmatic  disposition  is  sometimes  noticeable  in  this  variety,  and  emphys- 
ema is  commonly  associated.  The  dry  condition  of  the  bronchial  mu- 
cosa is  evidenced  by  sibilant  and  sonorous  rales.  This  form  occurs  in 
old  persons,  as  a  rule. 

5.  Osier  has  described  a  form  of  chronic  bronchitis  that  occurs 
most  frequently  in  women,  and  dates  its  onset  from  a  comparatively 
early  period  of  life.  It  does  not  undermine  the  general  health.  The 
cough  is  most  pronounced  in  the  morning,  and  is  accompanied  by  a  rela- 
tively small  amount  of  muco-purulent  expectoration.  An  examination 
of  the  chest  yields  negative  results.  The  condition  seems  to  proceed 
from  a  gouty  or  tuberculous  diathesis  in  some  instances.  I  have  had 
under  observation  for  several  years  a  young  woman  in  whom  this  form 
of  bronchitis  alternated  with  eczema  of  the  face. 

6.  Teichmiller  has  described  an  eosinophilic  bronchitis.  The  expec- 
toration is  mucoid,  as  a  rule,  though  occasionally  muco-purulent.  It  is 
characterized  particularly  by  rhe  presence  of  a  considerable  number  of 
eosinophile  cells  in  the  sputum.  It  is  not  dependent  upon  adenoid 
disease  of  the  naso-pharynx. 

Diagnosis. — The  diagnosis  of  chronic  bronchitis  is  rarely  difficult. 
Since  it  is  usually  a  secondary  condition,  it  is  of  the  utmost  importance 
to  determine  the  nature  of  the  primary  affection.  An  examination  of 
the  heart  and  of  the  urine  should  not  be  overlooked. 

Pulmonary  tuhercidosis  is  to  be  discriminated  from  chronic  bronchi- 
tis, and  the  distinctive  points  are — (1)  A  clear  tuberculous  history.  In 
phthisis  there  are  fever  and  loss  of  flesh  and  strength,  while  in  chronic 
bronchitis  fever  is  absent  and  the  general  health  is  not  impaired.  (2) 
In  pulmonary  tuberculosis  the  signs  of  localized  consolidation  (usually 
at  one  or  other  apex)  appear  early,  while  in  chronic  bronchitis  the  vesic- 
ular structure  is  not  involved.  (3)  In  phthisis  the  sputum,  when 
examined  microscopically,  shows  the  presence  of  the  tubercle  bacillus. 

In  acute  pulmonary  tuberculosis  the  fever,  dyspnea,  cyanosis,  and  in- 
creased prostration  constitute  a  group  of  features  that  should  serve  to 
avert  the  danger  of  its  being  confounded  with  chronic  bronchitis.  Co- 
existing pulmonary  emphysema  is  to  be  recognized  by  the  characteristic 
symptoms  and  signs  of  this  complaint.  Primary  fetid  bronchitis  must 
be  differentiated  from  the  various  other  conditions  previously  mentioned, 
in  which  the  breath  as  well  as  the  sputum  may  emit  the  characteristic 
fetor.  In  abscess  of  the  lung  the  sputum  contains  shreds  of  lung- 
tissue,  including  elastic  fibers,  crystals  of  hematoidin,  cholesterin,  and 


488  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

amorphous  blood-pigment;  usually  localized  dulness  and  broncho-cav- 
ernous breathing  coexist.  In  gangrene  there  are  contained  in  the  spu- 
tum shreds  of  lung-tissue,  but  separate  elastic  fibers  are  often  absent,  on 
account  of  the  presence  of  a  ferment  that  causes  a  solution  of  the 
elastic  tissue  (v.  Jaksch).  Bronchiectasis  is  usually  unilateral,  and 
gives  rise  to  dulness  and  other  physical  signs  that  are  confined  to 
limited  areas,  while  in  chronic  bronchitis  the  signs  are  general. 

Prognosis. — Recovery  is  the  exception,  though  improvement  may 
frequently  be  observed.  The  course  of  chronic  bronchitis  is  exceedingly 
protracted,  and  the  danger  from  the  late  development  of  certain  compli- 
cations and  sequels,  such  as  empliysema  or  right-sided  cardiac  disease, 
must  be  constantly  borne  in  mind.  Since  the  disease  is  generally  a 
secondary  aifection,  the  prognosis  in  most  instances  depends  upon  the 
outlook  in  the  primary  disease. 

Treatment. — The  treatment  falls  naturally  under  two  main  heads 
— (1)  Hygienic,  and  (2)  Medicinal. 

1.  Hjigienic. — This  has  reference,  frequently,  to  the  removal  of 
various  noxious  influences.  When  the  patient  cannot  make  a  suitable 
change  of  air  during  the  cold  season,  he  must  keep  his  room  during  in- 
clement weather;  he  should,  however,  be  allowed  to  spend  as  much  time 
as  possible  in  the  open  air  during  clear  and  pleasant  weather.  The 
vitiated  atmosphere  of  saloons  or  public  halls  is  to  be  avoided.  The 
patient  should  be  carefully  clad ;  he  should  wear  flannels  next  the  skin 
during  all  seasons  of  the  year,  but  his  outer  clothing  need  not  be  unu- 
sually cumbersome.  If  the  case  be  of  an  aggravated  type  and  the  cir- 
cumstances of  the  patient  permit,  he  should  be  sent  to  a  warm  latitude 
in  the  autumn,  in  order  thus  to  escape  the  effects  of  a  severe  northern 
winter.  It  is  an  excellent  rule  to  send  patients  in  whom  the  bronchial 
secretions  are  abundant  to  a  drv,  Avarm  climate  or  to  a  region  whose 
atmosphere  is  impregnated  with  the  balsamic  vapors  of  the  pine.  On 
the  other  hand,  patients  with  dry  bronchial  catarrh  are  most  relieved  by 
an  equable,  moist,  warm  climate.  Among  suitable  resorts,  those  that 
should  be  mentioned  are  the  Riviera,  Cannes,  San  Remo,  Sicily,  and 
Algiers  abroad,  and  Florida,  Southern  Georgia,  and  Southern  California 
at  home.  Change  of  air  becomes  not  only  a  means  of  relief,  but  also  an 
effective  means  of  prevention  if  resorted  to  at  the  proper  time. 

Prophylaxis  also  includes  the  removal  of  any  diseased  conditions 
that  are  causally  related.  The  coexistence  of  cardiac  disease,  the  gouty 
diathesis,  and  particularly  any  renal  disturbance,  call  for  the  primary 
treatment  of  these  conditions. 

The  diet  should  be  orenerous,  but  not  stimulatincj.  and  articles  easy 
of  digestion  should  be  selected.  Wines  and  li(|Uors  are  to  be  avoided 
unless  special  indications  for  their  use  exist.  Special  conditions,  how- 
ever (e.  g.  albuminuria),  may  render  necessary  a  sj)ecial  dietary. 

2.  Medicinal. — In  this  disease  medicines  are  palliative  in  their  effects 
rather  than  curative.  Relaxing  expectorants  are  to  be  avoided,  owing 
to  their  depressing  action,  and  the  stimulating  ex])ectorants  are,  in  a 
majority  of  cases,  not  only  valueless,  but  hurtful,  since  they  are  liable 
to  lessen  the  appetite  and  disorder  the  digestion.  When,  however,  the 
sputum  is  muco-))urulent  in  character  and  is  dislodged  with  difficulty, 
expectorants  of  this  class  (squills,  senega,  ammonium  muriate)  may  be 


BRONCHIECTASIS.  489 

tried.     I  have  obtained  good  results  from  the  use  of  the  following  in 
cases  attended  with  severe  paroxysms  of  cough : 

:^.  01.  eucalypti,  3Jss-3iij  (6.0-12.0) ; 

Codeinje,  gr.  vj       (0.388). 

M.  et  ft.  capsulie  No.  xviij. 
Sig.   One  every  four  hours,  as  required. 

Occasionally  potassium  iodid  exerts  a  curative  influence,  but  its  use 
may  be  limited  to  cases  that  are  due  to  the  syphilitic,  rheumatic,  and 
gouty  diatheses.  Five  or  ten  grains  of  the  iodid  four  times  daily  may 
be  exhibited,  and  should  there  be  present  a  syphilitic  taint  the  remedy 
should  be  pushed  to  the  limit  of  tolerance.  The  balsam  of  copaiba  is 
sometimes  efficacious,  several  instances  in  my  own  experience  having 
yielded  to  the  following  combination  : 

I^.  Balsami  copaibse,  3j-3ij  (4.0-8.0) ; 

Ammon.  muriat.,  3ij        (8.0); 

Extr.  glycyrrh.  pulv.,  3j  (4-0). 

Mist,  ammouiaci,     q.  s.  ad  foiij  (96.0). — M. 
Sig.  3ij  (8.0)  every  four  hours. 

Other  remedies  that  possess  great  value  in  certain  cases  are  creasote 
(in  ascending  doses),  turpentine,  terpine,  tar,  the  balsams  of  tolu  and 
Peru,  and  sandal-wood.  H.  C.  Wood  praises  sulphuretted  hydrogen  in 
cases  in  which  there  is  profuse  expectoration  :  "•  From  two  to  four  ounces 
of  the  saturated  watery  solution  may  be  administered  by  the  mouth  four 
or  five  times  a  day  or  until  the  breath  has  a  perceptible  odor." 

If  the  vital  powers  are  poor,  bitter  tonics,  as  iron,  quinin,  and 
strychnin,  and  other  measures  calculated  to  invigorate  the  system,  are 
indicated.  When  the  sputum  is  excessive  in  amount,  astringents  (zinc 
sulphate  and  oxid)  are  sometimes  useful.  Astringents  may  also  be  used 
with  advantage  in  the  form  of  a  spray  Avhen  the  expectoration  is  too  free. 
On  the  other  hand,  sprays  from  properly  selected  solutions  (e.  g.  am- 
monium muriate,  gr.  v-x  ad  ^j — 0.324-0.648  ad  32.0)  are  valuable  in 
assisting  expectoration.  In  fetid  bronchitis  sprays  of  antiseptic  solu- 
tions are  to  be  used,  anji  the  following  will  be  found  serviceable  : 

^.  Acidi  carbolici,  gr.  ij-iv  (0.129-0.259); 

Olei  eucalypti,  mij-iv    (0.133-0.266); 

Aquse,  Sj  (32.0). 

Sig.  To  be  inhaled  from  a  steam-  or  hand-atomizer. 

Pneumato-therapy  has  given  brilliant  results  in  certain  instances,  and 
G.  Carriere  obtained  good  results  in  streptococcic  chronic  bronchitis 
from  the  use  of  antistreptococcic  serum. 


BRONOHIEOTASIS. 


Definition. — The  universal  or  circumscribed  dilatation  of  the  bron- 
chial tubes. 

Pathology. — Two  main  forms  are  recognized — the  cylindrical  or 
simple,  and  the  saccular,  and  both  of  these  may  be  met  with  in  the  same 


490  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

lung.  Rarely  the  condition  is  congenital.  It  may  be  general  or  par- 
tial, the  former  variety  being  always  unilateral,  the  latter  sometimes 
bilateral.  In  universal  bronchiectasis  the  bronchial  tubes,  throughout 
their  extent,  are  the  seat  of  numerous  sacculi  communicating  with  one 
another.  These  present  smooth,  shining  Avails,  except  in  the  most  de- 
pendent parts,  where  ulcers  are  sometimes  seen.  Extreme  conditions 
of  dilatation  may  take  the  form  of  huge  cysts,  which  may  extend  to  the 
periphery  of  the  lung ;  the  lung-tissue  lying  between  the  sacculi  then 
becomes  cirrhotic  as  a  rule.  In  jjartial  dilatation  the  bronchial  mucous 
membrane  is  implicated,  with  an  occasional  narrowing  of  the  lumen. 
Most  commonly  these  dilatations  are  cylindrical,  though  they  may  be 
saccular,  and  rarely  fusiform.  The  partial  is  much  more  common  than 
the  general  variety. 

Histology. — When  the  walls  of  the  larger  dilatations  are  examined 
mici'oscopically,  the  cylindrical  epithelium  is  seen  to  be  replaced  by  a 
pavement  epithelium.  The  elastic  and  muscular  layers  are  thin,  and 
the  fibers  are  usually  separated.  Contained  in  these  dilatations  are 
frequently  found  secretions  that  may  be  fetid. 

Ktiology. — In  the  majority  of  instances  the  condition  doubtless 
arises  from  an  involvement  of  the  bronchial  mucosa  that  extends  to  the 
submucous  tissue  and  leads  to  muscular,  fibrous,  and  cartilaginous  atrophy. 
These  changes  render  the  wall  of  the  tube  unable  to  resist  the  pressure 
of  the  air  in  violent  paroxysms  of  cough,  and,  once  the  process  of  dila- 
tation is  commenced,  the  accumulated  secretions  may  tend  by  their  weight 
to  distend  further  the  already  weakened  walls.  Thus  the  elasticity  of 
the  latter  is  impaired,  and  finally  destroyed.  The  etiological  factors 
show  the  affection  to  be  secondary  as  a  rule,  and  are — (1)  Chronic 
bronchitis  and  emphysema,  chronic  phthisis  (usually  when  the  seat  of 
the  dilatation  is  at  the  apex),  broncho-pneumonia  (in  children),  and 
compression  of  a  bronchus.  Heubner  believes  that  bronchiectasis  in 
adults  may  be  sometimes  traced  to  whooping-cough  and  measles  in  young 
children.  (2)  Great  thickening  of  the  pleura,  especially  when  associated 
with  bronchitis  or  interstitial  pneumonia,  Avith  contraction  of  the  lung. 
(3)  Rarely  it  is  a  congenital  lesion. 

Among  predisposing  conditions  are — (a)  ^ijgr?,  bronchiectasis  being- 
most  common  in  adult  or  middle  life  ;  and  {b)  Sex,  it  being  more  com- 
mon in  males  than  females. 

Symptoms. — There  is  always  cough,  and  this  usually  occurs  in 
prolonged  and  severe  paroxysms.  The  attacks  take  place  most  gener- 
ally after  the  dilated  tubes  fill  in  the  morning,  and  a  change  of  posture 
may  excite  them.  Accompanying  the  cough  there  is  profuse  expectora- 
tion, which  may  amount  to  a  pint  or  more  in  twenty-four  hours.  The 
sputum  is  grayish-brown  in  color  and  muco-purulent,  emitting  a  sour  or, 
more  frequently,  a  horvWAy  fetid  odor.  On  standing,  the  expectoration 
separates  into  three  strata — the  uppermost,  of  brownish  froth  ;  the  mid- 
dle, of  a  thin,  sero-mucous  fluid ;  and  a  thick  sediment,  of  cells  and 
granular  debris.  Examined  microscopically,  the  sputum  is  seen  to  be 
composed  chiefly  of  pus-corpuscles,  with  which  are  intermingled  Char- 
cot-Leyden  and  fatty-acid  crystals,  the  latter  being  arranged  in  the 
form  of  bundles  ;  also  leptothrices,  vibrios,  and  bacteria  are  found. 
Elastic  fibers  may  be  observed  if  ulcers  be  present. 


BRONCHIECTASIS.  491 

Dyspnea  is  noted,  but  is  not  a  prominent  symptom,  unless  some 
other  chronic  aflfections  of  the  chest  coexist  or  some  complication  arises. 
Hemoptysis  occurs  rarely,  and  may  be  due  to  the  bronchiectatic  lesion. 
Abscess  of  the  brain  may  develop,  though  rarely. 

Physical  Signs. — These  differ  in  character  according  to  the  size,  situ- 
ation, and  nature,  of  the  dilatation,  and  also  according  to  the  condition 
of  the  surrounding  lung-tissue. 

On  inspection  retraction  of  the  chest-wall  may  be  noted  Avhen  chronic 
pleurisy  and  interstitial  pneumonia  are  associated.  The  tactile  fremitus 
is  usually  increased,  but  may  rarely  be  diminished.  The  percussion 
resonance  is  impaired  or  even  flat,  and  on  auscultation  bronchial  breath- 
ing is  heard,  with  occasional  rales  that  have  a  metallic  quality.  A  sac- 
cular dilatation  immediately  beneath  the  pleura  may  give  a  tympanitic 
note,  and  may  also  give  typical  cavernous  or  amphoric  respiration.  A 
tympanitic  resonance  over  a  circumscribed  area  which  prior  to  cough 
and  expectoration  presented  dulness,  is  a  significant  sign  (Babcock). 
These  signs  are  generally  discoverable  at  the  base  of  one  or  other  lung. 

Diagnosis. — Simple  dilatation  of  slight  degree  may  exist  without 
appreciable  signs,  and  in  other  instances  the  breathing  is  broncho-vesic- 
ular over  localized  areas,  with  rales  displaying  increased  metallic  quality. 

Saccular  Bronchiectasis.  Pulmonary  Tuberculosis. 

History  of  chronic  bronchitis,  chronic  History  of  cough,  hemoptysis,  with  pro- 
pleurisy,  and  interstitial  pneumonia,  or  gressive  loss  of  flesh  and  strength, 
of  foreign  body.  Family  history. 

Cough  is  paroxysmal,  and  sputum  cha-  Cough  less  paroxysmal.     Sputum  num- 

racteristic  and  copious.  mular  in  the  stage  of  cavity. 

Tubercle  bacillus  absent.  Tubercle  bacillus  present. 

Course  longer,  with  little  impairment  of  Course  relatively  shorter,  powers  of  the 

the  general  health.  system  progressively  undermined. 

Physical  Signs. 

The  condition  is  persistent,  but  non-pro-  Generally  progressive,  more  frequently  at 
gressive.      Usually  located  near  base  one  or  other  apex, 

posteriorly. 

Circumscribed  empyema  with  a  fistulous  connection  with  the  lung 
may  simulate  bronchiectasis.  There  is  often  in  such  cases  a  clear  his- 
tory of  an  acute  illness  with  a  sudden  onset,  the  symptoms  pointing  to 
pleural  inflammation.  The  patient  suddenly  expectorates,  at  irregular 
intervals,  large  quantities  of  purulent  matter.  Actinomycosis  may  also 
cause  conditions  that  simulate  bronchiectasis.  The  diagnosis  may  be  made 
by  finding  granular  particles  containing  the  actinomyces  in  the  sputum. 

Prognosis. — Apart  from  certain  remote  dangers  {e.  g.  abscess,  gan- 
grene), these  cases  pursue  a  favorable  but  exceedingly  protracted  course. 

Treatment. — The  lesion  being  a  permanent  one,  there  is  no  known 
remedy  that  will  either  abridge  or  influence  the  course  of  the  affection. 
Again,  since  the  cough  is  protracted  and  attended  with  profuse  expec- 
toration, sedatives  and  ordinary  expectorants  are  contraindicated.  For 
the  fetor,  antiseptics  are  to  be  employed  both  topically  and  internally, 
and  a  solution  of  carbolic  acid  (1-3  per  cent.)  or  thymol  (1 :  1000)  is 
to  be  used  by  inhalation.  Internally,  terebene  (TTLv-x — 0.333-0.666) 
in  capsules  every  four  hours  is  valuable ;   also  creasote  in  increasing 


492  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

doses  (inj — 0.066,  increasing  by  TTlj  each  day,  till  TTLvj — 0.399 — are 
taken  three  times  daily)  is  to  be  persistently  employed. 

Should  the  above  methods  prove  unavailing,  intrathoracic  injections 
of  disinfectants  are  often  resorted  to  with  gratifying  results. 

In  instances  in  Avhich  the  dilatation  is  situated  superficially  and  is 
not  amenable  to  therapeutic  measures,  it  may  be  frjeely  opened  and 
thoroughly  drained. 


BRONCHIAL  STENOSIS. 

Definition. — Narrowing  of  the  bronchus,  due  either  to  constriction 
or  to  compression. 

Pathology  and  :^tiology. — {a)  Stenosis  due  to  Constriction. — 
This  form  is  most  freijuently  occasioned  by  the  presence  of  foreign 
bodies ;  by  new  growths  (polypoid)  within  the  bronchi,  or  by  growths 
without,  or  the  cicatrices  of  healed  ulcers,  and  in  the  case  of  the  smaller 
bronchi  by  swelling  of  the  mucosa.  The  bronchial  walls  also  some- 
times become  thickened  by  inflammatory  exudates  in  certain  acute 
and  chronic  affections,  such  as  syphilis,  tuberculosis,  and  glanders. 

{b)  Stenosis  due  to  Compression. — Compression  of  one  or  more  bron- 
chi may  be  met  with  in  a  variety  of  enlargements  involving  the  organs 
within  the  thorax,  among  Avhich  are  aneurysm,  echinococcus  cyst,  solid 
tumors,  enlarged  glands,  mediastinal  and  pulmonary  abscesses,  and  ex- 
tensive pleural  effusion. 

Symptoms. — The  symptoms  do  not  depend  upon  the  cause  of 
the  obstruction,  but  their  extent  and  character  are  in  proportion  to 
the  size  of  the  bronchus  affected  and  the  degree  of  stenosis.  I^ys- 
pnea  is  the  most  conspicuous  symptom,  and  when  this  is  marked  the 
accessory  muscles  of  respiration  are  brought  into  active  play,  and  still 
the  proper  filling  of  the  lungs  with  air  is  not  accomplished.  Under 
these  circumstances  the  air  in  the  lungs  becomes  rarefied,  and  instead 
of  normal  expansion  everywhere  the  lower  part  of  the  sternum  and  the 
lower  ribs  are  retracted  on  inspiration,  and  expiration  is  accomplished 
only  Avith  difficulty.  Obstruction  of  the  primary  bronchus  on  either 
side  of  the  chest  would  naturally  be  followed  by  inspiratory  retraction 
of  the  inferior  part  of  the  chest-wall  and  intercostal  spaces  upon  the 
affected  side.  It  is  to  be  recollected  that  the  movements  of  the  larynx 
are  slight  in  bronchial  stenosis,  while  they  are  marked  in  laryngeal  ob- 
struction. Cough  and  expectoration  are  sometimes  present,  and  fever 
of  moderate  severity  is  often  noted. 

Physical  Signs. — Inspection  shows  defective  respiratory  movement 
upon  the  side  involved.  The  local  tactile  fremitus  is  diminished  or 
absent  upon  the  affected  side,  owing  to  the  obstruction  to  the  passage 
of  the  vibrations  of  the  voice  to  the  pulmonary  periphery.  The  />('r- 
cussion-note  remains  unaltered,  though  less  influenced  by  forced  respira- 
tion, and  particularly  expiration,  than  in  health.  Pulmonary  atelectasis 
may  occur  as  a  secondary  event,  and  is  shown  by  dulness  on  percussion. 
The  auscultatory  signs  consist  of  a  greatly  diminished  vesicular  murmur 
on  inspiration,  due  to  the  diminished  amount  of  air  entering  the  air- 


ASTHMA.  493 

cells  during  inspiration,  and  the  presence  of  rales,  sibilant  and  sonor- 
ous in  character,  at  the  seat  of  obstruction.  Obstruction  of  a  small 
bronchus  may,  however,  be  present  without  appreciable  physical  signs, 
owing  to  the  fact  that  the  surrounding  lung-tissue  may  take  on  com- 
pensatory emphysema. 

Diagnosis. — The  nature  and  site  of  the  affection  may  be  determined 
by  auscultation,  and  sibilant  and  sonoroils  rales  will  be  conspicuous  at 
the  point  of  constriction.  A  clear  history,  together  with  a  careful  in- 
vestigation of  antecedent  affections  of  the  thoracic  organs  leading  up 
to  the  stenosis,  are  factors  that  must  furnish  the  etiological  data  in  indi- 
vidual cases  after  the  exclusion  of  foreign  bodies  as  the  possible  cause. 
Tracheal  or  laryngeal  stenosis  may  be  eliminated  by  careful  laryngo- 
scopic  examination. 

Prognosis. — The  duration  is  indefinite,  though  usually  protracted, 
and  most  cases  yield  an  unfavorable  prognosis.  In  those  instances, 
however,  in  which  the  narrowing  is  due  to  foreign  bodies  the  latter 
may  rarely  be  dislodged  and  fortunately  ejected,  thus  averting  danger 
to  life. 

Treatment. — The  treatment  must  be  addressed  to  the  cause  in  in- 
dividual cases.  Obviously,  the  question  of  the  removal  of  foreign 
bodies  from  the  bronchi  falls  within  the  domain  of  surgery,  though  the 
administration  of  an  emetic  has  been  followed  by  complete  success  in 
certain  instances.  Obstruction  due  to  stenosis  of  a  main  bronchus 
may  be  treated  by  dilatation  with  bougies,  the  treatment  of  course  being 
carried  out  by  a  specialist. 


ASTHMA. 

{Bronchial  Asthma.) 


Definition. — A  chronic  affection,  characterized  mainly  by  paroxys- 
mal dyspnea,  due  to  contraction  of  the  muscles  of  the  smaller  bronchi. 
The  paroxysmal  dyspnea  produced  by  arterial  contraction  is  also  termed 
asthma  by  many  writers. 

Pathology. — In  many  cases  there  is  hyperemia  of  the  bronchial 
mucosa,  due  to  pneumogastric  or  vasomotor  functional  disturbances,  and 
also  a  characteristic  exudate  of  mucin.  In  others  there  may  be  no  lesions 
whatsoever,  and  the  condition  is  a  pure  neurosis,  often  of  reflex  origin. 
Von  Ley  den  considers  asthma  to  be  a  reflex  neurosis,  the  primum  movens 
of  which  may  be  situated  almost  anywhere  in  the  body.  The  morbid 
changes  peculiar  to  chronic  bronchitis,  pulmonary  emphysema,  and  right- 
ventricular  hypertrophy  with  dilatation  are  found  at  autopsy. 

Htiology. — There  is  present  either  a  constitutional  peculiarity  or  a 
singular  susceptibility  of  the  local  muscular  fibers  to  spasmodic  con- 
traction, both  of  which  are  of  unknown  nature.  The  exciting  factors 
are  very  various,  but  may  be  grouped  under  four  heads  : 

(1)  Acute  Bronchitis. — It  must  not  be  forgotten,  however,  that  a 
bronchitis  may  be  set  up  by  the  paroxysms.  Curschmann  has  observed 
also   a  local  croupous  inflammation  of  the  smaller  bronchioles  in  some 


494  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  bis  cases,  which  he  describes  as  hronchiolitis  exfoliativa,  and  which 
seems  to  have  given  rise  to  the  seizures  in  grave  cases. 

(2)  The  inhalation  of  numerous  and  widely  various  irritants,  as 
chemical  vapors,  smoke,  fog,  dust,  and  emanations  from  plants  or  cer- 
tain animals.  A  person  may  be  immune  in  the  city  and  suifer  greatly 
on  geing  into  certain  rural  districts. 

(3)  Reflex  Causes. — The  causal  connection  between  obstructive  affec- 
tions of  the  nose  and  asthma  is  a  subject  that  is  appreciated  by  the 
specialist.  Gastric  disturbances  and,  as  I  have  observed,  intestinal  irri- 
tation are  productive  of  this  complaint.  In  dyspeptic  asthma  Boas 
found  the  diaphragm  elevated  above  its  normal  position. 

(4)  Asthma  may  be  secondary  to,  and  most  probably  excited  by, 
cardiac  disease,  emphysema,  gout,  rheumatism,  syphilis,  Brights  dis- 
ease, emotional  excitement,  and  irritating  lesions  in  the  region  of  the 
medulla.  Possibly,  some  of  the  latter  affections  merely  constitute  pre- 
disposing factors.  In  this  connection  it  is  to  be  pointed  out  that  indi- 
vidual liability  to  the  disease  depends  upon  the  special  etiologic  factor. 

Predisposing  Causes. — ITeredit//  takes  first  place,  and  is,  when  discov- 
erable, well  marked  :  it  is  noted  in  about  50  per  cent,  of  all  cases.  The 
complaint  is  about  twice  as  frequent  in  males  as  in  females,  and,  if  we 
except  hay  asthma,  it  is  more  prevalent  in  winter  and  early  spring  than 
during  the  warm  season. 

Clinical  History. — Hyde  Salter's  collective  statistics  show  that 
prodromal  symjitoLus  appeared  in  about  one-half  the  instances  (in  111 
out  of  226  cases).  They  differ  widely,  but  are  chiefly  nervous  in  a 
great  proportion  of  cases,  and  appear  as  irritability  of  temper,  either 
depression  or  unusual  buoyancy  of  spirits,  headache,  drowsiness,  and 
vertigo.     Abundant  diuresis  and  digestive  disturbances  tend  to  appear. 

The  paroxysm  usually  comes  on  in  the  night  during  sleep,  and  at  a 
definite  time.  It  may  develop,  however,  while  awake  or,  again,  though 
rarely,  during  the  day.  The  onset  may  be  sudden,  but  perhaps  more 
frequently  the  patient  first  experiences  a  moderate  grade  of  dyspnea 
and  thoracic  constriction.  This  augments  with  unwonted  rapidity,  and 
often  attains  to  an  inordinate  degree,  until  the  patient  feels  smothered, 
sits  up,  grasps  his  knees  Avith  his  hands,  or  places  the  palms  upon  the 
bed  so  as  to  raise  the  shoulders  and  thus  reinforce  the  accessory  mus- 
cles of  respiration.  If  the  attack  be  severe,  he  rushes  to  an  open  win- 
dow Avhen  able  to  leave  his  bed.  or  sits  on  a  chair  and  places  his  arms 
on  the  back  of  another  chair,  so  as  to  fix  the  shoulders  and  thus  give 
purchase  to  the  auxiliary  muscles  of  respiration  while  frantically  en- 
deavoring to  maintain  the  act  of  breathing.  The/rtcc  is  pale,  anxious, 
and  soon  is  bedewed  with  cold  perspiration,  while  the  lips,  eyelids,  and 
finger-tips  are  livid,  owing  to  defective  oxygenation  of  the  blood.  The 
temperature  becomes  subnormal  and  the  j^ulse  feeble  and  rapid.  The 
clinical  picture  wears  an  alarming  aspect,  but  in  uncomplicated  cases 
death  never  supervenes. 

Physical  Signs. — Inspection  shows  enlargement  of  the  chest,  which  in 
the  advanced  stage  becomes  barrel-shaped.  The  reason  for  this  is  the 
presence  of  an  increased  amount  of  air  in  the  thorax  with  a  total  inabil- 
ity to  expel  it.  The  respirations  are  diminished  in  frequency  to  12  or 
10  per  minute.     The  natural  rhythm  is  also  greatly  disturbed,  and  in- 


ASTHMA. 


495 


spiration  is  seen  to  be  short  and  gasping,  and  followed  immediately  by 
expiration,  -which  is  greatly  prolonged.  The  expansile  movement  of  the 
chest  is  very  limited,  and  in  inverse  ratio  to  the  patient's  efforts  at 
breathing.  There  is  lowering  of  the  diaphragm.  Palpation  is  negative 
in  its  practical  results.  Percussion  yields  a  hyper-resonance ;  in  ad- 
vanced cases  with  associated  emphysema  semi-tympanitic  resonance  is 
common.  On  auscultatioyi  the  inspiration  is  found  to  be  short  and 
feeble,  and  the  expiration  much  prolonged  and  accompanied  by  a  Ioav- 
toned  wheezing  sound  that  may  also  be  audible  to  onlookers.  A  great 
variety  of  dry  rales  are  heard,  chiefly  high-pitched,  sibilant,  and  sonor- 
ous, that  are  more  marked  on  expiration  than  inspiration.  They  also 
change  their  character  and  situation  frequently.  At  the  close  of  the 
attack  moist  rales  may  be  heard,  and  occasionally,  when  bronchitis 
complicates  asthma,  the  moist  rales  may  be  combined  throughout  the 
paroxysms. 

The  duration  of  the  attack  is  various,  ranging  from  a  few  minutes 
to  several  hours,  though  rarely  it  may  endure  a  week  or  two,  Avith 
spontaneous  remissions  during  the  day  {e.  g.  when  chronic  bronchitis 
coexists).  Usually  it  subsides  dbrwptly.,  with  the  expectoration  of 
rounded  gelatinous  masses  and,  later  still,  of  muco-purulent  material. 
The  former,  when  floated  in  water,  are  found  to  be  composed  of  the  so- 
called  Cursclimann  s  spirals  (mucous  moulds  of  the  smaller  tubes),  and 
the  spiral  character  of  these  small,  ball-like  pellets  may  even  be  detect- 
able with  the  naked  eye.  When  examined  microscopically  their  spiral 
structure  is  evident.  Two  forms  are  recognized :  (1)  Composed  of 
mucin.,  arranged  spirally ;  in  its  meshes  may  be  observed  alveolar  cells, 
many  of  which  have  undergone  fatty  degeneration.  (2)  A  perfectly 
clear  and  translucent  filament  that  is  most  probably  composed  of  trans- 
formed mucin  and  occupies  the  center  of  the  coiled  spiral  of  mucin.  In 
the  early  stage  of  the  attack  Curschmann's  spirals  (Fig.  44)  are  invariably 


e^c7 


Fig.  4i.— Curschmann's  spirals. 


present  in  the  expectoration,  and  in  many  instances  Leyden's  octahedral 
crystals  are  also  visible.  For  a  time  the  latter  were  supposed,  though  erro- 
neously, to  excite  the  paroxysms  by  means  of  their  irritating  character. 
Similar  crystals  are  found  in  the  semen,  as  well  as  in  the  blood  in  cer- 
tain conditions  (e.  g.  leukemia).  Miiller,  Fink,  Leyden,  and  others  have 
demonstrated  extremely  large  numbers  of  eosinophile  leukocytes  in  the 


496  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

sputum.  Fink  and  Gabritchewski  likewise  have  found  a  large  excess 
(ranging  from  15  to  35  per  cent.)  of  eosinophile  leukocytes  in  the  blood. 
V.  Noorden  and  Swerchewski  found  the  same  increase,  but  only  at  the 
times  of  the  attacks. 

Diagnosis. — A  clear  history,  together  with  the  physical  signs  and 
a  microscopic  examination  of  the  sputum,  should  lead  to  correct  results. 
The  history  alone  is  inadequate  to  put  the  physician  upon  the  right 
track.  Laryngeal  affections,  which  give  rise  to  spasm  of  the  glottis 
and  dyspnea,  are  to  be  eliminated  by  the  alteration  of  the  voice  and  the 
aphonia  Avhich  are  usually  present,  while  the  characteristic  physical 
signs  of  asthma  are  absent.  Again,  the  dyspnea  is  inspiratory,  not 
expiratory  as  in  asthma. 

Emphysema  may  be  confounded  with  asthma.  The  presence  of  recog- 
nized causes,  of  typical  physical  signs,  and  the  paroxysmal  dyspnea  in 
asthma  are  the  chief  points  of  distinction  from  emphysema.  The  spu- 
tum should  be  examined  microscopically  if  doubt  remain. 

Course  and  Prognosis. — In  mild  cases  of  asthma  there  may  be  but 
one  or  two  nocturnal  paroxysms,  with  entire  freedom  from  cough  and  dys- 
pnea during  the  following  day.  On  the  other  hand,  in  severe  cases  there 
is  a  repetition  of  the  paroxysms  from  three  to  five  or  six  nights.  Under 
these  circumstances  in  the  intervals  (usually  corresponding  to  the  period  of 
day)  there  are  slight  Avheezing  and  some  cough.  In  long-standing  cases 
asthma  leads  constantly  to  the  development  of  chronic  bronchitis  and 
emphysema,  and  in  such  these  affections  are  invariably  combined.  The 
paroxysmal  character  of  the  affection  is  often  partly  or  wholly  lost,  the 
patient  rarely  being  entirely  free  from  asthmatic  dyspnea,  combined  with 
cough  and  muco-purulent  expectoration.  The  periodicity  of  the  attacks 
varies  greatly  ;  in  some  it  recurs  monthly  or  at  even  shorter  intervals,  and 
in  othei's  only  annually. 

There  is  rarely  any  danger  to  life,  except  when  the  secondary  affection 
is  emphysema  and  its  remote  consequence  is  dilatation  of  the  right  ven- 
tricle ;  but  the  percentage  of  cases  in  which  recovery  actually  takes  place 
is  comparatively  small,  since  the  affection  may  reappear  long  after  the 
paroxvsms  have  ceased  to  recur  in  the  usual  manner. 

Treatment. — The  indications  for  treatment  are — (1)  to  cut  short  the 
paroxysms,  and  (2)  to  prevent  a  recurrence  of  subsequent  attacks. 

(1)  To  bring  relief  during  the  paroxysms  we  should  ascertain  the  ex- 
citing cause,  and  remove  it  promptly  if  possible  to  do  so.  In  one  of  my 
own  cases  a  prolonged  paroxysm  was  cut  short  by  a  calomel  purge  fol- 
lowed by  an  enema.  An  overloaded  stomach  calls  for  an  emetic,  and 
other  causal  factors  are  sometimes  removable  {e.  g.  congestion  of  the 
nasal  mucosa,  dust,  animal  and  vegetable  emanations).  If  the  cause  is 
irremovable,  the  patient  should  be  kept  in  a  large  and  freely  ventilated 
apartment,  and  everything  that  tends  to  impede  respiration  must  be  re- 
moved. The  choice  of  posture  as  affording  the  greatest  relief  may  usually 
be  left  to  the  patient. 

To  cut  short  the  paroxysms :  The  particular  mode  of  treatment  that 
will  afford  most  speedy  relief  differs  widely  in  different  cases,  and  not 
infrequently  the  patient,  as  the  result  of  experience,  is  aware  of  the  rem- 
edies that  are  most  efficacious  for  good.  As  a  rule,  however,  sedative 
antispasmodics,   relaxants,   and  stimulants  are  the  classes   of  medicinal 


ASTHMA.  497 

agents  from  which  a  careful  selection  is  to  be  made  ;  and  whilst  a  great 
variety  of  these  have  been  employed,  I  shall  content  myself  by  adducing 
here  only  the  most  valuable  and  their  mode  of  administration.  In  the 
hands  of  some  observers  a  few  whiffs  of  chloroform  have  proved  highly 
efficacious,  but  in  my  own  they  have  produced  only  momentary  good 
effects ;  ether  is  the  safer  remedy  and  may  be  tried  in  like  manner.  In 
a  certain  proportion  of  the  cases  from  four  to  six  drops  of  amyl  nitrite 
thrown  upon  cotton-wool  or  a  handkerchief,  and  inhaled,  bring  speedy 
and  permanent  relief.  Of  stimulants,  coffee  is  the  best :  immediately 
upon  the  appearance  of  the  paroxysm  about  one  pint  of  strong  coffee  is 
to  be  taken  hot  (without  cream  or  sugar),  and  in  this  way  the  seizure 
may  sometimes  be  arrested.  Alcohol  when  given  hot  and  in  sufficiently 
large  doses  to  induce  mild  intoxication  may  be  found  very  useful ;  and 
with  "hot  toddy,"  spirits  of  chloroform  may  be  combined. 

The  inhalation  of  the  fumes  of  niter-paper  ^  often  gives  quick,  tempo- 
rary, and,  less  frequently,  permanent  relief.  When  employed,  the  atmo- 
sphere of  the  room  occupied  by  the  patient  must  be  well  filled  with  the  fumes. 

Among  depressant  antispasmodics  are  belladonna,  hyoscyamus,  stra- 
monium, and  lobelia,  and  these  seem  to  be  of  most  value  when  used  in 
the  form  of  cigarets.  The  leaves  of  the  plant  employed  are  first  steeped 
in  a  concentrated  solution  of  potassium  nitrate  or  chlorate,  and  a  trial 
should  be  made  of  different  sorts  of  cigarets  or  pastilles  (which  are  simi- 
larly prepared),  since  all  cases  are  not  benefited  by  the  same  brand.  The 
inhalation  of  tobacco-smoke  is  equally  beneficial  in  rare  instances. 

A  large  number  of  cases,  despite  the  use  of  the  measures  above  indi- 
cated, exhibit  an  obstinate  tendency,  and  for  their  treatment  no  remedy 
bears  favorable  comparison  with  morphin,  administered  hypodermically, 
for  potency  and  permanency  of  its  beneficial  effects.  It  is  best  given  in 
full  doses  (gr.  ^-^^ — 0.0216-0.0324),  and  may  be  combined  with  atropin 
or  cocain.  V.  Noorden  uses  atropine  in  ascending  doses  (gr.  j^  in- 
creased to  -^  daily),  then  gradually  diminishes  the  dose  ;  this  treatment 
is  repeated  every  few  months,  though  lessening,  the  dose  and  shortening 
each  course  of  treatment.  Strychnin  also  has  its  advocates  (Mays). 
The  use  of  opium,  oft  repeated,  has  occasionally  led  to  the  establish- 
ment of  the  morphin-habit ;  hence  it  must  not  be  used  indiscriminately. 
I  am  in  the  habit  of  supplementing  the  action  of  the  morphin  with  the 
following  formula : 

^.  Tr.  lobelife,  3J         (4.0); 

Tr.  nitro-glvcerini  (1  per  cent.),       TUxvj  (1.06); 

Sodii  bromid.,  3v        (20.0); 

Vini  ipecac,  3v        (20.0); 

Ext.  hyoscyami,  gr.  viij  (0.518) ; 

Elix.  simpiicis,  q.  s.  ad  giv       (128.0). — M. 
Sig.  3j  (4.0)  every  one  or  tv>-o  hours  in  water. 

S.  Solis-Cohen  lauds  hyoscin  hydrobromate  (gr.  yo^)  administered 
hypodermically.  In  the  protracted  cases  of  old  asthmatics,  associated 
with  chronic  bronchitis  and  emphysema,  the  above  mixture  may  be  also 
employed,  though  sodium  iodid  (gr.  v — 0.324)  should  be  substituted  for 
the  bromid,  and  the  same  dose  given  at  intervals  of  three  or  four  hours. 

^  Niter-paper  is  prepared  by  dipping  bibulous  paper  (filter-  or  blotting-paper)  in  a 
solution  of  saltpeter. 
32 


498  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

(2)  In  order  to  prevent  subsequent  attacks :  During  tlie  intervals 
the  physician  must  ascertain  Avhether  any  of  the  numerous  causes  (bron- 
chitis, gastric  disorders,  dust,  emanations  from  plants)  are  discoverable ; 
and  if  so,  efforts  to  remove  them  should  be  instituted.  A  methodical 
interrogation  of  the  various  organs  of  the  body  and  their  functions 
must  be  carried  out,  and  the  therapeutic  or  hygienic  indications  pre- 
sented by  them,  if  any,  must  be  met  judiciously.  The  nasal  passages 
should  be  examined  by  a  specialist,  and  any  causal  conditions  found 
therein  are  to  be  promptly  removed.  If  the  affection  be  a  pure  neuro- 
sis or  due  to  bronchitis,  a  suitable  climate  may  often  be  found  in  Avhich 
the  patient  will  enjoy  complete  immunity  from  asthma.  The  choice 
of  the  locality  cannot,  however,  be  determined  by  any  known  rules. 
The  patient  must  travel  from  place  to  place  until  he  finds  the  cli- 
mate that  possesses  preventive  properties  in  his  particular  case.  To 
those  who  cannot  adopt  this  plan  potassium  iodid  offers  the  best  hope  of 
relief,  though  its  use  must  be  long  continued  (gr.  x-xx — 0.648-1.296, 
three  times  daily).  The  systematic  use  of  compressed  air  in  the  pneu- 
matic cabinet,  and  also  the  inhalation  of  oxygen,  are  worthy  of  trial. 
The  presence  of  any  conditions  of  ill-health  calls  for  appropriate 
treatment.  Talma  believes  that  the  attacks  may  be  overcome  by  proper, 
rhythmic,  deep  breathing. 

There  are  also  certain  means  of  prophylaxis  for  impending  attacks. 
Thus,  if  there  be  premonitory  symptoms,  the  use  of  such  measures  as 
strong  coffee  or  the  "  hot  toddy  "  above  mentioned,  Hoffman's  anodyne, 
stramonium  or  belladonna  cigarets,  the  inhalation  of  the  fumes  of  niter- 
paper  or  of  a  few  drops  of  amyl  nitrite,  or  the  removal  of  the  sources  of 
irritation,  may  suffice  to  ward  off  the  attack. 


FIBRINOUS  BRONCHITIS. 

(P/asfir  Bronchitis  ;    Croupous  Broiichilis  :    Mucous  Bronchitis.) 

Definition. — A  rare  acute  or  chronic  catarrhal  affection  of  the 
bronchial  mucosa,  attended  with  the  production  of  fibrinous  casts  (?) 
that  are  expectorated  in  severe  paroxysms  of  cough  and  dyspnea. 
These  casts,  when  unfolded,  are  found  to  be  solid  moulds  of  the 
bronchial  tubes  from  which  they  come,  being  shaped  like  the  branches 
©f  a  tree,  and  thus  proving  that  a  bronchial  tube  and  its  subdivisions 
had  been  blocked.  When  the  moulds  are  lai-ge  or  medium-sized  they 
"are  hollow,   and   when  from  the   smaller  bronchi  they  are  solid. 

Pathology. — The  pathology  is  but  little  understood,  but  in  one  of 
my  own  cases  I  found  the  composition  of  these  casts  to  be  identical  with 
that  of  croupous  exudates  met  with  elsewhere,  though  more  dense,  per- 
haps, than  the  latter.  Croupous  bronchitis  is  attended  with  loss  of  epi- 
thelium in  the  implicated  bronchi,  as  is  the  case  in  croupous  inflamma- 
tion wherever  it  occurs;  but  the  answers  to  the  questions,  "  Why  should 
the  affection  be  limited  to  a  definite  portion  of  the  bronchial  tree?  "  and 
"  Why  does  it  recur  from  time  to  time  ?  "  are  obscure  indeed.  In  fatal 
cases  the  lesions  of  associated  or  antecedent  complaints,  such  as  chronic 
pleurisy,  pneumonia,  and  pulmonary  tuberculosis,  have  been  found. 


FIBEIXOrS  BROXCHITIS.  499 

Htiology. — "What  the  irritant  is  that  causes  the  condition  is  un- 
known, though  streptococci  have  been  found  in  the  moulds  and  in  the 
mucosa.  Some  of  the  predisposing  causes,  however,  have  been  recog- 
nized, and  are — (1)  Sex:  it  being  about  twice  as  frequent  in  males  as  in 
females.  (2)  Age :  though  met  with  at  all  periods  of  life,  it  is  relatively 
more  frequent  from  the  twentieth  to  the  fortieth  year.  (3)  Season :  the 
seizures  are  most  common  in  the  spring  months.  (4)  Epidemic  influ- 
ences :  Pichini  has  described  a  group  of  instances  that  occurred  in  indi- 
viduals in  the  same  locality.  (5)  hereditary  influence  has  been  trace- 
able in  a  few  cases.  (6)  Other  affections,  as  tuberculosis  (quite  fre- 
quently), chronic  pleurisy,  and  certain  skin-affections,  as  herpes,  im- 
petigo,  and  pemphigus,  form  antecedent  and  associated  conditions. 

Symptoms. — {a)  The  acute  form  is  rare.  It  begins  with  rigors  and 
fever  that  are  soon  followed  by  urgent  dyspnea  and  severe  paroxysms  of 
cough,  which  are  usually  attended,  soon  or  late,  by  the  expulsion  of 
bronchial  casts,  and  sometimes  rather  profuse  hemorrhage.  Abundant 
expectoration  usually  causes  amelioration  of  the  severer  symptoms.  On 
the  other  hand,  urgent  dyspnea,  oppressiveness,  and  severe  cough,  with 
little  expectoration,  are  grave  symptoms,  often  leading  to  fatal  aspliyxia. 

(l))  The  Chronic  Form. — The  attacks  recur  at  irregular  intervals  and 
are  less  severe  than  in  the  acute  form,  the  interim  varying  from  one 
week  to  a  year  or  more.  In  a  case  observed  by  myself  the  patient  has 
experienced  a  recurrence  once  annually  (on  or  about  May  Isc),  commen- 
cing three  years  ago.  The  paroxysms  may  occur  at  regular  though  much 
briefer  intervals.  The  cases  usually  manifest  ordinary  bronchitic  symp- 
toms, with  or  without  fever  at  the  onset.  The  cough  soon  becomes 
troublesome  and  is  paroxysmal  in  character.  There  is  expectoration  in 
the  form  of  rounded  masses,  which,  when  unravelled,  are  found  to  be 
true  moulds  of  the  affected  tubes  that  exhibit  a  laminated  structure. 
The  larger  casts  (which  are  of  the  size  of  a  goose-quill  or  even  larger) 
may  be  hollow.  They  are  of  whitish  or  grayish-white  color.  When 
examined  microscopically  they  are  seen  to  consist  of  a  fibrillated  base, 
a  few  scattered  leukocytes  and  mucous  corpuscles,  and,  rarely,  gland- 
and  blood-cells.  Curschmann's  sj)irals  are  often  found,  and  within 
these  or  associated  with  them  the  Leyden  crystals.  First,  Beschorner 
and  later'  Grandy  have  shown  the  casts  to  be  composed  of  mucin.  In 
other  cases,  however,  similar  studies  show  fibrin.    Hemorrhage  may  occur. 

Physical  Signs. — Owing  to  the  obstruction  offered  by  the  casts,  there 
is  a  diminished  amount  of  air  entering  the  corresponding  part  of  the  lung. 
As  a  necessary  result  the  tactile  fremitus,  local  expansion,  and  respira- 
tory murmur  are  diminished  over  the  affected  area.  The  note  on  percus- 
sion over  the  uniuvolved  portions  of  the  lung  is  clear  or  hyper-resonant, 
though  if  the  portions  of  the  lung  supplied  by  the  affected  tubes  collapse, 
there  is  dulness  on  percussion.  Dislodgement  of  the  casts  is  followed  by 
a  return  of  the  normal  respiratory  murmur. 

Diagnosis. — From  ordinary  bronchitis  it  is  to  be  distinguished  by  the 
presence  of  casts  of  mucin  or  fibrin.  Avhich  alone  are  sufiicient  for  a  posi- 
tive diagnosis.  The  fibrinous  moulds  met  with  in  diphtheria  and  pseudo- 
membranous croup,  with  extension  into  the  bronchi,  must  also  be  elimi- 
nated. In  doubtful  cases,  a  bacteriologic  examination  of  the  membran- 
ous casts  should  be  made.     If  the  Klebs-Lofiler  bacilli  are  then  found, 


500  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

all  doubts  as  to  its  diphtheritic  nature  are  set  at  rest.  In  truly  diph- 
theritic cases  the  membrane  does  not  present  the  laminated  structure. 

Prognosis. — The  prognosis  in  the  acute  form  is  quite  grave ;  the 
chronic  variety,  though  pursuing  an  exceedingly  long  course  that  ranges 
from  five  to  fifteen  years,  rarely  terminates  fatally. 

Treatment. — This  is  to  be  conducted  on  the  same  principles  as  those 
in  simple  acute  bronchitis.  In  the  acute  form  an  attempt  should  be  made 
to  soften  and  separate  the  casts  by  the  topical  application  of  steam,  by 
inhalation,  and  alkaline  sprays  (g.  g.  lime-water).  Pilocarpin  was  em- 
ployed in  one  instance  under  my  own  observation  with  apparent  good 
results ;  it  tends  to  excite  free  bronchial  secretion.  Emetics  should  be 
resorted  to  without  delay  when  the  signs  of  cyanosis  show  themselves. 

In  the  chronic  form  nothing  can  be  accomplished  by  treatment,  dur- 
ing the  intervals  between  the  acute  exacerbations,  that  will  tend  to  obviate 
a  recurrence  of  the  attacks  or  to  mitigate  their  severity. 


IV.    DISEASES   OF  THE   LUNGS. 
CIRCULATORY  DISTURBANCES  IN  THE  LUNGS. 


CONGESTION   OF    THE   LUNGS. 
{Hi/peremia  of  the  Lungs.) 


Definition. — The  surcharge  of  the  pulmonary  vessels  with  blood. 
Two  forms  are  recognized :  (1)  Active  hyperemia,  and  (2)  Passive  hy- 
peremia. 

ACTIVE    HYPEREMIA. 

Pathology. — The  blood-vessels  in  the  bronchial  mucosa  often  appear 
intensely  injected,  and  the  capillaries  in  the  alveolar  walls  are  prominent, 
while  on  section  a  scarlet-colored,  frothy  liquid  flows.  The  alveolar  epi- 
thelium may  become  swollen  and  granular. 

Etiology. — Active  hyperemia  is  usually  a  symptomatic  condition, 
though  rarely  it  may  arise  as  a  distinct  primary  affection.  Active  con- 
gestion of  the  lungs  exists  as  an  associated  condition  in  many  pulmonary 
affections,  as  pneumonia,  pleurisy,  bi'onchitis,  and  tuberculosis.  On 
the  other  hand,  active  congestion  of  the  lungs  may  be  engendered  as  an 
independent  affection  by  the  inhalation  of  hot  air,  highly  irritative  sub- 
stances, as  well  as  by  violent  physical  exercise,  the  ingestion  of  large 
amounts  of  alcohol,  and  strong  mental  emotion.  Collateral  hyperemia 
may  arise  from  anemia  of  the  opposite  lung. 

Symptoms. — The  capacity  of  the  air-cells  is  diminished;  hence 
the  oxygenation  of  the  blood  is  markedly  interfered  with.  This  embar- 
rassment of  the  function  of  respiration  is  compensated  for  in  part  by 
accelerated  breathing,  there  being  a  degree  of  dyspnea  proportionate  to 
the  extent  and  intensity  of  the  congestion.  There  is  some  cough, 
accompanied  by  frotliy,  bloody  expectoration. 

The  physical  signs  are  bilateral,  as  a  rule,  and  are  generally  confined 


CONGESTION  OF  THE  LUNGS.  501 

to  the  bases.  Palpation  shows  increased  tactile  fremitus.  The  percussion- 
note  is  impaired  or,  rarely,  dull,  and  it  is  generally  exceedingly  diflEicult 
to  determine  the  pitch  of  the  note,  owing  to  the  fact  that  both  sides  are 
usually  involved.  On  the  other  hand,  when  the  condition  is  unilateral 
and  not  associated  Avith  diseases  of  the  opposite  side,  the  impairment  is 
readily  appreciated.  The  vesicular  element  of  the  respiratory  sounds  is 
diminished,  and  the  bronchial  element  relatively  increased  (broncho-vesic- 
ular breathing).     Less  frequently  there  is  bronchial  breathing. 

DiagfUOSis. — In  the  presence  of  the  etiologic  factors  the  sudden 
development  of  dyspnea,  cough,  and  a  frothy,  bloody  expectoration,  and 
the  physiccd  signs  before  enumerated,  in  the  absence  of  fever,  the  diag- 
nosis is  easy. 

Prognosis. — Active  hyperemia  is  frequently  folloAved  by  collateral 
edema.  Its  course  is  brief,  and  terminates  either  fatally  in  a  few  hours, 
in  perfect  recovery  in  a  few  days,  or  in  pneumonia.  The  condition  is 
therefore  ominous. 

Treatment. — Prompt  measures  must  be  instituted  in  order  to  arrest 
the  active  fluxion.  The  special  causative  factors  must  be  actively  treated, 
so  as  to  diminish  the  quantity  of  blood  in  the  pulmonary  vessels  ;  dry 
and  wet  cups  over  the  entire  seat  of  congestion  must  be  tried :  and  in  the 
worst  cases  venesection  is  demanded.  Following  the  application  of  the 
cups,  turpentine  stupes,  sinapisms,  and  linseed  poultices  may  be  em- 
ployed. I  have  observed  excellent  results  from  the  use  of  veratrum 
viride  combined  with  saline  purgatives.  Other  cardiac  sedatives  may  also 
be  employed,  including  nitroglycerin  in  full  doses. 

PASSIVE    HYPEREMIA. 

Passive,  unlike  active,  hyperemia  is  always  a  secondary  condition,  and 
is  quite  common.  Two  forms  are  distinguishable  :  (a)  Mechanical,  and 
(6)  Hypostatic. 

(a)  Mechanical  Hyperemia  {Brown  Induration). — Pathology. — The 
pulmonary  vessels  are  distended,  the  lungs  as  a  whole  enlarged,  and  the 
air-cells  crepitate  but  little,  owing  in  great  part  to  the  encroachment  upon 
the  air-spaces  by  the  dark  venous  blood.  The  lungs  are  of  a  reddish-brown 
color  and  afford  increased  resistance  to  efforts  at  cutting  or  tearino-.  On 
section  the  reddish-brown  tint  rapidly  changes  to  a  vivid  red,  from  oxi- 
dation of  the  hemoglobin  when  exposed  to  the  atmosphere.  The  process 
commences  at  the  extreme  base,  extends  upward,  and  may  finally  become 
general.  The  interstitial  connective  tissue  is  increased,  and  is  often  edem- 
atous, while  the  epithelial  cells  of  the  alveoli  show  altered  blood-pigment, 
usually  in  the  form  of  hemosiderin  and  responding  to  the  usual  tests  for 
iron. 

Etiology. — Mechanical  hyperemia  results  from  the  obstruction  of  the 
return  of  blood  to  the  left  heart,  and  among  special  causative  conditions 
are  mitral  constriction,  mitral  regurgitation,  dilatation  of  the  right  ven- 
tricle, and  certain  cerebral  injuries  and  diseases.  It  may  also  be  a  symp- 
tom of  asphyxia,  and  rarely  it  arises  from  pressure  of  tumors. 

Symptoms. — The  most  marked  feature  is  dyspnea,  particularly  when 
secondary  to  organic  cardiac  diseases  with  failure  of  the  right  ventricle. 
Cough  is  common,  and  an  expectoration  o^  frothy  serum  or  blood  (hemop- 


502  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

tysis)  containing  pigmented  alveolar  epithelial  cells,  is  the  most  cha- 
racteristic clinical  feature. 

Diagnosis. — With  a  clear  history,  in  addition  to  the  dyspnea,  cough, 
and  the  characteristic  expectoration,  the  recognition  of  passive  hyper- 
emia of  the  lungs  is  a  simple  matter.  The  pi'ognosis  and  treatment  will 
be  considered  in  connection  with  the  causative  affections. 

(h)  Hypostatic  Hyperemia. — Pathology. — The  parts  of  the  lung  that 
are  affected  are  dark  in  color  and  the  vesicles  distended  Avith  a  transudate 
of  blood  and  serum.  In  this  way  the  air-cells  may  become  emptied  of 
air  (spleuizafion,  hypostatic  pneumonia),  and  the  resulting  condition  is 
in  most  instances  to  be  regarded  as  a  mild  gi'ade  of  lobular  pneumonia. 
This  view  is  confirmed  by  the  fact  that  tiio  same  etiologic  conditions  that 
favor  the  development  of  hypostatic  congestion  also  favor  to  an  equal 
extent  the  development  of  hypostatic  pneumonia. 

Etiology. — Feeble  cardiac  action,  as  in  long-continued  fevers,  debili- 
tating chronic  affections,  and  in  old  persons,  combines  with  a  prolonged 
dorsal  position  of  tlie  body  (gravitation  thus  favoring  its  development)  in 
producing  the  condition.  This  explains  why  the  condition  is  found  usu- 
ally at  the  bases  of  the  lungs,  and  is  most  marked  posteriorly.  It  is 
common  for  the  same  reason  in  carcinoma,  tuberculosis,  paralysis,  chronic 
rheumatism,  typhoid  fever,  etc. 

Symptoms. — The  symptoms  are  wholly  indefinite ;  indeed,  none  may 
be  present.  Priory  has  pointed  out  that  old  persons  in  tlie  incipiency  of 
the  disease  begin  to  sleep  with  the  mouth  open,  so  as  to  effect  the  entrance 
of  more  air.  Commencing  cyanosis  may  indicate  the  development  of 
hypostasis,  and  a  careful  physical  examination  of  the  lower  lobes  of  the 
lungs  will  show  increased  fremitus,  slight  dulness,  diminished  vesicular 
murmur,  and,  in  the  higher  grades,  bronchial  breathing,  with  liquid  bub- 
bling rales. 

The  prognosis  is  based  upon  the  character  of  the  underlying  affection. 

Treatment. — This  is  an  affection  in  which  the  treatment  of  causes 
alone  will  suffice,  save  in  instances  that  are  secondary  to  organic  heart- 
aflections,  in  which  prompt  bleedings  are  to  be  advocated.  From  a  pint 
to  a  quart  of  blood  should  be  taken,  and  I  have  seen  happy  results  from 
the  employment  of  this  measure  in  extreme  cases.  Tapping  the  right 
auricle  when  the  blood  refuses  to  flow  from  an  arm  vein  has  also  been 
successfully  accomplished  by  competent  surgeons.  The  patient's  posture 
must  be  changed  from  the  dorsal  to  the  lateral,  and  even  ventral,  and  as 
soon  as  possible  he  should  be  gotten  out  of  bed. 

PULMONARY   EDEMA. 
{Edema  of  the  Lruigs.) 

Definition. — An  effusion  of  serous  fluid  into  the  air-vesicles  and  in- 
terstitial lung-tissue.  Pulmonary  edema  is  scarcely  to  be  regarded  as  an 
independent  affection,  but  as  a  secondary  condition,  being  in  most  in- 
stances associated  with  pulmonary  congestion. 

Pathology. — It  consists  of  a  transudation  of  serum  into  the  alveolar 
walls,  interstitial  connective  tissue,  and  air-cells,  and  rarely  the  process  is 
limited  to  the  interstitial  tissue.  Two  forms  may,  for  the  sake  of  con- 
venience, be  recognized : 


PULMONARY  EDEMA.  503 

{a)  Collateral  Edema  {Inflammator-y  Edema). — This  is  usually  local  in 
character,  circumscribing  an  area  of  the  lung  that  is  affected  by  pneu- 
monia, abscess,  or  pulmonary  infarction,  and  is  the  result  of  a  mild  in- 
flammatory process  affecting  the  vessel-walls.  When  the  condition  follows 
hypostatic  congestion  the  terms  "hypostatic  edema"  and  "  splenization  " 
have  been  applied. 

{h)  General  Pulmonary  Edema. — If  congestion  be  not  associated,  the 
portions  of  the  lungs  involved  by  this  type  look  pale ;  when  pulmonary 
congestion  or  pigmentation  of  the  tissue  is  present,  the  lung  appears 
darker  than  the  normal  and  the  serum  is  blood-tinged.  The  weight  of 
the  lung-tissue,  owing  to  the  more  or  less  airless  condition  of  the  alveoli, 
is  increased,  and  yet,  though  heavier  than  the  normal  lung,  the  affected 
tissue  does  not  sink  in  water.  To  the  feel  it  is  boggy,  and  pits  on  pres- 
sure, while  on  section  a  serous  or  sero-sanguinolent  (if  congestion  be  pres- 
ent) fluid  of  low'  specific  gravity,  and  poorer  in  albumin  than  plasma,  flows 
from  the  cut  surface.  Edema  is  most  frequently  observed  at  the  bases 
of  the  lungs,  though  it  may  become  general,  and  as  a  rule  the  surface  of 
the  pleura  is  moist ;  hydrothorax  may  be  present. 

The  mode  of  production  of  pulmonary  edema  is  not  definitely  known. 
Increased  fluidity  of  the  blood  on  the  one  hand,  and  increased  tension  in 
the  pulmonary  vessels  on  the  other,  seem  to  be  influential  factors  in  many 
cases.  The  heightened  blood-pressure  may  be  in  great  part  due  to  a  fail- 
ure of  cardiac  power,  and  particularly  to  failure  of  the  left  ventricle 
(Welch).  When  weakness  of  the  left  is  out  of  proportion  to  the  weak- 
ness (paralysis)  of  the  right  ventricle,  we  are  apt  to  have  the  tension  in 
the  pulmonary  capillaries  greatly  increased,  at  least  until  transudation 
of  serum  is  induced.  Edema  also  occurs  as  a  result  of  Aveakness  of  the 
right  ventricle  alone.  Obstruction  to  the  outflow,  such  as  occurs  in 
weakening  of  the  left  ventricle,  or  even  obstruction  in  the  aorta,  leads 
to  heightened  tension  and,  secondarily,  to  paralysis  of  the  right  ven- 
tricle. The  third  factor  entering  into  the  production  of  pulmonary 
edema  is  the  increased  permeability  of  the  vascular  walls,  due  to  im- 
pairment of  their  nutrition  and  "  disturbance  of  the  cardiopulmonic 
innervation"  (Huchard).  This  usually  arises  in  connection  with  toxic 
and  infectious  diseases,  when  the  blood  also  exhibits  more  or  less  change, 
as  in  cachectic  states,  uremia,  general  septicemia,  and  the  like.  In- 
stances are  met  with  in  Avhich  pulmonary  edema,  due  to  vasomotor 
relaxation,  develops  suddenly. 

Htiology. — Pulmonary  edema  is  secondary  to  pneumonia  and  acute 
and  chronic  affections,  but  not  with  any  degree  of  constancy  ;  nor  is  it 
especially  liable  to  be  associated  with  congestion  or  with  low  grades  of 
inflammation  of  the  lungs.  Among  the  diseases  of  which  it  forms  a  ter- 
minal  condition  are — valvular  affections  of  the  heart,  fatal  forms  of  anemia, 
acute  and  chronic  Bright's  disease,  cerebral  lesions  (hemorrhage,  trauma- 
tism), and  acute  infectious  fevers  with  failure  of  cardiac  power. 

Symptoms. — In  edema  of  the  lungs  the  air-space  is  lessened  in  di- 
rect proportion  to  the  amount  of  serum  occupying  the  alveoli ;  hence 
dyspnea  is  always  present  and  is  often  a  conspicuous  symptom.  There 
are  cough  and  hro7ichorrhea.  The  sjjutmn  is  usually  abundant  and  frothy, 
and  is  expectorated  with  difficulty.  At  times,  and  especially  in  the  acute 
forms,  it  is  tenacious  and  may  give  rise  to  alarming  laryngeal  obstruction. 


504  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

It  is  blood-stained  if  congestion  be  combined.  The  condition  does  not 
give  rise  to  elevation  of  temperature,  except  in  the  inflammatory  type,  in 
which  fever  is  constantly  present.  The  pulse  is  accelerated  and  feeble, 
and  cyanosis,  particularly  in  cases  of  collateral  edema,  usually  appears. 
The  extremities  are  cool  and  often  livid. 

Physical  Signs. — The  reasons  adduced  to  explain  the  dyspnea  likewise 
render  intelligible  the  physical  signs  encountered.  There  is  dulness,  though 
rarely  complete,  over  the  areas  involved ;  the  vesicular  murmur  is  feeble 
or  absent,  or  there  mav  be  broncho-vesicular  breathing.  Since  the  bron- 
chioles  contain  serum,  small  rales,  having  a  liquid  character,  are  audible 
with  inspiration  and  at  the  beginning  of  the  expiration  over  the  seat  of 
the  edema. 

The  diagnosis,  with  a  clear  history,  is  based  upon  the  incomplete 
dulness  that  is  usually  bilateral  and  most  marked  at  the  bases,  upon  the 
bubbling  rales  heard  over  the  corresponding  area,  and  upon  the  absence 
of  any  febrile  movement,  except  the  latter  be  due  to  some  underlying 
affection.  Hydrotliorax  bears  some  points  of  resemblance  to  edema  of  the 
lungs,  but  in  this  condition  the  upper  level  of  dulness  is  movable  in  con- 
sequence of  change  of  position  of  the  patient,  as  is  not  the  case  in  edema 
of  the  lungs.  On  the  other  hand,  in  the  latter  affection  moist  rales  are 
present,  while  they  are  absent  in  hydrothorax.  Broncho-pneumonia  may 
be  mistaken  for  pulmonary  edema,  though  it  has  a  different  mode  of  onset. 
It  is  also  accompanied  by  fever,  glairy,  tenacious  expectoration,  and  more 
sharply-localized  areas  of  dulness  then  appear  in  edema. 

The  prognosis  is  governed  by  the  pre-existing  condition  to  which 
the  edema  is  due.  Thus,  if  secondary  to  a  general  dropsy  due  to  renal 
or  cardiac  disease,  it  often  destroys  life  with  great  rapidity.  Inflammatory 
edema,  following  lobar  pneumonia,  is  also  grave  in  the  extreme. 

Treatment. — The  treatment  is  that  of  the  associated  or  causative 
aff"ections.  These  must  be  sedulously  treated,  and  the  limitation  of  the 
transudation  and  the  direct  removal  of  the  serous  effusion  from  the 
lungs  is  of  great  importance.  AVe  should  not  fail  frequently  to  change 
the  position  of  the  patient's  body,  so  as  to  prevent  the  gravitation  of 
blood  to  the  dependent  portions  of  the  lungs.  I  have  witnessed  excel- 
lent results  from  the  use  of  dry  cups  placed  over  the  thorax,  particularly 
over  its  posterior  and  lateral  aspects,  and  renewed  at  intervals  of  six  to 
eight  hours.  The  number  applied  should  range  from  one  and  a  half 
dozen  to  three  dozen.  In  aggravated  forms  that  develop  quickly  prompt 
venesection  is  imperatively  demanded.  This  is  a  measure  Avhich.  if 
resorted  to  at  the  proper  moment,  will  often  rescue  the  patient  from 
imminent  danger.  The  condition  of  the  heart  and  kidneys  must  receive 
attention.  Tincture  of  strophanthus  (TTliij  every  three  hours)  is  effec- 
tive in  pulmonary  edema  in  children. 

HEMOPTYSIS. 
( Brnui'ho-pulmonarii  Hemorrhage) 
Definition. — An  expectoration  of  blood.  Its  source  may  be  the 
bronchial  mucous  membrane  (usually  the  small  bronchi),  and  less  fre- 
quently it  comes  from  eroded  vessels  in  lung-cavities  or  their  walls ; 
rarely  from  the  larynx,  trachea,  and  larger  bronchi.  When  from  the 
bronchial  tubes  the  term  hronchorrhaifia  should  be  applied.      The  source 


HEMOPTYSIS.  505 

of  the  hemorrhage,  however,  is  not  always  easily  demonstrable,  even  when 
it  has  resulted  fatally  and  the  lungs  are  minutely  examined. 

Patliology. — The  lesions  are  often  microscopic,  and  consist  for  the 
most  part  of  ruptured  capillary  blood-vessels,  though  larger  vessels  may  also 
become  the  seat  of  erosion  or  rupture.  After  death  the  bronchial  mucosa 
is  sometimes  found  to  be  swollen,  ble&ds  easily,  and  is  of  a  dark-red  color 
— soon  becoming  decidedly  pale.  The  lung-tissue  proper  may  look  paler 
than  in  the  sound  lung.  When  hemoptysis  occurs  in  advanced  pulmo- 
nary tuberculosis  the  lung-cavity  may  contain  a  ruptured  aneurysm,  or 
mere  ulceration  of  an  exposed  vessel  may  be  observed.  I  have  witnessed 
small,  dark -red,  dense  masses  in  the  air-sacs  scattered  throughout  the  lung 
whence  came  the  hemorrhage.  Doubtless  these  are  blood-coagula,  which 
result  from  the  clotting  of  the  blood  after  the  latter  has  been  carried  into 
the  alveoli.     Various  associated  lesions  may  be  observed. 

Ktiology. — (1)  Pulmonary  Affections. — (rt)  Pulmonary  congestion 
from  Avhatever  source  may  result  in  hemoptysis,  although  the  amount  of 
blood  lost  under  these  circumstances  is  usually  small.  There  are  many 
causes  that  excite  congestion  of  the  lungs,  some  of  which  reside  in  ad- 
jacent organs,  it  being  common  in  organic  disease  of  the  heart,  and  par- 
ticularly in  disease  of  the  mitral  segments.  That  form  of  pulmonary 
congestion  which  is  associated  with  other  affections  of  the  lungs,  as  well 
as  primary  active  congestion  due  to  inhalation  of  hot  air,  irritating 
substances,  and  violent  physical  exercise,  may  also  result  in  hemor- 
rhage, (h)  Hemorrhagic  infarction  may  lead  to  slight  hemorrhage  (inde 
Pulmonary  Embolism).  (c)  Croupous  Pneumonia. — In  this  disease 
hemorrhage  is  caused  by  the  rupture  of  the  capillaries,  and  the  blood, 
when  expectorated,  has  undergone  a  change,  has  become  rusty-colored. 
(d)  Pulmonary  Tuhercidosis. — This  is  pre-eminently  the  most  common 
cause.  Hemorrhage  may  take  place  early  when  it  originates  from  a 
sharply-limited  and  minute  tuberculous  focus,  and  it  may  also  be  attrib- 
utable to  congestion.  Undoubtedly  its  exact  source  is  the  mucosa  of 
the  small  bronchi ;  later  it  is  the  direct  consequence  of  the  ulceration  of 
an  artery  or  of  the  rupture  of  an  aneurysmal  sac  that  has  its  seat  in  a 
branch  of  the  pulmonary  artery.  After  the  tuberculous  cavities  have 
healed  or  while  quiescent,  calcareous  masses  are,  from  time,  to  time,  expec- 
torated, together  with  more  or  less  blood,  (e)  Ulcers  of  the  Larynx, 
Trachea,  or  Bronchi. — Rarely  ulcers  in  adjacent  structures  erode  the 
larger  branches  of  the  pulmonary  artery  and  cause  copious  and  speedily 
fatal  hemorrhages.  Osier  observed  a  fatal  hemorrhage  in  a  case  of  chronic 
bronchitis  with  emphysema.  (/)  Fibrinous  bronchitis  induces  hemop- 
tysis by  rupturing  the  capillaries  in  the  bronchial  mucosa  at  the  time  of 
separation  of  the  bronchial  casts,  (g)  Carcinoma  of  the  lung  produces 
frequent  expectoration  of  blood,     (h)  Gangrene  of  the  lung. 

(2)  Diseases  of  Other  Organs  than  the  Lung. — (a)  Affections  of  the 
heart  act  as  a  cause,  and  especially  advanced  mitral  disease,  when  it  is  due 
to  pulmonary  congestion.  It  not  infrequently  develops  during  the  stage 
of  adequate  compensation.  In  a  preponderating  proportion  of  the  latter 
instances  the  hemorrhage  is  slight,  but  it  may  be  profuse  and  recur  at 
intervals  for  many  years,  (b)  Aneurysm  of  the  branches  of  the  pulmo- 
nary artery  and  of  the  arch  of  the  aorta  (usually  with  rupture  of  its  coats) 
is  a  rare  cause  of  hemoptysis. 


506  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

■  (3)  Certain  diseases,  such  as  purpura  hcemorrhagica,  scurvy,  anemia, 
hemophilia,  and  malignant  forms  of  certain  acute  infectious  diseases 
{e.  g.  yellow  fever),  cause  hemoptysis.  In  this  class  of  cases  the  hemor- 
rha«yes  are  due  either  to  a  diseased  condition  of  the  vessel-walls  or  to 
blood-changes. 

(4)  Vicarious  hemoptysis  is  not  uncommon  during  menstruation  or 
when  amenorrhea  is  present.  Unless  occurring  at  the  time  of  the  regular 
menses  it  is  not  to  be  regarded  lightly,  and  is  of  the  same  significance  as 
when  taking  place  in  the  male.  I  cannot  agree  with  those  authors  who 
contend  that  hemorrhage  from  the  lungs  in  women  is  without  the  same 
dire  significance  as  in  the  opposite  sex.     {vide  infra). 

(5)  ^Arthritic  (Gouty)  Endarteritis. — According  to  Sir  Andrew  Clarke 
and  others,  this  is  a  common  cause  of  recurring  hemorrhages  in  aged  per- 
sons (over  fifty  years). 

Symptoms. — Hemoptysis  is  so  commonly  a  symptom  of  that  most 
frequent  and  dread  disease,  phthisis,  as  to  raise  suspicions  of  the  latter 
in  the  minds  of  the  laity  and  physicians  as  soon  as  it  occurs.  It  is 
appropriate,  therefore,  to  note,  first,  the  features  of  hemoptysis  when 
dependent  upon  pulmonary  tuberculosis,  and  then  to  point  out  its  clin- 
ical peculiarities  when  due  to  other  conditions. 

In  incipient  pulmonary  tuberculosis  hemoptysis  develops  suddenly  as  a 
rule,  a  ivarm,  saline  tastr,  lasting  but  a  few  moments,  generally  pre- 
ceding the  expectoration  of  blood.  The  blood  is  coughed  up,  and  the 
bleeding  may  last  only  a  few  minutes  or  may  continue  for  days,  the 
sputum  being  apt  to  remain  blood-stained  for  a  longer  interval.  The 
immediate  effect  of  the  hemorrhage,  however  slight,  is  to  alarm  the 
patient,  inducing,  besides  mental  agitation,  cardiac  palpitation  and  other 
nervous  concomitants.  A  small  hemorrhage  is  not  attended  with  any 
other  results,  but  large  ones  give  rise  to  the  symptoms  of  shock,  com- 
bined with  those  of  syniptuniatic  anemia.  A\  hen  the  hemorrhage  is  large, 
blood  to  the  amount  of  a  mouthful  may  be  ejected  with  each  cough,  and 
in  these  instances  the  effect  of  the  profuse  bleeding  is  evidenced  by  such 
symptoms  as  vertigo,  syncope,  cold  extremities,  excessive  pallor,  perspi- 
ration, and  a  rapid,  small,  feeble  pulse.  This  is  followed,  if  the  attack 
does  not  prove  speedily  fatal,  by  considerable  restlessness,  and  later  not 
infrequently  by  mild  delirium  and  more  or  less  fever. 

In  comparatively  rare  instances  the  same  patient  has  a  single  hemor- 
rhage ;  more  frequently  he  has  several  at  shorter  or  longer  intervals. 
Large  or  small  bleedings  may  precede  by  weeks,  months,  or  even  years 
any  rational  symptoms  or  physical  signs  of  pulmonary  tuberculosis.  In 
such  instances  latent  foci  of  disease  may  be  assumed  to  have  pre-existed. 

In  quantity  the  hemorrhage  varies  greatly :  there  may  be  less  than 
one  ounce  ejected  or  it  may  amount  to  a  pint  or  more  before  the  bleeding 
ceases.  In  advanced  cases  in  which  cavities  have  formed  large  vessels 
may  become  eroded,  followed  by  copious  and  dangerous  hemorrhage. 
Fatal  hemorrhage  may  take  place  into  a  cavity  without  the  occurrence  of 
hemoptysis,  as  in  a  case  dissected  by  Osier  at  the  Philadelphia  Hospital. 
The  distinctive  characters  of  the  blood  discharged  ai-e  mainly  as  follows : 
bright  color,  xery  frothy  (being  mixed  with  air),  and  not  clotted^  A  rare 
exception  to  the  rule  may  be  noted  in  the  case  of  hemorrhage  proceeding 
from  a  large  cavity,  the  blood  pouring  fortli  in  a  free,  dark  stream. 


HEMOPTYSIS.  507 

Physical  Sifjns. — These  are,  for  the  most  part,  negative.  Quite  com- 
monly moist  bronchial  rales  are  audible  on  auscultation  ;  palpation  and 
percussion  should  not  be  practised  either  during  or  immediately  after 
the  hemoptysis. 

Hemoptysis  not  Due  to  Pulmonary  Tuberculosis. — [a)  In  affections  of 
the  mitral  and  aortic  valves,  especially  in  mitral  stenosis,  hemorrhage 
from  the  bronchi  is  not  uncommon,  and  the  way  in  which  these  lesions 
lead  to  pulmonary  congestion  is  explained  in  the  discussion  of  Organic 
Affections  of  the  Heart.  During  the  progress  of  these  cases,  hemorrhages 
often  occur  at  considerable  intervals  ;  they  may  either  be  slight,  lasting 
only  a  few  minutes,  or  quite  free,  extending  over  periods  of  a  few  days 
or  a  week. 

{h)  K's,  a  rule,  in  the  beginning  small  hemorrhages  occur  for  several 
weeks  from  pressure  of  an  aneurysmal  dilatation  upon  the  bronchial  mu- 
cosa, or  there  may  be  weeping  of  blood  through  the  exposed  layers  of 
fibrin  composing  the  walls  of  the  sac.  The  bleeding  point  can  be  dis- 
covered with  the  laryngscope,  Avhen  an  aneurysm  of  the  innominate  or  of 
the  aorta  impinges  upon  the  trachea.  A  large  and  often  quickly  fatal 
hemorrhage  occurs  from  rupture  into  the  respiratory  tract. 

{c) '•'•  Arthritic  hemoptysis''  is  undoubtedly  associated  with  gouty, 
degenerative  changes  in  the  terminal  blood-vessels  of  the  lung,  though 
no  coarse  pulmonary  lesions  are  induced  by  the  recurring  hemorrhages. 
Although  the  hemorrhages  may  occur  at  intervals  for  years,  as  a  rule 
they  finally  become  arrested,  and  only  rarely  lead  to  a  fatal  issue.  I 
have  never  observed  this  form  of  hemoptysis  occurring  independently 
of  chronic  bronchitis.  In  emphysema  and  chronic  bronchitis  small  hem- 
orrhages may  occur,  and  occasionally  coagula  in  the  form  of  casts  are 
formed  in  the  bronchi  and  afterward  ejected.  It  is  probable  that  the 
source  of  the  large  bleedings  that  occur  under  these  circumstances  is  an 
ulcer  in  the  bronchial  mucosa. 

(d)  The  hemoptysis  that  is  connected  with  the  menstrual  function  is 
of  frequent  occurrence.  I  saw  recently  a  patient  in  whom  free  bleeding 
has  occurred  at  intervals  of  four  Aveeks  for  a  couple  of  years,  with  an 
absence  of  the  menses.  In  another  instance,  a  patient  of  Dr.  Byers, 
recurrino;  hemorrhages  of  the  lungs  took  place  instead  of  the  regular 
menstrual  discharge  for  three  successive  months,  and  a  comparatively 
rapid  and  fatal  form  of  phthisis  was  developed.  This  case  typifies  a 
large  class  that  is  especially  prone  to  develop  pulmonary  tuberculosis. 

(g)  The  preceding  group  is  to  be  distinguished  from  those  cases  in 
which  trivial  bronchial  hemorrhages  sometimes  occur,  and  in  delicate, 
hysterical  females.  Although  these  bleedings  are  accompanied  by 
cough,  it  is  not  uncommon  to  find,  upon  careful  examination,  that  the 
blood  comes  from  the  upper  air-passages. 

(/)  Hemoptysis  may  result  from  severe  injuries  infiicted  upon  the 
thorax,  and  last  for  days  together. 

(^)  A  person  may  have  a  single  or  many  recurring  attacks  of  hemop- 
tysis ivithout  assignable  cause,  if  we  except  severe  muscular  strain  or  in- 
tense mental  excitement.  Although  pulmonary  tuberculosis  does  not 
supervene  in  instances  of  this  sort,  yet  not  a  few  may  be  excited  by  a 
permanently  limited  tuberculous  focus  which  may  be  indeterminable  by 
the  usual  methods  of  examination.     I  have  more  than  once  seen  a  cure 


508  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

result  from  an  active  course  of  treatment  with  creasote  and  appropriate 
hygienic  measures.  In  well-marked  instances  of  the  kind  a  complete 
arrest  of  the  trouble   resulted  from  a  change  of  climate. 

Differential  Diagnosis. — A  reliable  diagnosis  necessitates  the  cer- 
tain exclusion  of  hemorrhage  from  the  higher  air-passages,  pharynx, 
esophagus,  and  stomach.  In  epistaxis  the  blood  may  directly  enter  the 
naso-pharynx,  exciting  cough  and  being  discharged  as  in  hemoptysis. 
An  examination  of  the  nasal  chambers  should  be  made  when  the  symp- 
toms are  suggestive  of  epistaxis.  Bleeding  may  take  place  from  the 
gums,  from  chinks  in  the  pharynx,  or  from  varicose  veins.  If  the  seat 
of  the  bleeding  be  the  phan/nx,  the  hemorrhage  is  not  free,  the  blood 
being  commingled  with  a  preponderating  proportion  of  mucus ;  if  from 
the  gums,  it  may  be  more  copious  (as  in  ptyalism  or  scurvy),  and  the 
hemorrhage  then  simulates  that  of  pulmonary  hemoptysis.  An  inspec- 
tion of  the  mouth  will  disclose  whether  or  not  the  gums  are  the  source 
of  the  hemorrhage.  Striimpell  distinguishes  hysterical  hemoptysis  by 
the  smaller  amount  of  bleeding,  the  absence  of  pus-elements,  and  the 
large  amount  of  squamous  epithelium,  leptothrix,  and  the  food-remnants 
present. 

(For  the  distinctive  points  between  hemoptysis  and  hematemesis,  vide 
Hematemesis. 

Prognosis. — The  gravest  apprehensions  are  constantly  entertained  by 
sufferers  from  hemoptysis,  but  immediately  fatal  results  are  of  rare  occur- 
rence ;  and  of  this  fact  the  patient  should  be  repeatedly  assured  by  the 
attending  physician.  In  case,  however,  the  existence  of  thoracic  aneur- 
ysm is  definitely  known,  the  consequences  of  hemoptysis  are  certainly 
fatal.  With  reference  to  the  effect  of  hemoptysis  upon  tuberculous  pulmo- 
nary disease  opinions  differ  widely  ;  I  am  of  the  belief,  however,  that  prior 
to  the  existence  of  cavities  it  exerts  a  favorable  rather  than  an  unfavor- 
able influence  upon  the  disease  in  most  cases.  On  the  other  hand,  in 
cases  in  which  cavities  exist  at  the  time  of  the  occurrence  of  hemoptysis 
an  opposite  effect  is  observed.  The  fact  that  hemoptysis  often  precedes 
by  prolonged  intervals  of  time  the  development  of  pulmonary  lesions  is 
no  argument  in  favor  of  Niemeyer's  view,  that  phthisis  is  caused  by  hem- 
optysis. There  can  be  no  doubt,  however,  that  some  blood  finds  its  way 
into  the  bronchi  below  the  point  of  bleeding  and  into  the  air-cells, 
causing,  at  times,  irritation  and  even  lobular  inflammation.  In  this 
way  hemorrhages  may  aid  in  rendering  the  tissues  more  susceptible 
to  tuberculous  infection.  In  cases  of  profuse  hemorrhage,  due  to  aneur- 
ysm or  to  the  erosion  of  large  branches  of  the  pulmonary  artery  in 
phthisical  cavities,  death  may  be  suddenly  induced,  and  is  caused  largely 
by  inundation  of  the  lung  and  the  consequent  impossibility  of  respiration. 

Treatment. — Since  the  hemorrhage  is  ascribable  to  (1)  congestion 
of  the  bronchial  mucosa,  (2)  erosion  of  the  vascular  walls,  and  (o)  blood- 
changes,  obviously  the  treatment  of  individual  cases  must  be  modified 
according  to  the  character  of  the  causative  condition. 

In  many  instances  of  liemoptysis  due  to  congestion  of  the  bronchial 
mucosa  the  hemorrhages  are,  comparatively  speaking,  slight ;  hence, 
apart  from  keeping  the  patient  at  absolute  rest,  little  treatment  is  re- 
quired. If  not  excessive,  they  are  often  salutary  in  their  effect.  If 
free,  the  physician's  aim  should  be  to  decrease  the  power  of  the  heart's 


HEMOPTYSIS.  509 

contraction,  and  to  accomplish  this  end  the  patient  should  be  placed  in 
bed,  and  not  allowed  to  change  his  position  nor  to  speak  above  a  whisper. 
The  diet  should  be  light,  nutritious,  and  non-stimulating,  all  hot  drinks 
and  alcoholics  being  prohibited.  Among  cardiac  sedatives  to  be  em- 
ployed with  a  view  to  reducing  the  rapidity  of  the  heart's  action  and  low- 
ering the  blood-pressure,  if  the  patient  be  neither  feeble  nor  anemic,  the 
ice-bag  to  the  precordia  is  most  valuable ;  if  the  pulse  be  full  and  strong, 
we  may  use  aconite  and  other  arterial  sedatives.  Arthur  Foxwell  ^  recom- 
mends venesection  in  cases  in  which  venous  congestion  is  present,  and  also 
lays  stress  upon  measures  that  confine  the  blood  to  the  systemic  circula- 
tion— i.  e.  nutritious  food,  large  doses  of  the  nitrites,  hot  foot-baths, 
leeches  to  the  anus,  and  ligatures  applied  to  the  thighs  and  arms.  The 
pulmonary  capillaries  may  also  be  effectually  depleted  by  the  use  of 
salines.  I  have  found  dry  cupping  over  the  chest  of  the  greatest  ser- 
vice in  cases  dependent  upon  congestion.  Eating  ice  and  partaking 
freely  of  iced  drinks  are  also  useful  measures.  If  the  attack  tends  to 
become  prolonged  and  exhausting,  we  may  increase  the  coagulability 
of  the  blood  by  the  use  of  gallic  acid,  acetate  of  lead,  or  calcium  chlorid. 
Hemoptysis  is  usually  accompanied  by  cougli,  that  constantly  disturbs 
the  vascular  serenity  and  excites  fresh  bleeding ;  it  demands  opium  or 
morphin  (hypodermically).  In  blood-spitting  due  to  the  gouty  diathe- 
sis Mays  recommends  the  salicylate  of  sodium.  Tripier  treats  hemop- 
tysis by  using  enemas  of  hot  water  (122°  F.)  night  and  morning. 

When  hemoptysis  is  associated  with  organic  disease  of  the  heart,  the 
main  indication  is  to  strengthen  that  organ  by  bodily  rest  and  quiet  and 
by  the  use  of  cardiac  tonics,  especially  digitalis.  I  have  had  under  ob- 
servation and  treatment  for  several  years  a  young  physician  who  has  been 
suffering  from  frequent,  marked  hemoptysis,  due  to  mitral  regurgitation, 
and  in  whose  case  the  bleedings  are  readily  controlled  by  the  free  use  of 
digitalis. 

When  in  thoracic  aneurysm  or  advanced  'pulmonary  tuherculosis  the 
blood  is  ejected  in  mouthfuls,  we  may  safely  infer  that  erosion  of  a  ves- 
sel or  rupture  of  the  aneurysm  has  taken  place.  Here  the  object  is  to 
bring  about  the  formation  of  a  thrombus  that  will  arrest  the  hemorrhage. 
Perfect  quiet  in  the  horizontal  position  tends  to  allay  the  vascular  excite- 
ment, and  the  induction  of  fainting  by  venesection  is  a  measure  worthy 
of  a  trial.  Opium  is  contra-indicated  in  the  latter  class  of  cases,  since 
if  cough  be  checked  inundation  of  the  bronchial  system  with  the  blood 
(the  chief  danger)  will  be  favored.  R.  H.  Babcock  gives  an  immediate 
injection  of  atropiu  sulphate  (gr.  -^ — ^)  when  hemorrhage  occurs  from 
a  cavity. 

In  all  instances  of  hemoptysis  treatment  should  not  cease  with  cessa- 
tion of  the  hemorrhage.  A  tendency  to  recurrence  is  manifested  in  many 
cases,  and  hence  measures  calculated  to  avoid  this  event  must  be  brought 
into  play.  The  patient  should  not  be  allowed  to  indulge  in  a  stimulating 
diet ;  he  should  eschew  tobacco  and  alcoholic  stimulants,  and  avoid  all 
physical  and  mental  strain.  Every  source  of  bronchial  irritation  should 
be  carefully  avoided,  and  attacks  of  bronchitis,  however  mild,  should  re- 
ceive the  most  careful  attention.  Moderate  exercise  is  serviceable,  as 
well  as  a  liberal  amount  of  nutritious  food. 

1  British  Medical  Journal,  1894,  p.  194. 


510  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

PNEUMORRHAGIA. 

{Pulmonary  Ajwjjlcx)/.) 

Definition. — An  escape  of  blood  into  the  air-cells  and  interstitial 
tissue,  with  or  without  laceration  of  the  pulmonary  parenchyma. 

Pathology. — It  may  be,  though  rarely,  (a)  diffuse,  when  the  lung- 
tissue  is  lacerated,  as  in  cerebral  apoplexy  ;  or  it  may  be  {b)  circum- 
scribed, as  Avhen  the  blood  is  effused  into  the  air-cells  and  the  interstitial 
tissue,  without  rupture  of  the  parenchyma.  The  latter  form  will  be 
considered  in  the  discussion  of  Pulmonary  Infarction. 

Ktiology. — Diffuse  pulmonary  apoplexy  is  caused  by  the  rupture 
of  a  thoracic  aneurysm  that  has  become  adherent  to  the  surface  of  the 
lung.  Its  most  common  cause  is  traumatism,  especially  penetrating 
wounds  of  the  lung,  but  adult  life  and  the  male  se.x  are  to  be  regarded  as 
predisposing  factors.  The  lung-tissue  is  sometimes  the  seat  of  diffuse 
hemorrhagic  infiltration  in  septico-pyemia  and  cerebral  disease. 

Symptoms. — These  are  ill-defined.  Profuse  hemoptysis,  urgent 
dyspnea,  and  cyanosis,  followed  by  increasing  evidences  of  collapse, 
together  with  a  clear  history,  should  raise  suspicions  of  the  existence 
of  diffuse  pneumorrhagia. 

The  physical  signs  are  indicative  of  extensive  consolidation  arising 
suddenly,  and  not  of  the  nature  of  the  lesion. 

The  prognosis  is  practically  hopeless,  and  abscess  or  gangrene  may 
result  if  these  cases  recover  from  the  immediate  effects  of  the  hemorrhage. 

Treatment. — Absolute  rest  of  the  body  in  the  horizontal  position  is 
the  one  measure  that  offers  a  slight  prospect  of  alleviation,  for  thus  the 
formation  of  a  clot,  followed  by  arrest  of  the  hemorrhage,  is  encouraged. 
It  is  unwise  to  use  opium  to  allay  the  cough,  since  the  action  involved 
assists  in  ejecting  the  extra vasated  blood,  which  will,  in  consequence  of 
gravitation  and  the  effect  of  respiration,  submerge  speedily  so  much  of 
the  lung-tissue  as  to  hasten  the  fatal  termination.  Ergot  is  not  to  be 
given  hypoderraically,  since  it  raises  the  blood-pressure  in  the  lesser  cir- 
culation, but  the  internal  and  external  use  of  cold  has  been  highly  recom- 
mended. With  the  onset  of  collapse  cardiac  stimulants  become  absolutely 
necessary,  though  many  cases  are  so  rapidly  progressive  as  to  reach  a 
moribund  state  before  remedial  agents  can  be  applied  by  the  physician. 


PULMONARY   EMBOLISM. 
(Hemorrhagic  Infarction  ,'  Embolism  of  the  Lungs.) 

Pathology. — Embolic  infarctions  are  firm,  airless,  brown  or  black, 
wedge-shaped  masses,  with  their  bases  usually  at  the  pleura,  which  soon 
becomes  lustreless  and  covered  with  a  delicate  layer  of  fibrin.  The  in- 
farctions may  be  single  or  multiple,  and  sometimes  occupy  the  greater 
portion  of  the  lobe;  in  the  majority  of  cases,  however,  their  size  equals, 
that  of  a  walnut.  Their  most  frequent  seat  is  at  the  back  of  the 
lower  lobe.  The  microscope  shows  the  presence  of  leukocytes  and  red 
blood-corpuscles  in  the  air-cells  and  in  the  alveolar  septa.  Collateral 
congestion  and  edema  are  frequent  concomitants,  and,  less  frequently, 
pneumonic  consolidation  appears. 


PULMONARY  EMBOLISM.  511 

Btiology. — The  condition  is  produced  by  the  blocking  of  the  pulmo- 
nary arteries  by  an  embolus  or  thrombus.  When  the  circulation  in  the 
pulmonar}^  capillaries  is  feeble,  hemorrhagic  infarction  may  be  the  result 
of  stasis,  and  this  is  probably  the  most  frequent  form.  It  is  met  in 
diseases  of  the  lungs,  and  also  in  mitral  affections.  The  plug  that 
occludes  the  blood-vessel  may  be  composed  of  leukocytes,  as  in  leuko- 
cythemia,  and  the  chief  sources  of  the  emboli  are  the  thrombi  in  the 
right  heart,  in  consequence  of  dilatation,  and  in  the  systemic  veins. 
Infectious  emboli,  resulting  in  abscesses,  occur  {vide  Abscess  of  the 
Lungs).  An  embolism  of  placental  cells  in  cases  of  eclampsia  has  been 
described.  Occlusion  of  a  branch  of  the  pulmonary  artery  cuts  oiT  com- 
pletely the  circulation  to  the  territory  supplied  by  that  branch,  and  hem- 
orrhagic infarction  occurs — venous  extravasation,  Avith  expression  of  air. 

Symptotns. — Not  all  infarctions  give  rise  to  symptoms  ;  on  the  con- 
trary, occlusion  of  a  main  branch  of  the  pulmonary  artery  usually  ter- 
minates life  speedily.  The  latter  accident  occurs  not  infrequently  in 
connection  with  organic  disease  of  the  heart,  and  if  death  be  not  the 
immediate  result  or  if  a  narrower  branch  be  occluded,  alarming  symp- 
toms ensue,  such  as  syncope,  dyspnea.,  ptain  in  the  side.,  and  convulsions 
with  unconsciousness.  The  first  and  most  distressing  symptom  is  dysp- 
nea, which  is  attended  by  frantic  efforts  at  breathing  and  by  great  mental 
anxiety.  Occasionally  hemoptysis  is  an  early  symptom,  and  of  primary 
significance  if  it  occur  in  a  patient  suffering  from  mitral  disease.  If, 
together  wuth  these  symptoms,  loss  of  consciousness  with  convulsions 
occurs,  the  diagnosis  becomes  wellnigh  complete.  Cough  usually  super- 
venes, accompanied  by  the  expectoration  of  dark,  gelatinous,  mucoid 
masses.  Large  lymph-cells  containing  blood-corpuscles  are  found  in  the 
sputum,  these  giant-cells  being  most  commonly  seen  in  instances  of 
organic  cardiac  affections.  They  are  supposed  to  transform  the  blood- 
corpuscles  into  pigment-matter. 

The  physical  signs  may  either  be  negative — as,  for  example,  when 
the  infarctions  are  small  or  deeply  located — or  they  may  give  informa- 
tion as  to  the  seat  and  extent  of  the  affected  part.  When  present  they 
are  the  symptoms  of  sharply-localized  consolidation  (increased  fremitus, 
percussion-dulness,  moist  rales,  and  bronchial  breathing),  and  it  is  not 
improbable  that  in  many  cases  the  physical  signs  are  due,  in  great  part, 
to  associated  conditions,  such  as  bronchitis,  edema,  or  collateral  consoli- 
dation. The  appearance  of  the  friction-sound  in  the  course  of  suspected 
cases  is  a  great  aid  in  diagnosis.  The  heay^t's  action  becomes  enfeebled. 
the  p)ulse  is  small  and  frequent,  and  the  surface  of  the  body  is  cool  and 
frequently  bedewed  Avith  cold  SAveat.  Fever  may  either  be  present  at  the 
onset  or  absent  throughout.  The  signs  of  embolic  abscesses  in  the  lungs 
will  be  elscAvhere  detailed  (vide  Pulmonary  Abscess). 

Diagfnosis. — To  establish  the  diagnosis  of  pulmonary  embolism  there 
must  be  a  clear  history  of  some  etiologic  condition,  and  the  sudden  appear- 
ance of  such  symptoms  as  dyspnea,  cough,  bloody  expectoration  (in  par- 
ticular), chest-pain,  loss  of  consciousness,  and  convulsions,  corroborated 
by  the  physical  signs  of  a  sharply-defined  spot  or  spots  of  consolidation. 

Prognosis. — The  prognosis  differs  Avith  the  character  of  the  primary 
condition.  On  the  Ayhole,  it  is  exceedingly  grave,  though  the  absorption 
of  an  embolism,  followed  by  the  disappearance  of  the  urgent  symptoms, 


512  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

is  not  impossible.  In  case  death  does  not  occur  soon,  infarcts  may  give 
rise  to  abscess  or  gangrene,  the  result  either  of  the  presence  of  bacteria 
in  an  original  embolus  or  of  their  entrance  through  the  air-passages.  In 
other  cases  an  infarct  may  undergo  fibroid  change  and  contraction,  and 
may  even  calcify. 

Treatment. — Beyond  procuring  absolute  rest  of  the  body  and  a  re- 
lief from  the  distressing  symptoms,  the  treatment  should  be  aimed  at  the 
affections  on  Avhich  this  form  of  embolism  depends.  Dyspnea  and  pain 
may  require  the  hypodermic  use  of  atropin  and  morphin,  preferably  in 
combination.      Heroin  relieved  the  dyspnea  in  one  of  my  cases. 


CHRONIC  INTERSTITIAL  PNEUMONIA. 

{Fibroid  Induration  ;    Cirrhosis  of  the  Lung.) 

Definition. — A  chronic  inflammation  of  the  lungs,  characterized 
by  the  formation  of  fibrous  or  connective  tissue.  It  may  occur  as  a 
primary  or  as  a  secondary  aff"ection. 

Pathology. — Two  leading  forms  of  cirrhosis  of  the  lung  may  be 
recognized:  ('/)  Local,  and  {li)  Diffuse,  though  these  do  not  demand  sep- 
arate description.  It  is  a  unilateral  affection,  and  the  lung  of  the  side 
involved  is  much  shrunken,  its  dimensions  in  some  cases  being  incred- 
ibly small.  I  have  seen  an  instance  in  which  the  organ  measured  four 
inches  in  its  longest  and  less  than  three  in  its  shortest  diameter.  It  lies 
tightly  against  the  spine,  and  has  frequently  been  overlooked.  The  heart 
occupies  the  affected  side,  being  drawn  in  that  direction  during  the 
progress  of  the  disease,  and  it  is  enlarged,  principally  owing  to  hyper- 
trophy of  the  right  ventricle,  and  the  pulmonary  artery  is  the  seat  of 
atheromatous  change.  The  other  lung  is  overdistended  {compensatory 
emphysema),  and  may  encroach  upon  the  mediastinum.  Intrapleural  and 
pleuro-pericardial  adhesions  may  be  exceedingly  firm  and  thick  on  the  one 
hand,  and  only  moderately  so  on  the  other,  though  rarely  the  pleurae  are 
intact.  The  cut  surface  of  the  affected  lung  is  hard,  dry,  airless,  shiny, 
and  usually  light-gray  in  color  (rarely,  reddish-yellow),  and  the  lung- 
tissue  cuts  with  great  resistance.  The  mouths  of  the  blood-vessels  and 
bronchi,  which  are  often  greatly  dilated  (bronchiectatic),  may  be  observed 
gaping  in  the  cut  section.  Cavities  may  be  wholly  or  in  part  due  to  the 
superaddition  of  a  tuberculous  process,  though  even  when  the  affection 
is  non-tuberculous  they  may  be  quite  numerous.  Phthisical  cavities  may 
often  be  discriminated  by  their  usual  situation  at  the  extreme  apex.  The 
lung  that  is  unaffected  by  the  fibroid  process  is  also  quite  often  the  seat 
of  tuberculous  change. 

Ktiology. — The  disease  is  almost  invariably  secondary,  and  very 
generally  accompanies  prolonged  inflammatory  and  chiefly  local  changes 
in  the  lungs.  It  in;iv  also  follow  acute  inflammatory  processes.  Ex- 
amples of  localized  interstitial  pneumonia  are  seen  in  connection  with  pul- 
monary tuberculosis,  emphysema,  syphilis,  hydatids,  and  fibroid  indura- 
tion secondary  to  thickening  of  the  pleura. 

Diffuse  interstitial  pneumonia  has  a  variety  of  causes  :  {a)  It  may  fol- 
low acute  lobar  pneumonia   in  cases  in  which  resolution  is  delayed,  and 


CHRONIC  INTERSTITIAL  PNEUMONIA.  513 

here  the  fibrinous  exudate  filling  the  air-cells  becomes  organized  into 
connective  tissue.  Fibrous  tissue  is  also  substituted  for  the  alveolar  walls. 
The  condition  is  exceedingly  rare,  and  no  instance  of  the  sort  has  fallen 
under  my  own  observation. 

{h)  Pneumonia,  appearing  as  a  complication  in  influenza,  is  very  liable 
to  produce  chronic  interstitial  pneumonia. 

(c)  The  disease  may  also  result  from  atelectasis  due  to  compression,  as 
by  aneurysms  or  neoplasms. 

(d)  It  most  frequently,  however,  follows  hroncho-pneumonia  in  either 
its  acute  or  subacute  form  (Charcot).  The  process  starts  in  the  bronchi 
and  extends  to  the  surrounding  lung-tissue,  till  finally  an  entire  lobe,  or 
even  an  entire  lung,  may  become  involved.  Tuberculous  broncho-pneu- 
monia also  leads  to  the  production  of  new  fibrous  tissue,  but  here  the  pro- 
cess is  a  conservative  one  (vide  Pulmonary  Tuberculosis),  and  hence  is 
not  to  be  classed  with  chronic  interstitial  pneumonia. 

(e)  The  initial  lesions  may  be  located  in  the  pleura,  and  the  lung  be- 
come involved  as  a  sequel,  and  the  principal  lesions  may  be  located  in 
the  adherent  pleural  membrane,  with  bands  of  connective  tissue  extend- 
ing into  the  lung.     The  bronchi  are  inflamed  and  sometimes  dilated. 

Chronic  interstitial  pneumonia  may,  however,  exist  without  implica- 
tion of  the  pleura,  and  in  view  of  this  fact  the  primacy  of  pleural  thick- 
enings cannot  be  granted  without  reserve  when  they  form  a  part  of  the 
lesions  of  fibroid  induration. 

The  various  forms  of  the  disease  thus  far  described  arise  seco7idarily. 
It  may  also  occasionally  originate  as  a  primary  afi'ection  (1)  from  the 
inhalation  of  diff"erent  forms  of  dust  {vide  Pneumonokoniosis).  (2) 
Delafield  describes  "a  special  form  of  lobar  pneumonia."  He  contends 
that  lobar  pneumonia  terminates  only  in  resolution  or  in  death,  and 
that  this  special  disease,  with  its  production  of  newly-formed  connective 
tissue,  is  from  the  first  a  special  form  of  inflammation  of  the  lung.  This 
variety  runs  a  subacute  or  even  chronic  course,  and  terminates  by  crisis. 
It  is  an  exudative  inflammation,  with  the  formation  of  new  tissue  from  the 
onset ;  but  the  consolidated  areas  are  not  so  large  as  in  ordinary  pneu- 
monia, and  cut  sections  lack  the  granular  character  of  the  latter. 

Symptoms. — The  patient  sufl'ers  from  cough,  which  increases  in  in- 
tensity with  the  progress  of  the  afTection.  There  is  a  mucous,  sero-mu- 
cous,  or  rarely  bloody  expectoration  ;  dyspnea  occurs  early,  and  fre- 
quently is  present  only  on  ascending  heights;  and  uneasiness,  or  even, 
pain,  over  the  side  of  the  chest  involved  may  be  experienced.  In  cases 
in  which  the  bronchi  become  dilated  the  characteristic  symptoms  of  bron- 
chiectasis are  superinduced.  The  general  symptoms  consist  merely  in  a 
loss  of  flesh  and  of  strength.     Fever  is  altogether  absent. 

Physical  Signs. — Inspection. — The  chest-wall  of  the  aifected  side  is  re- 
tracted, while  the  healthy  lung  is  enlarged  {compensatory  emphysema). 
The  spinal  column  is  curved  laterally.  The  aff'ected  side  is  fixed  during 
respiration,  and  the  heart  is  displaced  by  traction  toward  the  affected  side. 
If  the  left  lung  be  involved,  the  apex-beat  will  be  displaced  to  the  left 
and  slightly  upward ;  if  the  right,  the  apex-beat  will  be  observed  to  the 
right  of  the  sternum.  The  ribs  approximate,  thus  obliterating  the  inter- 
spaces, and  the  shoulder  droops  over  the  shrunken  chest-wall. 

Palpation. — The  tactile  fremitus  is  usually  increased  ;  if  the  pleura  be 

33 


514  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

much  implicated  or  thickened,  however,  fremitus  may  be  decreased.  Pal- 
pation discovers  no  expansile  motion. 

Percussion. — The  percussion-note  varies.  Dulness  is  common,  owing 
to  consolidation  of  the  lung,  but  flatness  is  sometimes  met  with,  and  a  tym- 
panitic or  amphoric  note  is  occasionally  elicited  over  a  dilated  bronchus. 

Auscultation. — The  breathing  is  bronchial  or  more  or  less  sonorous  as 
a  rule,  and  over  bronchiectatic  cavities  it  is  cavernous  or,  rarely,  amphoric. 
jNear  the  base  it  is  frequently  feeble,  distant,  or  even  altogether  sup- 
pressed. Subcrepitant,  sonorous,  sibilant,  or  gurgling  rales  may  be  audi- 
ble, and  dry,  creaking,  or  leathery  friction-sounds  may  also  be  heard. 

Prognosis. — The  course  of  the  complaint  is  exceedingly  chronic,  and 
lasts  over  many  years.  Death  may  result  from  an  intercurrent  attack  of 
acute  pneumonia  affecting  the  other  lung.  The  disease  always  shortens 
the  duration  of  life,  and  it  may  be  the  direct  cause  of  death.  Rarely 
a  fatal  issue  is  due  to  dilatation  of  the  right  heart,  followed  by  tricuspid 
regurgitation. 

Treatment. — The  condition  is  incurable.  The  patient  should,  how- 
ever, be  placed  under  the  best  sanitary  conditions,  and  if  practicable  he 
should  make  a  permanent  change  of  climate.  A  suitable  resort  should 
be  selected  in  accordance  with  the  rules  indicated  in  the  treatment  of 
Pulmonary  Tuberculosis,  and  every  effort  should  be  put  forth  to  improve 
the  general  nutrition  of  the  patient.  Due  attention  should  be  given  to 
the  associated  bronchitis,  as  well  as  to  any  symptoms  that  may  arise 
during  acute  exacerbations. 


BRONCHO-PNEUMONIA. 

[Capillary  Bronchitis;    Catarrhal  Fneumonia.) 

Definition. — An  inflammation  of  the  minute  bronchi  and  air-vesi- 
cles, due  either  to  the  extension  of  inflammation  from  the  capillary 
bronchi  to  the  air-vesicles  or  to  an  inflammatory  process  set  up  in  ate- 
lectatic lobules. 

Pathology. — Macroscopically,  the  lungs  present  decided  variations 
in  persons  who  have  died  of  broncho-pneumonia.  On  the  pleural  sur- 
face may  be  noticed  purplish  or  slaty  patches,  often  sunken  (atelectasis), 
intermingled  with  the  more  elevated  patches  of  healthy  lung  and  gray- 
ish consolidation,  and  smoother  and  more  moist  than  croupous  pneu- 
monia. Similar  appearances  are  presented  by  the  cut  surface.  On 
pressure  fluid  exudes — edematous  from  the  healthier  areas,  and  gray- 
ish and  puriform  from  the  consolidated  areas.  The  mucosa  of  the 
large  bronchi  may  look  natural,  though  frequently  it  is  congested,  while 
the  small  bronchi  usually  contain  more  or  less  muco-purulent  mate- 
rial. Their  walls  are  greatly  thickened,  and  on  section  the  cut  sur- 
face presents  a  nodular  appearance.  Dilatation  of  the  smaller  bronchi 
may  be  observed,  and  minute  consolidated  areas,  varying  in  size  from 
that  of  a  pin's  head  to  that  of  a  pea,  may  be  seen  surrounding  the  thick- 
ened walls  of  the  bronchi.  When,  as  frequently  happens,  they  become 
confluent,  large  areas — an  entire  lobe  and  even  an  entire  lung — of  lung- 


BRONCHO-PNEUMONIA.  515 

tissue  may  become  consolidated.  The  solidified  zones  are  firm  to  the 
touch,  being  destitute  of  air,  and  at  first  they  contain  blood  ;  hence  their 
color  is  a  dark-red,  but  later  it  presents  a  grayish  hue.  The  condition  is 
usually  bilateral.  As  a  rule,  the  bronchial  glands  are  swollen  and  in- 
flamed. In  the  non-consolidated  portions  of  the  lung  the  air-cells  are 
found  to  be  considerably  dilated. 

The  essential  lesion  is  a  productive  inflammation  of  the  bronchi  and 
of  the  immediately  surrounding  air-spaces.  The  inflammation  is  from 
the  first  not  exudative,  but  productive ;  that  is,  with  the  formation  of 
new  tissue  (Delafield).  This  form  of  inflammation  may  merge  into 
sclerosis  of  the  lung  or  chronic  thickening  of  the  pleura.  Microscoj)- 
ically,  the  walls  of  the  bronchioles  and  alveolar  passages  are  seen 
swollen  and  infiltrated  with  cells ;  they  likewise  contain  plugs  of  mu- 
cous exudate,  most  marked  near  the  centre  of  the  process.  The  air- 
cells  toward  the  periphery  show  much  less  exudate.  The  latter  con- 
sists of  serum,  some  mucus,  and  many  swollen  cells  from  the  alveoli 
(soon  showing  fatty  degeneration),  leukocytes,  and  also  red  blood-cells 
in  small  numbers.     Fibrin  is  seen  in  small  quantity  if  at  all. 

In  deglutition-  and  aspiration-pneumonia  the  leukocytes  are  present 
in  much  larger  numbers,  and  the  exudate  tends  to  suppuration,  while  in 
the  hemorrhagic  forms  the  red  blood-cells  are  relatively  increased. 

Kikodse^  found  the  blood  in  broncho-pneumonia  to  contain  an  in- 
creased number  of  white  corpuscles,  except  in  fatal  or  very  severe 
cases.  The  cause  of  this  increase  appears  to  be  the  return  into  the  cir- 
culation of  the  corpuscles  that  have  passed  into  the  alveolar  spaces ; 
hence  it  ceases  after  the  fever  declines. 

Among  the  associated  lesions  that  remain  to  be  mentioned  are — (a) 
Catarrhal  inflammation  of  the  mucous  membrane  of  the  bronchi ;  and 
(h)  Exudative  inflammation  of  the  air-cells,  which  become  filled  with 
epithelium,  fibrin,  and  pus,  with  resulting  consolidation  of  the  lung.  The 
epithelial  cells  lining  the  air-sacs,  since  they  are  more  numerous  in 
young  children  than  in  adults,  form  a  larger  part  of  the  inflammatory 
exudate  in  the  former  than  in  the  latter,  (c)  The  pulmonary  pleura  is 
often  coated  with  fibrin,  but  less  regularly  than  in  croupous  pneumonia. 

Ktiology. — (1)  A  marked  predisposing  influence  is  age,  the  disease 
being  most  prevalent  amongst  young  children.  In  them  it  may  appear  in 
association  with  measles,  whooping-cough,  scarlet  fever,  and  diphtheria, 
but  not  infrequently  it  is  entirely  independent  of  these  diseases.  Infants 
are  especially  susceptible  to  the  affection,  most  instances  of  pneumonia 
at  this  period  of  life  being  of  the  lobular  form.  Other  conditions  that 
act  as  predisposing  factors  in  children  are  improper  exposure  to  cold, 
unsanitary  surroundings  (especially  impure  air),  rickets,  and  chronic 
diarrhea.  Broncho-pneumonia  is  also  frequent  in  the  aged,  often  being 
occasioned  by  certain  debilitating  causes  and  chronic  diseases  that  are 
common  to  advancing  years  (emphysema,  gout,  chronic  valvulitis). 

(2)  Season. — The  afi'ection  prevails  especially  in  the  winter  and 
spring  months ;  particularly  is  this  the  case  in  those  forms  that  are 
unassociated  with  the  acute  infectious  group  of  diseases. 

(3)  It  also  supervenes  as  a  complication  in  such  acute  infectious  dis- 
eases as  influenza,  typhoid  fever,  erysipelas,  and  small-pox,  and  is  of 

^Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  i.  sec.  A. 


516  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

serious   import.     According  to  my  own  observations,  it  is  more   com- 
monly met  with  in  the  diseases  above  mentioned  than  is  lobar  pneumonia. 

(4)  The  inhalation  of  food-particles  and  other  substances  often  serves 
to  convey  the  agents  of  inflammation  to  the  lobules  of  the  lungs.  A 
long-continued  recumbent  posture  predisposes  the  patient  to  broncho- 
pneumonia. It  is,  however,  in  conditions  in  which  the  larynx  and 
bronchi  have  totally  or  in  part  lost  their  sensitiveness — as  in  coma  due 
to  apoplexy,  uremia,  and  allied  cerebral  states — that  retention  of  bron- 
chial secretions  occurs,  and  that,  owing  to  gravitation,  these  secretions 
reach  the  minute  bronchi.  Pneumonia  is  similarly  produced  when  we 
cut  the  vagus  nerves,  the  paralyzed  structures  permitting  irritants  to  be 
carried  to  the  lung  by  inspiration.  Inhalation  pneumoriia  may  follow 
operations  upon  the  nose,  mouth,  larynx  (tracheotomy  particularly), 
and  is  often  secondary  to  carcinoma  of  the  larynx  and  esophagus.  It 
is  also  the  pneumonia  of  new-born  children. 

(5)  It  must  not  be  forgotten  that  quite  commonly  broncho-pneumonia 
is  caused  by  the  tubercle  bacillus  (vide  Pulmonary  Tuberculosis). 

Bacteriology/. — Weichselbaum  has  shown  the  presence  of  strepto- 
cocci with  the  greatest  frequency  in  the  usual,  secondary  form.  The 
pneumococcus  is  often  found,  and  in  a  goodly  number  of  cases  the 
staphylococcus  aureus  (Neumann),  while  in  influenza  the  specific  organ- 
ism may  itself  cause  broncho-pneumonia  (Pfeiffer).  Numerous  other 
organisms  have  been  found  (typhoid  bacillus,  bacillus  coli  communis). 
Mixed  infection  with  the  Diplococcus  pneumonia  is  almost  the  rule 
when  lobular  pneumonia  is  secondary  to  the  acute  infections  (diphtheria, 
typhoid  fever,  influenza). 

Symptoms. — Two  clinical  forms  may  be  distinguished  : 

(«)  Primary  broncho-pneumonia  is  met  with  generally  in  adults,  and 
presents,  in  great  part,  the  symptoms  of  an  acute  bronchitis  of  severe 
grade  {cough,  dgspnea,  pain,  fever).  When  occurring  in  weakly  sub- 
jects the  onset  may  be  gradual.  The  cough  is  attended  with  expecto- 
ration (glairy  and  tenacious)  that  may  be  blood-tinged  in  the  form  of 
droplets  or  points.  The  fever  is  moderate,  the  temperature  ranging 
from  101°  to  104°  F.  (38.3°-40°  C),  and  is  of  irregular  type ;  in  severe 
cases,  however,  continued  high  temperature  may  occur.  Physical  ex- 
amination gives  the  same  result  as  in  the  secondary  form.  The  duration 
is  from  two  to  four  weeks,  the  fever  terminating  by  lysis.  West  holds 
that  primary  broncho-pneumonia  in  children  is  of  pneumococcus  origin. 

{h)  Secondary  broncho-pneumonia  is  the  variety  usually  met  with.  The 
symptoms  are  fre(iuently  veiled  by  those  of  the  primary  aff"ection,  and, 
indeed,  a  moderate  grade  of  lobular  pneumonia  is  fre(|uently  unsuspected 
during  life  when  arising  in  the  course  of  other  grave  diseases. 

It  is  usually  preceded  by  bronchitis  aflecting  the  larger  bronchi,  and 
in  this  common  event  the  first  symptom  that  directs  attention  to  the  dis- 
ease is  the  sudden  increase  in  the  frequency  of  the  respirations,  which 
rise  as  high  as  60  or  even  80  per  minute.  An  initial  chill  is  rare.  Fever 
develops  suddenly,  or,  if  previously  present,  increases  rapidly.  An  early 
symptom  is  the  cough,  which  is  usually  hard,  harassing,  frequently  pain- 
ful, and  accompanied  by  expectoration.  The  pulse-rate  is  abnormally 
frequent,  and  in  the  later  stages  may  be  quite  rapid,  feeble,  and  irreg- 
ular.    The  type  of  the  fever  is  similar  to  that  of  the  primary  form. 

Physical  Signs. — At  the  beginning  of  the* attack  the  only  sign  is  the 


BRONCHO-PNEUMONIA. 


517 


presence  of  subcrepitant  and  sibilant  rales,  pointing  to  a  general  capil- 
lary bronchitis.  Shortly  larger  or  smaller  areas  of  consolidation  become 
manifest.  At  first  rapid  breathing,  and  soon  cyanosis,  affecting  first  the 
lips  and  conjunctivae,  may  be  observed  ;  later,  the  face  becomes  dusky 


Fig.  45.— Illustrating  broncho-pneumonia.    The  dark  spots  represent  the  consolidated  areas  ;  the 
white  dots  indicate  rales  :  A,  coalescence  of  two  areas  of  consolidation. 

and  the  finger-tips  blue.  Palpation  shows  defective  expansion  and  in- 
creased tactile  fremitus  over  the  consolidated  areas.  The  percussion-note 
is  dull  or,  less  frequently,  hyperresonant  if  the  area  be  small.  Auscul- 
tationreyeals  numerous  fine,  subcrepitant  rales,  corresponding  to  the  con- 
solidated portions.  The  respiratory  murmur  may  be  bronchial,  though 
more  often  broncho-vesicular.    The  signs  are  usually  noted  in  both  lungs. 

Duration. — (1)  In  children  this  varies  considerably  in  different  cases. 
Rarely  do  fatal  instances  last  more  than  two  or  three  weeks,  while  they 
may  be  as  brief  as  two  or  three  days.  On  the  other  hand,  cases  in  which 
recovery  ensues  frequently  last  from  six  to  eight  weeks,  though  in  some 
instances  from  one  to  three  weeks  only.  Two  special  forms  demand  brief 
description  : 

(a)  The  cerebral,  in  which  restlessness,  convulsions,  and  delirium  be- 


518  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

come  so  marked  as  to  overshadow  entirely  the  pulmonary  symptoms.  Not 
infrequently  the  onset  is  characterized  by  convulsions,  high  fever,  pros- 
tration, and  alternating  stupor  and  delirium.  After  such  symptoms  have 
continued  for  from  two  to  five  days,  pulmonary  symptoms  appear,  Avhile 
the  cerebral  decline. 

(6)  Other  cases  may  manifest  a  subacute  onset,  in  Avhich  there  is  ano- 
rexia and  occasional  vomiting,  with  the  nervous  symptoms  before  noted. 

(2)  J'he  jvotracted  forms  are  those  in  which  (a)  the  symptoms  of 
acute  broncho-pneumonia  give  place  to  those  of  a  similar  though  chronic 
state.  The  general  disturbances  may  not  be  marked  in  some  in- 
stances, but  usually  there  are  cough,  loss  of  appetite,  or  inability  to 
gain  in  flesh  and  strength,  and  the  signs  of  consolidation  persist. 
(b)  Those  presenting  fever  of  an  irregular  type,  together  with  decided 
prostration,  in  addition  to  the  symptoms  of  the  preceding  variety.  In 
many  cases  belon^inj;  to  this  form  the  lesions  are  tuberculous. 

In  adolescence  the  cerebral  symptoms  are  not  as  well  marked  as  in 
children.  Two  anomalous  varieties  are  met  with  in  practice  that  demand 
brief  separate  description  : 

General  Broncho-pneumonia. — The  attack  develops  suddenly  and  is 
severe.  There  are  chills,  high  fever,  marked  pi'ostration,  headache, 
chest  and  loin  pains,  a  rapid  pulse  (soon  becoming  feeble),  rapid  and 
labored  respirations,  cyanosis,  restlessness,  delirium,  and  cough  that  is  at 
first  dry,  and  followed  by  mucous,  muco-purulent,  blood-tinged  sputum. 

The  physical  signs  are  defective  expansion  and  an  increased  tactile 
fremitus.  The  percussion-note  may  be  either  normal,  tympanitic,  or 
dull  ;  the  auscultatory  signs  are  large  moist,  subcrepitant,  crepitant,  sib- 
ilant, and  sonorous  rales  over  both  lungs,  and  a  harsh  or  broncho-vesicular 
respiratory  murmur.      The  affection  is  very  grave. 

Resembling  Tuberculous  Bronclio-pneumoma. — The  symptoms  appear 
slowly,  and  the  case  pursues  a  subacute  or  even  chronic  course.  Cough, 
catarrhal  expectoration,  moderate  fever  (often  of  a  hectic  type),  and  night- 
sweats  are  noted. 

Physical  examination  discloses  generalized  bronchitis,  coupled  with  cir- 
cumscribed areas  of  consolidated  lung-tissue.  Resolution  may  take  place 
at  the  end  of  eight  or  ten  weeks,  and  complete  recovery  ensue  ;  when,  how- 
ever, this  favorable  event  does  not  occur,  the  case  drags  on  for  an  indefinite 
period,  and  finally  terminates  fatally.    There  are  no  bacilli  in  the  sputum. 

Diagtiosis. — This  can  be  arrived  at  by  considering — 

(a)  The  nature  of  the  antecedent  afi'ections  and  their  etiologic  circum- 
stances : 

(6)  The  distribution  of  the  consolidated  areas  in  both  lungs  ; 

(c)  The  fact  that  the  physical  signs  of  consolidation  are  subsidiary  to 
those  of  generalized  bronchitis'; 

(d)  The  intense  dyspnea  and  cyanosis  ; 

(e)  The  type  of  the  fever,  irregular  as  a  rule,  and  its  gradual  decline ; 

(f)  The  frequent  long  duration. 

Differential  Diagnosis. — Doubtless,  loha)-  pneumonia  is  constantly  mis- 
taken for  broncho-pneumonia,  and  particularly  when,  in  the  latter  disease, 
a  large  portion  of  one  or  both  lungs  becomes  inflamed  in  consequence  of 
the  coalescence  of  small  areas  of  consolidation.  The  points  of  distinc- 
tion may  be  tabulated  as  follows  : 


BBONCHO-PNEUMONIA.  519 

Broncho-pneumonia.  Lobar  Pneumonia. 

Etiology. 

Presence  of  pathogenic  organisms  ^  (strep-      Presence  of  the  Diplococcus  pneumonise. 
tococci). 

Usually  secondary  to  bi'onchitis  and  acute      Usually  a  primary  disease, 
infectious  diseases  {e.g.  measles,  whoop- 
ing-cough). 

Clinical  History. 

Onset  gradual.  Onset  abrupt ;  previous  health  geiierally 

good. 

Fever  is,  in  proportion  to  the  extent  of  Fever  is  high,   of   continued   type,    and 

inflammation,   of  irregular   type,  and  falls  betvreen  the  fifth  and  ninth  days 

declines  by  lysis  after  a  variable  dura-  by  crisis. 

tion. 
Sputum  glairy,  tenacious,  and  in  adults  Sputum  characteristic   (rusty   or  prune- 
may  be  blood-tinged.  juice). 
Dyspnea  and  evidence  of  carbon-dioxid  Respiration   panting,    but   dyspnea   and 

poisoning  prominent.  cyanosis  relatively  less  marked. 

Physical  signs  of  generalized  bronchitis  Signs    of    bronchitis   generally    absent, 

always  marked,  and  usually  preponder-  those    of    lobar   consolidation    always 

ating  over  those  of  consolidation.  preponderating. 

Consolidation  commonly  bilateral.  Commonly  unilateral. 

Duration  indefinite,  often  extending  over  Duration  definite  as  a  rule,  convalescence 

many  weeks.  following  crisis. 

Consolidated  areas  liable  to  become  the  Far  less  likely  to  become  the  seat  of  tu- 

seat  of  tuberculous  infection.  berculous  infection. 

It  may  be  difficult  to  distinguish  tuhej^culous  broncho-23neuviGnia  from 
the  disease  under  consideration.  Indeed,  a  non-tuberculous  broncho-pneu- 
monia may  be  located  at  the  apex  of  the  lung  and  accurately  simulate 
the  symptoms  and  signs  of  the  tuberculous  form.  The  differentiation  is 
to  be  based  upon  the  presence  or  absence  of  the  signs  of  softening,  and 
upon  a  microscopic  examination  of  the  sputum  (which  in  a  child  may  be 
vomited).  The  softening  in  tuberculous  pneumonia  does  not,  however, 
begin  very  promptly  ;  but  if  elastic  fibers  and  tubercle  bacilli  be  found, 
the  diagnosis  is  at  once  set  at  rest. 

Prognosis. — In  broncho-pneumonia  the  severity  and  gravity  of  the 
symptoms  and  the  extent  of  the  involvement  of  lung-tissue  are  propoi'- 
tionate  to  one  another  ;  hence  it  follows  that  the  disease  may  either  be 
devoid  of  serious  import  or  it  may  be  fraught  with  great  danger  to  life. 
Its  course  is  subject  to  decided  fluctuations,  the  periods  of  exacerbation 
in  the  symptoms  often  marking  the  time  of  the  development  of  the 
gravest  features.  Apart  from  the  extent  of  the  lung-tissue  involved,  how- 
ever, we  must  consider  especially  the  condition  of  the  patient  at  the  time 
of  invasion.  If  the  constitution  have  been  previously  undermined,  as  is 
frequently  the  case  in  children,  broncho-pneumonia  is  very  apt  to  be 
fatal.  The  disease  is  less  dangerous  when  it  develops  in  the  course  of,  or 
follows,  measles  than  when  secondary  to  whooping-cough,  influenza,  or 
diphtheria.  Wiry,  thin  children  seem  to  stand  broncho-pneumonia  better 
than  fat,  flabby  ones  (Osier).  Deglutition  and  inspiration  lobular  pneu- 
monia,  especially  when  occurring  after  operations  upon  the  larynx  or 

■^  The  diagnostic  value  of  the  discovery  of  streptococci  is  not  pronounced.  Numer- 
ous other  organisms  have  been  found  in  broncho-pneumonia  in  their  absence,  and  a  sim- 
ilar organism  (Streptococcus  pneumomce,  Weichselbaum)  has  been  found  in  a  number  of 
cases  of  croupous  pneumonia. 


520  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

trachea,  are  frequently  fatal.  The  mortality -rate  in  this  disease  varies 
from  25  to  50  per  cent. 

Treatment. — Prophylaxis. — There  are  few  diseases  that  can  be  so 
eflfectually  prevented  as  can  broncho-pneumonia.  In  the  first  place, 
proper  attention  to  the  mouth  as  well  as  to  the  position  of  the  patient 
(which  should  be  changed  frequently)  during  attacks  of  acute  infectious 
diseases  will  prevent  its  development  in  a  great  proportion  of  this  large 
class  of  cases.  Adequate  protection  against  exposure  to  cold  during  con- 
valescence from  measles,  whooping-cough,  etc.  is  also  a  potent  factor  in 
preventing  the  disease,  as  is  the  timely  handling  of  catarrhal  aflFections 
of  the  nose,  pharynx,  larynx,  and  larger  bronchi. 

Treatment  of  the  Attack. — Certain  sanitary  arrangements  are  of  the 
utmost  practical  importance.  The  sick-room  should  be  well  ventilated 
and  its  atmosphere  kept  at  a  uniform  temperature — 68°  to  70°  F.  (20°- 
21.1°  C).  The  air  of  the  room  should  also  be  Avell  laden  with  moisture, 
which  may  be  generated  from  a  croup-kettle  or  other  suitable  vessel. 

Local  Measures. — In  young  children  the  chest  should  be  enveloped  in 
a  jacket-poultice  of  linseed  meal,  which  should  be  covered  with  a  layer 
of  oiled  silk  or  waxed  paper  so  as  to  prevent  its  growing  cool.  This 
should  be  renewed  at  intervals  of  about  six  hours.  After  the  more 
active  symptoms  have  subsided  the  linseed  jacket-poultice  may  be  re- 
placed by  one  of  absorbent  cotton,  which  should  also  be  covered  with  oiled 
silk  or  Avax  paper.  In  older  subjects  the  application  of  iced  poultices 
to  the  chest  exercises  a  most  favorable  influence,  not  only  upon  the  local 
inflammation,  but  also  upon  the  fever  and  the  nervous  symptoms. 

General  Measures. — High  fever  calls  for  tub-baths,  the  temperature 
of  the  water  at  first  being  set  at  95°  F.  (35°  C),  and  then  gradually 
cooled  to  75°  or  80°  F.  (26.6°  C).  The  gradually  cooled  bath  or  the 
cold  pack  may  be  used  two  or  three  times  daily.  The  effects  are  to 
reduce  temperature,  to  promote  refreshing  sleep,  and  to  improve  the 
character  of  the  respiration.  This  mode  of  treatment  is  especially 
effective  in  cases  that  begin  abruptly.  In  such  the  tincture  of  aconite 
or  veratrnm  viride  nuiy  be  employed  temporarily.  In  cases  presenting 
moderate  pyrexia  cold  spongings,  combined  with  the  use  of  the  ice-bag 
to  the  head,  may  suffice.  The  following  fever-mixture  may  be  employed, 
though  it  is  not  to  be  regarded  as  a  substitute  for  the  cold-water  method 
of  treatment,  but  is  merely  supplemental  to  the  latter : 

^.  Potassii  citrat.,  ^ijssflO.O); 

Spts.  ammon.  aromat.,       f;5ij    (8.0); 
Spts.  aether,  nitrosi,  f^ss  (16.0); 

Liq.  ammon.  acetat.,  fsiij  (96.0); 

Glycerini,  q.  s.  ad  fgiv  (128.0).— M. 

Sig.  3j  (4.0)  every  two  hours  for  a  child  of  five  years. 

In  children  a  mild  mercurial  purge  at  the  outset  is  advantageous, 
and  subsequently  by  the  use  of  salines  or  glycerin  suppositories  a  daily 
evacuation  of  the  bowels  is  to  be  secured. 

The  Diet. — The  bodily  strength  is  to  be  maintained  by  careful, 
methodical  feeding,  milk,  efro-s,  albumin,  and  broths  being  the  best 
forms  of  food.     The   milk   should   be   predigested  if  there   be   marked 


PULMONARY  ATELECTASIS.  521 

pyrexia,  and  egg-white  may  be  given  in  cold  water  or  as  egg-lemon- 
ade. The  cough  is  often  wellnigh  constant  and  very  distressing.  Fre- 
quently the  use  of  remedies  that  promote  secretion,  combined  with  a 
small  dose  of  opium,  will,  under  these  circumstances,  afford  relief.  A 
useful  formula  is  the  following : 

^.  Yini  antimonii,  3J       (4-0); 

Spts.  8eth.  nit.,  3ijss  (10.0); 

Tr.  opii  camph.,  3ijss  (10.0); 

Liq.  ammon.  acetat.,  q.  s.  ad  gij      (64.0). — M. 
Sig.  oj  ("l-O)  every  two  hours,  diluted,  for  a  child  of  from  three 
to  five  years. 

Dover's  powder  is  also  of  value  in  relieving  the  cough.  When  the 
expulsion  of  the  sputum  is  attended  with  great  difficulty  the  preparations 
of  ammonium  often  meet  the  indications.  Of  these  the  muriate  is  the 
most  effective,  but,  unfortunately,  this  is  often  objected  to,  and  we  must 
then  rely  upon  the  carbonate  or  the  aromatic  spirits.  The  bronchi 
may  contain  an  abundance  of  secretion  that  cannot  be  expelled,  despite 
the  use  of  the  above  measures.  Under  these  circumstances  an  emetic 
may  be  given,  composed  of  the  wine  of  ipecac  (sj — 4.0),  combined  with 
alum  (gr.  xx  to  xxx — 1.296-1.944),  and  administered  to  a  child  every 
ten  or  fifteen  minutes  until  emesis  occurs. 

Cardiac  stimulants  (alcohol  and  strychnin)  are  required  if  the  pulse 
fails.  The  preparations  of  ammonium  owe  much  of  their  reputation  in 
this  disease  to  their  stimulating  properties.  These  agents  when  boldly 
used  may  suffice  to  re-establish  the  cardio-pulmonary  circulation ;  but  if 
they  fail  in  this  and  cyanosis  supervenes,  oxygen  by  inhalation  should 
be  used  also.  Sudden  heart-exhaustion  may  occur,  associated  with 
mucous  rales  in  the  larger  bronchi  and  rapidly  increasing  cyanosis. 
Alternating  douching  Avith  hot  and  cold  water  and  electricity  should  be 
given  a  trial.  Injections  of  salt  solution  increase  arterial  tension  and 
act  as  a  "whip  "  to  all  emunctories ;  they  may  also  stimulate  phagocy- 
tosis, and  should  be  used  in  serious  cases.  In  streptococcic  broncho- 
pneumonia anti-streptococcus  serum  may  be  tried. 


PULMONARY  ATELECTASIS. 

( Collapse  of  the  Lungs ;   Compression  of  the  Lungs.) 

Definition. — Atelectasis  of  the  lungs  is  a  condition  occasioned  by 
the  removal  of  the  air  from  the  air-cells — a  state  directly  the  opposite 
of  emphysema.  The  air  disappears  largely  in  consequence  of  the  process 
of  absorption. 

Pathology. — The  affected  lung-spots  sink  in  water,  being  non-crep- 
itant.  They  also  present  through  the  pleura  a  bluish-red  tint,  and  on 
cross-section  a  brownish-red  color.  The  surface  of  the  affected  areas  is 
smooth  and  depressed  below  the  level  of  the  adjacent  lung-structure. 
The  bronchi  supplying  the  collapsed  parts  are  frequently  occluded  by 
inflammatory  products,  but  in  all  cases,  as  shown  by  Legendre  and 
Bailly,  the  latter  may  be  inflated  by  means  of  a  blowpipe. 


522  DISEASES  OF  THE  RESPIRATOEY  SYSTEM. 

Apai't  from  more  or  less  distention  of  the  pulmonary  capillaries  •with 
blood,  there  are  no  histologic  changes  in  the  atelectatic  areas,  though 
they  are  of  firm  consistence  (splenization,  carnification).  There  can  be 
no  longer  any  doubt  as  to  the  entire  propriety  of  the  pathologic  distinc- 
tion between  lobular  pneumonia  and  atelectasis. 

Ktiology. — The  condition  occurs  most  frequently  in  the  new-born, 
and  is  then  due  to  defective  respiration.  Thus  in  children  dying  soon 
after  birth  the  lower  lobes  may  be  found  to  be  atelectatic.  When  ac- 
quired, however,  there  are  three  modes  of  production  :  (1)  The  first  step 
consists  in  a  more  or  less  complete  plugging  of  the  smaller  bronchi  with 
muco-pus  and  other  products  of  bronchial  inflammation.  If  complete, 
air  can  no  longer  enter  on  inspiration,  and  as  the  contained  air  gradu- 
ally becomes  absorbed  atelectasis  is  the  natural  result.  This  condition 
is  very  commonly  associated  with  broncho-pneumonia,  especially  in  chil- 
dren. (2)  A  frerjuent  mode  of  origin  is  through  compression  of  the 
lungs,  resulting  from  positive  intrathoracic  pressure,  after  the  normal 
contractility  of  the  lung  has  been  overcome.  Instances  of  this  may  be 
produced  by  pleural  effusion,  hydrothorax,  pneumothorax,  pericardial 
effusion,  great  cardiac  hypertrophy,  a  solid  tumor,  or  an  aneurysm  of 
the  arch.  Not  iufreijuently  abdominal  tumors,  excessive  meteorism,  and 
ascites  make  sufficient  upward  pressure  against  the  diaphragm  to  cause 
compression  of  the  lower  lobes  of  the  lungs.  (3)  Conditions  that  weaken 
and  obstruct  the  inspiration  may  produce  this  disease,  such  as  certain 
brain-affections,  paralysis  of  the  pneumogastric,  and  paralysis  of  the 
chest-walls.  Thoracic  deformities  may  produce  pulmonary  atelectasis, 
and  in  extreme  grades  of  kyphoscoliosis  the  lung  occupying  the  side  cor- 
responding to  the  convexity  of  the  spinal  column  is  small.  Whilst  the 
lung-expansion  and  the  growth  of  the  organ  are  greatly  interfered  with, 
however,  and  particularly  if  the  condition  arises  in  youth,  true  atelec- 
tasis rarely  occurs  from  this  cause,  owing  to  the  natural  retractility  of 
the  luno:.  Amonir  conditions  arising  from  deformities  of  the  chest  is 
the  so-called  aplasia  of  the  lungs. 

Sytnptotns. — Atelectasis  is  a  secondary  condition,  and  its  symp- 
toms are  very  generally  veiled  by  those  of  the  primai-y  disease.  It 
arises  frequently  in  the  course  of  broncho-pneumonia,  but  passes  unno- 
ticed unless  it  becomes  very  extensive.  Respiration  is  carried  on  by 
the  upper  and  anterior  portions  of  the  lungs,  is  increased  in  fre(iuency, 
and  is  laborious.  The  pulse  is  small,  rapid,  and  feeble  ;  the  skiii- 
surface,  especially  that  of  the  extremities,  is  cool. 

The  form  presenting  the  most  typical  s^^mptoms  is  that  occurring 
in  the  new-born.  It  is  evidenced  by  shaUou\  rapid  breathing,  livid- 
ity,  cold  extremities,  a  faint  whining  cry,  drowsiness,  and  sometimes 
by  evidences  of  motor  irritation,  such  as  muscular  twitching  and  con- 
vulsions. Congenital  anomalies  of  the  circulatory  organs  are  asso- 
ciated. 

Physical  Signs. — When  it  involves  a  goodly  portion  of  the  lower  lobes 
posteriorly,  as  frequently  happens,  there  is  marked  retraction  during  in- 
spiration over  the  lower  portion  of  the  thorax,  due  partly  to  external 
atmospheric  pressure,  and  partly  to  the  contractile  efforts  of  the  dia- 
phragm. Dulness  on  percussion  is  revealed,  though  only  when  the  ate- 
lectasis is   extensive,  and   the  tactile  fremitus,  though  verv  various,  is 


PULMONARY  ATELECTASIS.  523 

generally  decreased.  Localized  compensatory  emphysema  may  present 
semi-tympanitic  resonance  over  small  areas  of  collapse. 

Auscultation  shows  a  greatly  diminished  or  absent  vesicular  murmur, 
and,  if  the  area  of  collapse  be  large,  bronchial  breathing.  Among  asso- 
ciated sounds  is  the  subcrepitant  rS,le,  due  to  broncho-pneumonia,  and, 
indeed,  capillary  bronchitis  and  atelectasis  are  often  combined,  there 
being,  moreover,  no  reliable  signs  that  will  separate  them  clinically. 

The  aplasia  of  the  lung  that  is  produced  by  spinal  curvature  {kypho- 
scoliosis) richly  deserves  brief  separate  description,  owing  to  its  clinical 
importance.  In  many  instances  the  chest  is  more  or  less  twisted  on  its 
own  axis,  shortened  in  the  vertical  diameter,  and  thoroughly  fixed. 
Under  these  circumstances  lung-expansion  is  impossible,  and  hence  res- 
piration is  purely  diaphragmatic.  In  many  other  patients  life  may  be 
prolonged  for  an  indefinite  period,  nothing  more  being  observed  than 
slightly  labored  breathing.  Such  persons,  however,  upon  great  physi- 
cal exertion  suffer  from  urgent  dyspnea,  and  the  development  of  an  ordi- 
nary bronchitis  may  lead  to  similar  results,  and  even  to  speedy  death. 

The  physical  signs  are  those  of  localized  emphysema,  combined  with 
those  of  more  or  less  compression  of  the  lungs.  There  is  an  extension 
of  the  cardiac  dulness  to  the  right,  and  other  evidence  of  right  ventricu- 
lar enlargement,  to  which  may  succeed  dilatation  with  the  usual  clinical 
events  produced  by  the  latter  condition.  Death  is  not  rarely  due  to  this 
failure  of  compensation. 

Autopsies  have  shown  the  lungs  to  be  small  and  more  or  less  com- 
pressed, some  portions  being  almost  airless.  Areas  of  emphysema  of 
the  lungs  are  often  associated.  The  right  ventricle  may  be  found  to  be 
hypertrophied  merely,  or  dilatation  may  also  have  taken  place.  Con- 
genital atelectasis,  by  keeping  up  high  pulmonary  pressure,  may  lead 
to  a  persistence  of  the  ductus  Botalli  and  of  the  foramen  ovale. 

Diagnosis. — Atelectasis  may  be  distinguished  from  lobar  pneu- 
monia by  the  absence  of  an  initial  rigor,  fever,  crepitant  rales,  and  the 
pain  of  the  latter  disease,  and  by  the  characteristic  inspiratory  retrac- 
tion of  the  lower  portions  of  the  chest  and  the  smaller  areas  of  dulness. 

Pleuritic  effusion  gives  a  flat  percussion-note,  the  upper  level  of 
which  varies  with  a  change  in  the  position  of  the  patient — a  sign  that 
is  wanting  in  atelectasis. 

Prognosis. — When  the  condition  is  limited  to  small  areas  it  is 
rarely  serious,  but  equally  seldom  does  extensive  atelectasis  lead  to 
recovery.  The  outlook  depends  to  some  extent  upon  the  nature  of  the 
associated  affections ;  thus,  when  it  is  secondary  to  whooping-cough  and 
widespread  broncho-pneumonia,  it  is  very  fatal.  Other  diseases  that  may 
complicate  and  increase  the  gravity  .of  the  atelectasis  are  pleurisy  and 
pulmonary  tuberculosis.  On  the  other  hand,  compensating  emphysema 
often  coexists,  and  is  to  be  regarded  as  salutary  in  its  effects.  When 
due  to  compression  by  pyo-pneumothorax,  tumors,  and  the  like,  the 
prognosis  is  especially  gloomy. 

Treatment. — The  treatment  corresponds  with  that  of  the  primary 
disease.  Qapillary  hroncliitis,  Avhich  is  so  apt  to  be  followed  by  collapse 
of  the  lobules,  must  receive  active  treatment,  and  prophylactic  measures 
are  of  the  utmost  practical  importance.  The  patient  should  be  instructed 
to  practise  full  inspiration  at  regular  intervals  ;  he  should  not  be  allowed 


524  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

to  lie  continuously  in  the  dorsal  decubitus,  but  should  be  told  to  change 
his  position  frequently.  Another  measure  that  may  effectually  pre- 
vent the  development  of  atelectasis  is  the  use  of  cold  shower-baths  {i.  e. 
a  stream  of  cold  water  poured  over  the  region  of  the  neck),  and  this 
can  sometimes  be  depended  upon  as  a  curative  agency  when  the  condi- 
tion already  exists.  Tonics  and  the  judicious  use  of  stimulants,  together 
with  a  nourishing  diet,  are  invariably  required.  I  have  also  seen  good 
results  follow  the  inhalation  of 'compressed  air  and  of  oxj-gen. 

In  kyphoscoliosis  tepid  baths  are  indicated.  The  heart-condition  de- 
mands careful  attention,  and  cardiac  stimulants  are  to  be  resorted  to  at 
the  first  loss  of  compensation  or  when  compensation  fails  to  become 
established. 


EMPHYSEMA. 


Definition. — In  general  this  term  implies  the  presence  of  air  in  the 
interstitial  alveolar  tissue.  As  applied  to  the  lungs,  hoAvever,  two  forms 
are  recognized  :  (1)  Interlobular ;  and  (2)  Vesicular,  an  abnormal  dila- 
tation of  the  alveoli. 

INTERLOBULAR   EMPHYSEMA. 

This  is  produced  by  the  rupture  of  the  air-cells,  the  air  contained  in 
the  lung  escaping  into  the  interlobular  connective  tissue.  Among  its 
causes  are — {a)  Injuries  of  the  lung  (usually  by  a  fractured  rib)  and 
perforating  wounds  of  the  chest ;  (7>)  Violent  paroxysms  of  coughing, 
as  in  whooping-cough  ;  and  rarely  defecation,  parturition,  and  hysterical 
convulsions.  When  arising  in  this  way  its  favorite  situation  is  the  an- 
terior margin  of  the  upper  lobe. 

Patholog'y. — In  the  interlobular  septa  immediately  beneath  the 
pleura  air-bubbles  are  sometimes  seen  to  be  arranged  in  well-defined 
rows.  The  pulmonary  pleura  may  become  detached,  an<l  the  air-tumors 
may  then  become  as  large  as  an  English  walnut  or  even  of  greater  size. 
Unlike  the  condition  in  vesicular  emphysema,  these  sacs  are  freely  mov- 
able, and  the  air  may  find  its  way  from  the  root  of  the  lung  into  the 
mediastinal  connective  tissue,  and  thence  into  the  subcutaneous  tissue 
of  the  neck  and  the  wall  of  the  thorax.  Rarely  these  air-sacs  perforate 
the  pleura,  setting  up  pneumothorax,  with  or  without  pleuritis. 

Interlobular  emphysema  is  sometimes  associated  with  advanced  vesic- 
ular emphysema. 

VESICULAR  EMPHYSEMA. 
[Alveolar  Ectasia.) 

Definition. — Dilatation  or  enlargement  of  the  alveoli  and  infundib- 
ular passages. 

Varieties. — The  cases  are  classified  into — (1)  Compensating,  (2) 
Hypertrophic,  and  (3)  Atrophic  forms. 


HYPERTROPHIC  EMPHYSEMA.  525 

COMPENSATING     EMPHYSEMA. 

This  variety  is  limited  to  certain  parts  of  the  lung,  and  arises  in 
consequence  of  pathologic  changes  in  other  parts  of  the  same  organ 
that  prevent  full  expansion  of  the  lung  on  inspiration.  Hence  a  vica- 
rious increase  in  the  volume  of  the  air-cells  is  observed  in  circumscribed 
morbid  processes  such  as  occur  in  pulmonary  tuberculosis,  lobular  pneu- 
monia, cirrhosis,  and  pleurisy  with  adhesions  (particularly  when  the 
latter  is  situated  at  the  inferior  border  of  the  lung).  An  entire  lung, 
unaffected  by  the  primary  disease,  may  be  the  seat  of  compensating  em- 
physema when  the  causal  disease  invades  the  whole  or  a  greater  portion 
of  the  other  lung,  as  in  cirrhosis,  extensive  pleurisy  with  effusion,  lobar 
pneumonia,  and  pyo-pneumothorax.  When,  however,  the  latter  condi- 
tions are  confined  to  a  portion  of  one  lung,  the  remainder  of  the  same 
organ  becomes  distended  also.  The  term  acute  emphysema  is  applicable 
to  many  of  the  cases. 

As  a  rule,  this  pulmonary  change  is  physiologic  and  beneficial :  only 
rarely  secondary  atrophy  of  the  walls  of  the  air-cells  develops. 

Symptoms  are  not  presented  by  the  lungs  in  consequence  of  the 
changes  met  with  in  compensating  emphysema.  The  condition  is  some- 
times recognizable  by  means  of  the  usual  physical  signs,  but  even  these 
are  not  always  to  be  relied  upon.  Fortunately,  its  existence  may  be 
safely  inferred  when  there  is  conclusive  evidence  of  the  presence  of  the 
local  causative  diseases  (broncho-pneumonia,  pulmonary  tuberculosis, 
pleurisy,  lobar  pneumonia). 

HYPERTROPHIC   EMPHYSEMA. 

Nature  of  Emphysema. — The  symptoms  are  dependent  upon  a  loss 
of  elasticity  in  the  lungs,  and,  the  latter  condition  being  the  result  of 
overstretching,  the  contractile  energy  of  the  lungs  is  in  great  part 
destroyed ;  hence  they  become  permanently  enlarged.  Nor  do  the  em- 
physematous lungs  contract  when  the  thorax  is  opened,  as  they  do  ordi- 
narily. We  may  in  some  cases  account  for  the  loss  of  elasticity  in  the 
lungs  by  the  operation  of  causes  that  produce  an  abnormal  degree  of 
stretching,  either  temporarily  or  constantly ;  but  under  these  circum- 
stances emphysema  would  be  developed  despite  the  pre-existence  of  nor- 
mal contractility  of  the  lung.  In  true  emphysema,  however,  which  de- 
velops at  a  comparatively  early  period  in  life,  we  may  safely  assume  that 
the  retractile  energy  is  defective  (probably  a  congenital  condition),  and 
hence  in  such  cases  the  action  of  the  usual  causal  factors  will  speedily 
engender  over-distention,  or  emphysema  may  develop  even  in  the  ab- 
sence of  causative  influences.  In  these  instances  there  is  probably  a 
quantitative  as  well  as  a  qualitative  defect  in  the  elastic-tissue  element  of 
the  lungs. 

Pathology. — The  thorax  is  enlarged  (barrel-shaped),  and  upon  re- 
moving the  sternum  the  lungs  are  found  completely  to  fill  the  mediasti- 
num, and  do  not  retract  as  in  health.  They  present  a  pale,  anemic 
appearance,  although  pigmented  patches  and  streaks  may  be  noted, 
while,  to  the  feel  they  appear  soft  and  feathery,  though  dry.  They 
readily  pit  on  pressure  (a  leading  characteristic). 


526  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Immediately  beneath  the  pleura  enlarged  air-cells  can  be  distinguished 
macroscopicallj,  and  air-sacs  as  large  as  a  walnut  or  even  larger  may 
project  above  the  lung-surface.  Occasionally  they  may  be  so  far  de- 
tached as  to  be  pedunculated.  At  the  anterior  borders  a  series  of  air- 
blebs,  resembling  a  frog's  lung,  may  be  observed.  Here,  as  well  as 
near  the  root  of  the  lung,  distention  is  usually  more  marked  than  else- 
Avhere,  due  to  the  direction  taken  by  the  distending  force.  The  pleura 
is  pale,  and  in  patches  the  pigment  may  be  -Ah^Qui^Virchoio' s  albinism). 

Upon  microscopic  examination  it  is  observed  that  the  dilatation 
starts  in  the  infundibular  and  alveolar  passages.  The  septa  are  partially 
obliterated,  the  alveolar  Avails  thinned  and,  lastly,  perforated,  Avhile  in 
conscfiuence  of  these  changes  the  air-cells  communicate  with  one  another, 
and  thus  form  larger  or  smaller  air-sacs.  The  process  is  an  atrophic  one, 
in  which  the  smaller  elastic  fibers  at  first  disappear,  Avhile  the  larger  be- 
come less  prominent  and  often  ruptured.  After  the  latter  changes  have 
begun  the  capillaries  likeAvise  disappear,  and  the  epithelium  of  the  air- 
cells  undergoes  fatty  degeneration,  though  in  the  larger  bullae  a  pave- 
ment layer  is  retained.  The  smooth  muscular  element  mav  also  occa- 
sionally be  seen  to  be  hypertrophied  (Rindfleisch).  The  clinical  phe- 
nomena probably  arise  from  the  loss  of  the  capillary  blood-vessel  sys- 
tem and  collateral  hyperemia  of  the  larger  bronchial  vessels. 

The  bronchial  mucous  membrane  is  usually  the  seat  of  chronic  inflam- 
mation. It  may  be  roughened  and  thickened,  or  the  submucous  elastic 
tissue  may  present  prominent  longitudinal  lines,  Avhile  the  bronchial 
mucosa  is  covered  Avith  muco-pus.  The  smaller  tubes  may  be  dilated 
(bronchiectasis),  and  this  condition  may  be  associated  Avith  hyperplasia 
of  the  peribronchial  connective  tissue.  The  diaphragm  is  loAvered  and 
the  subjacent  viscera  correspondingly  depressed. 

Physiologic  Pathology. — The  heart  is  pushed  downward  and  somewhat 
backward,  the  right  side  showing  Avell-marked  changes ;  the  cavities  are 
dilated  and  hypertrophied,  due  to  obstruction  in  the  pulmonary  circulation ; 
and  in  long-standing  cases  hypertrophy  of  the  left  chambers  may  also  de- 
velop. The  pulmonary  artery  and  its  branches  are  enlarged  and  the  seat 
of  atheromatous  degeneration.  The  liver,  kidneys,  and  other  viscera 
present  the  changes  that  belong  to  long-continued  venous  engorgement. 

Etiology. — The  affection  is  often  secondary  to,  and  develops  in 
consequence  of,  other  affections  of  the  lung — notably,  cJn'onic  bronchitis 
and  lohooping-cuwjh.  The  dry  form  of  chronic  bronchitis,  in  particu- 
lar, is  apt  to  generate  pulmonary  emphysema.  Under  these  circum- 
stances the  disease  is  directly  attributable  to  the  mechanical  influences 
to  Avhich  the  alveolar  Avails  are  subjected  during  respiration.  This  ab- 
normal strain  attends  inspiration  to  some  extent,  but  mainly  expiration, 
OAving  to  the  obstruction  to  the  egress  of  the  air  in  the  smaller  bronchi, 
Avith  increased  intra-aheolar  air-pressure.  The  increased  tension  in  the 
air-cells  may  be  accounted  for,  partly,  by  the  severe  and  persistent 
cough,  the  air  being  forced  during  violent  coughing  into  the  apices 
of  the  lungs,  forcibly  expanding  them  and  causing  emphysema. 

Bronchial  asthma,  on  account  of  the  obstruction  of  the  exit  of  the 
air  from  the  lungs,  produces  during  the  attacks  an  acute  emphysema 
that  may  result  finally  in  a  condition  of  permanent  over-distention. 
Certain  occupations,    such  as  blowing  Avind-instruments,  or  those  that 


HYPERTROPHIC  EMPHYSEMA.  527 

entail  severe  muscular  strain  {e.  g.  blacksmithing),  act  as  predisposing 
causes,  and  hence,  emphysema  is  of  common  occurrence  among  the 
"working  classes,  and  is  more  common  in  males  than  females.  The  con- 
stant straining  in  certain  pelvic  disorders  may  induce  emphysema.  The 
disease  is  often  hereditary.  During  advanced  years  the  lung-elasticity 
often  diminishes,  and  as  a  consequence  a  disposition  to  emphysema  is 
engendered.  On  the  other  hand,  emphysema  is  not  infrequently  met 
Avith  in  children,  and  in  such  there  may  be  a  temporary  respite,  with  a 
recurrence  at  a  later  period.  An  emphysematous  tendency  also  results 
from  congestion  of  the  lungs  associated  with  mitral  valvular  disease. 

Clinical  History. — In  nearly  all  cases  the  disease  develops  insidi- 
ously, the  symptoms  being  gradually  added  to  those  of  the  primary  aifec- 
tions  (chronic  bronchitis,  asthma,  etc.).  When  due  to  the  occupation  of 
the  patient  its  development  is  also  slow,  and  not  infrequently  its  origin 
dates  back  to  childhood  or  beyond  the  recollection  of  the  patient.  Rarely 
it  may  exhibit  a  more  acute  development,  as,  for  example,  after  whoop- 
ing-cough. 

The  first  symptom  is  a  variable  degree  of  dyspnea,  and  to  this  may 
be  added  temporary  cyanosis  and  cough.  The  severity  of  the  dyspnea 
varies  with  the  degree  of  distention  of  the  air-cells,  even  thoucrh  addi- 
tionally  aggravated  by  the  coexistence  of  the  primary  disease.  In 
moderate  emphysema  the  dyspnea  is  only  apparent  on  going  up  stairs, 
running,  walking  rapidly,  or  after  a  hearty  meal ;  on  the  other  hand, 
in  advanced  grades  of  the  affection  it  is  constant,  and  is  intensified 
by  the  slightest  exertion,  even  to  orthopnea.  Speech  is  interfered 
with,  the  patient's  utterances  taking  the  form  of  fragmentary  sen- 
tences or  syllables.  The  labored  breathing  is  shown  particularly  in 
expiration,  and,  as  in  asthma,  in  which  the  alveolar  spaces  are  acutely 
distended,  so  in  emphysema  the  rhythm  of  the  respiration  is  changed. 
The  inspiration  is  shortened,  and  the  expiration  is  greatly  prolonged 
and  accompanied  by  wheezing  when  chronic  bronchitis  coexists. 

In  the  later  stages  cyanosis  becomes  more  marked,  and  is  noticeable 
in  proportion  to  the  loss  of  compensation  and  interference  with  the  car- 
dio-pulmonary  circulation.  It  often  attains  to  an  extreme  degree,  and 
the  patient's  alarming  appearance  may  be  in  striking  contrast  with  his 
apparent  degree  of  comfort.  In  mild  forms  the  cyanotic  tint  is  con- 
fined to  the  lips,  lobes  of  the  ears,  and  the  extremities.  Any  increase 
in  the  degree  of  dyspnea  after  exertion  results  in  an  increased  blueness 
of  the  surface. 

The  cough  is  dependent  upon  the  presence  of  chronic  bronchitis,  and 
the  latter  disease  is  frequently  found  in  combination,  particularly  during 
the  winter.  There  is  also  an  expectoration  that  is  identical  with  that 
of  chronic  bronchitis,  and  when  this  disease  reaches  an  advanced  stage 
the  cough  persists  throughout  the  year  {vide  Chronic  Bronchitis).  In- 
tercurrent acute  attacks  of  bronchitis  are  often  followed  by  temporary 
attacks  of  asthma ;  and  since  chronic  bronchitis  in  its  highest  grades  is 
met  with  at  an  advanced  period  of  life,  so,  as  would  be  expected,  the 
cases  of  advanced  emphysema  are  also  met  with  at  the  same  period. 
Osier  has  described  a  group  of  cases  occurring  in  patients  "  from  twenty- 
five  to  forty  years  of  age  who,  winter  after  winter,  have  had  attacks  of 
intense  cyanosis  in  consequence  of  an  aggravated  bronchial  catarrh." 


528 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


These  patients  are  short-breathed  from  infancy,  and  their  condition  is 
attributed  to  a  primary  defect  of  structure  in  the  lung-tissue. 

G-eneral  Symjytoms. — There  is  an  absence  of  febrile  movement ;  the 
pulse  is  not  increased  in  frequency,  though  sometimes  feeble  ;  and  the 
temperature  of  the  body  is  generally  subnormal.  There  is  a  very  gradual 
loss  of  flesh  and  strength,  and  the  patient  is  stoop-shouldered,  present- 
ing a  peculiar  cachectic  appearance — a  condition  that  is  in  strong  con- 
trast with  the  dusky  appearance  of  the  face,  the  swollen  neck,  and  the 
enlarged  chest. 

Finally,  other  symptoms  may  be  mentioned  that  are  for  the  most 
part  secondary  to  hypertrophy,  followed  by  dilatation,  of  the  right  ven- 
tricle. This  hypertrophy  is  the  result  of  pulmonary  congestion  and 
obliteration  of  the  pulmonary  capillaries  induced  by  the  emphysema. 
Under  these  circumstances  severe  attacks  of  cough  occur,  attended  with 
extreme  dyspnea  and  lividity,  and  later  the  conditions  that  usually  suc- 
ceed a  moderate  grade  of  tricuspid  insufficiency  supervene,  such  as  con- 
gestion of  various  viscera  and  edema  of  the  feet.     Anasarca  is  rare. 

Physical  Signs. — The  shape  of  the  chest  is  characteristic :  owing 
to  the  increased  antero-posterior  diameter,  it  becomes  barrel-shaped 
(Fig.  46).  and   the   sternum  bulges,  as  do    also  the  costal   cartilages. 

The  infraclavicular  and  mam- 
mary regions  are  also  promi- 
nent, and  give  the  thorax  an 
abnormally  rounded  appearance. 
The  episternal  notch  is  deeper 
than  the  normal,  the  clavicles 
and  muscles  of  the  neck  are 
unduly  prominent,  and  the  neck 
itself  appears  to  be  shortened, 
owing  to  the  elevated  position 
of  the  clavicles  and  the  ster- 
num. There  is  an  antero-pos- 
terior curvature  of  the  spine 
and  a  winged  condition  of  the 
scapultie — changes  to  which  the 
stooping  posture  is  ascribable. 
Below,  the  thorax  appears  con- 
tracted. The  intercostal  spaces 
are  widened  and  depressed,  and 
a  network  of  dilated  venules  fre- 
(juently  extends  laterally  above 
the  inferior  costal  border,  but  is 
by  no  means  characteristic  of 
the  affection. 

The  movements  of  the  chest  are  vertical  rather  than  expansile,  and 
the  lungs  are  constantly  in  a  state  of  extreme  expansion  ;  in  the  lower 
thoracic  and  upper  abdominal  regions  there  may  be  observed  retrac- 
tion rather  than  expansion  during  the  act  of  inspiration.  The  respi- 
ratory acts,  as  a  whole,  are  labored,  and  the  diaphragm  and  abdomi- 
nal muscles  are  seen  working  with  considerable  violence.  The  heart's' 
apex-beat   is    invisible,  but   marked   epigastric   pulsation   is   frequently 


Fig.  46. — Barrel-shaped  chest  in  emphysema. 


HYPERTROPHIC  EMPHYSEMA.  529 

noticeable.  A  transverse  linear  depression  across  the  abdomen,  on  a 
level  with  the  lower  ribs,  may  also  be  present  during  inspiration.  Ven- 
ous pulsation  may  be  seen  in  the  neck  after  failure  of  the  right  ventricle 
has  occurred. 

On  palpation  the  character  and  direction  of  the  chest-movements 
may  be  accurately  appreciated.  The  tactile  fremitus  is  decreased,  but 
not  absent.  In  advanced  cases  the  apex-beat  cannot  be  felt,  and  even 
in  the  earlier  stages  it  becomes  more  and  more  enfeebled.  Owing  to 
displacement  of  the  heart  and  engorgement  of  the  right  ventricle  there 
is  a  distinct  systolic  shock  over  the  ensiform  cartilage,  and  also  a  pul- 
sation in  the  epigastrium. 

Percussion  yields  a  characteristic  hyper-resonance.  This  may  be 
distinctly  "  Skodaic  "  or  semi-tympanitic,  and  in  extreme  dilatation  of 
the  air-cells  the  tone  may  be  woodeny.  The  area  of  cardiac  dulness, 
owing  to  the  fact  that  the  lungs  overlap  the  heart,  becomes  lessened  and 
finally  obliterated  ;  while  the  upper  limit  of  liver-dulness,  both  ante- 
riorly and  posteriorly,  is  found  to  be  one  or  two  interspaces  lower  than 
normal,  owing  to  the  fact  that  the  diaphragm  is  depressed.  The  upper 
level  of  splenic  dulness  is  also  lowered,  and  the  area  of  percussion- 
hyper-resonance  extends  higher  above  the  clavicle  than  naturally. 

On  auscultation  the  inspiration  is  short  and  feeble,  while  the  expira- 
tion is  greatly  lengthened,  the  ratio  of  these  sounds  as  to  duration  being 
reversed  as  compared  with  the  normal.  Their  pitch  is  somewhat  low- 
ered, particularly  that  of  expiration ;  and  Avhen  rales  are  present  the 
respiratory  murmur  (particularly  the  inspiratory)  may  be  scarcely 
audible.  In  well-marked  instances  of  emphysema  inspiration  and 
expiration  may  rarely  be  of  equal  length.  It  is  a  fact  worthy  of 
emphasis  that  the  parts  of  the  lungs  that  are  not  so  markedly  emphy- 
sematous as  others  give  a  harsh,  exaggerated  vesicular  murmur,  owing 
to  the  great  efforts  of  breathing.  Rales  of  various  sorts  are  frequently 
audible,  due  to  bronchitis,  which,  it  must  be  recollected,  accompanies 
emphysema  in  a  majority  of  instances  ;  less  frequently  the  auscultatory 
signs  of  asthma,  pleuritis,  and  phthisis  are  encountered.  Rarely,  rub- 
bing sounds,  that  have  been  attributed  to  the  friction  of  enlarged  air- 
cells  against  the  pleura,  are  audible,  and  when  the  interlobular  variety 
supervenes  upon  vesicular  emphysema  a  crumpling  sound  is  heard.  The 
so-called  ^^  Laennecs  rale,"  which  resembles  somewhat  the  subcrepitant 
rale,  is  not  infrequently  present.  The  vocal  resonance  varies  from  an 
almost  total  absence  to  a  greatly  increased  intensity.  The  tricuspid  in- 
sufficiency that  develops  late  in  this  affection  is  betrayed  by  its  charac- 
teristic murmur. 

Diagnosis. — -A  positive  diagnosis  may  be  arrived  at  from  a  consid- 
eration of  the  history,  including  such  points  as  heredity,  occupation, 
the  long  duration  of  the  condition,  coupled  with  the  most  characteristic 
Symptoms  (dyspnea,  cyanosis,  signs  of  chronic  bronchitis),  and  from  the 
physical  signs.  In  a  case  of  beginning  emphysema,  particularly  among 
children,  a  certain  diagnosis  is  not  to  be  attempted. 

Differential  Diagnosis. — PneuynotTiorax  is  the  disease  most  apt  to  be 
confounded  with  emphysema.  It  develops  suddenly,  however,  while 
emphysema  is  of  slow  development,  and  the  rational  symptoms  of 
pneumothorax  are  more  constant  and  urgently  distressing  than  those  of 

34 


530  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

emphysema.  Pneumothorax  is  unilateral,  and  gives  a  purely  tympanitic 
percussion-note,  while  hypertrophic  emphysema  is  bilateral  and  its  per- 
cussion-note is  hyper-resonant.  Auscultation  in  pneumothorax  usually 
gives  amphoric  breathing,  metallic  tinkling,  the  characteristic  succussion 
splash,  and  an  absence  of  the  vesicular  murmur ;  all  of  which  ausculta- 
tory signs  are  very  unlike  those  of  emphysema. 

Another  aifection  giving  rise  to  dyspnea,  cough,  and  cyanosis  is 
pleurisy  with  effusion,  but  the  slow  course,  the  absence  of  fever,  and 
the  universal  hyper-resonance  that  characterize  emphysema  do  not  be- 
long to  pleurisy.  The  latter  affection  is  usually  unilateral,  and  over  its 
seat  a  flat  percussion-note  is  obtained. 

Prognosis. — Hypertrophic  emphysema  of  acute  form  {e.  g.  result- 
ing from  whooping-cough)  is  often  curable ;  but  the  usual  slowly- 
generated  variety,  so  far  as  recovery  is  concerned,  gives  a  totally  un- 
favorable prognosis.  In  many  cases,  however,  life  is  not  materially 
shortened.  Temporary  improvement  is  possible  when  the  lesion  con- 
sists merely  of  a  distention  of  the  airrcells,  and  this  is  shown  by  a 
corresponding  improvement  in  the  physical  signs.  The  effect  of 
frequently  recurring  attacks  of  bronchitis  is  only  to  intensify  the 
symptoms  of  a  disease  that  is  innately  ])rogressive.  Intercurrent 
affections,  however,  such  as  pneumonia  (lobar  and  lobular)  and  pulmo- 
nary tuberculosis,  may  prove  fatal.  Dropsy,  following  broken  compen- 
sation, is  often  a  late  and  dangerous  complication ;  other  late  accidents 
of  the  disease  are  hemoptysis  and  sudden  dilatation  of  the  right  heart. 

Individual  circumstances,  such  as  the  patient's  social  condition,  the 
stage  of  the  affection  in  which  he  comes  under  proper  treatment,  and 
the  degree  of  care  he  is  Avilling  to  exercise,  greatly  influence  the  out- 
come of  the  case. 

'  Treatment. — The  treatment  is  to  be  directed  toward  the  removal 
of  the  causes  of  emphysema,  and  chiefly  of  the  chronic  bronchitis. 
From  personal  observation  I  am  firmly  convinced  of  the  fact  that  the 
progress  of  the  disease  can  be  arrested,  and  that  the  condition  is  some- 
times improved,  by  relieving  the  chronic  bronchitis.  The  iodids  (po- 
tassium, sodium,  and  ammonium)  will  sometimes  produce  effects  that  are 
truly  remarkable,  and  the  syrup  of  hydriodic  acid  may  be  employed 
when  the  iodids  are  not  well  borne  by  the  stomach.  If  the  occupation 
of  the  patient  tends  to  aggravate  the  disease,  it  must  be  forsaken  for 
one  that  is  less  harmful.  Violent  paroxysms  of'  cough  also  contribute 
to  the  production  of  alveolar  distention,  and  hence  must  be  alleviated 
promptly.  Intercurrent  attacks  of  asthma  have  a  similar  eflfect,  and 
must  be  relieved  as  speedily  as  possible  by  a  resort  to  appropriate  ther- 
apeutic measures.  Attacks  of  acute  bronchitis  are  to  be  prevented,  if 
possible,  by  suitable  clothing,  by  avoidance  of  exposure  to  inclement 
weather,  dust,  and  the  vitiated  atmosphere  of  overcroAvded  halls,  churches, 
and  the  like ;  whenever  practicable  the  result  can  be  most  successfully 
obtained  by  a  residence  in  an  e(i[uable  climate.  Since  a  severe  bron- 
chitis is  apt  to  increase  the  severity  of  the  emphysematous  symptoms, 
it  must  be  relieved  as  speedily  as  possible. 

As  soon  as  passive  congestion,  flatulence,  and  constipation,  with 
other  gastro-intestinal  symptoms,  appear,  the  diet  will  demand  careful 
regulation,   and  especially  a  restriction   in  the  use  of   carbohydrates. 


GANGRENE  OF  THE  LUNGS.  531 

The  bowels  must  also  be  moved  reD-ularly  with  a  view  to  obviating-  the 
flatulence  and  portal  engorgement. 

The  heart  needs  to  be  carefullj  watched,  and  as  soon  as  signs 
of  broken  compensation  appear  digitalis  and  strychnin  will  be  found 
highly  useful.  Diuretics  and  cathartics  may  also  become  necessary. 
The  sudden  development  of  urgent  dyspnea  (or  orthopnea)  and  extreme 
lividity,  especially  if  associated  with  weak  cardiac  action  and  a  rapid, 
feeble,  irregular  pulse,  calls  for  free  bleedings,  and  more  than  once  in 
the  course  of  my  hospital  practice  have  I  seen  the  lives  of  patients 
suffering  from  emphysema  saved  by  timely  venesection. 

Besides  meeting  the  pathologic  and  symptomatic  indications,  we 
should  aim  to  assist  the  patient  in  expiration,  and  Gerhardt  has  sug- 
gested systematic  mechanical  compression  of  the  thorax  during  expira- 
tion as  a  useful  measure.  This  external  pressure  must  be  made  by  an 
attendant,  who  places  his  hands  flat  on  the  lower  lateral  portions  of 
the  thorax,  and  the  manipulation  is  to  be  continued  for  from  ten  to  fif- 
teen minutes  daily.  The  results  obtained  by  certain  German  authors 
have  been  encouraging,  .but  in  my  own  hands  the  method  has  failed, 
except  in  two  instances  occurring  in  young  adults  with  yielding  chest- 
walls,  in  whom  it  was  of  the  greatest  service.  Th.e  jyneumatic  treatment, 
comprising  the  inhalation  of  compressed  air  and  the  breathing  into 
rarefied  air,  richly  deserves  further  trial,'  its  use  having  been  productive 
of  permanent  improvement  in  a  number  of  cases,  as  shown  by  physical 
examination  (including  mensuration). 

SENILE   EMPHYSEMA. 

This  variety  is  in  reality  a  senile  atrophy  of  the  lungs,  and  has  been 
appropriately  termed  "small-lunged  emphysema"  by  Sir  Wm.  Jenner. 
In  consequence  of  the  complete  atrophy  of  the  alveolar  walls,  coalition 
of  the  air-cells  takes  place,  with  the  production  of  large  air-sacs.  The 
lungs  contain  less  than  the  normal  volume  of  air,  instead  of  an  abnormal 
quantity  as  in  true  hypertrophy  emphysema,  and  as  a  result  occupy  less 
space  in  the  chest-cavity  than  do  healthy  lungs.  The  pulmonary  tissue 
elements  are  deeply  pigmented.  The  condition  does  not  produce  right 
ventricular  hypertrophy. 

The  symptoms  are  negative,  although  subjects  in  whom  senile  em- 
physema develops  may  have  previously  had  chronic  bronchitis  with 
more  or  less  dyspnea.  They  quite  frequently  present  a  withered  ap- 
pearance, and  the  chest  on  inspection  is  seen  to  be  contracted,  owing 
to  the  fact  that  the  ribs  approximate  more  closely  and  take  a  more 
oblique  direction  than  in  health. 

Treatment  is  unavailing. 


GANGRENE  OF  THE  LUNGS. 

Pathology. — The  affection  presents  itself  in  two  forms — as  a  {a) 
diffuse,  and  a  (5)  circumscribed  process. 

(a)  The  diffuse  variety  is  rare.     It  may,  however,  be  met  with   in 
•^  Waldenburg's  portable  apparatus  is  convenient  for  use. 


532  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

lobar  pneumonia,  and  very  rarely  in  consequence  of  occlusion  of  the 
large  branch  of  the  pulmonary  artery ;  it  may  also  be  secondary  to  the 
circumscribed  form.  The  greater  part  of  the  lobe,  or  even  an  entire 
lung,  may  be  involved,  the  pulmonary  parenchyma  degenerating  into  a 
putrid,  greenish-black,  pulpy  mass,  Avith  no  obvious  line  of  demarcation. 

(h)  The  circumscribed  form  may  involve  either  one  or  both  lungs, 
though  the  right  is  aifected  somewhat  oftener  than  the  left.  To  this 
category  belongs  the  so-called  embolic  gangrene^  the  nodules  of  Avhich 
have  their  favorite  seat  in  close  proximity  to  the  pulmonary  pleura.  All 
etiologic  varieties  of  the  circumscribed  form  more  frequently  implicate 
the  lower  than  the  upper  lobe  of  the  lung,  occurring  in  sharply  defined 
areas,  which  may  either  be  single  or  multiple.  The  affected  area  first 
presents  a  greenish-brown  appearance ;  its  central  portion  soon  under- 
goes softening,  and  a  cavity  is  thus  formed  whose  walls  are  ragged  and 
irregular  and  contain  a  foul-smelling,  dark,  greenish  liquid.  The  sur- 
rounding lung  is  inflamed,  and  the  air-sacs  contain  inflammatory  prod- 
ucts (fibrin,  epithelium,  pus),  while  the  highly-irritating  and  putrid 
material  sets  up  an  intense  bronchitis.  These  gangrenous  foci  may  in- 
crease in  size  by  a  peripheral  extension,  and  thus  the  adjacent  veins 
may  become  plugged  with  infectious  thrombi  or  the  vessels  may  become 
eroded.  Emboli  may  then  be  detached  from  the  infectious  thrombi,  and, 
entering  the  circulation,  may  set  up  foci  of  septic  inflammation  in  re- 
mote organs.  A  truly  remarkable  connection  exists  between  circum- 
scribed gangrene  of  the  lung  and  cerebral  abscess.  When  the  gangren- 
ous spot  is  situated  near  the  pleura,  simple  or  gangrenous  pleurisy  may 
arise  as  a  complication,  or  the  pulmonary  pleura  may  be  perforated  and 
pyo-pneumothorax  result.  When  recovery  ensues  the  cavities  formed 
as  the  result  of  the  conversion  of  lung-tissue  present  a  limiting  wall  of 
dense  connective  tissue.  Such  cavities  may  remain  permanently  or  may 
slowly  become  contracted. 

Etiology. — Gangrene  of  the  lungs  is  caused  by  the  bacteria  of  putre- 
faction (probably  the  staphylococcus  albus  or  aureus).  The  disease  is 
rare,  even  though  the  opportunity  for  iritialing  the  bacteria  that  cause 
it  is  a  constant  one.  It  is  only  Avhen  the  lung-tissue  has  become  im- 
paired or  peculiarly  altered  that  the  specific  bacteria  are  capable  of  pro- 
ducing gangrene.      It  may  occur  in  several  ways  : 

(1)  Secondary  to  lobar  pneumonia,  hemorrhagic  infarctions,  cavities 
in  the  lungs,  bronchiectasis,  wounds  of  the  lung,  contusions  of  the 
thorax,  carcinoma  of  the  esophagus,  or  to  compression  or  embolism  of 
the  pulmonary  artery  or  of  the  bronchial  vessels. 

(2)  As  an  embolus,  derived  from  a  gangrenous  area  in  some  other 
organ  of  the  body,  it  may  lodge  in  the  lung  and  set  up  putrefactive 
changes. 

(S')  Pressure  from  a  thoracic  aneurysm  may  give  rise  to  gangrene. 

(4)  The  most  important  causal  factor,  however,  is  the  entrance  of 
foreign  bodies,  especially  bits  of  food,  into  the  bronchi  and  lungs. 
Whether  or  not  the  specific  bacteria  of  putrefaction  enter  the  lungs 
with  the  foreign  bodies,  the  latter  render  the  tissue-soil  receptive  to  the 
former,  and  once  the  process  has  been  initiated  it  is  apt  to  extend  itself. 
There  are  several  ways  in  which  these  foreign  particles  gain  entrance 
into  the  bronchi  and  lungs:  {a)  By  a  faulty  swallowing  of  the  food  ;   (b) 


GANGRENE  OF  THE  LUNGS.  533 

By  inhalation ;  (c)  By  a  carcinomatous  perforation  of  the  esophagus  into 
the  bronchus  or  into  the  lung. 

(5)  In  the  course  of  debilitated  states  of  the  systero,  as  during  con- 
valescence from  protracted  fever  (rarely),  and  in  diabetes  mellitus 
(frequently). 

Symptoms. — These  are  local  and  general,  the  former  alone  being 
diagnostic. 

Local  Symptoms. — There  is  cough  accompanied  by  an  exceedingly 
fetid  expectoratio)i  that  is  usually  quite  profuse.  When  abundant, 
and  when  expectorated  into  a  conical  glass  and  allowed  to  stand 
for  a  time,  it  separates  into  three  layers :  (a)  the  uppermost,  being 
frothy,  opaque,  and  of  a  grayish-yellow  color ;  [b)  the  middle,  clear 
and  watery ;  and  (e)  the  lowest,  appearing  as  a  greenish-brown  sedi- 
mentary layer  containing  shreds  of  lung-tissue  and  sometimes  blood. 
The  microscope  shows  it  to  consist  of  numerous  elastic  fibers,  bacteria, 
fat-crystals,  muco-pus,  granular  matter,  and  leptothrices.  Small  quan- 
tities of  blood  in  the  sputum  are  very  common.  Kannenburg  and  Strong 
have  also  described  ciliated  monads  as  occurring  in  the  sputum.  The 
patient's  breath  is,  as  a  rule,  intensely  fetid,  even  though  there  be  no 
expectoration,  but  this  fetor  of  breath  may  be  absent,  as  in  a  case  of  my 
own  (which  came  to  autopsy),  in  which  the  localized  gangrenous  process 
had  no  fistulous  connection  with  the  bronchus.  It  is  to  be  recollected 
that  if  any  of  the  large  branches  of  the  pulmonary  artery  be  eroded,  free 
and  even  fatal  hemoptysis  will  result. 

Physical  Signs. — The  physical  signs  are  sometimes  obscure,  as  when 
the  areas  involved  are  smaller  and  deeply  situated,  and  in  such  instances 
signs  of  bronchitis  only  may  be  detectable.  When  large  and  favorably 
situated,  however,  the  afi"ected  spots  usually  give  signs  of  consolidation, 
rapidly  followed  by  those  of  cavity.  In  addition  bronchial  rales — usually 
moist — and  coarse  cavernous  rales  are  usually  audible.  It  is  obvious 
that  when  the  pleura  is  implicated  the  signs  of  pleurisy  are  added,  and 
if  pneumothorax  be  present  those  belonging  to  the  latter  condition  also. 

The  chief  general  symptoms  are  irregular  fever,  emaciation,  and 
profound  prostration.  A  septic  condition  of  the  system  is  commonly 
developed,  and  the  patient  sinks  from  exhaustion.  Rarely  there  may 
be  an  almost  total  absence  of  constitutional  disturbances,  and  such 
instances  terminate  in  recovery. 

Diagnosis. — The  distinctive  feature  is  the  intense  fetor  both  of  the 
sputum  and  the  breath.  The  physical  signs  may  readily  determine  the 
existence  of  the  pulmonary  lesion,  but  it  is  difficult  to  eliminate  abscess 
and  fetid  bronchitis  associated  with  bronchiectasis.  The  results  of  a 
careful  examination  of  the  sputum,  together  with  the  less  horribly  fetid 
odor  of  the  breath,  in  abscess  will  usually  suffice  to  eliminate  the  latter 
affection.  In  fetid  bronchitis  the  fetor  of  the  breath  and  sputum  is  also 
less  marked  than  in  gangrene,  while  its  course  is  slower  and  more  favor- 
able  than  that  of  the  latter  affection. 

Prognosis. — The  prognosis  is  always  grave,  though  rarely  recovery 
in  circumscribed  gano-rene  of  the  lungs  ensues.  The  chief  dangers  are 
exhaustion  and  hemorrhage.  Improved  methods  of  surgical  treatment, 
however,  have  saved  life  in  a  few  instances,  and  promise  to  reduce  still 
further  the  mortality-rate  of  this  serious  affection. 


534  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Treatment. — The  leading  indications  are — 

{a)  The  disinfection  of  the  gangrenous  focus  or  foci  in  the  lungs. 
This  may  be  accomplished  by  the  internal  administration  of  creasote  or 
carbolic  acid  or  by  the  use  of  an  antiseptic  spray.  In  a  recent  case 
the  employment  of  Robinsons  inhaler,  charged  with  equal  parts  of 
creasote,  alcohol,  and  chloroform,  crave  encouraging  results. 

(b)  The  patient's  nutrition  must  be  maintained,  if  possible,  by  a  con- 
centrated liquid  diet,  administered  in  fixed  quantities  and  at  regular 
intervals ;  also  by  the  judicious  cultivation  of  the  digestive  functions, 
together  with  the  use  of  stimulants  and  tonics.  For  a  description  of 
the  suro-ical  treatment  of  o-ancrrenous  cavities  of  the  lungs  the  reader  is 
referred  to  special  works  on  surgery.  It  is  the  physician's  duty,  how- 
ever, to  determine  whether  or  not  the  patients  general  condition  will 
admit  of  surgical  intervention,  and  also  to  localize  as  nearly  as  may  be 
the  affected  zones  for  the  surgeon's  guidance. 


ABSCESS  OF  THE  LUNGS. 

( Suppurative  Pneumonitis.) 

Pathology. — This  affection  is  characterized  by  the  formation  of 
pus  and  the  degeneration  of  lung-tissue.  It  may  be  {a)  a  mere  infiltra- 
tion of  the  blood-vessels,  bronchi,  or  interstitial  tissue,  but  more  fre- 
(juently  purulent  inflammation  of  the  lungs  takes  the  form  of  {h)  an 
ordinary  abscess.  In  size  the  abscesses  range  from  that  of  a  walnut  to 
an  apple,  and  I  have  observed  in  one  case  inflammation  of  the  whole  of 
the  middle  lobe  of  the  right  lung.  The  abscess-walls  are  irregular  and 
decidedly  ragged :  and  in  the  case  of  old  lesions  there  is  a  dense  fibrous 
wall ;  the  contents  are  purulent  and  rareh'  necrotic.  If  the  contour  of 
an  abscess  touches  the  pleura,  empyema  is  the  usual  result,  though  sero- 
fibrinous pleurisy  may  rarely  follow.  Rupture  of  the  abscess  into  the 
pleura  may  also   occur. 

Htiology. — Streptococci  are  found,  though  they  are  not  the  only 
direct  causes  of  abscess  of  the  lung.  The  diplococcus  pneumoniae  and 
Friedlander's  bacillus  have  been  found,  as  well  as  certain  other  pyogenic 
organisms.  Predisposition  is  noted  in  certain  conditions,  as  (1)  during 
or  following  the  occurrence  of  inflammation,  as  in  lobar  and  lobular 
pneumonia.  Suppurative  infiltration,  however,  more  frequently  arises 
under  these  circumstances  than  abscess,  and  in  the  rare  instances  in 
which  the  latter  occurs  it  is  apt  to  be  comparatively  small  and  multiple. 
In  all  forms  of  inhalation  and  deglutition  broncho-pneumonia,  however, 
abscess  of  the  lung  is  a  frequent  se([uela. 

(2)  Perforation  of  the  lung  from  without  or  from  adjacent  organs,  as 
in  carcinoma  of  the  esophagus,  abscess  of  the  liver,  or  suppurating  hyda- 
tid cyst. 

(3)  Infectious  emboli,  found  in  connection  with  septico-pyemia,  fre- 
quently cause  metastatic  abscesses  in  the  lungs.  In  a  mechanical  manner 
they  may  produce  hemorrhagic  infarctions,  followed  by  suppuration,  or 
the  latter  process  may  occur  independently  of  the  former.    The  abscesses 


PNEUM0N0K0NI08IS.  535 

are  usually  situated  close  to  the  pleura,  and  are  frequently  wedge-shaped ; 
they  vary  in  number  from  one  to  several  hundred,  and  in  size  from  a 
pin's  head  to  an  orange. 

(4)  Abscess  of  the  lung  may  result  from  inward  extension  of  a  puru- 
lent pleurisy ;  and,  oppositely,  purulent  pleurisy  may  result  from  an 
extension  of  abscess  of  the  lung. 

(5)  As  elsewhere  stated  {vide  Pulmonary  Tuberculosis),  suppuration 
is  quite  generally  associated  with  chronic  pulmonary  tuberculosis. 

Syttiptoins  and  Diagnosis. — The  examination  of  the  sputum  is 
of  the  greatest  value  in  the  diagnosis  of  this  disease,  since,  being  puru- 
lent, it  usually  presents  a  yellow,  or  less  frequently  a  greenish-  or 
brownish-yellow,  color.  It  emits  a  fetor  that  is  less  pronounced  than 
that  of  either  gangrene  or  putrid  bronchitis.  Particles  of  lung-tissue 
may  be  visible  in  the  pus,  and  on  microscopic  examination  of  the  latter, 
elastic  fibers,  the  presence  of  which  is  of  the  utmost  importance  in  the 
diagnosis,  may  be  found  in  profusion.  Next  to  the  investigation  of  the 
sputum,  the  physical  signs  of  cavity  are  of  the  greatest  assistance  in 
distinguishing  abscess  of  the  lung ;  these,  however,  are  wanting  unless 
the  abscess  is  of  a  considerable  size.  By  themselves,  the  signs  of  cavity 
do  not  suffice  for  the  recognition  of  abscess,  but  when  combined  with  the 
characteristic  sputum  leave  no  room  for  doubt.  Chills  and  suppurative 
fever  often  attend.  The  history  is  of  considerable  importance,  as  con- 
firming the  more  characteristic  features.  Thus  antecedent  pneumonia 
or  septico-pyemia  would  be  strongly  corroborative. 

Prognosis. — The  prognosis  is  often  hopeless,  as,  for  example,  when 
the  disease  is  associated  with  pyemic  processes  in  other  parts  of  the 
body.  On  the  other  hand,  those  rare  instances  in  which  it  is  secondary 
to  pneumonia  give  a  comparatively  favorable  prognosis. 

Treatment. — The  chief  aim  in  the  therapeusis  should  be  to  sup- 
port the  system  by  the  administration  of  tonics,  stimulants,  and  anti- 
septics, as  well  as  by  methodic  feeding  Avith  light  and  concentrated 
forms  of  nourishment.  Inhalation  of  antiseptic  sprays  (creasote,  thy- 
mol) should  be  tried.  When  the  abscess  is  situated  near  the  periphery 
of  the  lung,  surgical  interference  is  to  be  advised  as  soon  as  the  first 
indications  of  increasing  weakness  appear.  For  the  details  of  the  ope- 
ration of  pneumonotomy  for  pulmonary  abscess  the  reader  is  referred 
to  special  works  on  surgery.  The  statistics  of  Eichhorst,^  showing  its 
favorable  results,  may,  however,  be  mentioned,  as  follows  :  in  13  opera- 
tions recovery  or  improvement  was  noted  in  6,  while  fatal  terminations 
occurred  in  7. 


PNEUMONOKONIOSIS. 

{Anthracosis ,  ChaUcosis,  etc.) 

Definition. — A  form  of  chronic  interstitial  pneumonia  that  arises 

from  the  inhalation  of  dust-like  particles.     Diff"erent  terms  have  been 

applied  to  the  condition  according  to  the  nature  of  the  dusts  inhaled, 

the   chief  among   these   being — (1)  Anthracosis   (coal-miners'    disease), 

^  Specielle  pathologie,  Bd.  1,  S.  519. 


536  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

due  to  the  inhalation  of  coal-dust ;  (2)  Chalicosis  (stone-cutters'  phthi- 
sis), caused  by  the  inhalation  of  mineral  dusts;  and  (3)  Siderosis, 
caused  by  inhaling  metallic  particles,  particularly  iron  oxid. 

(1)  Anthracosis. — Among  dwellers  in  cities  a  moderate  degree  of 
pigmentation  of  the  lung-tissue  with  coal-dust  is  the  rule,  while  in  those 
residing  in  rural  districts  the  condition  is  decidedly  less  common.  True 
anthracosis,  however,  has  reference  to  such  an  accumulation  of  the  car- 
bon particles  as  can  be  due  only  to  the  inhalation  of  a  well-laden  atmo- 
sphere, or  under  circumstances  when  the  mucous  membrane  is  unhealthy 
or  without  perfect  ciliary  action.  Under  such  circumstances  the  normal 
scavengers  of  the  respiratory  organs — the  mucous  corpuscles  lining  the 
trachea,  the  bronchi,  and  the  alveolar  cells — f\iil  to  deal  successfully 
Avith  the  numerous  dust-particles  that  gain  entrance  along  with  the 
inspired  air ;  hence  some  of  the  latter  pierce  the  mucosa  and  reach 
the  lymph-spaces  and  lymph-vessels.  On  reaching  the  bronchial  mu- 
cosa they  become  enclosed  in  leukocytes,  mucous  corpuscles,  and  alve- 
olar cells,  and  are  conveyed  by  the  latter  to  a  more  remote  destination. 
Arnold  shows  that  after  the  particles  enter  the  lymph-system  they  are 
carried  "  ('/)  to  the  lymph-nodules  surrounding  the  bronchi  and  blood- 
vessels ;  {h)  to  the  interlobular  septa  beneath  the  pleura,  where  they 
lodge  in  and  between  the  tissue-element ;  and  (c)  along  the  larger  lymph- 
channels  to  the  substernal,  bronchial,  and  tracheal  glands,  in  which  the 
stroma-cells  in  the  follicular  cord  dispose  of  them  permanently,"  with 
resulting  indurative  enlargement  of  these  structures.  Rarely  the  car- 
bon particles  may  find  their  way  into  the  general  circulation  ;  this  may 
occur,  as  shown  by  Weigert,  Avhen  the  pigmented  bronchial  glands  be- 
come adherent  to  the  pulmonary  veins,  thus  giving  opportunity  for  the 
escape  of  the  carbon  granules  into  the  blood. 

Anthracosis  leads,  primarily,  to  chronic  bronchitis,  to  be  soon  fol- 
lowed by  emphysema  ;  but  it  must  be  recollected  that  extensive  anthra- 
cosis may  be  present  Avithout  any  other  changes  in  the  lung  than  the 
presence  of  carbon  particles  stored  in  the  protoplasmic  cells.  The  lung- 
tissue  presents  great  variations  in  its  degree  of  susceptibility  to  these 
foreign  particles.  Sooner  or  later,  there  is  usually  produced,  as  the 
result  of  their  irritant  action,^  a  proliferation  of  the  connective-tissue 
elements — i.  e.  a  chronic  interstitial  inflammation.  This  fibroid  change 
usually  starts  in  the  peribronchial  lymph-structures,  though  the  bronchial 
and  tracheal  glands  are,  as  a  rule,  similarly  involved  at  a  comparatively 
early  period.  The  affected  lung-tissue  is  frequently  coal-black,  dense,  and 
airless.  The  pneumonokoniotic  areas  vary  greatl}^  in  size  and  numbers, 
and  not  infreipiently  they  coalesce,  in  which  case  large  portions  of  the 
lung-tissue  may  become  the  seat  of  fibroid  change.  The  alveolar  Avails  are 
observed  to  be  much  thickened  in  some  instances,  and  firm  pleuritic  ad- 
hesions exist.  Bronchiectatic  cavities  may  be  present,  and  later  necrotic 
softening  of  the  indurated  areas  occurs,  leading  to  the  formation  of  small 
cavities  that  contain  a  dark  fluid.  When  the  latter  communicate  with 
the  bronchi  their  Avails  are  prone  to  ulcerate.  I  have  noticed  that  the 
process  almost  invariably  terminates  in  pulmonary  tuberculosis,  and  par- 

'  Cohnheim  contends  that  coal  particles  do  not  produce  irritative  changes  in  the 
lung,  and  that  the  latter  are  due  to  irritating  substances  inhaled  with  the  particles  of 
coal. 


PNEUMONOKONIOSIS.  537 

ticularly  is  this  true  of  cases  that  follow  the  inhalation  of  mineral  and 
vegetable  dusts  {vide  infra). 

(2)  Chalicosis. — Changes  similar  to  those  previously  described  are  in- 
duced in  the  pulmonary  connective  tissue  by  the  inhalation  of  stone- 
dust  by  those  who  follow  certain  occupations,  such  as  stone-cutting, 
knife-  and  axe-grinding,  and  millstone-making.  The  irritating  proper- 
ties of  this  form  of  dust  cannot  be  denied,  as  shown  by  the  great  dispo- 
sition in  this  subvariety  of  pneumonokoniosis  to  the  formation  of  fibrous 
nodules  and  diffuse  areas  of  sclerosis  in  the  lungs.  The  nodules  have 
a  gray  center  and  a  darker  periphery ;  they  are  exceedingly  dense,  and 
sections  are  made  Avith  much  difiiculty.  The  cut  surface  may  present  a 
grayish  and  distinctly  glistening  appearance. 

(3)  Siderosis. — This  term  implies  a  collection  of  iron  oxid  in  the 
lungs,  also  due  to  the  pursuit  of  certain  occupations  (dyeing,  iron- 
smithing,  etc.).  Cases  of  much  the  same  nature  are  caused  by  the  in- 
halation of  vegetable  dusts  by  grain-shovellers,  cotton-spinners,  cigar- 
makers,  etc.  The  'pathologic  changes  are  identical  with  those  in  anthra- 
cosis,  though  the  color-appearance  is  red  instead  of  black. 

Symptoms. — Rarely  the  onset  is  marked  by  the  symptoms  of  acute, 
followed  by  those  of  chronic,  bronchitis ;  but  in  a  vast  majority  of  in- 
stances chronic  bronchitis  gradually  develops  after  long  exposure  to  the 
action  of  the  exciting  cause.  The  symptoms  of  emphysema  are  soon 
superadded,  the  patient  now  suffering  from  dyspnea,  and  less  frequently 
from  asthma.  The  sputum  is  diagnostic  in  anthracosis,  being  quite 
dark  ;  in  chalicosis  a  microscopic  examination  is  essential  to  show  the 
particles  of  silica ;  while  in  siderosis  the  expectoration  presents  a  red- 
dish color.  Apart  from  the  foreign  particles,  the  sputum  is  for  a  long 
period  of  years  muco-purulent  in  character,  and  later  it  often  contains 
the  tubercle  bacillus. 

The  physical  signs  are  not  distinctive,  being  identical  Avith  those  met 
with  in  chronic  bronchitis  associated  with  emphysema,  and  followed  by 
those  of  interstitial  pneumonia,  and  sometimes  by  those  of  cavity. 

The  diagnosis  is  to  be  made  both  from  the  history  and  from  a  gross 
or  microscopic  examination  of  the  sputum.  It  may  be  confirmed  by  the 
invariable  presence  of  the  signs  of  bronchitis  and  emphysema,  as  well 
as  by  the  effect  of  removal  to  an  atmosphere  free  from  dust.  In  the 
later  stages  the  detection  of  infallible  evidences  of  phthisis  only  serves 
to  corroborate  the  earlier  diagnosis  of  pneumonokoniosis. 

The  prognosis  is  favorable  in  hygienic  surroundings  until  the  more 
advanced  stage  is  reached.  The  condition  favors  the  invasion  of  new 
growths  (lympho-sarcoma,  or  cobalt-miners'  disease;  vide  infra). 

Treatment. — A  change  of  occupation  or  several  hours  of  exercise 
in  the  open  air  daily  for  those  who  are  exposed  to  dust  in  work-rooms 
should  be  advocated. 

The  active  treatment  is  the  same  as  for  chronic  bronchitis  and  em- 
physema from  other  causes,  and  is  to  be  appropriately  modified  when 
pulmonary  tuberculosis  develops. 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

NEW  GROWTHS  OF  THE  LUNGS. 

CARCINOMA    OF   THE    LUNG. 

All  varieties  of  carcinoma  have  been  met  with  in  the  lung,  but,  with 
rare  exceptions,  carcinoma  of  this  organ  is  secondary  to  similar  growths  in 
other  parts  of  the  body.  To  explain  its  origin  it  may  safely  be  assumed 
that  the  primary  new  growth  involves  a  vein  or  lymph- channel,  and  that 
the  latter  carries  the  germ  of  the  disease  to  the  lung.  It  is  also  to  be 
recollected  that  it  may  result  from  extension,  or  by  contiguity  from 
neighboring  organs  (as  the  esophagus,  mamma,  pleura,  or  mediastinum). 

!Btiologfy. — The  causes  of  primary  carcinoma  of  the  lung  must  be, 
in  the  main,  identical  Avith  those  of  carcinoma  in  general,  and  are  as  yet 
unknown.  Most  cases  occur  in  middle-aged  persons,  and,  while  sex  has 
no  influence  upon  the  appearance  of  the  primary  form  of  the  disease, 
the  secondary  form  is  more  frequent  in  the  female  than  in  the  male.  In 
the  female  secondary  carcinoma  of  the  lung  is  often  preceded  by  car- 
cinoma of  the  breast.  We  may  also  regard  hereditary  influence  as  a 
potent  predisposing  factor.  Secondary  carcinoma  of  the  lung  is  most 
commonly  consecutive  to  primary  carcinoma  of  the  bones,  and  of  the 
digestive  and  urinary  tracts. 

Pathology. — The  pathologic  varieties  of  the  primary  form  are 
scirrhous,  encephaloid,  and  epithelioma,  and  of  these  the  latter  is  the 
most  common.  Primarij  carcinoma  is  usually  unilateral,  the  tumors  at- 
taining to  a  massive  size  and  fi'equently  involving  the  greater  part  of  one 
lung.  Their  favorite  seat  is  in  the  upper  part  of  the  right  lung,  though 
the  pleura  is  quite  often  invaded  by  the  carcinomatous  process.  Less 
frequently  there  is  pleurisy  with  sero-fibrinous  exudate,  which  may  be 
hemorrhagic.  Carcinomatous  involvement  of  the  cervical,  bronchial,  and 
tracheal  lymph-glands  is  quite  usual,  and  rarely  even  the  inguinal  glands 
become  implicated.  Secondary  earcinomata  are,  as  a  rule,  multiple,  and 
may  be  miliary  in  size.  They  are  disseminated  widely  throughout 
both  lungs,  though  in  the  rarest  instances  they  may  be  unilatei'al.  In 
the  softer  varieties  the  central  portion  of  the  tumor-mass  may  undergo 
fatty  degeneration,  with  subsequent  discharge  through  adjacent  bronchi. 

Symptoms. — The  symptoms  of  carcinoma  of  the  lung  vary  accord- 
ing to  the  location  and  extent  of  tlie  disease.  Among  the  most  marked 
symptoms  belongs  pain^  particularly  when  the  pleura  is  implicated. 
As  a  rule,  for  a  considerable  period  of  time  the  symptoms  of  bronchitis 
obtain,  and  later  the  breathing-space  is  diminished  sufficiently  to  excite 
dyspnea  and  cyanosis.  With  the  increase  in  size  of  the  new  growth 
compression  of  the  heart,  aorta,  and  large  veins  may  result,  whereupon 
di»turhances  of  the  circulation  will  arise.  The  new  growth  may  exert 
pressure  on  the  esophagus,  causing  dysphagia ;  or  upon  the  recurrent 
laryngeal  nerve,  causing  aphonia  and  hoarseness ;  or  on  the  trachea  or 
a  main  bronchus,  followed  by  the  s^'^mptoms  of  stenosis  of  those  organs. 
There  are  cough  and  expectoration,  the  latter  frequently  containing 
blood-corpuscles  with  mucus,  and  resembling  in  appearance  currant- 
jelly  ;  the  sputa  may  also  rarely  exhibit  a  grass-green  color,  due  to  trans- 
formation of  the  blood-pigment.  In  cai'cinomatous  lungs  putrefactive 
changes  sometimes  take  place,  and  if  so  the  expectoration  and  breatli 


SARCOMA    OF  THE  LUNG.  539 

emit  an  offensive  odor,  while  a  microscopic  examination  of  the  sputum 
frequently  discloses  the  presence  of  carcinomatous  elements.  The  well- 
known  cancerous  cachexia  invariably  develops. 

Physical  Signs. — These  will  naturally  depend  upon  the  extent  and 
location  of  the  new  growth.  Inspection. — If  the  lung-tissue  be  exten- 
sively involved,  the  walls  of  the  thorax  become  unduly  prominent  and 
fixed  over  the  seat  of  the  tumor.  Indeed,  the  tumor  may,  though  rarely, 
protrude  between  the  ribs.  The  intercostal  spaces  are  widened,  and  the 
superficial  veins,  in  view  of  the  fact  that  they  cannot  empty  themselves 
into  the  internal  veins,  appear  engorged ;  from  the  same  cause  edema 
affecting  the  thorax,  neck,  face,  and  arms  may  be  noted.  Swelling  of 
the  lymph-glands  in  the  neck  or  axilla  is  a  symptom  of  importance. 
On  palpation  the  tactile  fremitus  may  be  found  to  be  diminished  or  ab- 
sent. The  peroussion-note  will  be  flat,  since  the  air-vesicles  and  smaller 
bronchi  are  replaced  by  the  solid  growth.  On  auscultation  friction- 
sounds  are  the  rule.  The  respiratoiy  sounds  may  be  greatly  enfeebled 
or  absent ;  but  if  the  carcinomatous  tumor  communicates  with  a  wide- 
mouthed  bronchus,  bronchial  breathing  may  be  audible,  and  the  phys- 
ical signs  of  lung-cavity  may  be  developed.  The  signs  of  general 
bronchitis  are  present  in  most  instances,  especially  in  the  disseminated 
form  of  the  disease  ;  in  the  latter  variety  the  lung  may  shrink,  with  retrac- 
tion of  the  chest- walls  on  the  affected  side.  If  secondary  pleurisy  with 
effusion  occurs  the  detection  of  the  characteristic  cancer-cells  in  the  con- 
tents of  the  pleural  cavity  will  show  the  precise  nature  of  the  thoracic 
affection. 

Diagnosis. — The  following  symptom-group  will  pretty  well  estab- 
lish a  diagnosis :  A  peculiarly  shaped  dull  area  (as  when  it  extends 
under  the  sternum),  perhaps  a  marked  prominence  over  the  site  of  the 
tumor,  enlarged  and  hard  lymphatic  glands  in  the  vicinage,  and  more 
or  less  of  the  compression-symptoms — circulatory,  nervous,  bronchial, 
or  trachial  stenosis.  In  rarer  instances  the  diagnosis  may  be  made  by 
the  occurrence  of  metastasis  to  the  chest-wall.  Again,  the  discovery  of 
cancer-tissue  in  masses  accidentally  detached  gives  reliable  indication 
of  the  disease.  An  exact  diagnosis  can  often  be  made  from  the  ex- 
amination of  the  particles  obtained  on  aspiration  of  the  tumor  itself. 

The  differential  diagnosis  between  pulmonary  carcinoma  and  pul- 
monary tuberculosis  can  be  made  Avith  positiveness  only  by  a  careful 
microscopic  examination  of  the  sputum.  From  fibroid  induratio7i  of  the 
lung  it  is  easily  discriminated,  owing  to  the  history  and  slower  course 
of  the  latter  affection. 

Prognosis. — This  is  bad,  as  death  may  occur  suddenly  from  abun- 
dant hemorrhage  or  more  frequently  from  either  exhaustion  or  asphyxia. 
The  duration  of  the  affection  varies  from  six  months  to  a  year,  or,  rarely, ' 
even  two  years. 

Treatment. — The  treatment  must  be  addressed  solely  to  the  relief 
of  pain  and  other  subjective  symptoms. 

SARCOMA   OF   THE   LUNG. 

Primary  sarcoma  of  the  lung  is  rare,  but  in  instances  of  generalized 
sarcomatosis  the  lungs  show  larger  or  smaller  nodules  "  in  almost  every 


540  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

case  "  (Birch-Hirschfelcl),  occurring  in  connection  -nith  osteo-sarcoma 
of  other  organs  or  in  lympho-sarcoma  of  the  cervical  glands. 

Secondary  sarcoma,  occurring  in  consequence  of  invasion  of  the  root 
of  the  lung  by  sarcomatous  disease  of  the  post-bronchial  glands,  is 
more  common  than  secondary  carcinoma.  The  diagnosis  is  reached  as 
in  carcinoma  {vide  p.  539). 

Neoplasms  occurring  among  the  cobalt-miners  of  Schneeberg  Avere 
described  by  Hesse  and  Tragner  as  lympho-sarcomata — slowlv  growinor 
masses  that  attained  to  a  large  size  and  gave  metastasis  to  lymph-glands, 
pleura,  liver,  and  spleen.  In  most  cases  there  was  an  associated  pneu- 
monokoniosis,  which  had  probably  predisposed  to  the  new  growth. 

HYDATID  CYST  OF  THE  LUNG. 

Hydatids  in  the  lungs  may  either  be  primary  or  secondary,  the  former 
variety  being  exceedingly  rare  and  the  latter  somewhat  less  so.  Almost 
invariably  the  echinococci  are  developed  in  other  organs — the  liver  in 
particular — and  find  their  way  to  the  lungrs.  either  by  direct  perforation 
through  the  diaphragm  or  by  entering  through  the  blood-current.  The 
lungs  are  involved  in  about  12  per  cent,  of  hydatid  disease. 

For  etiology  and  pathology  see  Hydatid  Cysts  of  the  Liver. 

Symptoms. — The  clinical  manifestations  are  quite  varied,  even 
though  the  cyst  may  entirely  conceal  itself.  It  is  important  to  recollect 
that  similar  involvement  of  the  liver  usually  coexists  :  and  in  addition 
to  the  symptoms  of  the  latter  affection  there  may  be  pain  in  the  chest, 
dyspnea,  considerable  cough,  and.  rarely,  blood-stained  expectoration. 

The  physical  signs,  when  present,  are  as  follows  :  Diminished  vocal 
fremitus,  defective  expansion,  dulness  on  percussion  with  an  absence  of 
the  respiratory  murmur — all  signs  pointing  to  pleural  effusion.  The 
cysts  are  more  common  in  the  right  lung  and  frequently  cause  marked 
bulging  over  the  base.  Later  signs  of  cavity-formation  may  appear. 
In  other  cases,  the  signs  of  consolidation  may  preponderate. 

A  positive  diagnosis  of  hydatid  cyst  of  the  lung  can  be  made 
only  when  the  sculices,  pieces  of  membrane,  or  the  booklets  of  the 
echinococcus  are  demonstrable  in  the  sputum.  Besides  being  evacuated 
into  the  bronchi,  the  cysts  may  rupture  into  the  adjacent  serous  sacs  (pleura, 
peritoneum,  percardium).  or  externally,  the  latter  being  the  most  favor- 
able mode  of  termination.  Unless  they  are  discharged  early  by  ulceration 
into  the  bronchi  or  externally,  they  are  apt  to  excite  inflammation  of  the 
adjacent  lung-tissue  and  tubes,  accompanied  by  an  active  febrile  move- 
ment and  an  aggravation  of  the  symptoms  before  detailed :  these  com- 
plications (pneumonia,  gangrene)  may  assume  a  dangerous  form,  or  the 
patient  may,  if  the  growth  attains  large  dimensions,  become  asphyxiated. 
Yvova  gangrene.,  pleurisy,  ^nA  phthisis  echmococci  are  distinguished  by 
the  sputum-test  or  by  an  examination  of  the  aspirated  fluid. 

Rrogfliosis. — The  affection  is  always  attended  with  great  danger, 
and  is  of  more  serious  import  when  secondary  to  involvement  of  the 
liver  than  when  primary. 

Treatment. — When  it  can  be  shown  that  the  growths  are  situated 
at  the  periphery  of  the  lung  operation  should  be  carefully  considered. 
The  physician  stands  powerless  to  do  more  than  to  relieve  urgent  symp- 
toms in  special  cases  and  to  support  the  vital  functions. 


DISEASES  OF  THE  PLEURA.  541 


V.   DISEASES   OF  THE   PLEURA. 
PLEURISY. 

{Pleuritis.) 

Definition. — An  inflammation,  either  local  or  general,  of  one  or 
both  pleural  membranes.  The  disease,  as  shown  by  postmortem  exam- 
inations, is  of  great  frequency. 

Varieties. — Pleurisy  has  been  variously  classified.  Etiologically , 
the  distinction  between  primary  and  secondary  forms  of  the  disease 
should  be  made,  as  well  as  a  division  into  tuberculous,  carcinomatous, 
septic,  etc.  Pathologically,  all  cases  may  be  summarized  under  the 
following  heads:  Localized  and  generalized  and  dry  (plastic)  pleurisy 
and  pleurisy  w-ith  effusion  (sero-fibrinous,  purulent,  hemorrhagic).  They 
may  also  be  classified  according  to  their  duration  into  acute,  subacute, 
and  chronic  pleurisies.  I  shall  describe  the  following  forms,  which  are 
based  partly  upon  their  etiology  and  clinical  course,  though  mainly 
upon  their  pathologic  manifestations — viz.  («)  acute  plastic  pleurisy  ;  (h) 
sero-fibrinous  pleurisy;  (c)  purulent  pleurisy  (empyema);  and  {d) 
chronic  adhesive  pleurisy. 

Bacteriology. — In  all  forms  of  the  disease  the  direct  causes  are 
various  micro-organisms  or  their  irritating  chemical  products.  Con- 
spicuous among  these  is  the  bacillus  of  tuberculosis,  even,  though  rarely, 
found  in  the  pleuritic  exudate.  Inoculation  of  guinea-pigs  Avith  the 
latter  by  Eichhorst  gave  positive  results  in  15  out  of  23  cases,  and  by 
La  Damany  in  47  out  of  55  cases.  Although  rarely  containing  bac- 
teria, Netter,  Prudden,  and  others  have  found  in  the  exudation  of 
fibrino-serous  pleurisy  the  streptococcus  pyogenes,  the  staphylococcus, 
the  typhoid  bacillus,  and  the  diplococcus  of  jmeumonia.  The  micro- 
organisms most  commonly  present  in  empyema  are  the  micrococcus 
lanceolatus  and  the  streptococcus,  the  former  especially  in  the  pleurisy 
associated  with  pneumonia  (in  two-thirds  of  the  cases  occurring  in 
children — Levy),  and  the  latter  in  those  independent  of  pneumonia, 
particularly  in  adults.  Among  other  bacteria  that  have  been  found 
rarely  in  the  efiusion  are  the  colon  bacillus,  the  p>roteus  vulgaris,  the 
gonococcus,  the  Ameba-coli,  Friedldnder  s  bacillus,  anthrax  bacillus, 
influenza  bacillus,  and  various  saprophytic  bacteria.  Except  in  the 
case  of  the  pleuritic  exudation  (usually  purulent)  in  pneumonia,  in 
which  the  diplococcus  is  alone  present  in  about  one-half  of  the  cases, 
the  afore-mentioned  microorganisms  are  generally  found  in  association. 

ACUTE    PLASTIC   PLEURISY. 
{Dry,  Fibrinous  Pleurisy.) 

Pathology. — The  lesions  are  usually  circumscribed,  the  part  in- 
flamed being  intensely  injected.  It  has  lost  its  natural  lustre,  and 
instead  has  a  dull,  non-glistening  surface  "like  a  tarnished  mirror," 
due  to  a  slight  fibrinous  exudate.  Minute  ecchymoses  are  seen  at  dif- 
ferent points.     Later  the  exudate  may  become  more  copious,  when  the 


542  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

pleura  presents  a  rough,  shaggy  appearance.  On  account  of  the  fric- 
tion between  the  two  pleural  membranes  in  high  grades  of  dry  plastic 
pleurisy,  the  exudate  may  be  very  thick,  and  its  color-appearance  is 
then  yellowish-  or  reddish-gray.  This  sheeting  of  fibrinous  exudate 
entangles  in  its  meshes  numerous  embryonic  round  cells,  out  of  which 
blood-vessels  and  connective  tissue  are  developed.  The  opposing  sur- 
faces of  the  pleura  adhere.  Occasionally,  in  the  lighter  grades,  the 
disease  does  not  advance  to  firm  adhesion,  and  in  such  instances  the 
products  of  the  exudate  undergo  fatty  degeneration  and  are  absorbed. 
The  respiratory   movements  are  but  little  disturbed  in  these  cases. 

Htiology. — The  affection  may  be  (a)  primary  or  (6)  secondary. 
(a)  By  i\xe  primarij  form  is  meant  an  inflammation  of  the  pleura  occur- 
ring in  previously  healthy  persons.  It  is  exceedingly  rarC;  and  doubt- 
less many  instances  of  true  secondary  pleurisy  are  regarded  as  belong- 
ing to  this  category.  Aschoff 's  studies  of  200  cases  of  pleurisy  showed 
41  to  be  idiopathic.  Of  great  etiologic  prominence  is  exposure  to  cold 
and  wet,  and  next  to  this  stands  mechanical  injury.  It  is  more  com- 
mon in  men  than  in  women,  and  especially  during  the  time  of  active 
life,  on  account  of  the  greater  degree  of  exposure  of  the  former 
than  the  latter  sex.  In  almost  all  instances  a  careful  search  will 
disclose  the  existence  of  some  diathesis  (tuberculous,  gouty,  rheu- 
matic) that  may  be  properly  regarded  as  the  favoring  cause.  The 
changeable  weather  of  the  winter  and  spring  augments  the  propor- 
tion of  cases  during  these  seasons  as  compared  with  summer  and 
autumn. 

(6)  The  secondary  form  of  dry  plastic  pleurisy  arises  from  extension 
of  acute  and  chronic  inflammatory  aff'ections  of  the  lungs  and  other 
neighboring  organs.  Hence  it  frequenth^  follows  croupous  pneumonia, 
somewliat  less  frequently  broncho-pneumonia,  and  more  rarely  still 
hemorrhagic  infarct,  abscesses,  and  pulmonary  carcinoma  and  gangrene. 
When  pleurisy  occurs  on  the  right  side  it  must  be  recollected  that  it 
may  have  originated  in  hepatitis.  Plastic  pleurisy  sometimes  arises 
in  acute  articular  rheumatism,  to  which  it  may  essentially  belong. 
It  is  an  almost  constant  accompaniment  of  chronic  pulmonary  tuber- 
culosis, and  may,  though  rarely,  even  constitute  the  primary  lesion 
(primary  tuberculous  pleurisy).  The  disease  may  appear  as  a  com- 
plication in  chronic  alcoholism  and  in  chronic  Bright's  disease.  Finally, 
inflammation  of  other  serous  membranes,  as  of  the  pericardium  and  peri- 
toneum, by  direct  extension  through  the  lymphatics  of  the  diaphragm, 
may  invade  the  pleura. 

Symptoms. — The  affection  may  vary  in  intensity  between  the  ex- 
tremes of  mildness  and  great  severity,  though,  as  a  rule,  well-marked 
local  symptoms  attend  the  onset.  Among  the  latter  a  s/mr;.)  "  «f/f(^7/ " 
in  the  side,  that  is  usually  referred  to  the  nipple,  is  the  most  prominent. 
The  pleural  pain  is  increased  by  inspiration  as  well  as  by  voluntary 
motion  of  the  affected  side,  and  hence  the  patient  assumes  a  fixed  position 
in  Avhich  he  favors  the  affected  side  by  leaning  toward  it.  There  is  a 
dry,  distressing  cough  that  is  restrained  for  obvious  reasons,  and  the 
respiration  is  somewhat  liurried.  painful,  and  jerking  in  character  until 
the  exudation  is  poured  out,  when  relief  from  this  and  other  local  symp- 
toms ensues. 


ACUTE  PLASTIC  PLEURISY.  543 

The  general  symptoms  are  not  pronounced,  and,  save  in  compara- 
tively rare  instances,  do  not  correspond  with  the  local  signs.  The  tem- 
perature is  not  typical,  rarely  exceeding  103°  F.  (39.4°  C.),  and  more 
often  it  is  below  101°  F.  (38.3°  C).  The  pulse  is  usually  small  and 
tense  or  soft  in  character,  registering  from  90  to  120  beats  per  minute. 
Not  infrequently  the  cases  are  so  mild  as  to  be  attended  by  few,  if  any, 
subjective  symptoms.  The  patient  may  complain  of  ill-defined,  uneasy 
sensations  in  the  affected  side,  but  does  not  discontinue  his  usual  occu- 
pation. On  the  other  hand,  the  worst  cases  of  acute  plastic  pleurisy — 
■which,  fortunately,  are  rare — manifest  violent  symptoms :  there  is  a 
distinct  chill,  a  speedy  development  of  high  fever  (104°  F. — 4.0°  C), 
and  profound  prostration,  and  the  general  and  local  symptoms  are  pro- 
portionately aggravated.     The  illness  then  is  often  a  fatal  one. 

Physical  Signs. — On  inspection  the  movements  of  the  chest-wall  on 
the  affected  side  are  observed  to  be  much  restricted,  particularly  during 
the  first  day  of  the  affection.  Palpation  confirms  the  results  of  inspec- 
tion, while  percussion  yields  a  normal  note.  Auscultation  renders  au- 
dible a  grazing  friction-sound,  most  intense  at  the  end  of  inspiration. 
These  signs  are  not  uncommonly  situated  at  the  apices. 

With  the  occurrence  of  fibrinous  exudation  palpation  detects  over 
the  corresponding  area  a  diminution  of  the  tactile  fremitus.  On  p>er- 
eussion  there  is,  as  a  rule,  a  slight  though  variable  degree  of  dulness  ; 
and  on  auscultatioyi  the  rubbing  friction-sounds  or  a  rustling  sound 
due  to  fine  rales  are  heard  both  on  inspiration  and  expiration,  being 
intensified  by  deep  breathing.  These  sounds  frequently  endure  for  a 
day  or  two  after  the  other  symptoms  have  disappeared.  Rarely  the 
plastic  exudation  may  be  so  extensive  as  to  cause  compression  of  the 
lung,  in  which  instance  the  breath-sounds  may  become  bronchial  in 
character  ;  and  I  have  known  a  case  of  this  sort  to  be  mistaken  for 
lobar  pneumonia. 

Diagnosis. — By  exercising  ordinary  care  the  clinician  can  scarcely 
mistake  other  thoracic  affections  for  dry  pleurisy,  the  latter  being  diag- 
nosticated to  a  certainty  by  the  presence  of  the  characteristic  friction- 
murmur.  Intercostal  neuralgia  may  present  features  not  unlike  those 
of  acute  pleurisy.  In  both  affections  there  is  frequently  a  history  of 
exposure,  followed  by  severe  chest-pains  that  are  excited  by  coughing 
and  deep  breathing.  In  neuralgia,  however,  there  are  painful  pressure- 
points,  and  the  pleuritic  friction-sound  "does  not  occur.  Pleurodynia 
may  also  give  a  history  very  similar  to  that  of  acute  pleurisy,  but  the 
presence  of  the  characteristic  physical  signs  of  pleurisy  are  absent. 

Prognosis. — The  duration  of  the  affection  varies  from  a  few  days 
to  three  weeks,  and  the  immediate  outcome  is  favorable  as  a  rule.  It 
cannot  be  doubted,  however,  that  a  primary  attack  predisposes  to  subse- 
quent attacks,  and  thus,  as-  a  result  of  repeated  seizures,  pleural  thicken- 
ing and  intrapleural  adhesions  often  arise.  Lung-expansion  may  in  this 
manner  be  restricted,  with  the  gradual  development  of  interstitial  pneu- 
monia as  a  consequence.  Acute  plastic  pleurisy  is  not  infrequently  a 
terminal  condition  in  serious  forms  of  illness  {e.  g.  septicopyemia  and 
chronic  nephritis). 

Treatment. — The  first  object  in  the  treatment  is  to  relieve  the 
pain,  and  this  can  best  be  accomplished  by  the  hypodermic  use  of  mor- 


544  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

phin.  The  inflammatory  process  is  best  controlled  by  absolute  rest  in 
the  recumbent  posture,  allowing  the  patient  to  assume  that  position 
which  gives  him  most  comfort.  I  am  also  in  the  habit  of  administer- 
ing moderate-sized  doses  of  ([uinin  (gr.  iv — 0.259 — three  times  daily). 
After  the  exudation  has  appeared,  the  iodids  of  iron  and  potassium, 
in  combination,  may  be  employed.  Locally,  nothing  is  so  effective 
as  cold  in  the  form  of  the  ice-water  bag  or  Leiter's  coil,  preceded, 
in  robust  patients,  by  the  local  abstraction  of  blood  (.^iij  to  vj — 96.0- 
192.0)  by  leeches.  At  the  end  of  one  week  the  morphin  may  usually  be 
discontinued.  During  convalescence  the  patient  should  be  instructed 
to  take  deep  inspirations  several  times  in  succession,  not  less  than  a 
dozen  times  each  day,  with  a  view  to  obviating  so  far  as  possible  the 
pleural  adhesions  and  other  unfavorable  consequences.  Symptomatic 
anemia  may  be  present  at  this  time,  and  should  be  met  by  iron  given 
internalh' .  At  this  time  iodin  may  be  used  locally  with  great  benefit ; 
I  have  not,  however,  seen  any  favorable  results  from  blisters.  For  the 
pain  which  continues  in  the  side  after  all  detectable  physical  signs  have 
disappeared  the  use  of  the  constant  current  over  the  seat  of  the  pleur- 
isy for  twenty  minutes  at  a  time  gives  almost  instantaneous  relief 
(Loomis). 

SERO-FIBRINOUS    PLEURISY    (PLEURISY   WITH   EFFUSION,    SUBACUTE 

PLEURISY). 

Pathology. — During  the  first  stage  of  sero-fibrinous  pleurisy  the 
changes  are  the  same  in  character  as  those  met  with  in  dry  pleurisy, 
though  of  severer  grade,  and  usually  involving  the  greater  portion  of 
the  pleura  on  the  side  affected.  There  is  an  abundant  exudation  of 
serum,  and  usually  the  entire  pleura  becomes  coated  with  a  fibrinous 
exudate,  that  varies  greatly  in  thickness  and  arrangement.  The  latter 
is  thin  and  smooth  in  some  instances,  though  more  frequently  it  forms 
a  thick  layer,  presenting  a  shaggy  surface  on  the  one  hand  or  an 
irregular,  honeycombed  surface  on  the  other.  Lymph  in  the  form 
of  flocculi  is  rather  abundant  in  the  serous  effusion.  The  interlobu- 
lar pleural  surfaces  are  also  invaded  as  a  rule,  in  consequence  of 
which  they  become  adherent.  The  fluid  exudate  varies  greatly  in  quan- 
tity {h  to  8  pints — 4  liters),  is  often  of  a  citron  color,  and  is,  in  the  ma- 
jority of  instances,  clear  or  slightly  turbid.  Rarely  it  is  of  a  dark- 
brown  color. 

Unless  adhesions  between  the  pleural  surfaces  have  previously  existed 
the  effusion  gravitates  to  the  most  dependent  portion  of  the  pleural  cav- 
ity. Microscopically,  there  are  found  leukocytes,  red  blood-corpuscles, 
endothelial  cells,  threads  of  fibrin,  and.  rarely,  crystals  of  cholesterin 
and  uric  acid.  The  composition  of  the  fluid  is  almost  identical  with  that 
of  blood-serum,  and  on  boiling  it  is  found  to  be  rich  in  albumin.  Spon- 
taneous coagulation  may  take  place  on  standing. 

Chancjes  in  the  Neighhoring  Organs. — So  long  as  the  normal  retrac- 
tility of  the  lung  is  not  overcome  by  the  fluid  that  collects  in  the  pleural 
cavity,  the  latter  does  not  produce  positive  intrathoracic  pressure,  and 
hence  does  not  produce  displacement  of  adjacent  organs.  It  may  be 
assumed  that  until  the  pleural  sac  is  at  least  one-half  filled  with  sero- 


SEBO-FLBRINOUS  PLEURISY.  545 

fibrinous  exudate  the  natural  contractility  of  the  lung  is  not  destroyed. 
At  this  period  there  may  be  a  slight  displacement  of  the  mediastinum 
toward  the  opposite  side,  due  to  traction  exerted  by  the  normal  retrac- 
tility of  the  sound  lung.  Obviously,  large  effusions  must  in  a  mechani- 
cal manner  displace  the  pleural  membranes,  thus  causing  compression 
of  the  pulmonary  structures  lying  above  the  effusion.  A  very  copious 
effusion  may  push  the  lung  up  and  back  against  the  vertebral  column 
and  convert  it  into  a  small,  flat,  bloodless,  and  airless  mass  (atelectasisj. 
While  a  total  absence  of  air  in  the  collapsed  lung  is  due  chiefly  to  com- 
pression by  the  fluid,  to  some  extent,  however,  the  air  may  be  absorbed 
by  the  vessels  or  even  by  the  effusion  (Strlimpell). 

Together  with  compression  of  the  lung  by  the  effusion,  pressure  is 
also  exerted  by  the  latter  against  the  mediastinum,  causing  displacement 
of  the  heart.  The  mediastinum  also  loses  the  normal  traction-force  of 
the  lung  upon  the  affected  side,  and  hence  the  lung  on  the  sound  side 
draws  the  mediastinum  toward  itself  by  its  own  retractile  energy.  Osier 
shows  that  even  in  the  most  extensive  left-sided  effusion  the  heart's  apex 
is  not  rotated,  but  that  the  normal  relative  position  of  the  apex  and  base 
obtain,  though  the  apex  is  in  some  instances  lifted,  and  in  others  the 
heart  lies  more  transversely.  The  right  chambers  of  the  heart  occupy 
most  of  the  anterior  part  of  the  organ,  showing  that  the  displacement 
of  the  mediastinum  with  the  pericardium  and  its  contents  to  the  right 
involves  no  appreciable  twisting  of  the  heart  itself. 

Downward  displacement  of  the  diaphragm  takes  place  in  extensive 
effusion,  and  shows  itself  on  the  right  side  by  the  lowering  of  the  liver 
to  a  variable  distance  below  the  inferior  costal  border ;  on  the  left  side 
large  effusions  produce  pressure-displacement  of  the  stomach  and  the 
transverse  colon,  and,  to  a  slighter  extent,  of  the  spleen.  It  must  be 
recollected  that  adhesions  may  prevent  displacement  of  any  of  the 
adjacent  organs. 

Ktiology. — In  the  present  state  of  our  knowledge  the  causal  factors 
are  identical  in  nature  with  those  producing  dry  plastic  pleurisy.  It  is 
highly  probable  that  the  degree  of  severity  is  dependent  upon  the  pre- 
vious condition  of  the  patient,  whether  he  be  suffering  from  some  other 
affection  or  not,  and  upon  the  amount  of  specific  poison  gaining  access 
to  the  pleura. 

The  affection  may  be  ijrimary,  but  is  much  more  often  secondary ; 
and  this  fact  may  be  explained  by  reference  to  any  of  the  specific 
micro-organisms  producing  the  affection. 

Direct  Causes. — Many  of  the  cases  follow  quickly  upon  exposure  to 
cold  or  wet  or  an  injury  to  the  thorax.  I  thoroughly  agree  with  those 
authors  who  contend  that  about  three-fourths  of  the  cases  of  sero- 
fibrinous pleurisy  are  induced  by  tuberculous  infection  of  the  pleura. 
The  tuberculous  process  may  invade  the  pleura  primarily,  but  more 
often  it  is  secondary  to  tuberculosis  of  the  lungs ;  less  frequently, 
though  oftener  than  is  generally  supposed,  it  is  secondary  to  tubercu- 
lous peritonitis.  In  these  instances  the  tubercle  bacilli  probably  find 
their  way  from  the  peritoneum  to  the  pleura  by  traversing  the  lymphat- 
ics in  the  diaphragm.  Resinelli  believes  that  pleurisy  with  effusion 
may  be  the  direct  result  of  neoplasms  of  the^  ovaries.  I  am  con- 
vinced that  a  large  percentage  of  apparently  primary  cases  of  tubercu- 

35 


54(j  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

lous  pleurisy  have  their  origin  in  a  circumscribed  and  more  or  less 
latent  tuberculous  focus  in  the  lungs.  It  is  not  improbable  also  that 
tuberculous  processes  in  other  viscera  may  furnish  the  tubercle  bacilli 
for  secondary  pleural  infection.  Moreover,  the  fact  that  many  cases  of 
sero-fibrinous  pleurisy  recover  does  not  disprove  their  tuberculous  nature. 

The  affection  is  not  infrequently  secondary  to  acute  articular  rheu- 
matism, Avhich  is  itself  most  probably  a  microbic  aff"ection.  It  also 
arises  as  a  complicating  condition  in  the  course  of  various  acute  and 
chronic  aff'ections  of  the  chest,  as  pericarditis  and  catarrhal  pneumonia, 
and  may  develop  in  acute  infectious  diseases,  as  typhoid  fever  or  lobar 
pneumonia.  The  typhoid  bacillus  of  Eberth  has  also  been  known  to 
provoke  pleurisy  (Bozzolo,  Fernet,  and  others).^  It  may  occur  as  a  com- 
plication in  the  chronic  aff'ections  of  various  viscera  (chronic  nephritis, 
cirrhosis  and  carcinoma  of  the  liver).  The  predisposiy^g  causes  are  the 
same  as  for  the  dry  plastic  form. 

Symptoms. — The  description  here  refers  particularly  to  primary 
sero-fibrinous  pleurisy,  and  it  is  important  to  recollect  that  when  second- 
ary to  other  acute  and  chronic  affections  characterized  by  great  bodily 
"weakness  the  pleuritic  symptoms  may  be  in  abeyance. 

With  few  exceptions  the  onset  is  insidious,  the  symptoms  being 
quite  mild ;  but  rarely  there  is  a  sudden  onset  with  active  symptoms 
(rigor,  high  fever).  In  the  majority  of  instances  the  patient  first 
complains  of  a  stitch-like  pain  in  the  side;  this  is  rarely  ])ronounced, 
but  is  aggravated  upon  deep  breathing  and  upon  any  muscular  exertion. 
Dyspnea  soon  arises  and  gradually  increases  in  intensity.  Cough  may 
be  present  or  absent,  and  in  some  instances  is  attended  by  a  scanty 
mucoid  expectoration  that  may  rarely  be  blood-streaked. 

The  constitutional  syynptoms  are  of  correspondingly  slow  and  gradual 
development.  From  the  commencement  of  the  attack  a  moderate  febrile 
movement  at  night  may  be  observed,  and  the  pulse  will  be  found  to  be 
frequent,  small,  and  compressible,  or,  more  rarely,  tense.  At  the  time 
of  the  patient's  first  visit  to  his  physician  he  may  give  a  history  of  having 
gradually  lost  flesh  and  strength  for  a  period  of  weeks  together,  though 
he  may  not  have  been  obliged  to  abandon  his  vocation.  He  looks  pale, 
his  countenance  wears  an  anxious  expression,  and  he  is  Avithout  appetite. 
These  cases  frequently  drag  on  from  two  to  four  weeks  before  con- 
sulting a  physician,  the  local  symptoms  going  unnoticed,  and  the  patient 
making  complaint  only  of  weakness,  anorexia,  headache,  etc. 

Sometimes  the  period  of  invasion  develops  acutely  and  after  lasting 
a  few  days  the  symptoms  exhibit  a  decided  remission  ;  but  at  another 
subsequent  period  there  may  be  a  sudden  recurrence  of  the  local  and 
general  phenomena,  and  particularly  of  the  dyspnea.  The  pleural 
cavity,  which  may  have  been  one-half  or  two-thirds  full,  now  becomes 
completely  filled. 

Special  Symptoms. — Pain. — Chest-pain  is  an  almost  constant  but  not 
highly  characteristic  symptom,  and,  though  usually  among  the  earliest 
symptoms,  it  may  not  be  present  until  a  few  hours  or  a  day  after  the 
commencement  of  the  affection.  It  may  be  described  as  a  sharp,  shoot- 
ing pain,  and  is  popularly  termed  a  "stitch  in  the  side."  It  may,  how- 
ever, be  tearing  or  dragging  in  character.  Its  intensity  is  not  a  safe  in- 
^  Annual  of  the  Universal  Medical  Sciences,  1892,  vol.  ii.  p.  12. 


SERO-FIBBINOUS  PLEURISY.  547 

dication  of  the  severity  of  the  disease.  It  is  usually  referred  to  a  small 
spot  below  the  nipple  or  to  the  mid-axillary  region ;  exceptionally,  how- 
ever, it  is  more  diffuse,  and  in  my  experience  it  has  not  infrequently 
been  retrosternal  or  referred  to  limited  areas  below  the  inferior  costal 
border.  When  absent  it  may  be  excited  by  coughing,  sneezing,  deep 
inspiration,  and  stooping.  With  the  appearance  of  the  effusion  the  pain 
diminishes,  and,  as  a  rule,  soon  disappears. 

Dyspnea. — The  respiration  is  shallow,  catching  in  character,  and 
hurried  in  consequence  of  the  severe  pleural  pain  ;  in  copious  effusions, 
that  render  one  lung  almost  or  wholly  functionless,  the  dyspnea  may 
become  intense,  even  attaining  to  well-marked  orthopnea.  It  reaches  its 
most  pronounced  form  in  persons  who  have  previously  been  robust,  and 
in  those  in  Avhom  the  effusion  has  developed  rapidly.  On  the  other 
hand,  when  the  pleural  sac  fills  slowly  dyspnea  may  be  absent,  except 
on  exertion.  This  symptom  appears  frequently  before  the  effusion  takes 
place,  and  is  then  due  partly  to  the  fever  and  partly  to  the  pleuritic 
pain.  Following  marked  disturbances  in  the  respiration,  cyanosis  ap- 
pears and  may  become  quite  pronounced. 

Cough  and  Uxyeetoration. — Little  need  be  added  to  what  has  already 
been  stated.  When  there  is  present  much  expectoration  it  is  not  uncom- 
monly due  to  associated  bronchitis  or  to  pulmonary  tuberculosis  ;  there 
may,  however,  be  a  total  absence  of  expectoration,  and  in  such  instances 
the  exciting  cause  of  the  cough  is  probably  the  pleuritis.  Both  the 
cough  and  expectoration  are  apt  to  be  increased  during  the  process  of 
resorption  of  the  exudate  as  the  result  of  a  catarrhal  bronchitis  that  is 
prone  to  develop  in  the  re-expanding  lung. 

Ffver. — The  rise  of  temperature  is  not  rapid  as  a  rUle,  nor  does  it 
reach  a  high  point  (101.5°  to  103°  F.— 38.6°-39.4°  C).  At  the  end 
of  a  variable  period — usually  one  to  three  weeks — the  temperature  falls 
by  lysis,  and  soon  touches  the  normal.  The  temperature  may  be  of  the 
continued  type  in  many  acute  cases.  In  subacute  forms  the  temperature 
may  rarely  rise  above  101°  F.  (38.3°  C),  or  may,  finally,  assume  a  hec- 
tic type.  The  surface-temperature  of  the  affected  side  is  from  one-half 
to  two  degrees  (.4°-1.6°  C.)  higher  than  that  of  the  normal  side. 

Pulse. — The  pulse  is  quickened,  beating  100  or  more  per  minute, 
and  its  volume  and  tension  are  diminished.  Irregularity  both  of  the 
volume  and  rhythm  of  the  pulse  may  also  be  observed.  These  pulse- 
characteristics  are  to  be  attributed  to  the  pressure  of  the  effusion  upon 
the  heart  and  great  vessels. 

Gi  astro -intestinal  Symptoms. — Loss  of  appetite  is  commonly  present, 
and  more  rarely  nausea  and  occasional  vomiting  may  be  met  with  at  the 
outset.     Constipation  is  the  rule. 

Renal  Symptoms. — The  amount  of  urine  is  diminished  both  during 
exudation  and  while  the  exudate  remains  at  the  same  level.  The  daily 
quantity  may  not  exceed  eight  or  ten  ounces,  but  the  specific  gravity  is 
increased,  ranging  from  1018  to  1028.  Rarely,  the  quantity  is  increased 
with  existing  effusion.  An  increase  in  the  daily  amount  of  urine  ex- 
creted is  frequently  the  first  sign  of  commencing  absorption  of  the 
exudate,  and  the  rapid  resorption  of  the  copious  effusion  may  greatly 
augment  the  flow  of  urine  to  80  or  100  ounces  (2.5  to  3  liters)  daily 
(Strlimpell).  The  cause  of  the  diminished  secretion  of  urine  is,  in  the 
main,  diminished  arterial  pressure. 


548  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Physical  Signs. — The  physical  signs  of  sero-fibrinous  pleurisy  differ 
with  the  amount  of  effusion  present,  and  also  with  the  particular  stage 
of  the  affection  :  those  of  the  first  stage,  however,  are  identical  with  the 
signs  pointed  out  in  connection  with  dry  plastic  pleurisy,  and  need  not 
be  restated  here.  We  will  note  the  physical  signs  (1)  during  the  stage 
of  effusion,  as  well  as  (2)  those  presented  Avhen  resorption  of  the  effusion 
has  taken  place. 

(1)  Stage  of  Effusion. — When  the  pleural  sac  is  only  partly  filled 
there  is  noted,  on  inspection,  but  little  change  in  the  thoracic  contour. 
The  respiratory  movements  are,  however,  restricted,  owing  to  mechani- 
cal hindrance  to  the  lung-expansion.  In  the  majority  of  instances  the 
effusion  increases  until  positive  intrathoracic  pressure  and  noticeable 
bulo;inor  in  the  middle  and  lower  third  of  the  chest-wall  on  the  affected 
side  take  place ;  the  intercostal  spaces  below  are  widened  and  more  or 
less  nearly  effaced.  The  apex-beat  of  the  heart  is  displaced,  being 
visible  in  right-sided  pleurisy  to  the  left  of  the  vertical  mammary  line 
in  the  fourth  and  fifth  interspaces,  and  in  left-sided  pleurisy  to  the  right 
of  the  right  mammarv  line,  or  even  bevond.  in  the  third  and  fourth  in- 
terspaces.  The  apex  of  the  heart  may  take  a  position  behind  the  ster- 
num, Avhen  no  impulse  will  be  visible. 

Palpation. — The  limitt^d  movement  of  the  chest  is  readily  appreci- 
ated on  palpation,  arid  in  large  effusions  the  chest-wall  is  practically 
fixed.  The  separation  of  the  ribs  and  the  obliteration  of  the  intercostal 
spaces  are  easily  made  out  in  the  same  manner.  Edema  of  the  chest- 
wall  is  rarely  present,  and  fluctuation  almost  never.  An  important 
and  early  physical  sign  is  the  diminished  tactile  fremitus,  which  is 
soon  abolished, 'except  in  infants,  in  whom  it  may  be  excited  on  crying. 
This  is  a  less  valuable  sign  in  women  than  in  men,  owing  to  the  differ- 
ences in  the  vocal  vibrations  in  the  two  sexes.  In  copious  effusions  tac- 
tile fremitus  may  sometimes  be  obtained  when  bands  of  adhesion,  which 
serve  as  a  medium  for  the  transmission  of  vocal  fremitus,  connect  the 
pulmonary  with  the  costal  pleura.  The  apical  impulse  can  also  be 
readily  located  by  palpation.  The  displaced  spleen  or  liver  can  be  read- 
ily felt  through  tlie  abdominal  wall,  and  must  not  be  mistaken  for  an 
actual  enlargement  of  these  organs. 

Mensuration. — It  must  not  be  forgotten  that  in  right-handed  adults 
the  right  side  is,  normally,  slightly  larger  than  the  left ;  and  it  is  only 
after  the  effusion  is  considerable  in  amount  that  the  cyrtometer  shows 
any  alteration  in  the  thoracic  contour  or  an  enlargement  of  the  affected 
side.  The  tape,  however,  exhibits  the  difference  in  expansive  motion 
of  the  two  sides  early,  or  when  there  is  a  moderate  amount  of  fluid.  At 
the  end  of  expiration  the  circumference  of  the  affected  side  will  be  found 
to  be  one  or  two  inches  greater  than  that  of  the  left  side,  while  at  the 
end  of  inspiration  the  difference  will  be  but  slight.  The  cyrtometric 
tracing  also  shows  a  discrepancy  between  the  horizontal  outlines  of  the 
two  sides. 

Percussion. — At  first  the  percussion-note  is  impaired,  either  poste- 
riorly or  in  the  infra-axillary  region,  and  a  little  later  there  is  dulness, 
tending  toward  flatness  (deadness),  with  increasing  effusion.  The  resist- 
ance to  the  pleximeter-finger  becomes  greatly  au<:^mentod.  In  cases  in 
which  the  effusion  rises  to  the  fourth  rib  anteriorlv  there  is  dulness  over 


,  SERO-FIBBINOUS  PLEURISY.  549 

the  fluid  above  and  absolute  flatness  beloAv.  Since  both  the  flatness  and 
dulness  are  due  to  the  fluid,  it  is  obvious  that  the  upper  level  of  the 
latter  must,  whenever  free,  change  with  the  posture  of  the  patient ; 
hence  the  limit  of  dulness  will  be  higher  in  the  sitting  than  in  the  re- 
cumbent position.  When  the  pleural  sac  is  filled  or  when  the  effiision 
is  confined  by  adhesions,  the  latter  sign  is  not  obtainable.  Displace- 
ment of  pleuritic  fluid  when  the  patient's  position  is  changed  and  also 
with  the  movements  of  the  diaphragm  has  been  noted  with  the  fluoro- 
scope  (Bergenia  and  Carriere).  If  the  upper  level  of  the  fluid  reaches 
the  lower  border  of  the  third  rib,  the  percussion-note  above  the  line  of 
dulness  is  tympanitic  or  vesiculo-tympanitic  {Skoda  s  resonance).  In 
copious  exudations  the  cracked-pot  sound  may  be  elicited  immediately 
below  the  clavicle  in  the  usual  manner,  and  "  Williams  s  tracheal  tone  " 
may  sometimes  be  obtained  in  large  exudations.  This  may  also  be 
obtained  near  to  the  spine  on  the  afi"ected  side  or  at  a  point  correspond- 
ing to  the  seat  of  the  compressed  lung.  When  the  patient  is  sitting 
or  in  the  erect  posture  the  upper  limit  of  dulness  in  large  effusions 
is  not  a  horizofttal  line,  but  is  highest  at  the  spine  and  falls  as 
we  proceed  to  the  front,  which  is  its  lowest  point.  The  upper  line 
of  dulness  in  moderate  effusions  begins  "relatively  low  down  in  the 
back,  passes  upward  from  the  vertebral  column,  and  soon  turns  upward 
and  proceeds  obliquely  across  the  back  to  the  axillary  region,  w^here  it 
reaches  its  highest  point ;  thence  it  advances  in  a  straight  line,  but  with 
a  slight  descent,  to  the  sternum"  (Ellis).  This  curved  line  resembles 
the  italic  letter  S  (Garland).  On  the  right  side  the  flatness  is  con- 
tinuous with  that  of  the  displaced  liver ;  on  the  left  it  passes  into  and 
may  obliterate  Traube's  semilunar  space. 

Auscultation — The  signs  of  the  first  stage  have  already  been  de- 
scribed {vide  Plastic  Pleurisy).  With  the  appearance  of  the  eff"usion 
the  breath-sounds  become  weak,  distant,  and  have  a  bronchial  quality. 
Soon  the  respiratory  sounds  over  the  aff"ected  side  Avill  be  entirely  ab- 
sent, except  near  the  upper  level  of  the  fluid  posteriorly,  where  distant 
bronchial  breathing  is  audible.  The  latter  sounds  may  exhibit  a  metallic 
or  amphoric  quality,  and  may  be  accompanied  by  rales  (pseudo-cavernous 
signs).  The  latter  are  more  frequently  met  with  in  children  than  in 
adults,  and  often  give  rise  to  a  false  diagnosis.  Above  the  level  of  the 
fluid  there  is  broncho-vesicular  breathing,  and  on  the  opposite  side  in- 
tensified breath-sounds  may  usually  be  noted.  In  pneumonia  with  pleural 
effiision  there  may  be  loud  and  persistent  bronchial  respiration  over  the 
exudate.  The  vocal  resonance  may  manifest  a  nasal  or  metallic  qual- 
ity, simulating  somewhat  the  bleating  of  a  goat  {Laennec  s  egophony). 
This  is  best  obtained  near  the  upper  level  of  the  fluid  in  large  effusions, 
and  at  or  above  the  angle  of  the  scapula  when  the  eff'usion  is  moderate. 

(2)  Stage  of  Resorption. — With  resorption  of  the  fluid  there  is  a  de- 
crease in  the  size  of  the  aff'ected  side,  together  with  a  return  of  the  nor- 
mal appearance  of  the  intercostal  spaces  and  the  respiratory  movements. 
In  many  instances  there  is  positive  retraction,  leading  to  thoracic  defor- 
mity with  displacement  of  neighboring  organs  toward  the  aff'ected  side ; 
and  this  retraction  may  be  either  general  or  circumscribed.  The  infe- 
rior intercostal  spaces  are  more  or  less  narrowed ;  the  shoulders  droop  ; 
the  nipple  approaches  the  median  line ;  the  spine  may  be  curved,  the 
convexity  being  directed  toward  the  sound  side  (quite  rarely  toward  the 


550  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

affected  side) ;  and  the  scapula  projects  from  the  chest-wall  on  the  af- 
fected side.  In  children,  and  even  in  adults,  the  lungs  and  thorax  grad- 
ually expand  in  order  to  overcome  this  chronic  deformity.  On  the 
other  hand,  permanent  shrinkage  of  the  thorax  may  occur. 

Palpation. — The  tactile  fremitus  closely  follows  the  fluid  as  it  sub- 
sides from  above  downward  without  any  extreme  degree  of  thickening 
of  the  pleural  membranes,  though  cohesion  of  their  surfaces  may  pre- 
vent its  return  over  the  lower  segment.  The  inspiratory  movement  of 
the  chest-wall  gradually  returns,  but  not  to  its  former  limit. 

Mensuratuni  shows  a  steady  diminution  in  the  size  of  the  side  in- 
volved, which  finally  becomes  smaller  than  its  fellow. 

Percussion. — The  dull  or  flat  note  gives  way  to  normal  percussion- 
resonance,  proceeding  from  above  downward  in  a  gradual  manner ;  but 
the  latter  is  not  renewed  over  the  lower  portion  of  the  pleural  cavity  for 
a  long  period  after  the  exudation  has  disappeared.  The  abnormal  areas  of 
flatness  due  to  displacement  of  organs  (liver,  spleen,  heart)  also  disappear. 

Auscultation  discloses  most  important  signs  during  the  stage  of  re- 
sorption. The  breath-sounds  reappear  at  first  above,  and  then  lower 
down,  until  the  base  is  reached.  With  commencing  subsidence  of  the 
fluid  the  respiratory  sounds  are  feeble  and  distant,  but  later  they  resume 
their  natural  distinctness ;  and  partly  as  a  result  of  the  revival  of  the 
natural  muscular  tonicity,  and  partly  in  consequence  of  the  disappear- 
ance of  the  fluid,  the  two  roughened  pleui'al  surfiices  come  in  contact 
and  play  upon  one  another,  giving  rise  to  a  rubbing,  creaking  friction- 
sound  on  auscultation.  These  friction-murmurs  may  persist  for  months 
after  the  effusion  has  been  absorbed.  Occasionally  the  lower  portion  of 
the  compressed  lung  remains  permanently  inexpansile  ;  the  upper  portion 
of  the  lung  is  now  the  seat  of  compensatory  emphysema. 

X-rays. — Williams  '  states  when  the  effusion  is  large  no  more  rays 
pass  through  it  than  through  the  liver,  and  the  outlines  of  the  dia- 
phragm, ribs,  and  heart  are  obliterated  on  the  side  of  the  effusion.  The 
fluoroscope  also  shows  the  direction  and  extent  of  cardiac  displacements 
due  to  pleural  effusions.  Williams  affirms  that  displacement  of  the 
heart  to  the  right  may  not  be  recognized  by  percussion,  even  when  it 
has  been  pushed  much  beyond  its  normal  place.  * 

Special  Clinical  Forms  of  Acute  Sero-fibrinous  Pleurisy. — 
The  heart-sounds  return  to  their  normal  position. 

(1)  Tuberculous  Pleurisy .-^This  is,  in  the  majority  of  instances,  second- 
ary to  pulmonary  tuberculosis.  On  the  other  hand,  the  primary  lesions 
maybe  situated  in  the  pleural  sac  and  give  rise  to  (1)  Acute  sero-fibrinous 
^>/t'«</7".s-?/ (with  the  usual  course);  (2)  Subacute  pleurisi/ (yviih  insidious 
course),  leading  to  tuberculous  invasion  of  the  lungs ;  and  (3)  Cftronic 
adhesive  lAeurisji,  in  which  the  course  and  physical  signs  correspond 
with  those  that  will  be  depicted  in  a  special  section  on  Chronic  Pleurisy. 

The  morbid  lesions  are  similar  to  those  met  with  in  other  forms,  plus 
the  specific  tubercles,  which  may  be  exceedingly  numerous  (miliary 
tubercles)  on  the  one  hand,  or  confined  to  a  few  circumscribed  areas  on 
the  other.  This  variety  of  pleurisy  has  no  special  etiologic  connection 
with  empyema,  and  the  effusion  is  usually  sero-fibrinous  and  often  blood- 
stained. 

Brief  reference  should  be  made  to  those  instances  in  which  tubercu- 

'  Philadelphia  Medical  Journal,  January  »5, 1900. 


SERO-FIBBINOUS  PLEURISY.  551 

lous  pleurisy  is  followed  by  tuberculous  pericarditis  or  peritonitis,  or 
both.  The  two  latter  afFections  will  be  considered  elsewhere.  Suffice  it 
to  state  here  that  tuberculosis  of  the  serous  membranes  usually  pursues 
a  chronic  course,  lasting  a  year  or  more,  and  exhibits  widely  varying 
degrees  of  intensity  in  its  symptoms  in  different  cases,  and  from  time  to 
time  in  the  same  sufferer.  We  must  grant  that  tuberculous  pleurisy 
may  pursue  a  favorable  course  with  apparent  recovery,  though  too  often, 
after  a  variable  interval  of  time,  tuberculous  symptoms  are  manifested. 

(2)  Diaphragmatic  Pleurisy. — This  term  is  applied  to  those  instances  in 
which  the  diaphragmatic  portion  of  the  pleura  is  involved,  either  alone 
or  in  part.  There  occurs  an  exudate  that  may  be  either  plastic  or  sero- 
fibrinous, though  rarely  large  in  amount.  The  symptoms  are  acute,  and 
the  pain,  which  is  lancinating  in  character  and  situated  in  the  epigastric 
region,  is  the  most  prominent  feature.  Geuneau  de  Mussy  ^  holds  that 
pain  along  the  tenth  rib,  extending  from  the  anterior  extremity  to  the 
sternum  and  xiphoid  cartilage,  is  pathognomonic.  It  is  increased  by 
deep  inspiration  and  by  pressure  over  the  insertion  of  the  diaphragm  at 
the  tenth  rib,  and  often  abates  Avhen  effusion  takes  place.  Dyspnea  is 
a  marked  symptom  in  most  cases,  and  the  patient  may  be  forced  to 
assume  a  stooping  or  sitting  posture,  the  respirations  being  superficial, 
purely  thoracic,  and  "catching."  Cough,  nausea,  and  even  vomiting, 
may  occur.  In  a  case  under  my  own  care  vomiting,  due  most  probably 
to  associated  peritonitis,  was  a  troublesome  symptom. 

The  constitutional  features  are  quite  pronounced,  and  particularly 
the  fever,  which  exceeds  that  met  with  in  other  forms  of  pleurisy.  The 
patient's  anxiety  is  extreme.  The  effusion  may  be  purulent,  and  if  so 
bulging  of  the  lower  intercostal  spaces,  followed  by  edema,  may  occur. 

The  physical  signs  are  for  the  most  part  negative. 

(3)  Encysted  Pleurisy. — This  term  has  reference  to  effusions  that  are 
circumscribed  in  consequence  of  adhesions  between  the  pleural  mem- 
branes. There  may  be  Wo  or  more  pouches,  with  or  without  communi- 
cation. This  so-called  encapsulated  pleurisy  may  occupy  any  part  of 
the  chest,  and  is  exceedingly  variable  in  extent.  The  symptoms  and 
physical  signs  are  rarely  trustworthy  for  diagnosis,  but  should  usually 
afford  ground  for  suspicion,  and  hence  should  lead  in  every  instance  to 
the  employment  of  the  exploratory  puncture. 

(4)  Interlobar  Pleurisy. — This  variety  is  usually  secondary  to,  or 
associated  with,  the  ordinary  type  of  acute  sero-fibrinous  pleurisy.  The 
serous  surfaces,  dipping  between  the  lobes,  are  involved  in  the  inflam- 
matory process,  and  the  fluid  becomes  encapsulated  in  this  position  in 
consequence  of  interlobar  pleural  adhesions.  It  is  more  frequent  on 
the  right  than  on  the  left  side,  and  its  favorite  seat  is  near  the  root  of 
the  lung,  between  the  upper  and  middle  lobes.  Osier  ^  met  w^ith  a  case 
following  pneumonia  in  which  there  was  between  the  lower  and  upper 
and  middle  lobes  of  the  right  side  an  enormous  jDurulent  collection  that 
looked  at  flrst  like  a  large  abscess  of  the  lung.  Fistulous  connection 
with  a  bronchus  often  occurs,  and  the  purulent  expectoration  that  follows 
may  be  the  first  symptom  to  attract  the  attention  to  the  process  of  sup- 
puration in  the  thorax.  Prior  to  the  occurrence  of  this  accident  the 
patient  gives  evidence  of  indisposition  without  definite  symptoms.     The 

^  Arch.  gen.  de  Med.,  1853,  vol.  si.,  quoted  by  Fox.         ^  Practice  of  Medicine,  p.  567. 


552 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


patient  may  or  may  not  give  a  clear  history  of  antecedent  pleurisy. 
These  cysts  contain,  as  a  rule,  but  a  small  amount  of  fluid,  and  do  not 
cause  much  bulging  of  the  intercostal  spaces.  Indeed,  in  a  case  of  my 
own  at  the  Philadelphia  Hospital  there  was  actual  retraction,  though  the 
aspirating  needle  showed  the  presence  of  effusion.^ 

(5)  Hemorrhagic  Pleurisy. — By  this  term  is  meant  an  admixture  of 


Fig.  47. — Illustrating  pleurisy  with  efifusion :  1,  compressed  lung-tissue,  giving  dull  tympany  on  per- 
cussion ;  2,  fluid  exudation  obliterating  intercostal  spaces  ;  3,  depressed  liver ;  4,  displaced  heart. 

blood  with  the  exudate  in  acute  sero-fibrinous  pleurisy,  in  quantities  suf- 
ficient to  be  detectable  by  the  unaided  eye.  The  condition  must  be  sep- 
arated from  hemothorax.  The  causes  of  hemorrhagic  pleurisy  are — (1)  Tu- 
berculous infection,  either  of  the  miliary  or  the  chronic  (circumscribed) 
form,  following  tuberculous  disease  of  the  lung ;  (2)  Carcinoma  of  the 
pleura;  (3)  Bright's  disease  and  cirrhosis  of  the  liver;  (4)  Adynamic  states 
of  the  system  associated  with  malignant  forms  of  acute  infectious  diseases 
(pneumonia).  (5)  Advanced  age  and  alcoholism  are  among  tlie  contrib- 
uting conditions. 

'  liilernalional  Clinics  (1894),  vol.  i.  p.  39. 


SEBO-FIBRINOUS  PLEURISY. 


553 


In  a  certain  proportion  of  the  cases  no  assignable  cause  can  be  found, 
and  if  the  condition  be  observed  for  the  first  time  after  aspiration,  the 
fact  that  it  may  have  been  engendered  by  an  accidental  Avound  of  the 
lung  must  be  remembered. 

Diagnosis. — In  diagnosticating  pleurisy  our  attention  must  be 
directed  chiefly  to  the  physical  signs.  Unfortunately,  in  view  of  the 
fact  that  the  rational  symptoms  are  often  ambiguous,  a  physical  explor- 
ation of  the  chest  is  apt  to  be  neglected.  The  chief  difficulties  are 
encountered  in  distinguishing  this  affection  from  conditions  in  which 
the  lung  is  either  consolidated,  retracted,  or  compressed  by  solid  new 
growths,  etc.  Chief  among  the  former  is  crowpous  pneumonia,  and  I. 
have  tabulated  below  the  most  important  distinctions  between  it  and 
pleurisy.  The  reader  will  be  further  aided  by  comparing  Fig.  47 
(which  shows  the  physical  conditions  in  pleurisy)  with  Fig.  17,  on 
page  150,  which  shows  the  physical  conditions  in  pneumonia. 


Pleurisy  with  Effusion. 


Primary  Lobar  Pneumonia. 


Rational  Symptoms. 


Onset  marked  by  chilliness,  persisting  for 
a  few  days. 

The  pain  is  sharp,  "  stitch-like,"  and 
strictly  localized. 

Cough  frequent  and  irritating ;  no  ex- 
expectoration,  or  catarrhal. 

Absent. 

Moderate  fever  of  continuous  type ;  de- 
cline by  lysis. 

Systemic  prostration  (moderate). 

Countenance  pale  and  anxious. 

Herpes  does  not  appear. 


Onset  acute,  rigor,  lasting  one  hour. 

Acute  pain,  similar,  but  soreness  more 

diffused. 
Cough  accompanied  by  rusty  or  bloody 

expectoration. 
Sputum  shows  presence  of  pneumococcus. 
Intense  fever  ;  decline  by  crisis  from  the 

fifth  to  the  ninth  day. 
Prostration  marked. 
Countenance  congested  ;  mahogany  flush 

on  the  cheeks. 
Herpes  quite  common. 


Physical  Signs. 


Inspection. 
Marked  distention  of  the  thorax. 

Palpation. 
Diminished  or  absent  tactile  fremitus. 

Percussion. 

Flatness,  with  great  resistance  to  the 
pleximeter-finger. 

Shows  displacement  of  neighboring  or- 
gans.. 

If  the   sac   be   partly  filled,   there   is  a 
change  in  the  line  of  flatness  on  change 
of  position. 
Auscultation. 

Diminished  or  absent  breath-sounds, 
bronchial  breathing  frequent,  but  dif- 
fused and  distant  and  unaccompanied 
by  rales,  as  a  rule. 

Vocal  resonance  diminished  or  absent; 
egophony. 

Triction-sound  in  early  and  late  stages. 

Aspiration. 
Yields  serum. 


None. 

Marked  tactile  fremitus  (absent  only 
when  a  bronchus  is  plugged). 

Dulness  less  complete,  less  resistance, 
and  sometimes  a  tympanitic  note. 

No  displacement  of  neighboring  organs, 
if  uncomplicated. 

Absent. 


Harsh  bronchial  breathing  and  presence 
of  rales  in  first  and  third  stages,  unless 
a  bronchus  be  plugged. 

Bronchophony  (loud),  unless  a  bronchus 

be  blocked. 
No  friction-sound,  except  crepitant  rtles 

in  the  first  stage. 

Yields  a  few  drops  of  thick  blood. 


554  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Consolidation  of  the  lung,  due  to  tuberculous  infection,  may  be  dif- 
ferentiated from  pleuris}'^  ^vith  effusion  by  means  of  the  physical  signs 
contrasted  in  the  foregoing  table,  by  the  history  of  the  case,  and  by  the 
discovery  of  the  tubercle  bacillus  in  the  sputum. 

Hydrothorax  presents  physical  signs  that  simulate  strongly  those  of 
pleural  effusion.  Hydrothorax,  however,  gives  the  history  of  cardiac 
or  renal  disease,  is  oftener  bilateral,  and  is  unassociated  Avith  a  rise  in 
temperature  or  with  the  pain  or  friction-sounds  peculiar  to  pleurisy.  In 
hydrothorax  the  withdrawn  fluid  has  a  specific  gravity  below  1015, 
while   that  of  the   pleural  exudate  is  above  1017. 

Tumors  and  cysts  of  the  thorax  will  give  complete  dulness,  will  dis- 
place the  heart,  and  compress  the  lung  on  the  affected  side,  thus  caus- 
ing an  absence  of  the  respiratory  murmur,  etc.  But  the  history  of  the 
case,  the  situation  of  the  dulness  (usually  over  the  upper  or  middle  parts 
of  the  lung),  the  absence  of  uniform  distention  extending  to  the  base, 
and  the  exaggerated  tactile  fremitus  and  vocal  resonance  will  serve  to 
distinguish  these  affections  from  pleurisy  with  effusion. 

Echinococcus  cyst  of  the  liver,  or  abscess  of  this  organ,  pushing  up- 
ward, Avill  cause  retraction  or  even  compression  of  the  lung,  and  hence 
will  also  produce  most  of  the  physical  signs  of  pleurisy  with  effusion. 
The  former  affections  can  be  discriminated  only  by  a  correct  appreciation 
of  the  history,  by  the  presence  not  infrequently  of  a  friction-sound  on 
auscultation,  and  by  the  immovable,  fixed  upper  convex,  boundary  of 
dulness.  If  doubt  .remains,  an  exploratory  puncture  should  be  made, 
and  the  fluid  withdrawn  should  be  subjected  to  a  chemical,  microscopic, 
and  bactcriologic  investigation. 

An  enormous  pericardial  effusion  may  be  mistaken  for  a  pleural  effu- 
sion on  the  left  side.  In  the  former,  however,  there  is  commonly  a  his- 
tory of  rheumatism,  and  dyspnea  is  the  most  urgent  symptom,  while 
the  heart-sounds  are  greatly  enfeebled ;  moreover,  the  heart  is  not  dis- 
placed to  the  right  as  in  pleural  effusion.  Again,  flat  tympany  is  ob- 
tained in  the  posterior  portion  of  the  axilla  and  good  pulmonary  reson- 
ance at  the  base  in  the  postero-lateral  region  of  the  chest,  differing  from 
the  results  of  percussion  in  pleuritis. 

For  practical  purposes  it  is  desirable  to  distinguish  the  tuberculous 
from  the  rarer  forms  of  pleurisy.  This  is  sometimes  possible  by  paying 
due  regard  to  the  previous  history  of  the  patient,  including  hereditary 
taint,  by  noting  certain  clinical  peculiarities  (such  as  associated  dis- 
ease of  other  serous  membranes  and  of  the  lung  and  bilateral  inflam- 
mation of  the  pleura),  and  by  the  results  of  an  examination  of  the 
exudate.  In  a  dubious  case  the  guinea-pig  should  be  inoculated  Avith 
the  exudate,  and  if  the  patient  be  tuberculous  positive  results  may  be 
confidently  expected. 

Duration  and  Prognosis. — This  depends  largely  upon  the  cause. 
The  course  of  acute  sero-fibrinous  pleurisy  is  not  definite,  but  is  made  up 
of  two  parts — the  febrile  followed  by  the  non-febrile  stage.  The  fever 
lasts  from  one  to  three  weeks,  and  is  due  to  inflammation ;  it  corre- 
sponds to  the  period  when  the  effusion  occurs,  and  the  appearance  of  a 
non-febrile  period  indicates  the  subsidence  of  the  inflammatory  action. 
The  effusion  may  be  poured  out  rapidly,  and  is  removed  by  absorption 
not   less   rapidly ;  more    commonly,   however,  the   effusion   takes   place 


SEBO-FIBETNOUS  PLEURISY.  555 

rather  gradually,  and  the  same  is  true  of  resolution.  Again,  large 
effusions  may  persist  in  consequence  of  a  purely  mechanical  hindrance 
to  resorption ;  and  finally,  the  course  may  become  subacute  or  chronic 
in  consequence  of  the  development  of  empyema.  The  continued  absence 
of  bacteria  in  the  pus  speaks  for  tuberculosis.  Such  facts  as  these  con- 
stitute an  explanation  for  the  great  differences  in  the.  duration  of  the 
cases.  Simple  sero-fibrinous  pleurisy,  including  the  hemorrhagic  variety, 
unless  it  appears  as  a  complication  in  the  later  stages  of  some  other 
grave  disease,  has  a  comparatively  favorable  prognosis.  Death  rarely 
ensues  suddenly,  without  adequate  lesions  to  explain  its  occurrence. 
Moreover,  the  fact  that  a  sero-fibrinous  effusion  may  be  converted  into 
a  purulent  one  is  not  to  be  forgotten.  Again,  the  crippling  influence 
upon  the  lung-tissue  of  previous  attacks,  owing  to  resulting  adhesions, 
must  be  borne  in  mind,  since  chronic  bronchitis  and  emphysema  often 
supervene. 

Treatment. — In  the  first  stage  the  treatment  is  the  same  as  for  dry 
or  plastic  pleurisy.  During  the  second  stage,  that  of  effusion,  the  objects 
of  treatment  are  threefold :  (!)  To  limit  the  extent  and  intensity  of  the 
inflammatory  process ;  (2)  To  accomplish  the  removal  of  the  effusion ; 
and  (3)  To  support  the  strength  of  the  patient. 

(1)  To  Limit  the  Extent  and  Intensity  of  the  Inflammatory  Process. — 
To  this  end  two  classes  of  agents  are  employed — namely,  («)  Internal, 
and  (h)  External. 

Among  the  latter  are  counter-irritants,  as  sinapisms  and  iodin,  by 
means  of  which  gentle  but  constant  counter-irritation  is  to  be  main- 
tained. Another  agent  of  great  worth  is  cold,  applied  by  means  of  the 
ice-bag  or  ice-water  bag,  and  if  the  temperature  rises  to  102°  F.  (38.8°  C.) 
cool  spongings  of  the  surface  of  the  body,  together  with  the  use  of  the 
ice-cap,  will  be  found  highly  useful.  Roberts  recommended  keeping 
the  affected  structures  at  complete  rest  by  fixing  in  a  mechanical  manner 
the  side  affected.  ,  For  this  purpose  strips  of  adhesive  plaster  must  be 
firmly  and  evenly  applied  to  the  chest,  and  by  this  means  the  pain  is 
relieved  and  the  amount  of  inflammatory  product  poured  out  is  greatly 
limited. 

The  internal  remedies  embrace  quinin,  the  salicylates,  and  opium. 
Opium  and  quinin  are  potent  in  controlling  inflammation  of  serous 
membranes ;  the  former  being  given  preferably  either  in  the  form  of 
suppositories  or  hypodermically,  and  the  latter  in  divided  doses,  in  cap- 
sule, followed  by  a  few  drops  of  mineral  acid,  administering  gr.  xvj  to 
XX  (1.036-1.296)  daily. ^  I  have  observed  good  results  from  the  salicy- 
lates (oj-ij — 4.0-8.0,  daily),  which  have  been  warmly  advocated  by 
Fiedler,  Koester,^  and  others,  as  valuable  in  mitigating  or  even  aborting 
the  inflammation  of  the  pleurae,  and  thus  in  limiting  the  amount  of 
effusion.  It  must  not  be  forgotten  that  the  effusion  is  due  to  an  inflam- 
mation, and  not  to  a  simple  transudation.  The  use  of  mild  diaphoretics 
and  diuretics,  coupled  with  repeated  small  closes  of  salines,  also  aids  in 
reducing  the  inflammation  in  the  pleura.  With  a  subsidence  of  the 
inflammatory  process  the  temperature  falls,  and,  when  the  latter  reaches 
a  point  near  to  the  normal,  our  efforts  should  be  directed  toward  the 

^  International  Clinics  (1892),  vol.  i.,  second  series. 

^  Annual  of  the  Universal  Medical  Sciences  (1893),  vol.  i.  (A-31). 


556  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

fulfilment    of   the  second    leading   indication,   (2)   the  removal  of   the 
effusion. 

Little  is  to  be  accomplished  by  local  means,  though  iodin,  per- 
sistently employed,  sometimes  does  good.  The  folloAving  ointment  may 
also  be  tried : 

I^.   Ung.  ichthyol.  (12  per  cent.), 

Ung.  iodinii  comp.,  da.  .5vj  (24.0); 

Ung.  belladonnae,  q.  s.  ad  sij  (64.0). — M. 

Sig.  Apply  twice  daily. 

Blisters  are  not  admissible. 

Mild  hydragogue  cathartics,  and  especially  the  salines,  after  the 
Matthew  Hay  method  (/.  e.  .^ij  to  sss — 8.0-16.0,  in  the  smallest  possible 
amount  of  Avater,  on  rising  in  the  morning),  stimulate  absorption  from 
the  pleural  cavities  by  draining  the  blood  of  a  certain  amount  of  serum. 
Unirritating  diuretics  may  also  be  employed,  but  I  have  found  no  appre- 
ciable advantage  from  their  use.  Free  diaphoresis  (from  the  use  of  pilo- 
carpin)  sometimes  assists  in  the  absorption  of  the  exudate,  but  it  should 
not  be  employed  in  the  presence  of  feeble*  heart-action  or  marked  dis- 
placement of  the  organ.  Among  measures  to  promote  absorption,  the 
best,  in  my  own  experience,  is  the  following  combination  : 

]^.  Potassii  iodidi,  3j   (4.0); 

Syr.  ferri  iodidi,  3ij(8.0); 

Syr.  sarsap.  comp.,  5j   (32.0); 

Ess.  pepsinjB,  q.  s.  ad  |ij  (64.0). — M. 

Sig.  3j  (4.0)  every  four  hours,  diluted;  the  dose  to  be  doubled  at 
the  end  of  four  days  if  well  borne  by  the  stomach.^ 

The  patient  should  be  put  upon  a  dry  diet  in  order  to  increase  the 
plasticity  of  the  blood,  which  is  thus  induced  to  absorb  the  liquid  exu- 
date from  the  pleural  cavity.  The  modus  operandi  of  this  treatment  is 
different,  but  the  effect  aimed  at  is  the  same  as  when  saline  purgatives 
are  given.  The  exudation,  however,  defies  all  efforts  at  removal  in  about 
33  per  cent,  of  the  cases,  and  in  such  the  withdrawal  of  the  liquid  by 
aspiration  (thoracentesis)  must  be  practised.  The  indications  for  thora- 
centesis arise  at  two  different  periods  in  the  course  of  pleurisy  with 
effusion  : 

(1)  During  the  febrile  stage,  while  efforts  are  being  directed  to  com- 
bating the  inflammatory  process.  The  object  during  this  stage  is  to 
avert  imminent  danger  to  life,  and  not  merely  to  remove  the  fluid. 
The  conditions  demanding  immediate  thoracentesis  are — {a)  when  one 
pleural  sac  is  completely  filled  or  Avhen  Skoda's  resonance  extends  from 
the  clavicle  downward  no  farther  than  the  second  inter.space ;  (b)  in 
double  pleurisies,  when  both  sides  are  half  filled,  since  death  may  occur 
from  rapid  filling  of  one  or  the  other  side ;  {c)  in  cases  of  copious  effu- 
sions, upon  the  first  signs  of  involvement  of  the  unaffected  side,  such  as 
moist  rales,  broncho-vesicular  breathing,  and  impaired  resonance ;  {d) 
the  appearance  of  serious  symptoms,  such  as  orthopnea  or  syncopal 
attacks  with  cyanosis ;  (e)  marked  displacement  of  the  heart,  especially 
if  one  or  more  murmurs  develop  in  the  organ. 

^  Tlie  author  has  employed  this  formula  in  more  than  60  cases  with  very  good  results. 


SEBO-FIBRINOUS  PLEURISY.  557 

(2)  The  indications  for  aspiration  during  the  second  or  afebrile 
period,  when  the  main  object  is  to  remove  the  exudate,"  are — (a)  if  no 
diminution  in  the  quantity  of  liquid  effusion  has  taken  place  one  week 
after  the  temperature  has  reached  the  normal ;  (b)  in  subacute  cases, 
in  which  there  is  little,  if  any,  temperature  from  the  beginning;  aspira- 
tion should  not  then  be  withheld  longer  than  three  weeks. 

The  operation  is  free  from  danger  if  carried  out  under  antiseptic  pre- 
cautions and  if  a  modern  aspirator  is  employed.  The  instrument  should 
ahvays  be  tested  before  it  is  used.  The  patient  rests  in  bed  in  the  semi-re- 
cumbent posture,  the  arm  of  the  affected  side  being  brought  forward  with 
the  hand  placed  on  the  opposite  shoulder,  so  as  to  separate  the  ribs  from 
one  another.  The  point  of  puncture  is  in  the  sixth  interspace  on  the  right- 
hand  side  and  the  seventh  interspace  on  the  left,  in  the  mid-axilla,  or 
just  below  the  outer  angle  of  the  scapula  in  the  seventh  right  and  eighth 
left  interspaces,  respectively.  An  assistant  draws  up  the  skin  from  the 
interspace,  while  the  operator  uses  the  fore  finger  of  his  free  hand  as  a 
director.  The  needle  should  be  introduced  with  a  quick  thrust,  hug- 
ging the  rib  below  the  interspace,  but  endeavoring  to  avoid  striking  its 
periosteal  covering.  The  fluid  may  not  be  obtained  at  the  first  opera- 
tion, and  the  reasons  for  this  failure  are  several.  The  costal  pleura 
may  be  excessively  thickened,  or  we  may  meet  with  a  much-thickened 
fibrous  band.  Again,  the  fluid  may  be  encapsulated ;  and,  lastly,  the 
needle  may  become  blocked.  Under  these  circumstances  repeated  trials 
should  be  made. 

The  amount  of  fluid  withdrawn  at  one  time  should  never  be  large 
(|xij  to  xxiv — 384.0-768.0),  though  a  relatively  larger  quantity  may 
be  taken  during  the  febrile  stage  than  during  the  afebrile,  since  in  the 
latter  instance  the  lung  has  been  compressed  for  a  longer  period  of  time. 
The  fluid  is  allowed  to  drain  away  slowly,  a  small  needle  being  used,  so 
as  to  invite  the  lung  to  expand  in  a  gradual  manner.  If  this  precaution 
be  not  taken,  the  paretic  pulmonary  capillaries  are  apt  to  become  the 
seat  of  sudden  fresh  congestion,  followed  by  edema,  and  often  by  a 
speedily  fatal  termination.  Thoracentesis  is  to  be  repeated  at  intervals 
of  several  days  if  nature  does  not  take  up  the  work  of  absorption,  fol- 
lowing the  first  operations.  If  during  the  operation  incessant  cough, 
dyspnea,  a  tendency  to  syncope,  marked  thoracic  constriction,  or  sudden 
intense  pain  be  developed,  the  needle  must  be  withdrawn  instantly. 

Thoracentesis  should  not  be  resorted  to  in  cases  in  which  croupous 
pneumonia  is  associated,  and  never  in  very  aged  and  excessively  feeble 
persons. 

(3)  To  Support  the  Strength  of  the  Patient. — The  powers  of  the  sys- 
tem are  to  be  maintained  by  a  nutritious  diet,  bodily  rest,  and  other 
hygienic  measures.  The  lighter  forms  of  solid  food  may  be  allowed 
whenever  they  are  found  to  agree,  and  it  is  important  to  promote  the 
digestive  poAver,  should  the  latter  be  weak,  by  the  administration  of 
suitable  remedies.  During  the  stage  of  convalescence,  therefore,  tonics 
(strychnin,  quinin,  and  arsenic)  are  to  be  administered.  The  dietary 
should  be  liberal,  though  composed  of  wholesome  articles.  Gentle  exer- 
cise in  the  open  air  is  to  be  encouraged,  and  massage  of  the  muscles  of 
the  affected  side  tends  to  re-establish  their  usual  vigor.  To  bring  about 
the  best  possible  chest-expansion  nothing  is  so  good  as  light  gymnastic 


558  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

exercises,  together  Avith  the  methodical  practice  of  deep  inspirations  for 
a  minute  or  two  at  intervals  of  three  or  four  hours.  I  am  of  opinion 
that  the  management  of  the  third  stage,  or  that  of  convalescence,  is 
similar  to  that  of  tuberculosis. 


EMPYEMA    (purulent   PLEURITIS). 

Definition. — A  suppurative  inflammation  of  the  pleura. 

Pathology. — On  opening  the  pleural  sac  after  death  we  may  find  a 
thick,  creamy  pus,  though  more  frequently  it  is  sero-purulent  and  sepa- 
rated into  two  layers — an  upper,  clear,  greenish-yellow  serous,  and  a 
lower,  thick,  purulent  layer.  In  a  smaller  proportion  of  cases  the  exu- 
date is  fibrino-purulent.  The  odor  emitted  from  the  purulent  collection 
is  either  sweetish  or  fetid  (e.  g.  when  due  to  wounds),  and,  when  the 
condition  is  associated  with  gangrene  of  the  lung  or  pleura,  horribly 
oftensive.  Microscopic  examination  shows  that  the  inflammatory  prod- 
ucts are  identical  with  those  of  purulent  inflammation  in  general  The 
pleural  membranes  are  the  seat  of  a  more  intense  inflammation  than  in 
acute  sero-fibrinous  pleurisy,  and  are  greatly  thickened  (1  to  2  mm.). 
They  present  a  granular  suppurating  surface,  and  both  visceral  and 
costal  pleurge  exhibit  perforations,  and  the  latter,  often  erosions. 

Histologically,  the  altered  membranes  consist  of  new  connective  tis- 
sue, new  blood-vessels,  and  numerous  leukocytes. 

Htiology. — The  following  are  the  chief  circumstances  under  which 
empyema  arises :  (1)  As  a  sequel  of  the  acute,  sero-fibrinous  variety. 
However  clear  the  effiision  may  be,  it  always  contains  corpuscular  ele- 
ments, which  in  the  further  progress  of  certain  cases  undergo  coincident 
increase  in  numbers  until  tlie  effusion  presents  a  milky  aspect,  when  it 
is  said  to  be  purulent.  Thoracentesis  may  be  responsible  for  this 
change,  though  never  if  performed  under  rigid  aseptic  precautions. 

(2)  In  children  the  effusion  early  becomes  purulent  in  many  instances. 

(3)  Secondary  to  the  acute  and  chronic  infectious  diseases — blood 
metastasis — (pyemia,  scarlatina,  pneumonia,  tuberculosis,  and  dysentery 
most  frequently  ;  typhoid  fever,  measles,  whooping-cough  rarely). 

(4)  Secondary  to  malignant  affections  of  contiguous  organs  (lungs, 
esophagus),  or  tuberculous  cavities  which  perforate  the  pleura.  Rarely, 
carious  ribs  and  vertebrae  may  cause  empyema. 

(5)  Lymphatic  metastasis  is  probably  an  important  means  by  which 
bacteria  reach  the  pleura  from  neighboring  but  not  contiguous  tissues 
(McFarland). 

(6)  Injuries  to  the  chest  may  set  up  empyema  (fracture  of  the  ribs, 
stab  or  other  penetrating  wounds). 

Bacteriologic  investigation  has  shown  that  the  organisms  most  fre- 
quently present  are  the  micrococcus  lanceolatus  {meta-pneiimonia),  strep- 
tococcus, staphylococcus,  and  tubercle  bacillus.  The  cases  due  to  pneu- 
niococci  usually  pursue  a  favorable  course.  The  leptothrix  pulmonalis 
is  often  found  in  ])utrid  effusions. 

Clinical  History. — The  symptoms  vary  with  the  cause.  The  on- 
set may  be  characterized  by  acute  symptoms,  such  as  rigor,  followed  bv 
high  temperature  and  signal  prostration,  and  in  the  affected  side  there 
may  be  severe  pains,  aggravated  by  deep  breathing  and  bodily  move- 
ments. 


E3IPYEMA.  559 

If  the  exudate  becomes  gangrenous,  a  typhoid  state  develops  early, 
and  the  case  is  apt  to  prove  fatal  in  the  course  of  a  few  weeks.  It  is 
quite  a  common  event  for  the  acute  symptoms  that  characterize  the  in- 
vasion to  be  replaced  at  the  end  of  a  week  or  more  by  the  more  obscure 
rational  symptoms  of  chronic  empyema.  The  latter,  however,  may  de- 
velop very  insidiously  as  a  secondary  affection.  The  rational  symptoms 
in  a  well-marked  case  should  always  excite  a  suspicion  of  the  presence 
of  the  affection,  but  cannot  set  the  question  of  diagnosis  at  rest.  The 
heal  symptoms  (pain  cough,  and  expectoration)  are  of  a  mild  character ; 
the  dyspnea,  however,  that  is  usually  present  may  be  more  or  less  in- 
tense. I  have  on  more  than  one  occasion  found  an  utter  absence  of 
these  symptoms.  The  general  symptoms  are  those  of  septic  infection — 
diurnal  chills  occurring  at  irregular  intervals,  followed  by  intense  parox- 
ysms of  fever  and  profuse  sweating — and  such  patients  lose  flesh  and 
grow  pale  and  weak.  The  temperature  is  higher  than  in  pleurisy  with 
effusion  and  is  intermittently,  though  irregularly,  elevated. 

Peptonuria  is  a  symptom  of  purulent  pleurisy  that  is  not  without 
diagnostic  value.  It,  however,  also  occurs  in  suppuration  associated 
with  the  third  stage  of  pulmonary  tuberculosis,  and  ii5  suppuration  due 
to  other  causes.  While  not  indicative  of  empyema,  it  nevertheless  serves 
sometimes  to  eliminate  sero-fibrinous  pleurisy.  The  urine  also  con- 
tains indican  in  excess  in  the  various  suppurations,  at  least  from 
time  to  time,  if  not  constantly.  Blood-examination  invariably  shows 
leukocytosis. 

If  the  pus  is  not  removed  artificially,  it  frequently  breaks  into  the 
lung,  penetrates  it,  and  finally  discharges  through  a  bronchus.  Pneu- 
mothorax now  tends  to  supervene.  Traube  contends  that  necrosis  of 
the  pulmonary  pleura  may  allow  of  the  soaking  of  the  pus  through  the 
spongy  lung-tissue  into  the  bronchi,  without  the  establishment  of  a  fis- 
tulous connection  between  the  latter  and  the  pleural  sac,  and  hence 
without  the  formation  of  pneumothorax.  Besides  rupture  into  the 
lung  and  external  rupture,  empyema  may  perforate  neighboring  organs, 
as  the  esophagus,  pericardium,  stomach,  and  peritoneum.  In  rare  in- 
stances the  pus  burrows  along  the  spine  behind  the  peritoneum  and  the 
psoas  muscle,  reaching,  finally,  the  iliac  fossa  and  simulating  psoas  or 
lumbar  abscess. 

Physical  Signs. — These  are,  for  the  greater  part,  identical  with  those 
of  pleurisy  with  effusion.  Attention  will  therefore  be  called  only  to 
such  as  are  more  or  less  distinctive  of  the  affection.  Slight  edema  of 
the  chest-wall  over  the  seat  of  effusion,  especially  in  children,  is  often 
present,  and  if  the  pleural  sac  be  not  aspirated,  the  abscess  may  point 
externally  and  evacuate  itself  spontaneously.  In  the  latter  event  a  pro- 
trusion betw'een  the  ribs  shows  itself:  this  may  be  the  seat  of  fluctua- 
tion, and  present  an  inflammatory  appearance  prior  to  its  rupture,  with 
subse(}uent  discharge  of  its  contents.  The  opening  is  usually  found  in 
the  fifth  interspace  in  front,  and  less  frequently  in  the  third  and  fourth 
interspaces  or  below  the  angle  of  the  scapula  behind.  The  upper  level 
of  the  fluid  does  not  change  so  readily  on  changing  the  posture  of  the 
patient,  but  requires  a  longer  period  of  time. 

Baccellis  sign,  or  the  transmission  through  a  serous  exudate  of  the 
whispered  voice,  is  sometimes  an  aid  in  the  discrimination  of  pleurisy 


560  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

with  effusion  from  empyema.  According  to  my  own  observation,  though 
it  is  not  invariably  propagated  by  large  serous  exudations  of  the  pleura, 
it  is  yet  detectable  in  a  large  majority  of  instances,  whilst  I  have  never 
observed  it  in  empyema. 

Pulsating  Pleurisy. — Pulsation  synchronous  with  the  cardiac  beat  in 
pleural  eftusion  has  received  various  designations  {ptdsating  empyema, 
empyema  necessitatis,  pulsating  pleurisy).  The  latter  term  is  the  most 
appropriate  one,  in  view  of  the  fact  that  it  occurs  not  only  in  empyema 
necessitatis,  but  also  in  empyema  (which  manifests  no  tendency  to  point 
externally)  and  rarely  in  sero-fibrinous  pleurisy. 

Its  etiology  is  not  definitely  known.  The  principal  causal  factors, 
however,  seem  to  be — (1)  a  copious  eifusion  ;  (2)  paresis  of  the.  inter- 
costal muscles,  inducing  relaxation  of  the  thoracic  wall ;  (3)  a  somewhat 
forcible  heart-beat  (Henry).  The  rational  symptoms  of  empyema  are 
present.  The  physical  signs  are  also  identical  with  those  of  the  latter 
affection,  with  the  pulsation  superadded.  There  are  instances  in  which 
palpation  alone  detects  the  systolic  pulse  in  the  pleural  effusion.  With 
rare  exceptions  the  effusion  occupies  the  left  pleural  sac.  The  pulsation 
may  be  limited  to"  two  or  three  interspaces  or  it  may  be  visible  over  the 
entire  antero-lateral  aspect  of  the  chest ;  pulsation  at  the  back,  however, 
is  rare. 

DiflFerential  Diagnosis. — An  absolute  distinction  between  empy- 
ema and  pleurisy  with  effusion  rests  solely  upon  the  results  of  an  aseptic 
exploratory  puncture.  For  this  purpose  the  needle  attached  to  the  ordi- 
nary hypodermic  syringe,  or,  preferably,  the  surgeon's  exploring-needle, 
may  be  employed,  withdrawing  but  a  very  small  quantity  of  the  fluid, 
which,   if  purulent  in  character  should  be  examined  bacteriologically. 

Pulsating  pleural  effusion  simulates  closely  aneurysm  of  the  thoracic 
aorta.  When  pulsation  occurs  in  empyema,  however,  it  is  seen  to  be  to 
the  left  of  the  normal  course  of  the  aorta :  the  rational  symptoms  and 
usual  physical  signs  of  purulent  pleural  effusion  are  usually  present  also, 
while  the  vascular  symptoms  and  signs  of  aneurysm  of  the  aorta  (thrill, 
bruit)  are  absent. 

Prognosis. — Empyema  is  a  serious  disease,  but,  obviously,  the  out- 
look Avill  be  modified  by  the  special  etiology.  Spontaneous  absorption 
may  occur,  though  it  is  extremely  rare.  The  discharge  of  the  contents 
of  the  pleural  sac  through  the  bronchial  tubes  is  a  comparatively  f^ivor- 
able  event,  some  cases  in  which  this  occurs  recovering,  while  in  others 
death  follows  in  consequence  of  the  sudden  inundation  of  the  bronchi. 
An  empyema  may,  in  rarer  cases,  empty  itself  externally  with  favorable 
issue  [empyema  necessitatis).  Evacuation  of  the  pleural  cavity  is  often 
followed  by  a  continuous  discharge  of  pus  for  an  indefinite  period.  As 
a  result  of  the  long-continued  suppurative  process,  death  may  take  place 
by  slow  asthenia.  It  must  not  be  forgotten,  however,  that  an  unfavor- 
able termination  may  be,  in  part  at  least,  ascribable  to  certain  associated 
affections  (phthisis,  pericarditis).  Double  empyema,  fortunately  a  rare 
condition,  is  exceedingly  grave. 

Among  children  the  outlook  is  much  more  favorable  than  among 
adults.  The  prognosis  has  been  rendered  less  serious  by  the  applica- 
tion of  surgical  principles  in  the  treatment  of  the  disease.  In  all  cases 
in  which  recovery  ensues  there  is  a  progressive  obliteration  of  the  pleural 


EMPYEMA.  561 

cavity,  owing  to  adhesions,  which  finally  become  universal  and  lead  to 
marked  retraction  of  the  affected  side  (pleuritis  retrahens). 

Treatment. — The  treatment  of  empyema  is  chiefly  surgical.  In  a 
child  the  condition  may  terminate  in  recovery  without  operation,  and 
hence  may,  at  this  period  of  life,  be  allowed  to  run  for  two  or  three  weeks, 
thoracentesis  being  resorted  to  if  suffocation  be  threatened.  In  an  adult, 
however,  if  the  purulent  effusion  be  copious,  aspiration  should  be  per- 
formed at  once  as  a  temporary  means  of  relief.  Empyema  following  pneu- 
monia may  terminate  favorably  after  one  or  more  tappihgs ;  but  unless 
contraindicated  by  an  unfavorable  general  condition  of  the  patient,  such 
as  is  met  with  in  the  closing  stages  of  pulmonary  tuberculosis,  free  incision 
should  be  made  without  delay.  The  pleural  sac  should  be  opened  in  the 
fifth  or  sixth  interspace  to  the  left  of  the  mammary  line,  the  incision 
being  from  2  to  3  cm.  in  length.  Resection  of  a  rib  (Estlander's  opera- 
tion) is  advocated,  but  if  the  drainage  afforded  by  free  incision  be  complete 
resection  is  unnecessary.  It  is  only  indicated  when,  by  approximation 
of  the  ribs,  the  free  exit  of  the  pus  is  hindered  (Verebeyli  ^).  Opinions 
are  divided  as  regards  the  value  of  irrigation  of  the  pleural  cavity. 
When  the  pus  emits  an  offensive  odor  irrigation  with  a  disinfecting 
solution  is  imperative.  Carbolic  acid  should,  however,  not  be  used. 
In  rare  instances  accidents  arise  during  irrigation  (sudden  collapse, 
convulsions),  and  I  have  repeatedly  observed  a  dangerous,  and  in  one 
instance  a  fatal,  collapse  as  the  result  of  irrigation  in  children.  The 
careful  insertion  of  a  roll  of  iodoform  gauze  is  a  method  to  be  preferred 
to  irrigation,  except  Avhen  the  effusion  is  stinking.  For  further  details 
in  the  operative  treatment  of  empyema  the  reader  is  referred  to  text- 
books on  surgery.  Every  effort  should  be  made  to  favor  obliteration  of 
the  cavity  during  post-operative  treatment.  The  indication  is  to  bring 
about  the  best  possible  degree  of  re-expansion  of  the  compressed  lung, 
and  in  order  to  accomplish  this  the  method  advised  by  Ralston  James 
has  been  practised  with  great  success  in  the  surgical  wards  of  the  Johns 
Hopkins  Hospital.  The  patient  daily  for  a  certain  length  of  time,  in- 
creasing gradually  with  the  increase  of  his  strength,  transfers  water  by 
air-pressure  from  one  bottle  to  another.  The  bottles  should  be  large, 
holding  at  least  a  gallon  each,  and  by  an  arrangement  of  tubes,  as  in 
the  Wolff  bottle,  an  expiratory  effort  of  the  patient  forces  the  water 
from  one  bottle  into  the  other.  In  this  way  expansion  of  the  com- 
pressed lung  is  systematically  practised.  The  abscess-cavity  is  gradu- 
ally closed,  partly  by  the  falling  in  of  the  chest-wall  and  partly  by  the 
expansion  of  the  lung.^  In  long-standing  cases,  in  which  the  lung  cannot 
expand  on  account  of  thick  bands  of  adhesion,  the  pleural  layers  can- 
not be  brought  into  juxtaposition  without  more  or  less  sinking  in  of 
the  chest-Avall.  De  Lorme's  operation  (stripping  the  pseudo-membrane 
from  the  compressed  lung)  may  be  advisable.  This  retraction  of  the 
thorax  is  probably  hastened  by  timely  resection  of  one  or  more  ribs,  the 
amount  of  bone  to  be  removed  depending  upon  the  "  expansive  power 
of  the  lung  and  elasticity  of  the  thorax." 

The  duration  of  empyema  is  longer  than  in  pleurisy  with  effusion, 
and  the  former  affection  tends  to  exhaust  to  a  greater  degree  the  powers 
of  the  system  than  the  latter ;  hence  the  physician's  attention  should  be 

^  Quoted  in  Annual  of  the  Universal  Med.  Sciences,  1892,  vol.  i.  sec.  A. 
^  Osier's  Text-book  of  Medicine,  p.  605. 
36 


562  DISEASES  OF  THE  RESPIRATORY  SYSTE3L 

directed  to  the  support    of  the   vital  forces   by  all  possible    agencies, 
modified  to  some  extent  by  the  special  etiology  of  the  case. 

CHRONIC   PLEURISY    (cHRONIC  ADHESIVE   PLEURISY). 

Definition. — Chronic  inflammation  of  the  pleural  layers — (a)  with 
effusion,  and  {b)  without  effusion. 

(a)  Chronic  Pleurisy  with  Effusion. — This  sub-variety  may  follow  acute 
sero-fibrinous  pleurisy,  and  less  frequently  it  has  an  insidious  develop- 
ment. The  morbid  lesions,  including  the  character  of  the  exudate,  may 
also  be  identical  with  those  of  the  acute  or  subacute  forms  of  the  affec- 
tion. Fibrin  and  serum  are  present  in  varying  relative  proportions,  the 
latter,  however,  as  a  rule,  in  preponderating  proportion  when  compared 
with  the  composition  of  the  exudate  in  acute  pleurisy.  The  secondary 
consequences  of  copious  acute  effusions  also  are  met  with — i.  e.  displace- 
ment of  adjacent  organs  (liver,  spleen,  heart)  and  unilateral  dilata- 
tion of  the  chest.  When  the  fluid  is  either  absorbed  or  removed  and 
the  case  ends  in  recovery,  marked  contraction  of  the  affected  side  re- 
sults, since  the  lung,  which  is  covered  by  thick,  organized  bands  of 
adhesion,  cannot  re-expand.  Symptoms. — But  for  slight  dyspnea  upon 
muscular  exercise  the  subjective  symptoms  are  frequently  wanting.  The 
pulse  is  compressible  and  accelerated,  as  a  rule,  and  there  is  a  trifling 
rise  of  temperature  in  the  evening  hours.  If  the  effusion  becomes 
purulent,  hectic  fever  develops,  leading  to  asthenia,  and  the  latter  con- 
dition eventually  terminates  life.  Death  may  also  be  due  to  secondary 
suppurations  (abscess  of  brain,  etc.).  In  most  cases  occurring  in  chil- 
dren the  effusion  early  changes  to  pus.  The  physical  signs  do  not  differ 
from  those  in  acute  sero-fibrinous  pleurisy.  The  duration  of  the  cases 
varies  from  three  months  to  several  years,  or  intercurrent  pulmonary 
tuberculosis  may  shorten  the  course  of  the  affection. 

(6)  Chronic  Dry  or  Adhesive  Pleurisy. — (1)  This  may  succeed  to  the 
acute  or  chronic  sero-fibrinous  pleurisy.  If  the  liquid  portion  of  the 
exudate  is  absorbed,  the  pleural  membranes  come  into  more  or  less  close 
apposition,  being  separated  only  by  fibrinous  elements  that  become 
organized  into  a  layer  of  firm  connective  tissue.  Hence  the  two  layers 
of  the  pleura,  that  are  gi*eatly  thickened,  cannot  be  separated,  owing  to 
the  firmness  of  the  adhesions.  In  most  cases  the  autopsy  shows  the 
latter  condition  to  be  most  pronounced  at  the  base,  while  the  lung  is 
found  to  be  compressed  and  the  seat  of  fibroid  change.  If  it  follows 
the  acute  form,  the  extent  of  retraction  is  slight,  since  there  are  no 
dense  fibrous  bands  to  prevent  a  fair  degree  of  lung-expansion ;  if  it 
succeed  the  chronic  form,  however,  or  empyema,  the  extent  of  retraction 
and  flattening  will  be  quite  marked.  The  exudate  may  undergo  cal- 
careous degeneration,  and  occasionally  little  pouches  of  fluid  may  be 
found  between  the  false  bands. 

There  is  a  large  class  of  cases  that  are  dry  from  the  onset  {idio- 
pathic  dry  chronic  jyJeurisy),  and  this  variety  may  either  be  a  sequel 
of  acute  plastic  pleurisy  or  primarily  tuberculous.  The  condition  is 
very  commonly  met  with  at  autopsy  in  subjects  who  during  life  had 
never  presented  symptoms  of  pleurisy  Avith  effusion.  The  plastic  exu- 
date, however  slight,  invariably  tends  to  become  organized,  with  result- 


CHRONIC  PLEURISY.  563 

ing  fibrinous  adhesion  of  the  two  layers  of  the  pleura.  Most  generally 
the  adhesions  are  circumscribed,  and  if  tuberculous  in  origin  are  most 
frequently  apical  and  often  bilateral.  Under  these  circumstances  small 
caseous  masses  and  little  tubercles  may  be  found  embodied  in  the  some- 
what thickened  pleura.  General  synechia  is,  however,  not  rare,  par- 
ticularly unilateral. 

Symptoms. — Definite  rational  symptoms  are  rarely  present,  and  the 
physical  signs  lack  uniformity  or  may  be  entirely  negative.  In  other 
cases  of  a  mild  grade  the  main  characteristics  are  restrained  mobility  of 
the  aff"ected  side  and  feebleness  of  the  respiratory  murmur.  In  rarer 
cases  the  weakness  of  the  breath-sounds  is  out  of  all  proportion  to  the 
expansive  motion  of  the  chest.  In  still  another  category — composed  of 
a  considerable  number  of  instances — certain  physical  signs  are  quite 
pronounced.  Inspection  reveals  decided  contraction,  with  immobility 
of  the  aff"ected  side  and  a  compensatory  distention  of  the  healthy 
side.  The  heart  is  displaced,  and  the  apex-beat  may  be  missing 
(e.  g.  when  the  heart  is  drawn  or  pushed  behind  the  sternum,  or  over- 
lapped by  the  emphysematous  lung).  The  spinal  column  is  curved,  the 
scapula  dislocated,  the  shoulder  ill-shapen  and  drooping,  and  the  lower 
part  of  the  thorax  shrunken,  Avhile  the  ribs  are  obliquely  placed  and 
closely  approximated,  or  even  overlap  one  another.  The  tactile  fremitus 
is  decreased  or  absent  over  the  lower  portion  of  the  chest,  and  there  is 
impaired  percussion-resonance  or  dulness  over  the  same  area.  The 
breath-sounds  on  auscultation  are  exceedingly  feeble,  and  in  some 
instances  an  occasional  dry,  leathery,  or  creaking  friction-sound  is 
audible. 

Rarely,  and  particularly  if  the  case  be  tuberculous,  vasomotor  symp- 
toms arise  in  chronic  pleurisy,  such  as  unilateral  flushing  or  sweating  of 
the  face,  or  dilatation  of  the  pupil. 

Doubtless  some  of  the  instances  belonging  to  this  aff'ection  merge 
into  the  pleurogenous  type  of  cirrhosis  of  the  lung,  and  fatal  complica- 
ting conditions  may  arise  in  connection  Avith  the  general  circulation. 
Thus  I  have  observed  in  one  instance  enlargement  followed  by  dilatation 
of  the  right  ventricle,  and  in  turn  by  general  dropsy,  with  fatal  result. 

Treatment. — In  the  treatment  of  this  affection  two  objects  must 
receive  especial  attention  :  (1)  the  removal  of  any  efiusion  that  may  be 
present ;  and  (2)  the  improvement  of  the  nutrition  of  the  patient.  The 
first  indication  is  presented  only  by  a  limited  number  of  the  cases,  and 
the  rules  for  meeting  it  have  been  stated  in  the  treatment  of  sero-fibrin- 
ous  pleurisy  and  empyema  ;  the  second  indication  is  presented  by  all 
cases.  Careful  regulation  of  the  diet  is  of  the  utmost  importance :  it 
must  be  generous,  with  modifications  to  suit  special  diatheses  (as  the 
gouty  or  tuberculous),  if  they  be  present.  Lung-gymnastics  are  most 
useful  if  methodically  pursued.  The  method  of  Ralston  James  (pre- 
viously described)  richly  deserves  a  trial  in  suitable  cases.  It  is  to  be 
borne  in  mind,  however,  that  in  old  cases  eff"orts  at  overcoming  the 
lung-pressure  will  be  unsuccessful.  Climato-therapy  is  advantageous 
for  this  class  of  sufi"erers,  particularly  if  the  slightest  tendency  toward 
tuberculosis  exists ;  and  in  my  own  experience  low,  mountainous  eleva- 
tions combined  with  purity  of  atmosphere  have  given  the  best  results. 
Of  medicines  little  need  be  said.     It  is  especially  important  to  promote 


564  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  digestive  power  of  the  patient  to  the  greatest  possible  extent.  In 
cases  in  which  the  digestive  function  has  been  feeble  I  have  observed 
excellent  results  from  a  brief  stay  at  any  well-regulated  seaside  resort 
or  in  the  country.  We  may  also  try,  with  a  probability  that  the  effect 
will  be  beneficial,  small  doses  (oj— 4.0)  of  cod-liver  oil,  three  times 
daily  after  food,  or  the  following  formulse : 

]^.  Acidi  muriat.  dil.,  Sijss  (10.0); 

Pepsini  pur..  5ij     (8.0) ; 

Tinct.  nucis  vom.,  3iss  (6.0); 

Glycerini,  3iss  (48.0); 

Aquge,  q.  s.  ad  sij    (64.0). — M. 

Sig.  3j  (4.0),  well  diluted,  ten  minutes  after  each  meal. 

Intercurrent  catarrh  of  the  stomach  may  sooner  or  later  become  a 
troublesome  feature,  and  in  combating  it  lavage  is  frequently  our  most 
effective  measure. 


PNEUMOTHORAX. 

{Seropneumothorax ;  Pyo-pneumoihorax.) 

Definition. — A  collection  of  air  in  the  pleural  cavity.  Since  the 
latter,  as  a  rule,  contains  at  the  same  time  serum  or  pus,  the  terms  sero- 
and  pyo-pneumothorax  are  frequently  employed  to  describe  the  same 
condition.     It  is  an  uncommon  condition. 

Pathology. — When  the  pleural  sac  is  punctured  air  usually  escapes, 
accompanied  sometimes  by  an  audible  hissing  sound.  The  pleural  sac 
in  pure  pneumothorax  is  greatly  distended,  and  the  lung  is  impacted 
against  the  spinal  column.  Other  organs  (spleen,  heart)  are  also  dis- 
placed, owing  to  positive  intrathoracic  pressure.  The  heart  is  not  ro- 
tated, however,  and  the  relation  of  its  parts  is  maintained  much  as  in 
the  normal  condition  (Osier).  The  air  may  occupy  but  a  portion  of  the 
pleural  cavity,  on  account  of  previous  firm  adhesions  {circumscribed 
pneumothorax).  The  point  of  perforation,  as  a  rule,  can  be  easily 
found,  and  frequently  corresponds  to  the  seat  of  rupture  of  the  tuber- 
culous cavity  or  superficial  caseous  mass.  In  other  instances  the  cause 
of  pneumothorax  cannot  be  discovered.  Inflation  of  the  lung  under 
■water  may  reveal  the  aperture,  Avhich  is  usually  small,  by  the  escape  of 
air-bubbles  at  the  seat  of  puncture.  Occasionally  a  fistulous  connection 
between  the  pleural  sac  and  the  bronchi  can  be  traced. 

Simple  pneumothorax  is,  however,  of  rare  occurrence.  The  air  that 
gains  admission  into  the  pleural  sac  is  laden  with  micro-organisms  (vide 
Bacteriology,  p.  541),  which  set  up  various  forms  of  inflammation,  ac- 
com|)anied  by  equally  various  exudations.  Hence  the  cavity  is  usually 
filled,  in  part,  with  an  effusion  that  is  purulent  or  sero-purulent,  as  a  rule, 
and  rarely  serous  or  sero-fibrinous.  The  gas  in  cases  of  pneumothorax 
mav  be  of  bacterial  origin  :  this  contains  substances  not  found  in  air, 
such  as   II,  TIjS,  or  marsh-gas,   and  gas-forming  organisms  (b.   colil. 

Ktiology. — The  predisposing  m^nences  are — (a)  age — the  condition 


PNEUMOTHORAX.  565 

occurring  in  adults  as  a  rule,  thougli  instances  are  also  observed  in  young 
children  ;  {h)  sex — males  suffer  more  often  than  females  ;  (c)  the  left  side 
is  affected  nearly  twice  as  often  as  the  right ;  (d)  emphysema,  in  which 
the  superficial  air-sacs  are  dilated  and  atrophied,  rendering  the  latter 
liable  to  rupture  from  excessive  muscular  exertion. 

The  exciting  causes  are — (1)  Perforation  of  the  lung  and  ^pulmonary 
pleura  (the  most  frequent  cause),  arising  in  one  or  other  of  three  ways 
— {a)  From  the  rupture  of  a  tuberculous  cavity  into  the  pleural  cavity. 
This  accident  rarely  occurs  at  the  apex  of  the  lung,  but  commonly  near 
the  upper  border  of  the  lower  or  middle  lobe ;  and  less  frequently  near 
the  loAver  border  of  the  upper  lobe.  A  caseous  focus  immediately  be- 
neath the  pleura  may  also,  during  the  process  of  softening,  puncture 
the  pleural  sac  and  invite  the  entrance  of  air  during  the  early  stages. 
It  cannot  occur,  however,  except  in  cases  in  which  previous  adhesions 
have  failed  to  form  at  the  point  of  perforation.  At  least  70  per  cent,  of 
the  cases  of  pneumothorax  are  tubercular  (Morse  ).^  {h)  As  the 
result  of  necrotic  processes,  in  connection  with  certain  other  lung- 
affections,  as  gangrene,  broncho-pneumonia,  suppurating  bronchial 
glands,  abscess,  and  echinococcus  cysts,  (c)  From  rupture  of  the  normal 
air-sacs  in  consequence  of  severe  muscular  effort  (S.  West,  DeH.  Hall). 
This  accident  is  sometimes  ascribable  to  the  violent  paroxysms  of  cough 
in  pertussis. 

(2)  Some  cases  of  empyema^  by  perforating  the  visceral  pleura,  the 
lungs,  and  bronchi. 

(3)  Perforations  of  the  pleura  in  malignant  disease  and  abscess  of  the 
esophagus. 

(4)  A  peripheral  bronchiectasis  may  open  the  pleural  space  and  thus 
establish  a  communication  between  it  and  a  bronchus. 

(5)  Pyo-pneumothorax  may  be  of  subdiaphragmatic  origin,  consec- 
utive to  perforation  by  malignant  disease  or  ulcer  of  the  stomach  or  colon. 

(6)  Pneumothorax  may  be  occasioned  by  gases  resulting  from  the 
action  of  a  gas-forming  bacterium  on  the  pleural  exudate. 

(7)  Wounds  causing  direct  or  indirect  perforative  lesions  of  the 
lungs'.  Fractures  of  the  ribs  may  produce  laceration  of  the  visceral 
pleura,  and  allow  the  air  to  enter  the  pleural  sac. 

Symptoms. — The  earliest  symptoms  vary  according  to  the  cause  or 
causes  that  produce  the  condition.  When  it  develops,  as  it  does  so 
often,  in  the  course  of  pulmonary  tuberculosis,  the  onset  is  sudden, 
marked  by  agonizing  pain  in  the  side,  by  intense  dyspnea,  and  frequently 
cyanosis.  The  dyspnea  is  often  accompanied  by  a  sense  of  impending 
suffocation.  The  severity  of  the  pain  and  the  degree  of  oppression 
depend  largely,  however,  upon  the  amount  of  air  that  gains  entrance 
into  the  pleural  sac  or  is  formed  from  the  exudate,  the  rapidity  with 
which  it  enters,  and  the  condition  of  the  pleural  cavity  as  regards  the 
presence  or  absence  of  previous  pleuritic  adhesions.  If  the  orifice  be 
large  and  valvular,  the  air  cannot  escape,  but  rapidly  accumulates  and 
forces  all  the  air  out  of  the  lung  by  compression ;  the  patient  then  sinks 
rapidly  into  collapse  from  shock,  and  sudden  death  ensues.  Fortunately, 
the  open  form  is  commoner,  especially  in  non  tuberculous  pul- 
monary affections.  The  respirations  are  frequent ;  the  pulse  is 
^  American  Journal  Medical  Sciences,  May,  1900. 


666 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


also  frequent  and  feeble,  sometimes  reduced  to  a  thread :  and 
cold  sweats  are  not  uncommon.  The  ti'mperature  at  first  is  apt 
to  fall  one  or  two  degrees  below  the  normal,  owing  to  sudden  col- 
lapse; /ever,  however,  follows  almost  invariably,  and  frequently  is  of 
the  hectic  type.  Its  cause  is  pleuritis.  often  of  a  purulent  form,  and  if 
this  be  the  case,  the  dyspnea  may  be  due  in  part  to  the  increasing  effusion. 
The  patient  now  also  suffers  from  the  grave  symptoms  of  empyema  above 
described.     Edema  of  the  hand  of  the  affected  side  is  sometimes  present 


Fig.  48.—].  Air  in  the  pleural  sac;  2,  fluid  exudate  at  base  of  pleural  sac;  3,  compressed  portion 
of  lung;  4,  displaced  heart;  5,  depressed  spleen;  6,  mediastinum  pushed  toward  the  right. 


as  an  early  manifestion  ;  it  rapidly  disappears  (Weil).  When  pneumo- 
thorax develops  in  the  last  stages  of  phthisis  acute  symptoms  may  be 
entirely  absent. 

Physical  Signs. — These  are  marked  (see  Fig.  48).  Inspection  shows 
marked  distention  and  immobility  of  the  affected  side;  also  some  degree 
of  distention  with  unnatural  mobility  of  the  healthy  side. 

PaJpation  shows  the  tactile  fremitus  to  be  diminished  above  and 
greatly  diminished  or  wholly  absent  over  the  effusion  below.     Edema  of 


PXEUMOTHORAX.  567 

the  chest-"^all   can  frequently  be  made  out.     The   impulse-beat  of  the 
heart  is  found  to  be  feeble  and  displaced. 

On^pereussion  a  deep  and  full,  or  modified  tympanitic  note  {bell-tym- 
pany)  can  usually  be  elicited  over  the  area  corresponding  to  the  contained 
air,  and  the  excessive  tension  in  the  pleural  sac,  due  to  the  enormous 
amount  of  air  it  contains,  may  cause  an  elevation  in  the  pitch  of  the 
note  even  to  dulness.  The  "cracked-pot"  sound  is  audible  when  the 
air  in  the  pleural  cavity  freely  communicates  with  the  external  air. 
Wintrich's  sign,  or  a  change  in  the  pitch  of  the  percussion-sound  when 
the  mouth  is  open  or  closed  (being  raised  when  the  mouth  is  closed  and 
lowered  when  open),  may  also  be  observed.  In  pyo-pneumothorax  a  flat 
note  is  elicited  from  the  base  upward  as  far  as  the  fluid  extends,  and 
there  is  a  more  marked  temporary  change  in  the  upper  level  of  flatness 
than  in  pleurisy  with  change  of  posture.  Modifications  in  the  pitch  of  the 
percussion-sound  result  from  an  alteration  in  the  form  as  well  as  in  the 
dimensions  of  the  air-space.  Owing  to  displacement  of  the  heart,  there 
is,  as  a  rule,  resonance  over  the  normal  cardiac  region,  and  particularly 
when  the  patient  assumes  a  recumbent  posture.  The  liver  and  spleen, 
according  to  the  side  affected,  are  displaced  downward  to  a  greater 
degree  than  in  simple  pleural  effusion. 

Auscultation  discloses  a  greatly  weakened  or  altogether  suppressed 
respiratory  murmur  when  collapse  of  the  lung  is  incomplete.  Amphoric 
breathing  is  audible  in  cases  of  open  pneumothorax,  and  bronchial  rales 
possessing  a  metallic  quality  are  sometimes  heard,  as  well  as  metallic 
tinkling  on  deep  inspiration  or  on  coughing.  The  metallic  tinkling  is 
caused  frequently  by  drops  of  fluid  falling  from  above  upon  the  surface 
of  the  effusion  :  less  frequently  by  a  re-echoing  of  vibrations  of  moist 
bronchial  rales  communicated  to  the  air  in  the  pleural  chamber.  The 
vocal  resonance  is  enfeebled,  as  a  rule,  and  evinces  the  same  metallic 
quality.  The  so-called  coin-test  is  a  pathognomonic  sign,  and  is  elicited 
in  the  following  manner :  An  assistant  places  one  coin  on  the  front  of 
the  chest  and  taps  it  with  another  while  the  ear  of  the  examiner  is 
placed  on  the  thorax  posteriorly,  where  will  be  heard  the  intensified  echo 
of  the  coin-sound  thus  produced.  Another  most  characteristic  sign  is 
the  so-called  Hippocratic  succussion,  which  is  elicited  by  placing  one 
ear  upon  the  patient's  chest  while  the  latter"s  body  is  shaken,  and  a 
distinct  splashing  sound  is  heard. 

Diagnosis. — When  the  attack  is  of  ordinary  severity,  pneumo- 
thorax is  diagnosticated  by  the  history  of  one  or  other  of  the  causal 
factors,  together  with  certain  physical  signs  that  do  not  belong  to  any 
other  affection  (coin-sound,  succussion-splash).  It  is  only  when  the 
air  and  fluid  in  the  pleural  sac  are  encapsulated  that  it  may  become 
difficult  to  eliminate  («)  a  large  pulmonary  cavity ;  (l>)  excessive  gaseous 
distention  of  the  stomach ;  (c)  an  abscess  below  the  diaphragm  into 
which  air  has  entered  (pyo-pneumotliorax  suhp)lirenicus) :  (d)  a  diaphrag- 
matic hernia;  (e)  emphysema;  and  (/)  pleurisy  with  effusion. 

(«)  A  Large  Pulmonary  Cavity. — The  '''  cracked-pot  sound  "  and 
"Wintrich's  sign  are  more  frequent  in  cavity  than  in  pneumothorax, 
and  the  former  condition  does  not  tend  to  dislocate  the  adjacent  organs. 
There  is  no  response  to  the  coin  test  and  an  absence  of  the  succussion- 


568  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

splash  ;  both  of  which  signs  are  often  present,  even  in  circumscribed 
pyo-pneumothorax.      Tabulated,  these  points  of  difference  are — 

PVO-PNELMOTHORAX.  LaRGE    PuLMONARY    CaVITV. 

Immobility  and  bulging  of  the  inter-  Immobility,  flattening  of  the  chest,  and 
spaces.  The  apex-beat  is  usually  dis-  depression  of  the  interspaces.  Apex- 
placed,  beat  not  displaced. 

Diminished  vocal  fremitus.  Fremitus  usually  increased. 

Percussion-note  deep  and  full.    The  effu-  Percussion  gives  tympany  or  a  "cracked- 

sion  sinks  to  the  base,  and  yields  flat-  pot  sound,"  and  Wintrich's  change  of 

ness,  the  outline  of  which  changes  with  sound  as  a  rule, 
the  posture  of  the  patient. 

Respiratory  murmur  and  vocal  resonance  Bronchial  bi'eathing  is  heard,  and  the 
usually  absent.  Amphoric  breathing  vocal  resonance  is  increased.  Crack- 
may  be  heard  if  the  opening  in  the  ling,  gurgling  rales,  cavernous  or  am- 
lung  is  patulous.  The  coin-sound  and  phoric  breathing, and  pectoriloquy  may 
Hippocratic  succussion- splash  are  be  present.  Absence  of  bell-tympany 
noted.  and  succussion-splash. 

(b)  The  possibility  of  excessive  gaseous  distention  of  the  stomach  is  to 
be  eliminated  by  the  history  of  the  case  and  by  the  happy  results  af- 
forded by  the  application  of  the  therapeutic  test,  evacuation  of  the 
stomach  and  bowels. 

(c)  Subphrenic  Abscess  containing  Air. — This  is  exceedingly  rare, 
and  occurs  relatively  oftener  on  the  right  than  on  the  left  side  (Leyden). 
Its  leading  causes  are  ulcers  of  the  stomach  or  duodenum,  followed  by 
circumscribed  peritonitis,  perforation,  and  abscess,  the  latter  occupying 
a  position  immediately  beneath  the  diaphragm  and  above  the  liver.  The 
gases  that  gain  admission  to  the  abscess-sac  from  the  intestines  force  the 
diaphragm  upward,  and  thus  cause  retraction  or  even  compression  of  the 
lung.  The  symptoms  and  signs  are  now  identical  with  those  of  circum- 
scribed pyo-pneumothorax,  limited  to  the  base.  A  knowledge  of  the 
steps  in  the  production  of  subphrenic  abscess ;  the  absence  of  cough 
and  expectoration,  and  of  marked,  displacement  of  the  heart;  and  the 
presence  of  bulging  of  the  hypochondriura,  of  striking  depression  of  the 
liver,  and  of  Pfuhl's  sign  {vide  p.  877),  are  indications  favoring  sub- 
phrenic abscess. 

{d)  Diaphragmatic  Hernia. — This  either  results  from  a  severe  injury 
or  is  congenital,  and  the  most  valuable  point  of  difference  between  hernia 
of  the  diaphragm  and  pneumothorax  is  the  peculiar  cause  of  the  former. 
The  next  most  valuable  point  is  the  fact  that  the  hernial  protrusion  may 
return  suddenly  to  its  normal  position,  whereupon  the  patient  will  be  re- 
lieved ;  the  condition  may  then  reappear  not  less  suddenly.  The  third 
distinctive  feature  is  the  presence  of  rumbling  sounds  in  the  protruded 
bowel.  All  other  signs  and  symptoms  of  one  affection  may  have  their 
counterparts  in  those  of  the  other. 

(e)  Pneumothorax  may  be  confounded  with  emphysema  by  the  care- 
less observer;  but  the  latter  aff'ection  is  slow  in  onset,  free  from  serious 
shock,  is  bilateral  as  a  rule,  and  does  not  exhibit  the  distinctive  physical 
signs  of  pneumothorax  (metallic  tinkling,  coin-sound,  succussion-splash). 
In  pleurisg  with  effusion  hyper-resonance  may  be  noted  above  the  fluid, 
but  it  lacks  the  bell-like  tympany  of  pneumothorax.  Over  the  same 
area  there  is  diff"use,  distant,  bronchial  breathing  (at  times  slightly  am- 
phoric), whilst  the  metallic  tinkling,  coin-sound,  and  succussion-splash 
are  totally  wanting. 


HYDROTHOEAX.  569 

Prognosis. — This  depends  largely  upon  the  cause.  The  cases  at- 
tributed to  advanced  phthisis  usually  reach  a  fatal  issue  in  the  course 
of  one,  two,  or  more  weeks,  and  rarely  they  run  a  very  rapid  and  fatal 
course.  On  the  other  hand,  the  pulmonary  condition  is  at  times  favor- 
ably influenced  by  its  occurrence.  Following  empyema,  or  when  due  to 
trauma  or  abscess  of  lung,  pneumothorax  sometimes  takes  a  favorable 
course.  It  is  fraught  with  especial  danger  when  it  is  the  resultant  con- 
dition of  some  acute  lung-disease  (gangrene,  broncho-pneumonia). 

Treatment. — The  leading  indication  is  the  alleviation  of  the  pa- 
tient's sufi"erings  by  a  prompt  resort  to  morphin,  and  it  often  becomes 
necessary  to  administer  it  hypodermically.  If  the  patient's  previous 
strength  has  been  moderately  good,  the  question  of  operative  interven- 
tion should  be  seriously  considered,  the  nature  of  the  surgical  proced- 
ure-then depending  upon  the  character  of  the  effusion.  If  this  be  sero- 
fibrinous, aspiration,  as  in  simple  pleurisy,  must  be  performed  to  relieve 
the  urgent  dyspnea ;  if  purulent,  permanent  drainage  should  be  pro- 
cured for  the  same  indication.  A  costal  resection  may  be  advis- 
able. When  pneumothorax  develops  late  in  phthisis  radical  measures 
are  not  to  be  thought  of,  and  the  physician  must  rely  upon  aspira- 
tion (when  necessary)  to  relieve  urgent  symptoms.  We  may  also  tap 
the  air-chamber  above  the  fluid  with  a  fine  needle,,  with  a  view  to  lessen- 
ing the  excessive  tension.  Unverricht  has  recently  reported  good  results 
from  a  somewhat  novel  mode  of  treatment.  When  there  is  a  pulmonary 
fistula  present,  he  inserts,  a  tube  into  the  pleural  sac.  This  allows  free 
entrance  of  air,  the  lung  collapses  completely,  and  the  fistula  has  a 
chance  to  heal.  For  the  dyspnea,  atropin  administered  hypodermically 
is  valuable ;  for  the  feeble  cardiac  action,  alcoholic  stimulants,  aromatic 
spirits  of  ammonia,  strychnin,  ether,  and  other  cardiac  stimulants  should 
be  employed.  Locally,  cutaneous  irritants  may  be  applied  (turpentine 
stupes,  mustard  pastes). 


HYDROTHORAX. 

{Dropsy  of  the  Pleura ;   Thoracic  Dropsy). 

Definition. — A  collection  of  transuded  serum  in  the  pleural  cavity. 

Pathology. — Hydrothorax  is  generally  a  bilateral  condition.  The 
transudate  is  a  clear,  amber-colored  liquid  that  is  free  from  fibrin,  but 
may  contain  cholesterin  aijd  a  few  endothelial  cells.  It  has  an  alkaline 
reaction,  a  comparatively  low  specific  gravity  (1009  to  1012),  and  is  non- 
inflammatory. The  pleural  surfaces  are  usually  smooth,  though  some- 
times decidedly  pale  and  edematous.  The  mechanical  effects  of  hydro- 
thorax  upon  the  lungs  and  other  thoracic  and  abdominal  viscera  are 
similar  to  those  of  the  exudates  that  accompany  inflammation  of  the 
pleura,  though  they  are  rarely  so  marked  as  in  sero-fibrinous  pleurisy. 

Htiologfy. — Hydrothorax  is  a  secondary  aff"ection,  and  is  usually 
connected  Avith  one  or  other  of  the  various  forms  of  general  dropsy 
(hemic,  renal,  cardiac).      The  cases  that  are  due  to  blood-impoverish- 


570  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ment  are  more  numerous  than  is  generally  indicated  by  writers  upon  the 
subject,  and  not  infrequently  is  hydrothorax  symptomatic  of  either 
chronic  dysentery,  chronic  diarrhea,  leukemia,  pernicious  anemia,  car- 
cinoma, malaria,  syphilis,  or  scurvy.  Strictly  local  causes  may  also 
induce  it,  as  carcinoma  of  the  pleura,  or  the  compression  of  the  superior 
vena  cava  or  of  the  thoracic  duct  by  a  tumor. 

Symptoms. — The  subjective  spnpfoms  are  attributed  to  the  mechan- 
ical effects  of  the  fluid,  and  the  causal  aflfection  may  have  symptoms 
quite  in  common ;  these  are  dyspnea  (often  culminating  in  orthopnea), 
cyanosis,  asthmatic  seizures^  irritative  cough,  and  a  feeble  circulation. 
The  general  sumptoms  arise  from  the  primary  affection. 

Physical  Signs. — The  physical  signs  are  much  the  same  as  in  pleurisy 
with  effusion — with  this  difference,  that  they  are  more  often  bilaterally 
distributed.  Hydrothorax  is  often  unilateral,  however,  and  an  enlarged 
right  auricle  may  be  the  cause  of  this  condition  in  some  instances. 
The  right  side  is  the  one  usually  affected.  I  have  also  observed  that 
quite  frequently  the  two  sides  of  the  chest  exhibit  great  variations  as 
to  the  relative  amount  of  fluid  contained.' 

Prognosis. — This  depends  upon  the  nature  of  the  primary  disorder 
that  causes  the  dropsical  transudation. 

Treatment. — The  treatment  of  hydrothorax  has  intimate  relations 
with  the  indications  presented  by  the  underlying  affection.  If  the 
measures  directed  toward  the  removal  of  the  general  dropsy  (anasarca), 
of  which  hydrothorax  is  a  part,  are  unsuccessful,  and  the  amount  of 
transudation  in  the  pleural  sac  interferes  with  the  functions  of  the  heart 
and  lungs,  then  aspiration  must  not  be  too  long  delayed,  and  must  be 
repeated  as  often  as  occasion  demands. 


NEW  GROWTHS  OF  THE  PLEURA. 

Almost  all  instances  of  ncAv  growths  developing  in  the  pleura  are 
secondary  to  primary  carcinoma  of  the  lung,  the  pleura  being  invaded 
by  the  direct  extension  of  the  neoplasm.  It  may  also  arise  by  meta- 
stasis from  carcinoma  of  the  lung,  mammary  glands,  etc.  The  pleura 
presents  circumscribed  areas  of  thickening,  or  the  growth  takes  the  form 
of  papular  projections  from  its  surface,  and  as  these  enlarge  they  become 
pedunculated.  Their  size  varies  from  that  of  a  pea  to  that  of  an 
orange.  The  adjacent  pleura  is  inflamed,  often  adherent,  and  much 
thickened,  and  an  effusion  into  the  pleural  cavity  is  often  observed. 

Primary  carcinoma  of  the  pleura  is  very  rare  indeed,  and  E.  Wag- 
ner, who  first  described  it,  called  it  endothelial  carcinoma.  Most  pa- 
thologists of  to-day,  however,  look  upon  endothelioma  as  a  variety  of 
sarcoina.  It  owes  its  orgin  to  a  proliferation  of  the  endothelial  cells  of 
the  connective  tissue  and  the  lymph-apparatus  of  the  pleura.  This  in- 
variably assumes  the  diffuse  form,  and  by  metastasis  we  have  involve- 
ment of  the  other  organs  (lungs,  lymphatics,  liver). 

Spindle-cell  sarcoma  of  the  pleura,  as  well  as  the  round-cell  variety, 
is  occasionally  met  Avith. 

'  For  the  diHerential  diagnosis  between  pleurisy  and  hydrothorax  see  Pleurisy,  p.  554. 


DISEASES  OF  THE  MEDIASTINUM.  571 

Symptoms. — The  subjective  symptoms  are  slight  in  cases  in  which 
there  is  a  single  circumscribed  carcinomatous  mass  in  the  pleura ;  but 
they  are  quite  severe  in  the  diffuse  form,  particularly  when,  as  com- 
monly occurs,  it  is  of  a  secondary  nature.  The  symptoms  are  now 
those  of  plastic  or  sero-fibrinous  pleurisy,  in  addition  to  those  of  pri- 
mary carcinoma  of  the  lung,  and  the  former  may  oftentimes  more  or 
less  completely  overshadow  the  latter. 

Diagnosis. — The  circumstances  under  which  the  condition  arises 
often  throw  the  strongest  light  upon  its  nature.  The  symptoms  of 
slowly  developing  pleurisy,  either  plastic  or  sero-fibrinous,  following 
carcinoma  of  the  lung  or  the  breast,  and  accompanied  by  the  cancerous 
cachexia,  would  point  strongly  to  the  existence  of  carcinoma  of  the 
pleura.  Characteristic  cancerous  elements  may  also  be  found  by  micro- 
scopic examination  of  the  usually  hemorrhagic  fluid  obtained  on  aspira- 
tion.    The  exudate  contains  fatty  endothelial  cells. 

The  difficulties  surrounding  the  diagnosis  of  primary  carcinoma  of 
the  pleura  are  great  and  usually  insurmountable.  The  cases  are  very 
similar  in  their  clinical  manifestations  to  chronic  pleurisy  with  or  tvithout 
effusion.  Pain  is  always  a  more  prominent  symptom,  however,  than  in 
simple  chronic  pleurisy,  and  this  fact,  when  combined  with  evidences  of 
a  cancerous  cachexia,  should  excite  strong  suspicions. 

The  prognosis  is  wholly  unfavorable,  and  the  treatment  merely 
palliative. 


DISEASES  OF  THE  MEDIASTINUM. 

The  affections  of  the  mediastinum  may  be  divided  into  four  classes : 
(a)  Inflammation,  {h)  Tumors,  (c)  Diseases  of  the  thymus  gland,  and  {d) 
Mediastinal  hemorrhage. 

(a)  Inflammation. — This  may  affect  (1)  the  glands  or  (2)  the  connec- 
tive tissue.  Lymphadenitis  of  moderate  grade  is  found  in  association 
with  broncho-pneumonia  and  the  various  forms  of  bronchitis.  The  con- 
dition appears  in  its  most  pronounced  form  in  the  bronchitis  of  measles, 
influenza,  and  Avhooping-cough,  and  De  Mussy  held  that  enlargement 
of  the  glands  in  the  posterior  mediastinum  is  potent  in  exciting  parox- 
ysms of  whooping-cough.  According  to  De  Mussy  and  Guiteras,  these 
glands  when  greatly  enlarged  give  rise  to  dulness  in  the  upper  part  of 
the  interscapular  region  or  down  to  the  fourth  dorsal  vertebra  in  cases 
of  influenza  and  whooping-cough.  I  have,  moreover,  been  able  to  con- 
firm this  dictum  in  cases  of  influenza,  though  aware  of  the  fact  that 
many  authorities  consider  it  questionable.  Tuberculous  lymphadenitis 
is  elsewhere  described  {vide  Tuberculosis,  page  271).  The  mediastinal 
lymph-glands  may  undergo  suppuration  in  consequence  of  local  specific 
infection,  and,  though  not  recognizable  during  life,  it  should  be  recollected 
that  the  condition  may  lead  to  perforation  into  either  the  esophagus  or 
a  bronchus,  with  serious  results.  In  other  instances  spontaneous  absorp- 
tion occurs,  leaving  behind  inspissated  contents  that  undergo  calcareous 
change. 


572  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Abscess  of  the  Mediastinum. — This  is  of  rare  occurrence,  its  most 
frequent  seat  being  the  anterior  mediastinum.  Of  the  commoner  causes 
may  be  mentioned  traumatism  and  the  infectious  diseases — erysipelas, 
rheumatism,  measles,  and  small-pox  in  particular.  It  may  also  be  the 
result  of  an  extension  of  a  suppurative  process  from  neighboring  struc- 
tures. Pulmonary  tuberculosis  is  the  most  potent  factor  in  j^roducing 
chronic  abscess  in  this  situation. 

Sj^mptoms. — Acute  Abscess. — Pain  and  tenderness  in  the  sternum 
are  the  most  prominent  features,  the  pain  being  acute  and  often  of  a 
throbbing  character.  Cough  and  dyspnea  are  usually  present.  The 
general  features  are  fever,  frequently  accompanied  by  rigors  and  pro- 
fuse sweats  and  considerable  physical  prostration.  The  chief  physical 
sign  is  dulness  upon  percussion,  usually  found  anteriorly  and  increasing 
gradually  with  the  development  of  the  abscess.  Later,  the  tumor  may 
reach  the  surface  of  the  body,  and  rarely  the  sternum  is  eroded.  Pal- 
pation now  detects  pulsation  and  fluctuation.  The  abscess  may  either 
find  its  Avay  doAvnward  into  the  abdomen,  or  it  may  perforate  the  trachea 
or  the  esophagus. 

In  chronic  abscess  the  symptoms  bear  a  closer  similarity  to  those  of 
solid  tumors  than  those  in  the  acute  form.  Fortunately,  chronic  abscess 
quite  often  results  in  spontaneous  cure,  in  which  case  it  is  in  part  ab- 
sorbed, and  the  remainder  of  its  contents  become  inspissated.  In  obscure 
cases  an  exploratory  puncture  with  a  small  needle  may  be  safely  prac- 
tised, and  with  definite  results,  as  a  rule. 

Diagnosis. — Acute  abscess  must  be  differentiated  from  solid  medias- 
tinal tumors  and  aneurysm.  The  more  acute  onset  and  general  symptoms 
of  the  suppurative  process  (hectic  type  of  fever,  chills,  sweats)  and 
the  more  rapid  course  Avill  serve  to  distinguish  abscess  from  aneurysm 
on  the  one  hand,  and  solid  tumors  on  the  other.  Further,  the  absence 
of  strong  expansile  pulsation,  diastolic  shock,  and  the  aneurysmal  bruit 
aid  materially  in  eliminating  aneurysm  of  the  arch. 

The  treatment  is  mainly  surgical. 

{b)  Tumors  of  the  Mediastinum. — Two  forms  only  demand  practical 
consideration — carcinoma  and  sarcoma.  Hare's  analysis  of  520  cases 
gave  the  following  ratio :  of  carcinoma,  134 ;  sarcoma,  98 ;  lymphoma, 
21 ;  fibroma,  7  ;  dermoid  cyst,  11 ;  hydatid  cyst,  8  ;  and  fewer  cases,  of 
ecchondroma,  lipoma,  and  gumma.  In  48  of  the  cases  of  carcinoma  and 
in  33  of  sarcoma  the  tumor  occupied  only  the  anterior  mediastinum.  It 
is  quite  probable,  however,  that  sarcoma,  and  not  carcinoma,  is  the  com- 
moner neoplasm  of  this  region.  The  clinical  term  "  cancer  "  was  formerly 
used  promiscuously  by  many  authors,  and  the  pathologic  diagnosis  was 
then  difficult,  so  that  statistics  are  notoriously  fallacious.  Upon  inves- 
tigating 25  of  tlie  older  reports  of  '"cancer,"  Pepper  and  Stengel  found 
in  13  unquestionable  evidence  that  the  growth  was  sarcoma,  while  in 
the  remaining  12  they  could  not,  for  the  greater  part,  decide  to  which 
form  the  disease  belonged.  Primary  sarcoma  may  spring  from  the  rem- 
nant of  the  thymus  gland,  from  the  h^mphatic  glands,  the  pleura,  or 
lungs,  or  from  the  fibrous  tissues  of  the  mediastinum.  Primary  carcinoma 
may  originate  in  the  esophagus,  bronchi,  lungs,  or  rarely  in  the  thymus 
gland.  Secondary  mediastinal  tumors  are  most  apt  to  have  their  seat  in 
the  lymphatic  glands.      Carcinoma  is  less  frec^uently  primary  than  sar- 


DISEASES   OF  THE  MEDIASTINUM.  573 

coma.  Among  predisposing  causes  are  sex  and  age — males  being  more 
prone  to  the  affection  than  females,  and  the  period  of  chief  liability  is 
between  the  thirtieth  and  fortieth  years. 

Symptoms. — The  earlier  symptoms  are  vague  (slight  substernal 
pains,  dyspnea,  general  languor).  Later,  pressure-symptoms  gradually 
supervene. 

The  pairi  may  or  may  not  be  severe,  but  is  invariably  accompanied 
by  a  feeling  of  oppression.  Its  chief  seat  is  in  the  upper  sternal  region, 
but  it  may  radiate  to  the  sides  of  the  chest  and  even  down  the  arms  (in 
which  case  it  is  due  to  pressure  on  the  brachial  plexus).  Dysp>nea 
appears  early,  is  constant,  and  may  become  intense.  It  is  caused  by 
pressure  either  upon  the  trachea,  upon  a  primary  bronchus,  or  upon  a 
recurrent  laryngeal  nerve.  Asthmatic  seizures  may  occur  before  there 
is  constant  dyspnea  and  before  the  tumor  has  reached  notable  size  within 
the  chest.  There  is  cough.,  which  may  be  paroxysmal  and  of  a  brazen 
character.  Aphonia  may  be  present.  There  may  be  dysphagia  from 
pressure  upon  the  esophagus,  though  this  is  rare.  If  there  is  an  inflam- 
mation of  the  vagus  or  sympathetic  nerve,  the  rate  of  the  pulse  may  be 
either  slowed  or  markedly  quickened.  Owing  to  implication  of  the 
sympathetic  there  may  be  local  hyperemias  and  pupillary  inequalities. 

Oomjjression  of  the  superior  vena  cava  or  of  the  subclavian  vein  may 
be  followed  by  cyanosis  and  edema  of  the  parts  drained  by  these  vessels, 
and  the  early  occurrence  of  venous  occlusion  and  marked  dilatation  of 
the  superficial  veins  is  quite  characteristic.  Collateral  circulation  may 
be  rarely  established.  Less  frequently  the  inferior  cava  may  also  be 
pressed  upon. 

Physical  Signs. — Inspection. — In  advanced  cases  a  swelling,  usually 
somewhat  irregular  and  often  diffuse,  appears  in  the  sternal  region. 
The  tumor  may  cause  erosion  of  the  sternum,  and  a  little  later  occupy 
a  position  immediately  beneath  the  skin,  Osier  ^  being  of  the  opinion 
that  the  rapidly-groAving  lymphoid  tumors,  more  commonly  than  others, 
perforate  the  chest-wall.  I  saAv  a  case  in  which  the  perforation  occurred 
at  the  right  edge  of  the  sternum,  precisely  at  the  point  at  which  aneur- 
ysms of  the  ascending  arch  most  frequently  appear.  In  the  early  stages, 
however,  this  prominence  is  not  present.  Palpation. — When  a  tumor  is 
present  it  may  pulsate  distinctly,  and  the  heart's  apical  impulse  may  be 
detected  in  various  abnormal  positions.  Tactile  fremitus  is  absent  over 
the  seat  of  the  growth  if  the  latter  be  in  contact  with  the  chest-wall. 

On  percussion  dulness  is  noted,  and  this  is  true  even  in  many  instances 
that  do  not  present  a  visible  swelling.  The  dull  area  varies  in  outline 
Avith  the  size  and  position  of  the  tumor.  Auscultation  usually  reveals 
no  sounds  over  the  dull  area,  except  a  bruit  in  rare  instances.  The 
heart-sounds  are  inaudible  over  the  tumor-site  as  a  rule,  and  the  breath- 
sounds  and  vocal  resonance  are  feeble  or  absent.  To  the  above  physical 
signs  are  frequently  added  those  of  pleural  effusion. 

The  diag"liOSis  of  mediastinal  growths  is  made,  if  at  all,  principally 
by  exclusion. 

Aneurysm  is  differentiated  from  solid  mediastinal  tumors  Avith  only 
slight  success  in  many  instances.  It  is  most  valuable  to  note  carefully 
the  length  of   time  the  condition  has  lasted,   since  aneurysm  runs   a 

^  Practice  of  Medicine,  p.  579. 


574  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

longer  course,  on  the  average,  than  mediastinal  tumor.  The  tumor 
when  due  to  aneurysm  communicates  a  strong,  heaving,  expansile  pul- 
sation— a  characteristic  that  is  absent  or  only  feebly  manifested  in  the 
case  of  solid  mediastinal  growths.  The  severe  diastolic  shock,  as  noted 
on  both  palpation  and  auscultation  in  cases  of  aneurysm,  is  also  absent 
in  solid  tumor.  Kassabian  has  shown  that  new  growths  can  be  early 
recognized  by  an  a;-ray  examination.  On  the  other  hand,  shadows  sit- 
uated in  the  anterior  portion  of  the  chest  and  to  the  right  of  the 
median  line  are  generally  produced  by  aneurysms. 

The  duration  of  the  disease  varies  from  six  to  eighteen  months. 

The  prognosis  is  absolutely  hopeless,  except  in  the  case  of  benign 
tumors,  which  may  be  removed  in  some  instances. 

The  treatment  is  directed  toward  the  relief  of  the  most  urgent 
symptoms.  Anodynes  are  required  sooner  or  later,  and  should  not  be 
withheld  if  indicated.  As  a  routine  the  preparations  of  iodin  and  mer- 
cury are  employed ;  but,  as  these  are  useless,  they  are  unwarranted. 
Arsenic  has  sometimes  seemed  to  influence  sarcomatous  and  lymphade- 
nomatous  growths  favorably,  though  only  temporarily. 

((.')  Diseases  of  the  Thymus  Gland. — Nothing  is  known  definitely  con- 
cerning the  functions  of  the  thymus  gland.  Tumors  may  have  their 
origin  in  the  thymus  gland,  and  the  organ  may  become  enlarged  (hyper- 
trophy, abscess) ;  these  conditions  are  indistinguishable  from  and  asso- 
ciated with  mediastinal  tumor  or  abscess  as  above  described. 

Jacobi  believes  that  fatal  cases  of  laryngismus  stridulus  may  be  rarely 
ascribable  to  an  enlargement  of  the  thymus  gland.  C.  H.  Hunter' 
reports  two  cases  of  primary  fatal  laryngeal  stenosis  occurring  in  the 
same  family  in  children  aged  19  and  7  months  respectively.  The  ques- 
tion as  to  the  existence  of  the  so-called  asthma  thymicum,  hoAvever,  is 
still  sub  judice,  although  the  number  of  sudden  deaths  in  young  children 
reported  in  connection  with  various  forms  of  enlargement  of  the  thymus 
gland  is  steadily  increasing.  The  dyspnea,  generally  fatal,  that  has 
been  found  to  be  caused  by  an  enlarged  thymus  is  scarcely  the  result 
of  direct  pressure  on  the  trachea.  Arnold  Paltauf  attributes  sudden 
death  in  cases  in  which  the  thymus  was  found  enlarged  to  hyperplasia 
of  the  entire  lymphatic  system  {constitutio  lyniphatica).  Ohlmacher- 
noted  in  18  cases  of  epilepsy  a  large  and  apparently  functionally-active 
thymus  gland.  There  Avas  hyperplasia  of  the  lymph-glands  throughout 
the  body  and  of  the  lymph-follicles  of  the  mucous  surfaces. 

Persons  Avho  manifest  the  hemorrhagic  diathesis,  or  those  who  suffer 
from  hemorrhagic  affections,  may  also  show  hemorrliage  into  the  thymus 
gland — a  condition  that  is  identical  Avith  that  produced  by  hemorrhage 
into  the  mediastinum.  There  is  no  treatment  for  enlargement  of  the  thy- 
mus, although  Siegel  in  one  case,  a  boy  of  2^  years,  elevated  and  stitched 
the  thymus  to  the  fascia  over  the  sternum,  Avith  the  result  that  threaten- 
ing dyspnea  disappeared  and  the  child  eventually  made  a  good  recovery. 

{(i)  Mediastinal  Hemorrhage. — This  term  signifies  hemorrhage  into 
the  mediastinal  connective  tissue.  It  oftenest  results  from  the  rupture 
of  aneurysms  of  the  arch  or  of  the  large  vessels  Avithin  the  thorax,  or 
it  may  be  of  traumatic  origin  (wounds,  fractures). 

'  British  Mexi.  Jour.,  April  2,  1898. 

2  Phila.  Med.  Jour.,  Jan.  1,  1898;  Saunders'   Year-Book  for  1899. 


PART  V. 

DISEASES   OF   THE   CIRCULATORY 
SYSTEM. 


I.  DISEASES  OF  THE  PERICARDIUM. 


PERICARDITIS. 


Definition. — An  inflammation  of  the  serous  covering  of  the  heart. 

Varieties. — (a)  Plastic,  or  fibrinous ;  (b)  sero-fibrinous,  or  subacute ; 
(c)  purulent ;  (d)  hemorrhagic ;  (e)  adhesive.  There  is  also  a  tuberculous 
pericarditis  which  has  been  described  (vide  Tuberculosis,  page  308). 

Bacteriology.— Rudini's  experiments  have  shown  that  the  staphylo- 
coccus aureus  may  be  a  cause  of  pericarditis ;  but  they  have  not  con- 
clusively demonstrated  that  it  is  the  specific  cause,  as  is  evidenced  by 
the  fact  that  the  disease  is  sometimes  caused  by  other  organisms. 
Moreover,  staphylococci  have  not  been  encountered  without  demon- 
strable cause.  Among  other  organisms,  the  pneumococcus,  streptococ- 
cus, the  bacillus  coli,  the  tubercle  bacillus,  and  probably  also  a  variety 
of  the  bacillus  pyocyaneus  and  the  gonococcus  may  be  named.  Micro- 
organisms are  not  always  found  in  pericarditic  exudates. 

ACUTE   PLASTIC    OR   FIBRINOUS   PERICARDITIS. 

Pathology. — The  morbid  changes  are  frequently  localized,  and  less 
frequently  are  general.  At  the  onset  the  membrane  is  smooth,  swollen, 
and  injected,  and  punctured  ecchymotic  spots  may  be  visible;  soon  it 
presents  a  grayish,  roughened  appearance  in  consequence  of  a  deposition 
of  a  thin  layer  of  fibrin.  In  the  severer  types  the  fibrinous  deposit  in- 
creases in  thickness  for  a  time,  and  the  natural  movements  of  the  peri- 
cardial surfaces  upon  one  another  sometimes  cause  the  exudate  to  assume 
a  honeycombed  appearance.  Most  examples  that  I  have  seen,  however, 
have  resembled  the  roughened  surfaces  produced  by  separating  two  slices 
of  bread  that  had  been  thickly  buttered ;  the  surfaces  are  grayish-yellow 
in  color.  In  the  later  stages  the  exudation  becomes  partly  organized, 
and  as  the  result  of  friction  produced  between  the  opposed  surfaces  by 
the  incessant  action  of  the  heart,  the  pericardial  surface  may.  present  a 
villous  appearance ;  hence  the  term  "  hairy  heart  "  which  was  employed 
by  ancient  authors.  For  like  reasons  Ave  may  see  the  exudate  arranged 
in  the  form  of  little  ridges,  forming  a  "  tripe-like  membrane."     Though 


576  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

invariably  present,  the  amount  of  serous  eifusion,  as  the  term  would  in- 
dicate, is  never  large  in  dry  or  plastic  pericarditis.  Myocarditis  may 
frequently  be  found  as  an  associated  condition. 

Htiology. — In  each  variety  of  pericarditis  there  are  special  contrib- 
uting factors,  so  that  it  is  desirable  to  give  its  etiology  separately,  except 
in  the  sero-fibrinous  and  acute  plastic  types,  which  have  practically  the 
same  etiology.  The  two  latter  are  the  more  common  forms  of  the  disease. 
Acute  plastic  pericarditis  most  frequently  occurs  in  young  and  middle- 
aged  males.  It  may  be  p7'{mari/  or  secondary.  It  often  occurs  in  acute 
articular  rheumatism  (in  more  than  one-half  the  cases),  chronic  neph- 
ritis, and,  rarely,  in  other  acute  infectious  diseases.  In  this  form  the  in- 
fective agents  are  transmitted  to  the  pericardium  by  means  of  the  circula- 
tion. It  may  be  caused  also  by  direct  extension  of  inflammation  from 
adjacent  structures  (secondary  pericarditis),  as  in  simple  pleurisy ;  more 
commonly  the  extension  occurs  from  a  pneumonia  or  tuberculous 
pleurisy,  or  the  condition  may  complicate  new  growths  and  inflamma- 
tory conditions  aff"ecting  the  esophagus  and  bronchial  glands.  It 
may  also  be  secondary  to  chronic  disease  of  the  aortic  valve, 
the  pericardium  becoming  involved  by  extension  through  the  walls 
of  the  aorta.  Finally,  it  may  be  the  result  of  traumatism,  and  this 
may  cause  any  of  the  other  forms  of  pericarditis. 

Clinical  History. — Owing  to  the  fact  that  acute  plastic  pericarditis 
is  usually  a  secondary  aff'ection,  the  symptoms  that  enable  one  to  recog- 
nize it  are  obscured  by  the  disease  of  which  it  is  a  sequel.  This  is  par- 
ticularly true  of  that  large  class  of  cases  that  develop  in  acute  articular 
rheumatism,  in  which  subjective  symptoms  are  often  entirely  wanting. 
It  is  only  in  the  severest  types  of  this  sort  that  the  symptoms  referable 
to  the  heart  are  well  enough  marked  to  arrest  the^ittention.  There  may 
be  a  feeling  of  distress  or  constrietion  with  or  without  slight  ^>am  in  the 
precordium.  During  the  first  stage  or  prior  to  the  pouring  out  of  the 
eff'usion  the  pain  is  most  marked,  extending  sometimes  into  the  left  arm 
or  the  back,  and  at  others  to  the  ensiform  cartilage  or  even  to  the  abdo- 
men. This  pain  is,  rarely,  increased  by  pressure  over  the  pericardium. 
Palpitation  and  dyspnea  may  be  present,  and  the  pulse  is  increased  in 
frequency  and  strength,  as  a  rule,  except  in  the  later  period,  when  it 
may  be  weak  and  slightly  irregular,  particularly  if  the  muscular  tissue 
of  the  heart  be  involved.  There  is  some  fever.,  but  the  degree  of  ele- 
vation of  temperature  perhaps  never  exceeds  102°  F.  (38.8°  C).  In 
this  class  of  cases  the  urinary  features  depend  largely  upon  the  charac- 
ter of  the  leadinjx  etiolos;ic  factors ;  thoush  in  many  instances  the  urine 
is  scanty,  high-colored,  and  acid  in  reaction. 

Physical  Signs. — Inspection  discloses  increased  vigor  of  the  apex- 
beat.  Friction-fremitus  (due  to  rubbing  of  the  altered  pericardial 
layers  upon  one  another)  may  sometimes  be  felt  during  the  earlier  and 
later  courses  of  the  disease  or  when  the  membrane  is  comparatively  dry, 
and  is  usually  most  intense  near  the  base,  just  to  the  left  of  the  sternum. 
Percussion  gives  negative  results.  Auscultation  usuallv  reveals  a  double 
friction-sound,  sometimes  quadruple  (locomotive  murmur) — a  character- 
istic sign,  though  one  on  which  sole  reliance  must  not  be  placed  in  this 
disease.  The  friction-rub  is  caused  partly  by  the  exudate  and  partly  by 
the  dry  state  of  the  membrane.    Its  usual  seat  of  maximum  pronunciation 


ACUTE  PLASTIC  OR  FIBRINOUS  PERICARDITIS.  577 

is  m  the  fourth  and  fifth  interspaces  and  the  adjacent  portions  of  the 
sternum — i.  e.  that  portion  of  the  heart  which  is  most  closely  in  contact 
with  the  front  of  the  chest  (Osier).  Another  favorite  point  is  the  cardio- 
aortic  junction.  It  is  usual  to  hear  the  rub  over  small  areas,  though  oc- 
casionally it  is  audible  over  the  whole  precordia,  and  its  distinguishing 
feature  is  its  superficiality,  seeming  closer  to  the  ear  than  endocardial 
murmurs.  Pressure  with  the  stethoscope,  which  approximates  the  layers, 
increases  its  intensity  ;  though  if  too  much  force  be  exerted,  the  murmur 
may  disappear  entirely.  In  like  manner  the  friction-sound  is  influenced 
by  respiration,  losing  in  distinctness  on  deep  inspiration  and  change  of 
posture.  The  quality  of  the  sounds,  like  their  position,  exhibits  great 
variability.  They  are  sometimes  soft;  but  quite  commonly  they  are 
grating  or  rubbing,  and  in  the  later  stages  I  have  noticed  that  they  may 
have  a  loud  creaking  quality.  Though  with  few  exceptions  they  are 
double,  and  are  primarily  produced  by  the  rhythmic  movements  of  the 
heart,  they  do  not  always  occur  synchronously  Avith  the  heart-sounds, 
and  usually  exceed  the  latter  in  duration — -facts  that  go  to  show  that 
the  quality,  location,  or  superficial  area  of  a  given  murmur  does  not 
indicate  the  extent  of  the  lesion. 

Complications. — There  may  be  an  extension  of  the  inflammatory 
process  to  the  external  surface  of  the  pericardium,  either  from  the  deeper 
pericardial  structures  or  from  the  pleura,  particularly  the  left.  This  is  a 
complicating  condition  termed  ''  external  jjleural  pericarditis  "  or  "  medi- 
asti7io-pericarditis,"  in  which  the  mediastinal  connective  tissue  is  also,  as 
a  rule,  involved.  It  is  most  frequently  secondary  to  tuberculous  pleurisy 
(tuberculo-mediastino-pericarditis),  sometimes  also  to  pleuro-pneumonia, 
and  rarely  to  simple  pleurisy  or  plastic  pericarditis.  The  recognition  of 
these  combined  lesions  rests  chiefly  upon  the  detection  of  a  friction-mur- 
mur that  is  partly  dependent  upon  the  cardiac  and  partly  upon  the  respi- 
ratory movements.  These  sounds  are  most  distinctly  heard  along  the 
left  edge  of  the  heart.  Momentary  arrest  of  breathing  suppresses  the 
pleuritic  friction-sound,  there  remaining  merely  the  sounds  produced  by 
the  rhythmic  cardiac  action,  and  even  these  may  be  absent.  On  the 
other  hand,  during  forced  respiration  nothing  is  audible,  as  a  rule,  except 
the  strong  pleural  rub.  In  normal  respiration  the  inspiratory  movements 
decrease  while  expiratory  movements  increase  the  intensity  of  the  sounds. 
During  inspiration  the  j^ulse  may  become  small  and  slow,  owing  to  the 
partial  occlusion  of  the  aorta,  brought  about  by  the  traction  of  fibrous 
bands  of  adhesions  which  pass  over  the  vessel,  being  at  the  same  time 
connected  with  the  pleura.  When  these  bands  pass  from  the  exterior  of 
the  heart-muscle  or  pleura,  they  may  cause,  as  first  pointed  out  by 
Riegel,  an  absence  of  the  apex-beat  during  expiration.  Instances  of  this 
sort  are  not  uncommon. 

Diagnosis. — Although  the  presence  of  a  to-and-fro  friction-sound  is, 
as  a  rule,  indicative  of  plastic  pericarditis,  it  is  an  error  to  regard  it  as 
an  infallible  sign,  since  complete  calcification  of  the  coronary  arteries,  as 
well  as  excessive  dryness  of  the  pericardial  surfaces,  may  rarely  produce 
friction-murmurs. 

Differential  Diagnosis. — The  harsh  double  murmurs  due  to  clironic  val- 
vular lesions  can  be  eliminated  if  it  be  recollected  that  they  are  more 
constant,  more  distant,   and  that  each  has  an  area  of.  transmission  beyond 

37 


578  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

the  limits  of  the  precordia.  The  sitting  posture,  leaning  forward,  or 
moderate  pressure  with  the  stethoscope,  all  fail  to  produce  or  to  increase 
endocardial  murnmrs,  Avhether  acute  or  chronic.  A  double  aortic  mur- 
mur is  associated  with  cardiac  hypertrophy,  the  Corrigan  pulse,  and  sys- 
tolic flushing  of  the  capillaries. 

Prognosis. — The  termination  is  always  favorable  as  to  life.  Com- 
plete resolution  does  not  often  occur,  but  the  exudate  becomes  connective 
tissue,  and  agglutinates  the  two  layers  of  the  pericardial  sac.  The  acute 
may  merge  into  the  chronic  form,  and  dry,  plastic  pericarditis  often  con- 
stitutes the  first  stage  of  severer  grades  of  the  disease. 

Treatment. — Absolute  quiet  in  the  recumbent  position  should  be 
enjoined.  The  diet  should  be  composed  chiefly  of  light,  easily  digested 
solids,  allowing  as  little  drink  as  is  possible,  and  thus  endeavoring  to 
avoid  an  overfilling  of  the  vessels.  With  the  same  object  in  view,  if  the 
patient's  strength  be  good,  a  half-dozen  leeches  should  be  applied  over 
the  heart,  followed  by  the  use  of  the  ice-bag ;  the  bowels  are  to  be  kept 
soluble  by  using  stewed  fruits  or  saline  laxatives  if  needful.  Calomel 
in  doses  ranging  from  gr,  \  to  ^  (0.016-0.032)  every  hour  or  two,  com- 
bined with  a  little  opium  to  prevent  purgation,  is  serviceable.  At  the 
beginning  veratrura  viride  may  also  be  cautiously  administered,  with  a 
view  to  dilating  the  arterioles  throughout  the  rest  of  the  body,  and  thus 
virtually  "  bleeding  the  patient  into  his  own  vessels."  Later,  digitalis  in 
combination  with  the  iodids  of  potassium  and  iron  should  be  substituted 
for  the  purpose  of  absorbing  the  effused  material.  Tonics  and  a  change 
of  air  may  be  required  during  convalescence. 

SEBO-FIBRINOUS    PERICARDITIS. 

Pathology. — The  anatomic  changes  may  be  grouped  into  three 
stages — the  ^V.s-^  being  cliaracterized  by  a  plastic  exudation  (correspond- 
ing with  the  lesions  in  dry,  plastic  pericarditis,  though  more  pronounced) ; 
the  second  stage,  by  a  variable  amount  of  effusion  composed  largely  of 
serum.  The  exudation  usually  begins  about  the  origin  of  the  great  ves- 
sels springing  from  the  base  of  the  heart,  and  ultimately  forms  a  thick 
covering  of  fibrin,  especially  on  the  visceral  layer.  The  quantity  of 
serous  effusion  may  be  from  2  to  10  ounces  (64.0-320.0),  but  occasionally 
it  is  as  much  as  3  pints  (1^  liters).  The  admixture  of  a  slight  amount 
of  blood-  or  pus-corpuscles  sometimes  occurs  in  this  form  of  the  complaint. 
The  third  is  the  stage  of  absorption  in  the  most  favorable  cases.  Perfect 
resolution  rarely  takes  place,  but,  instead,  the  liquid  effusion  is  alone  ab- 
sorbed, and  the  lymph  causes  firm  adhesions  of  the  visceral  and  parietal 
membranes.  If,  as  sometimes  happens,  the  serum  remains,  the  acute 
passes  into  a  chronic  condition.  The  muscular  tissue  of  the  heart  may 
become  involved  by  an  extension  of  inflammation  from  the  visceral  layer 
which  lies  in  contact  with  it ;  it  is  always  the  seat  of  more  or  less  col- 
lateral edema.  The  grade  of  the  myocardial  inflammation  will  depend 
much  upon  the  extent  and  duration  of  the  pericarditis,  though  usually  it 
is  moderate  in  the  fibrino-serous  variety. 

Ktiology. — The  disease  is  most  frequently  observed  to  be  associated 
with  acute  rheumatism,  Bright's  disease,  and  pulmonary  tuberculosis. 
Sears  collected  100  cases  of  pericarditis,  of  which  51  were  due  to  acute 


SEBO-FIBRINOUS  PERICARDITIS.  579 

rheumatism  ;  and,  according  to  Baumgarten,  the  former  disease  arises  as  a 
complication  of  the  latter  in  about  one-third  of  the  cases.  I  believe 
that  exceptionally  both  serofibrinous  and  plastic  pericarditis  may  occur 
in  the  course  of  rheumatic  dyscrasia  Avithout  the  slightest  evidence  of 
arthritis.  The  disease  also  occurs  in  the  course  of  the  eruptive  fevers 
and  lobar  pneumonia,  and  from  extension  of  inflammation  from 
neighboring  parts.  Of  66  instances  of  pericarditis  in  children,  24 
were  caused  by  rheumatism.  Next  in  frequency  were  tuberculosis 
and    pleuro-pneumonia  (Baginsky).     (See  also  Bacteriology,  p.  575.) 

Clinical  History. — When,  as  rarely  occurs,  s,  primary  pericarditis 
develops,  the  initial  symptoms  common  to  inflammation  of  other  serous 
membranes  manifest  themsel.ves,  as  anorexia,  sometimes  nausea  and  vorri' 
iting,  chills,  fever,  increased  respiratio7i  and  pulse-rate,  together  with 
local  pain.  The  pain  is  usually  of  a  dull,  aching  character,  and  less  fre- 
quently merely  a  slight  soreness,  or  it  may  be  absent  altogether.  Acute 
pain  is  experienced  only  when  the  pleura  is  implicated. 

When  pericarditis  is  secondary  there  are,  in  many  cases,  no  subject- 
ive symptoms  to. indicate  its  presence.  In  other  instances  there  may  be 
precordial  oppression  with  or  without  slight  pain  or  a  feeling  of  sore- 
ness. Hence  the  rule  should  be  absolute  that  in  all  aff'ections  in  which 
pericarditis  is  likely  to  arise  physical  examinations  of  the  heart  should 
be  frequently  made,  and  particularly  during  the  height  of  the  disease. 

Dyspnea  comes  on  simultaneously  Avith  the  appearance  of  the  effusion 
and  may  lead  to  actual  orthopnea.  Pressure  is  exerted  upon  the  left 
lung  if  the  eff'usion  be  large — a  fact  that  explains  in  part  the  presence 
of  dyspnea.  The  cardiac  muscle,  especially  the  right  ventricle,  is  also 
pressed  upon  by  the  eff'usion,  thus  impeding  to  a  greater  or  lesser  extent 
the  cardio-pulmonary  circulation  as  Avell  as  the  cardiac  diastole.  We  have 
here  an  additional  reason  why  dyspnea  occurs,  and  also  Avhy  deficient 
aeration  of  the  blood  and  a  feeble  peripheral  circulation  are  found  in 
this  complaint.  Prior  to  the  occurrence  of  the  eff'usion  the  circulation 
is  too  actively  carried  on,  the  pulse  being  full  and  strong.  It  is  clear 
from  the  above  explanation  relative  to  the  mechanical  effects  of  large 
effusions  that  during  the  second  stage  the  pulse  is  small,  feeble,  and  irreg- 
ular. When  the  liquid  effusion  is  not  large  the  heart-action  may  be  ap- 
parently feeble,  Avhile  the  pulse  remains  strong — a  valuable  rational  sign. 
On  the  other  hand,  an  excessive  amount  of  fluid  may  cause  the  radial 
pulse  to  become  quite  small  or  even  to  disappear  during  inspiration 
(the  jmlsus  paradoxus).  Fever  is  present,  as  a  rule  ;  the  tem.perature  is 
irregularly  elevated,  ranging  from  101°  to  103°  F.  (38.3°-39.4°  C). 
In  favorable  cases  defervescence  takes  place  by  lysis.  I^ervous  symp- 
toms, as  headache  and  mild  delirium,  often  appear,  and  sometimes  give 
place  to  stupor  or  even  coma. 

Physical  Signs. — Inspection. — The  skin-surface  and  mucous  mem- 
branes are  observed  to  be  pale  and  more  or  less  cyanotic.  The  neck- 
veins  are  prominent,  and  sometimes  exhibit  undulatory  movements  or 
pulsations.  The  face  wears  an  anxious  expression ;  the  respirations  are 
increased,  labored,  and  at  times  irregular.  The  decubitus  is  dorsal ;  the 
head  and  shoulders  are  elevated,  and  the  patient  may  be  forced  to  assume 
the  sitting  posture.  In  young  subjects  precordial  prominence,  with  efface- 
ment  or  even  bulging  of  the  intercostal  spaces,  may  result  from  the  pres- 


580  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ence  of  a  moderate  effusion.  In  adults,  however,  a  large  collection  is 
indispensable  for  the  production  of  this  effect.  If  the  lung  be  shrunken 
or  if  there  are  pleuritic  adhesions,  expansion  of  the  pericardium,  and 
hence  also  bulging,  will  be  prevented.  The  distended  pericardium  may 
depress  the  diaphragm.  Elevation  of  the  left  nipple  in  consequence 
of  marked  anterior  expansive  bulging  has  been  observed.  In  the  first 
stage  the  apical  beat  is  exaggerated,  but  as  the  effusion  increases  (forcing 
the  heart  backward  and  upward)  it  is  displaced  in  an  upward  and  outward 
direction,  at  the  same  time  becoming  Aveaker  as  well  as  more  diffused, 
since  with  expansion  of  the  sac  comes  greater  mobility  of  the  organ. 
When  the  pericardial  sac  becomes  filled  the  impulse-beat  disappears,  for 
the  reason  that  the  fluid  now  completely  surrounds  the  heart  and  pushes 
it  away  from  the  chest-wall. 

Palpation  confirms  the  results  of  inspection.  The  apical  beat  is  dif- 
fused and  feeble  or  lost.  When  detectable  it  is  found  to  be  displaced 
upward  and  to  the  left.  Altering  the  patient's  posture  changes  the  seat 
of  the  apex-beat  (Oppolzer),  and  if  the  shock  has  been  lost,  turning  the 
patient  on  his  left  side  or  bending  his  body  forward  may  cause  its  return. 
The  cardiac  impulse  disappears  earlier  when,  on  account  of  myocarditis, 
the  systole  is  greatly  enfeebled.  On  the  other  hand,  old  adhesions  and 
marked  hypertrophy  of  the  heart,  may  retain  the  apex-beat  in  contact 
with  the  chest-wall,  despite  the  presence  of  a  large  accumulation.  A 
friction-rub  can  be  felt  occasionally  over  the  base  of  the  heart  even 
in  the  stage  of  effusion,  and,  if  absorption  takes  place,  the  friction 
fremitus  becomes  more  marked.  Fluctuation  is  rarely  detected.  In 
large  effusions  the  liver  is  depressed  and  easily  'palpable. 

Percussion. — The  area  of  cardiac  dulness  is  greatly  increased,  and 
assumes  a  characteristic  triangular  outline  with  the  base  downward  and 
the  apex  extending  up  to  the  third  or  even  second  interspace  to  the 
left  of,  though  near,  the  sternum.  The  lateral  border-lines  of  dulness 
obviously  diverge  from  above  downward,  the  right  passing  to  a  point 
corresponding  with  the  right  edge  of  the  sternum,  along  which  it 
runs  to  the  seventh  rib ;  the  other  to  the  left,  finally  intersecting  the 
base-line  at  the  left  anterior  axillary  line.  Flatness  may  be  met  in  the 
axillary  region,  even  obliterating  Traube's  semilunar  space.  The 
lower  level  of  the  fluid,  being  continuous  with  the  liver  dulness,  is  not 
definable.  Rotch  points  out  that  even  in  moderate  effusions  there  is  flat- 
ness in  the  fifth  interspace  to  the  right  of  the  sternum  {cardio-hepatic 
triangle — Ebstein)  in  large  pericardial  effusions.  The  margins  of  the 
lungs  surrounding  the  heart  may  be  retracted  and  the  heart  carried  for- 
ward or  dilated,  owing  to  the  presence  of  adhesions  ;  the  dull  space  will 
then  appear  larger  than  is  justified  by  the  amount  of  fluid.  Retraction  or 
moderate  compression  of  the  lung  may,  hoAvever,  give  rise  to  a  modified 
tympanitic  resonance  to  the  left  of  the  flat  area.  Occasionally  the 
lung  is  attached  anteriorly,  and  the  heart  is  croAvded  backAvard  by  the 
effusion,  Avhile  the  area  of  flatness  on  percussion  is  relatively  diminished. 
The  triangular  shape  of  the  flat  space,  noted  when  the  patient  is  in  the 
sitting  posture,  is  to  a  considerable  extent  lost  and  its  area  diminished 
when  he  changes  to  the  supine  position  or  lies  on  either  side,  the  ef- 
fusion obeying  the  hiAvs  of  gravitation.  The  feeble  impulse  can  be  at 
times  felt  Avithin  the  dull  area  and  not  at  its  boundary. 

Auscultation. — The  characteristic  friction-rub  of  the  first  stage  has 


SEEO-FIBEIXOUS  PERICARDITIS.  581 

already  been  described.  It  may,  however,  also  be  audible  over  the  base 
during  the  stage  of  effusion,  and  always  returns,  after  absorption  of  the 
fluid,  for  a  brief  period.  The  heart-sounds  grow  more  and  more  distant, 
faint,  and  muffled,  though  the  second  sound,  as  heard  over  the  extreme 
base  of  the  organ,  may  remain  clear.  Over  the  area  of  dull  tympany 
corresponding  to  the  lower  antero-lateral  portion  of  the  left  lung  (which, 
as  before  pointed  out,  is  more  or  less  compressed)  may  be  heard  broncho- 
vesicular  breathing. 

Course  and  Duration. — It  will  appear  obvious  that  the  course  must 
vary  in  individual  cases  with  the  cause  and  severity  of  the  special  type  of 
infection.  Observation  has  shown  that  in  one  class  of  cases  the  three 
stages  (dry,  effusion,  and  absorption)  are  passed  through  in  rapid  succes- 
sion, while  in  another  class  each  stage  is  proportionately  lengthened. 
The  latter  form  has  been  termed  "  chronic  "  by  some  and  "  subacute  "  by 
others.  The  acute  may  also  be  followed  by  the  chronic  variety.  Usually 
sero-fibrinous  effusions  complicating  rheumatism  are  absorbed  with  rapidity 
once  the  process  has  begun,  seldom  requiring  more  than  two  weeks. 
When  recovery  is  about  to  occur  the  temperature  falls  by  lysis;  the 
dyspnea  gradually  disappears,  and  with  it  the  effusion  is  gradually  ab- 
sorbed. Convalescence  is  further  indicated  by  a  return  of  the  appetite, 
normal  heat  of  the  skin,  and  a  less  frequent,  full,  and  regular  pulse.  In 
cases  that  tend  to  a  fatal  termination  either  the  fever  continues  or  there 
is  suddenly  developed  hyperpyrexia,  as  may  happen  when  pericarditis 
occurs  in  the  course  of  acute  rheumatism ;  in  such  cases  the  dyspnea  is 
urgent  and  cyanosis  is  often  marked,  with  signs  of  failing  circulation. 
Nervous  symptoms.,  as  extreme  restlessness,  insomnia,  and  active  delir- 
ium, may  be  present.  Under  these  circumstances  death  usually  ensues 
at  the  end  of  a  week  or  ten  days.  In  a  fatal  case  of  acute  articular 
rheumatism  that  I  saw.  complicated  by  pericarditis,  Avith  hyperpyrexia, 
death  occurred  on  the  sixth  day. 

Complications. — Copious  effusion  may,  by  causing  pressure  upon  the 
recurrent  laryngeal  nerve,  produce  paralysis  of  the  vocal  apparatus,  or, 
it  may  press  upon  the  esophagus,  and  cause  difficult  deglutition.  Rarely 
acute  pleuritis  with  effusion  is  a  complication,  and  its  occurrence  usually 
lengthens  the  course  of  the  pericarditis  and  renders  the  outcome  uncer- 
tain. When  there  coexists  extensive  myocarditis  syncopal  attacks  often 
endanger  the  life  of  the  patient.  Associated  endocarditis  and  a  compli- 
cating pneumonia  may  be  observed. 

Prognosis. — In  sero-fibrinous  pericarditis  recovery  is  the  rule  under 
favorable  conditions.  The  outlook,  however,  becomes  gloomy  when  the 
above-mentioned  complications  arise,  and  particularly  when  there  is  hyper- 
pyrexia in  connection  with  acute  rheumatism.  Occurring  as  a  secondary 
event  in  serious  acute  diseases,  as  pneumonia,  or  in  chronic  diseases,  as 
Bright's,  or  organic  affections  of  the  heart,  the  pericarditis  often  precip- 
itates a  fatal  termination.  The  strong  possibility  that  these  cases  may 
only  partially  recover  or  assume  a  chronic  form  must  be  recollected  in 
making  a  prognosis. 

Diagnosis. — The  disease  is  often  overlooked,  because  unsuspected. 
Ordinarily  the  recognition  of  pericarditis  by  the  characteristic  triangular 
area  of  percussion-dulness  and  by  the  friction-sound  is  not  difficult. 
Atypical  cases  or  those  first  seen  during  the  stage  of  effusion  can  only  be 
correctly  diagnosticated  by  exclusion. 


582  DISEASES  OF  THE  CIRCULATORV  SYSTEM. 

Diflferential  Diagnosis. — Acute  pleurisy  of  the  left  side  may  simulate 
pericarditis  with  copious  effusion,  and,  as  before  stated,  these  diseases 
may  coexist.  Acute  pain,  hoAvever,  belongs  to  pleurisy  alone.  In  peri- 
carditis the  characteristic  physical  signs  are  elicited  over  the  precordia ; 
in  pleurisy  they  are  apt  to  occupy  not  only  the  anterior  but  also  the 
axillary  and  posterior  aspects  of  the  chest ;  hence  the  percussion-flatness 
in  pleurisy  extends  to  the  left,  far  beyond  the  boundary-line  of  the  per- 
cussion-flatness in  pericarditis.  The  pericardial  friction-sound  has  a  dif- 
ferent situation  usually  from  the  pleuritic,  and  the  latter  is  heard  syn- 
chronously with  the  respiratory  movements,  while  the  former  is  intimately 
related  to  the  time  of  the  cardiac  movements.  The  friction-murmur  of 
pleurisy  ceases  if  the  breathing  be  momentarily  suspended.  Encapsulated 
pleural  effusions  that  are  limited  in  area  to  the  antero-lateral  portion  of 
the  chest  are  exceedingly  diflficult  of  elimination,  and  especially  in  the 
absence  of  pleuritic  friction.  In  the  latter  complaint,  however,  the  heart- 
sounds  are  clear  and  the  apex-beat  often  pushed  some  little  distance  to 
the  right ;  on  the  other  hand,  in  pericarditis  the  general  disturbance  is 
usually  greater,  while  a  friction-rub  may  be  detectable  over  the  base. 
The  heart-sounds  are  distant  and  muffled.  The  diagnosis  is  often  aided 
by  a  consideration  of  the  previous  history  and  the  bearing  of  any  facts 
thus  obtained  upon  the  known  etiology  of  these  affections.  We  encounter 
formidable  difiiculties  when  we  attempt  to  exclude  cardiac  dilatation, 
though  the  following  brief  table  will  be  of  assistance  in  the  diagnosis : 

Pericarditis  with  Effl'sion.  Cardiac  Dilatation. 

{Previous  History.) 
Recent  history  of  ^out,  acute  rheumatism,       Usual  history  of  chronic  valvular  disease 
acute  infectious  or  septic  disease,  scur-  of  the  heart, 

vy,  chronic  nephritis,  or  tuberculosis. 

(  Clinical  History.) 
Fever  and  slight  pain  are  usually  asso-      No  fever  or  pain,  as  a  rule. 

ciated. 
Nervous  symptoms  are  often  present.  Absent. 

(Physical  Signs.) 

Inspection   often   reveals  bulging  (more  Apex-beat    usually   visible,    wavy,  ^nd 

marked    in    the    young).      Apex-beat  diffused, 
pushed  up,  is  feeble,  and  later  absent. 

Heart's  impulse  usually  absent  or  occu-  Though  feeble,  the  impulse  is  palpable, 
pies  center    of    dull    area.      Friction- 
fremitus  may  be  present  over  the  base. 

Percussion  shows  a  triangular  flat  area,  Dull  area  varies  with  chambers  dilated ; 

and  the  boundary-line  above  changes  it  is  coextensive  with  a  wavy  impulse, 

on  altering  the  position.    Tliere  is  dull  does  not  extend  so  high  (except  in  mi- 

tympany  (flatness  in  'massive   exuda-  tral  stenosis),  and  does  not  vary  with 

tions)  in  the  axillary  region.  change  of  position.     No  dull  tympany. 

^Hse»//oA/rt?(  shows  the  first  sound  distant  First  sound  clear,  short,  and  sharp.     No 

and  muffled  ;  a  double  friction-rub  is  friction-murmur  present,  but  an  endo- 

ot'ten  present  over  the  base.  cardial  murmur  may  appear. 

^ray  shows  triangular,  movable  shadow.  Upper  level  of  shadow  (quadrangular) 

fixed. 

Treatment. — The  management  of  the  fii'st  (or  dry)  stage  is  identical 
with  that  detailed  in  discussing  the  plastic  variety.  During  the  stage  of 
effusion  the  patient  should  be  kept  at  absolute  rest  in  the  recumbent  pos- 
ture, and  mental  excitants  should  be  rigidly  prohibited  with  a  view  to 


PURULENT  PERICARDITIS.  583 

minimizing  the  labor  of  the  heart.  The  diet  is  to  consist  mainly  of 
easily  digested  albuminous  articles ;  fluids  are  not  to  be  given  in  large 
amounts,  since  this  tends  to  overfilling  of  the  vessels,  increases  the  arte- 
rial tension,  and  delays  absorption. 

Local  Measures. — Flannel  should  be  kept  over  the  precordia,  so  as  to 
avoid  exposure  and  undue  chilling.  The  ice-bag  or  Leiter's  coils  (to  be  used 
in  the  first  stage)  should  be  cautiously  employed  during  the  second  stage, 
until  the  temperature  has  defervesced  considerably,  thus  indicating  a  sub- 
sidence of  inflammation  in  the  pericardium.^  Subsequently,  if  absorption 
does  not  proceed  satisfactorily,  blisters  may  be  applied  over  the  pre- 
cordia ;  but  should  the  patient's  general  condition  be  decidedly  bad,  an 
absorbifacient  containing  iodin,  lanolin,  and  ichthyol  may  be  substituted 
with  advantage. 

The  therapeutic  measures  must  be  chosen  with  sole  reference  ito  the 
primary  disease,  which  the  physician  must  continue  to  treat  while  he 
attempts  by  other  means  to  relieve  certain  symptoms  and  promote  absorp- 
tion. For  example,  if  the  pericarditis  be  due  to  rheumatism,  the  use 
of  the  salicylates  must  be  persevered  in,  and  opium  may  be  added  to 
quiet  restlessness  and  procure  relief  from  pain.  In  my  own  experience 
absorption  has  been  best  promoted  by  the  use  of  the  double  iodid  of 
potassium  and  iron,  or  of  iron  and  manganese.  These  agents  are  seldom 
contraindicated  unless  they  are  badly  borne  by  the  stomach.  Diuretics 
and  saline  purgatives  are  not  without  value,  but  do  good  only  in  the 
later  stages.  Depressing  measures  of  whatever  sort  are  not  to  be  re- 
sorted to  unless  the  circulation  be  good.  If  the  pulse  be  small,  weak, 
and  rapid,  with  marked  cyanosis,  stimulants  are  indicated  and  are  to  be 
given  in  moderate  quantity ;  the  pulse  will  then  be  found  to  grow 
stronger  and  the  dyspnea  and  cyanosis  less  marked.  Strychnin  and  the 
salts  of  ammonium  will  be  found  to  be  useful.  Digitalis  and  strophan- 
thus  are  not  to  be  thought  of  when  myocarditis  is  associated  ;  at  other 
times  they  often  improve  the  peripheral  circulation  and  increase  the  urin- 
ary secretion.  When  the  breathing  becomes  greatly  embarrassed  and  the 
circulation  fails,  as  shown  by  the  feeble,  broken,  rapid  pulse  and  the 
cyanotic  hue  of  the  lips,  eyelids,  and  finger-tips,  cardiocentesis  is  indicated, 
and  in  sero-fibrinous  eff'usion  aspiration  has,  in  recent  years,  given  good 
results  if  not  too  long  delayed.  If  the  slightest  doubt  arises  as  to  the 
character  of  the  fluid,  a  preliminary  puncture  with  a  hypodermic  needle 
should  be  made.  The  point  for  puncturing  is  the  fourth  interspace,  1 
inch  (2.5  cm.)  from  the  parasternal  line,  or  the  fifth  interspace,  1|-  inches 
(3.7  cm.)  from  the  left  edge  of  the  sternum.  The  operation  must  be  per- 
formed with  the  strictest  asepsis,  and  the  amount  of  liquid  withdrawn  at 
any  one  time  should  not  exceed  two  or  three  ounces.  It  is  better  to  re- 
peat the  puncture  several  times  than  to  remove  the  pT:essure  too  suddenly 
from  the  damaged  heart.  Of  60  cases  of  paracentesis  for  pericarditis 
of  diff'erent  varieties,  collected  by  Roberts,  24  terminated  in  recovery. 

PURULENT   PERICARDITIS. 

(Emjyi/ema  of  the  Pericardivm.) 

Pathology  and  Etiology. — The  condition  often  follows  the  sero- 
fibrinous form.     Septic  and  tuberculous  processes  involving  the  pericar- 

*  If  the  pericarditis  be  secondary  to  an  acute  febrile  disease,  this  fact  must  modify 
the  method  here  recommended  accordingly. 


584  DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

dium  are  also  apt  to  cause  purulent  eifusion,  and  many  of  the  cases  that 
arise  in  the  course  of  the  acute  infectious  diseases  belong  to  this  category. 
The  pneumococcus  has  been  found  in  the  pus  (Shattuck  and  Porter). 
The  membrane  is  much  thickened  and  presents  a  gray,  granular  surface, 
and  the  myocardium  underlying  the  visceral  layer  is  softened,  fragile, 
and  pale-looking  (fatty). 

Clinical  History. — The  local  subjective  symptoms  and  physical 
signs  are  the  same  in  kind  as  in  the  former  variety,  but  the  amount  of 
exudation  is  frequently  less.  At  the  onset  rigors  often  occur,  and  may 
be  repeated  at  varying  intervals.  The  temperature-curve  is  of  the  sup- 
purative type ;  the  pulse  is  small,  rapid,  and  irregular ;  and  physical 
prostration  is  pronounced.  Purulent  pericarditis  runs  a  comparatively 
rapid  and  an  almost  uniformly  unfavorable  course. 

Diagnosis. — The  chief  clinical  features  are  often  referable  to  the 
primary  or  cau.^al  disease ;  hence  in  every  instance  in  which  purulent 
pericarditis  is  apt  to  arise  a  physical  exploration  of  the  chest  is  impera- 
tive. The  purulent  character  of  the  eifusion  cannot  readily  be  ascer- 
tained, as  a  rule ;  but  the  history  of  an  affection  having  etiologic  impor- 
tance, the  observance  of  rigors,  and  the  presence  of  the  fever-curve  pecu- 
liar to  suppuration  Avould  all  point  strongly  to  purulent  effusion,  and  should 
lead  to  aspiration  -with  the  hypodermic  needle — a  harmless  procedure  if 
carefully  performed,  and  one  that  almost  constantly  gives  reliable  results. 

Treatment. — It  is  within  the  physician's  province  to  treat  the  pri- 
mary disease  assiduously,  but  not  pericardial  empyema.  Incision  (after 
preliminary  resection  of  a  rib — Brentano).  irrigation  of  the  sac,  and 
drainage  by  a  strand  of  iodoform  gauze  are  advisable  and  feasible 
measures. 

HEMORRHAGIC    PERICARDITIS. 

In  purulent  pericarditis  the  effusion  may  be  hemorrhagic,  and  par- 
ticularly Avhen  it  is  of  tuberculous  origin.  In  non-purulent  tuberculous 
pericarditis  also  the  exudation  is  apt  to  be  hemorrhagic.  In  the  non- 
purulent instances  that  are  due  to  chronic  Bright's  disease  or  that  occur 
in  the  aged  the  effusion  is  sometimes  blood-stained;  and  future  observa- 
tion may  show  that  the  hemorrhagic  variety  is  of  more  frequent  occur- 
rence than  has  hitherto  been  supposed.  In  ordinary  serous  pericarditis 
there  is  apt  to  be  present  more  blood  than  in  serous  pleuritis.  M.  T. 
Ferrier  has  found  o  examples  in  9  collections.  Sears  found  a  pure 
growth  of  pneumococci  in  the  exudate  from  a  case  of  hemorrhagic  peri- 
carditis. This  etiologic  variety  scarcely  calls  for  separate  clinical  con- 
sideration. 

ADHESIVE   PERICARDITIS. 

( Chronic  Pericarditis.) 

Pathology  and  Btiology. — Chronic  pericarditis  follows  the  acute 
forms,  and,  as  in  the  case  of  the  latter,  it  may  be  partial  or  general. 
The  effusion  may  rarely  remain  as  a  permanent  condition,  though  not 
infrequently  a  clear  history  of  the  preceding  acute  attack  is  wanting.  In 
most  instances  the  opposed  surfaces  of  the  membrane  are  either  univer- 
sally or  over  a  limited  area  firmly  adherent.  The  amount  of  new  con- 
nective tissue  present  or  the  degree  of  thickening  of  the  layers  varies 
greatly,  and  is  dependent  upon  the  type  of  the  primary  acute  attack.     If 


ADHESIVE  PERICARDITIS.  585 

the  latter  is  of  mild  grade — as,  for  example,  in  the  case  of  .the  sero-fibrin- 
ous  variety  complicating  rheumatism — then  not  much  thickening  is  en- 
countered in  the  resulting  chronic  form. 

Chronic  tuberculous  pericarditis  is  not  uncommon,  and  may  be  pri- 
mary, though  more  commonly  it  is  secondary,  in  its  origin.  The  disease 
may  be  chronic  from  the  time  of  onset.  I  have  noticed  that  often  more  or 
less  effusion  prevails.  The  layers  become  enormously  thickened,  and  total 
obliteration  of  the  sac  by  agglutination  of  the  surfaces  is  not  infrequent. 

In  the  dense  exudate  that  remains  after  complete  absorption  of  a  peri- 
cardial effusion  calcareous  depositions  occur,  forming  a  bony  casing, 
which  either  partially  or  totally  encircles  the  organ.  The  external 
surface  of  the  pericardium  may  become  united  with  adjacent  tissues. 
The  myocardium  is  the  seat  of  atrophic  and  degenerative  changes. 

Symptoms. — Autopsies  frequently  discover  an  unsuspected  adhesive 
pericarditis.  Hypertrophic  dilatation  of  the  chambers  usually  develops 
sooner  or  later,  and  is  due  to  adhesions  that  interfere  with  the  free  action 
of  the  organ  as  well  as  with  its  systole.  When  present  the  subjective 
symptoms  point  to  a  giving  way  of  the  right  ventricle,  as  shown  by  the 
presence  of  venous  stasis  and  dropsy.  The  fulse  is  rapid,  of  low  tension, 
and  irreo-ular,  and,  though  not  diagnostic,  the  pulsus  paradoxus  is  noted. 

Pericarditis  Callosa  (Galvagni  ^). — A  form  of  chronic  fibrous  pericar- 
ditis Avhich  comes  on  insidiously  during  childhood  and  is  exceedingly 
difficult  of  diagnosis  {vide  infra).  Pericarditis  callosa  is  characterized 
principally  by  facial  cyanosis,  slight  edema,  full  and  tortuous  jugular 
veins  without  pulsation.  The  typical  physical  signs  of  pericarditis  are 
wanting  also.  On  the  other  hand,  a  congestive  cirrhosis  of  the  liver 
may  supervene  and  lead  to  ascites. 

Physical  Signs. — Inspection. — Depression  or  pitting  of  the  intercostal 
spaces  over  the  position  of  the  heart  may  be  noticed.  Synchronous 
with  the  systole  there  is  also  a  retraction  of  the  chest-wall  in  the  apical 
area,  and  less  frequently  over  the  whole  precordia,  the  latter  being  an 
unerring  sign  of  universal  adhesions.  The  degree  of  systolic  recession 
is  slightly  influenced  by  the  respiration,  inspiration  increasing  it,  except 
adhesions  exist  between  the  pericardium  and  the  adjoining  pleura,  and 
it  is  best  appreciated  on  palpation.  When  the  apex-beat  is  not  palpable, 
the  systolic  pitting  over  its  site  may  be  due  to  atmospheric  pressure. 
During  the  diastole  the  heart  forcibly  rebounds,  causing  the  so-called 
diastolic  shock,  which  is  of  great  diagnostic  importance  when  associated 
with  marked  systolic  retraction.  Though  not  always  visible,  it  can  be 
readily  felt  on  palpation.  Friedreich's  sign  (the  sudden  collapse  of  the 
jugulars  during  diastole)  may  frequently  be  observed,  but  I  have  also 
noticed  this  in  cardiac  dilatation  without  adhesions.  Prior  to  the  onset 
of  dilatation  the  apex-beat  may  be  forcible  and  visible  over  an  increased 
area,  indicating  hypertrophy ;  but  after  the  myocardium  is  weakened 
(from  interference  Avith  its  nutrition)  and  dilatation  comes  on,  the 
impulse-beat  is  faint  or  wanting,  and  in  marked  systolic  retraction  may 
be  seen  to  be  vibratory.  The  fixed  position  of  the  apex-beat  Avhen  the 
patient  is  turned  over  upon  his  left  side  is  a  strong  confirmatory  sign. 

Percussion. — The  area  of  cardiac  dulness  is  increased,  especially  up- 
ward and  to  the  left,  owing  to  the  associated  hypertrophy  and  pleuro- 

^  University  Med.  Mag.,  March,  1899 ;    Clinique  moderne,  ami.  iv.,  No.  341, 


586  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

pericardial  adhesions,  and,  since  the  adhesions  between  the  pleura  and  the 
pericardium  do  not  allow  the  lungs  to  overlap  the  heart  during  inspira- 
tion, the  upper  and  left  lines  of  dulness  remain  fixed  (C  J.  B.  Williams). 

Auscultation. — When  dilatation  reaches  a  high  degree  the  auscultatory 
signs  peculiar  to  that  condition  appear.  In  many  cases  no  murmurs  are 
detectable,  but  in  a  third  group  loud  murmurs,  quite  independent  of  any 
value  as  regards  cardiac  lesions,  are  audible ;  these  murmurs  may  be  due 
to  the  vortiginous  movements  in  the  endocardial  blood-current  occa- 
sioned by  the  jogging  cardiac  action.  The  murmur  of  tricuspid  regur- 
gitation, from  a  breakdoAvn  of  the  right  ventricle  without  apparent 
exciting  cause,   is  most  significant. 

Differential  Diagnosis. — The  condition  is  apt  to  be  confounded 
with  chronic  myocarditis  and  simple  hyiiertrophic  dilatatio7i. 

As  before  stated,  chronic  pericarditis  may  be  associated  with  effusion, 
and  it  is  important  to  distinguish  such  instances  from  the  adhesive 
form,  if  we  would  institute  a  proper  treatment.  In  chronic  pericarditis 
with  moderate  effusion  the  seat  of  the  apex-beat  is  higher  and  less  un- 
dulatory,  and  when  the  amount  of  effusion  is  large  the  impulse  is  absent 
and  there  is  bulging.  Adhesive  pericarditis  with  hypertrophy  causes 
bulging  in  young  subjects,  but  the  apical  beat  is  retained.  In  pericar- 
ditis with  effusion  the  upper  and  left  limits  of  dulness  are  not  stationary, 
and  there  is  an  absence  of  systolic  retraction  and  diastolic  concussion. 

Course  and  Prognosis. — The  hypertrophy  that  comes  on  early  in 
consequence  of  the  obstruction  offered  to  cardiac  action  is  compensatory, 
and  this  harmonious  balance  may  be  maintained  for  a  long  period  of  time 
with  apparent  comfort.  After  myocardial  degeneration,  followed  by 
atrophy  or  dilatation,  has  occurred,  the  condition  becomes  quite  serious, 
and  death  usually  ensues  amid  signs  of  extreme  cardiac  dilatation. 

The  treatment  must  be  ordered  chiefly  with  reference  to  the  nutri- 
tion of  the  heart-muscle,  following  the  principles  noted  in  dealing  with 
the  manajrement  of  valvular  affections  of  the  heart.  If  chronic  effusion 
be  present  early,  operative  measures  are  to  be  Avarmly  advocated. 


HYDROPERICARDIUM. 

(Dropsy  of  the  Pericardium.) 

Definition. — A  condition  in  which  the  pericardium  contains  a  serous 
transudation,  wliile  the  membrane  itself  shows  no  signs  of  inflammation. 

!^tiology. — {a)  Hydropericardium  is  usually  associated  with  general 
cardiac  or  renal  dropsy,  of  which  it  forms  a  component  part.  Under 
these  circumstances  it  develops  late,  and  frequently  follows  hydrothorax, 
on  account  of  which  condition  it  is  liable  to  be  overlooked.  It  may  also 
occur  suddenly  in  chronic  nephritis,  and  particularly  in  the  scarlatinal 
variety,  (b)  It  arises  not  infrequently  from  local  mechanical  causes,  as 
the  pressure  of  mediastinal  tumors,  aneurysm,  or  thrombosis  of  the  car- 
diac veins. 

Symptoms. — No  subjective  symptoms  are  present,  save  perhaps 
dyspnea,  and  the  diagnosis  rests  upon  the  history  and  the  physical  signs. 
None  of  the  latter,  however,  are  particularly  significant.     They  point  to 


HEMOPERICARDIUM— PNEUMOPERICARDIUM.  587 

the  presence  of  fluid,  and  the  area  of  percussion-dulness  assumes  the  same 
form  and  exhibits  even  greater  change,  with  alteration  of  the  patient's 
posture,  than  in  pericarditis.  No  friction-murmurs  are  heard  and  no 
bulging  of  the  pericardium  is  observed.  It  is  rare  indeed,  I  have  found,  to 
see  an  excessive  amount  of  serum  in  the  pericardium  at  the  postmortem. 
The  symptoms  and  signs  of  hydrothorax  generally  precede  and  accompany 
hydropericardium,  and  the  latter  condition  tends  to  intensify  the  effect  of 
the  former.  The  condition,  pe?'  se,  is  rarely  of  serious  import.  Osier 
remarks :  "  Naturally  there  are  in  the  pericardial  sac  a  few  cubic  centi- 
meters of  clear,  citron-colored  fluid,  which  probably  represents  a  post- 
mortem transudate."  In  rare  instances  the  transudate  has  a  milky 
appearance  {eliylo-pericardium). 

The  treatment  suitable  for  cases  of  general  dropsy,  as  a  rule,  aff"ords 
relief.     In  large  serous  accumulations  aspiration  should  be  practised. 


HEMOPERICARDIUM. 

By  the  term  "  hemopericardium  "  is  meant  hemorrhage  into  the  peri- 
cardial pouch — a  rare  event.  Among  the  causes  are — {a)  perforation  by 
aneurysms  of  the  aorta  and  the  coronary  arteries  into  the  sac :  (6)  rupture 
of  the  heart,  due  to  injuries  or  cardiac  aneurysms  and  fibrous  formations 
from  myocarditis  ;  (c)  direct  injuries,  especially  stab-  and  bullet-wounds. 
The  symptoms  and  course  depend  greatly  upon  the  nature  of  the  exciting 
cause.  The  most  frequent  factor,  rupture  of  an  aneurysm,  proves  quickly 
fatal  from  overcrowding  of  the  heart.  In  rupture  of  the  heart-muscle 
there  is  sometimes  a  slow  outpouring  of  blood,  with  a  correspondingly 
slow  course,  varying  from  a  few  hours  to  a  couple  of  days  in  duration. 
The  physical  signs  of  efiusion  come  on  with  dyspnea  and  failing  circula- 
tion, which  lead  to  cardiac  exhaustion  and  death.  The  blood-stained 
effusions,  before  considered,  that  are  met  with  in  certain  forms  of  peri- 
carditis, are  not  to  be  regarded  as  instances  of  hemopericardium. 


PNEUMOPERICARDIUM. 

{Air  in  the  Pericardium.) 

In  this  complaint,  besides  air  or  gas,  there  is  usually  present  pus,  and 
less  frequently  blood  ;  hence  an  appropriate  term  in  most  instances  would 
be  pyo-p7ieumo2)ericardium.  When  the  pericardium  is  perforated  puru- 
lent pericarditis  results.  Tlie  causes  are  the  following  :  (a)  wounds  ;  {h) 
a  fistulous  connection  between  the  adjacent  air-containing  organs  and 
the  pericardium  as  the  result  of  diseased  processes,  such  as  pulmonary 
tuberculosis  or  empyema ;  (c)  rarely  decomposition  of  liquid  pericardial 
effusions.  The  syinptoms  are  equivocal.  In  the  main  they  do  not  differ 
from  those  of  pericarditis  with  effusion,  excepting  that  dyspnea  is  more 
intense  than  in  the  latter  affection.     By  attention  to  the  physical  signs 


588  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  distinction  from  pericarditis  can  rarely  be  made.  In  pneumoperi- 
cardium there  is  tympanitic  percussion-resonance  over  the  precordia, 
though  the  fluid,  "when  present,  gives  rise  to  a  boundary-line  of  dulness. 
The  change  of  the  patient's  posture  decidedly  alters  the  area  of  the  tym- 
panitic note.  On  auscultation  may  be  heard  loud,  rasping,  friction- 
sounds  having  a  metallic  quality,  intermingled  with  churning,  splashing 
noises,  or  the  so-called  "  ^vater-wheel  sounds."  I  have,  however,  met 
with  two  cases  in  which  the  heart-sounds  were  exceedingly  feeble. 
Pneumothorax  when  encysted  in  close  proximity  to  the  heart,  displacing 
the  latter  organ,  must  be  eliminated.  The  latter  complaint  gives  cardiac 
dulness  in  an  abnormal  position  and  a  metallic  sound  synchronously  with 
the  respiratory  movements — two  signs  diagnostic  of  pneumothorax  that 
are  absent  in  pneumopericardium.  The  prognosis  is  grave,  death  coming 
on  most  commonly  in  a  day  or  two.  The  admission  of  air  might  alone 
result  in  a  spontaneous  cure,  as  occurs  rarely  in  pneumothorax.  The 
treatment  is  the  same  as  has  been  recommended  for  purulent  pericarditis. 


II.  DISEASES  OF  THE  HEART. 

ENDOCARDITIS. 

Definition. — Inflammation  of  the  lining  membrane  of  the  heart. 
The  process  is  usually  confined  to  the  valves,  though  the  cardiac  layer 
may  also   be  affected. 

Varieties. — (a)  Simple  acute  endocarditis  ;  {h)  ulcerative  endocarditis  ; 
(c)  chronic  endocarditis.  The  pathologic  processes  involved  in  the  first 
two,  the  acute  forms,  are  identical  in  nature,  though  they  diff"er  in  severity. 
I  have  met  with  two  instances  that  could  be  referred  to  neither  sub-variety, 
apparently  occupying  a  middle  ground. 

SIMPLE   ACUTE    ENDOCARDITIS. 
{^Endocarditis   IWi'iicosa.) 

Pathology. — The  disease  is  characterized  by  the  formation  of  small 
vegetations  on  the  segments,  varying  in  size  from  excrescences  that  are 
scarcely  visible  to  those  the  size  of  a  pea.  They  are  found  chiefly  on 
surfaces  that  are  opposed  to  the  blood-current,  near  the  margin  of  the 
valve,  and  "forming  a  row  of  bead-like  outgrowths."  Their  seat  corre- 
sponds to  the  point  of  maximum  contact  (Sibson),  but  the  mitral  valve 
is  much  more  commonly  aff"ected  than  the  aortic.  With  the  segments  the 
chordse  tendineae  are  sometimes  aff'ected,  and  very  rarely  the  latter  are 
alone  involved.  The  left  side  of  the  heart  is  much  more  frequently  the 
seat  of  acute  endocarditis  than  the  right,  except  during  fetal  life,  when 
the  right  side  is  almost  exclusively  involved.  To  account  for  the  greater 
frequency  of  occurrence  on  the  left  side  after  birth,  it  has  been  suggested 
that  freshly  oxygenated  blood  aff"ords  the  most  favorable  condition  for  the 
multiplication  of  the  micro-organisms  that  are  concerned  in  the  inflamma- 
tory process.     As  corroborating  this  view,  the  fact  is  adduced  that  during 


SIMPLE  ACUTE  ENDOCARDITIS.  589 

fetal  life  the  blood  in  the  right  chamber  is  the  more'  completely  oxygen- 
ated. It  has  also  been  pointed  out  that  before  birth  the  right  side,  and 
after  birth  the  left  side,  is  the  more  active,  and  that  the  active  side  is  apt 
to  suffer  on  account  of  higher  pressure.  Obviously,  the  vegetations  form 
an  obstruction  to  the  current  of  the  circulation  as  it  flows  through  the 
valvular  opening.  In  the  early  stage  the  membrane  in  the  vicinity  of 
these  excrescences  shows  a  bright-red  color,  which  has  usually  disappeared 
in  fatal  cases  before  they  come  to  autopsy.  The  histologic  changes  con- 
sist in  a  proliferation  of  the  subendothelial  tissue  (small-celled  infiltra- 
tion), which  forms  the  principal  component  part  of  the  vegetation.  On 
this  basal  mass  of  granulation  tissue  there  is  deposited  fibrin  from  the 
blood,  the  latter  being  separable  from  the  former  in  acute  forms  of  the 
complaint.  Micro-organisms  have  repeatedly  been  found  in  the  fibrinous 
depositions,  but  the  specific  causal  irritant  has  not  as  yet  been  discovered. 
In  favorable  cases  either  the  vegetation  is  ultimately  absorbed  or  there 
remains  a  small  indurated  mass.  When  the  vegetations  are  of  consider- 
able size  emboli  may  become  detached  by  the  force  of  the  blood-current, 
and  be  carried  to  the  vessels  of  the  extremities  and  to  the  various  viscera, 
particularly  the  brain,  spleen,  and  kidneys,  giving  rise  to  embolic  infarcts. 
The  latter  event  is  frequently  observed  in  cases  in  which  acute  endocar- 
ditis is  engrafted  upon  chronic  valvulitis. 

Simple  acute  endocarditis  may  end  in  the  more  serious  or  ulcerative 
variety.  Here  the  cellular  proliferation  proceeds  actively,  leading  to 
necrosis  of  the  newly-formed  tissue  and  to  the  production  of  an  ulcer. 
Much  more  commonly,  however,  does  the  simple  form  terminate  in  chronic 
(sclerotic^  valvulitis  with  deformity. 

Ktiology. — The  most  frequent  cause  of  acute  endocarditis  is  acute 
articular  rheumatism,  Avhich  induces  the  disease  in  not  less  than  40 
per  cent,  of  the  cases.  In  young  subjects  suffering  from  rheumatism  the 
liability  to  the  complaint  is  particularly  pronounced.  The  severity  or 
mildness  of  the  rheumatic  attack  does  not,  however,  influence  the  appear- 
ance of  the  cardiac  complication.  Cases  of  acute  endocarditis  of  rheu- 
matic origin  are  met  with  in  which  the  arthritic  phenomena  are  secondary. 
It  may  complicate  tonsillitis  when  the  latter  is  due  to  or  associated  with 
rheumatism.  In  sj^ecific  fevers  it  is  also  encountered,  and  found  to  be 
common  in  scarlet  fever,  but  rare  in  typhoid  fever,  diphtheria,  measles, 
erysipelas,  variola,  and  varicella.  It  is  not  uncommon  as  a  complication 
in  pneumonia  and  'pulmonary  tuherculosis,  and  Osier,  as  the  result  of  100 
autopsies  in  cases  of  pneumonia,  found  it  present  in  5  instances,  while  in 
216  postmortems  upon  phthisical  cases  it  was  present  in  12  instances.-^ 
It  has  frequently  developed  in  the  more  serious  forms  of  chorea,  and  inter- 
current acute  endocarditis  may  result  from  chronic  diseases  attended  with 
emaciation  and  general  weakness  or  suppuration,  such  as  ulcerative  carci- 
noma, gleet,  gout,  chronic  Bright's  disease,  and  diabetes.  Lastly,  acute 
endocarditis  may  occur  as  a  secondary  event  in  pre-existing  sclerotic 
endocarditis,  when  it  is  termed  acute  recurrent  endocarditis.  In  chronic 
endocarditis  the  liability  to  the  acute  form  is  greatly  increased  by  the 
puerperal  state,   and  also,   though  to  a  lesser  extent,   by  pregnancy. 

Bacteriology. — All  cases  of  acute  endocarditis  are  probablv  micro- 
organismal  in  character.  The  disease,  however,  is  the  result  of  various 
^  Text-hook  of  Medicine,  Osier,  pp.  628,  629. 


590  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

microorganisms  or  their  toxins,  whose  action  is  assisted  by  the  friction 
between  the  blood  current  and  the  surfaces  of  the  valves.  Frankel  and 
Sanger  affirm  that  the  staphylococcus  pyogenes  aureus  is  the  chief 
specific,  causative,  agent.  The  diplococcus  pneumoniae,  the  streptro- 
coccus  pyogenes,  and.  less  commonly,  the  Bacillus  coli  communis,  the 
gonococcus,  the  Bacillus  diphtherioe,  the  bacillus  of  Eberth,  and  the 
micrococcus  endocarditis  capsulatus  and  rugatus,  have  been  found. 

Clinical  History. — It  is  only  occasionally  that  definite  subjective 
symptoms,  as  precordial  pain  (sometimes  extending  down  the  left  arm), 
dyspnea,  and  cardiac  palpitation,  are  complained  of  by  the  patient.  If 
fever  have  been  present,  as  is  common,  the  temperature  usuallv  rises 
rather  abruptly.  In  the  vast  majority  of  instances  the  condition  is  discov- 
ered accidentally.  This  being  true,  its  frequent  occui'rence  in  acute  artic- 
ular rheumatism,  and  its  occurrence  in  the  other  diseases  mentioned  under 
"  Etiology,"  should  be  kept  in  remembrance.  The  symptoms  of  embolism 
are  rarely  observed.     F.  Billings  reports  a  case  with  multiple  emboli. 

The  physical  signs  by  which  acute  endocarditis  is  recognizable  are 
dependent  upon  the  valvular  insufficiencies  caused  by  the  morbid  lesions 
previously  described.  Hence  there  must  be  not  a  small  proportion  of 
mild  cases,  including  those  in  which  the  valves  are  not  affected,  that 
give  rise  to  no  distinct  physical  signs. 

On  inspection  the  area  of  visible  impulse  may  be  seen  to  be  increased, 
though,  as  a  rule,  it  is  normal.  The  impulse  is  sometimes  forcible  and 
often  irregular  during  the  initial  period,  but  later  it  becomes  less  distinct 
and  more  feeble.  Palpation  confirms  the  result  of  inspection.  I  have 
found  the  impulse  to  vary  at  each  visit,  with  a  general  tendency  to  lessen 
in  intensity  in  the  later  period  of  the  disease.  A  very  weak  impulse  is 
indicative  of  associated  myocarditis  or  of  the  poisonous  effect  of  a  severe 
type  of  primary  infection.  In  recurrent  endocarditis  the  apical  impulse 
is  often  heaving,  on  account  of  pre-existing  compensatory  hypertrophy, 
and  its  area  is  exceedingly  variable.     A  systolic  thrill  is  sometimes  felt. 

On  percussion  the  area  of  the  hearts  dulness  is  found  to  be  normal, 
except  in  cases  of  intense  myocardial  involvement,  with  dilatation  of 
the  chambers  when  the  area  of  percussion-dulness  is  increased  in  the 
transverse  diameter.  In  recurrent  acute  endocarditis  the  area  of  dul- 
ness  corresponds  to  the  increased  area  of  the  apical  beat. 

Auscultation. — Acute  endocarditis  is  usually  attended  with  a  soft 
blowing,  systolic  murmur,  which,  owing  to  the  fact  that  the  mitral  seg- 
ments are  the  favored  seat  of  the  disease,  is  heard  much  more  frequently 
at  the  apex  than  at  the  base.  The  point  of  maximum  intensity  of  this 
murmur  is  often  movable,  but  its  area  of  transmission  is  limited.  In 
rheumatic  endocarditis  this  murmur  is  preceded  by  a  prolongation  of 
the  first  sound,  and  it  may  be  rough  in  character,  and  associated  with 
accentuation  of  the  aortic  second  sound,  later  with  a  valvular  pulmonary 
second.  The  murmur  is  sometimes  heralded  by  a  feeble  or  muffled  first 
sound,  with  apparent  intensification  of  the  second,  suggesting  ventricular 
dilatation  as  the  cause  of  the  murmur.  In  acute  endocarditis  affecting 
the  mitral  valves  aortic  murmurs  may  coexist,  but  their  true  nature  is 
more  than  doubtful.  There  is  also  a  short,  low-toned,  and  double  sys- 
tolic murmur  over  the  tricuspid  orifice  in  a  small  proportion  of  the  cases  ; 
this  is  due  most  probably  to  a  relative  incompetency.  When  acute 
endocarditis  arises  in  connection  with  chronic  valvular  disease,  the  aus- 


SDIPLE  ACUTE  EXDOCARDITTS.  591 

cultatory  signs  of  the  latter  are  but  little  changed;  and  hence  an  assured 
diagnosis  is  not  possible. 

Complications. — There  may  be  developed  by  direct  extension  sec- 
ondary myocarditis,  a  disease  that  will  receive  separate  consideration. 

The  diagnosis  is  based  principally  on  the  physical  signs,  though 
these  are  by  no  means  trust"^orthy.  The  points  gained  by  careful, 
inspection  and  palpation  are  of  especial  diagnostic  importance,  as  is  also 
the  previous  history  of  the  patient. 

Differential  Diagnosis. — The  soft  bellows  murmur  is  often  present  in 
acute  febrile  diseases  in  which  the  autopsy  fails  to  reveal  the  lesions  of 
acute  endocarditis.  The  functional  murmurs  that  arise  in  the  specific 
fevers,  however,  are  principally  heard  over  the  aortic  area,  while  those 
occurring  in  endocarditis  are  commonly  heard  over  the  mitral  area. 
Leube  ^  points  out  that  if  the  dulness  is  slightly  increased  to  the  left 
and  there  is  fever ;  in  fact,  if  there  is  infectious  disease  present,  a  diag- 
nosis must  be  made  of  acute  insufficiency  of  the  ostium  mitralis  occurring 
in  the  course  of  acute  endocarditis.  The  distinction  between  simple  acute 
endocarditis  and  periearditis  should  be  categorical,  in  view  of  the  manifold 
differences  between  their  signs.  But  the  fact  that  these  two  affections 
may  be  associated,  more  especially  when  they  are  of  rheumatic  origin, 
must  be  steadily  borne  in  mind,  and  also  that  when  combined  the  signs 
belonging  to  the  endocarditis  are  not  open  to  observation,  owing  to  the 
pericardial  friction-sound,  and  later  the  presence  of  the  effusion.  I  have 
found,  however,  that,  fortunately,  endocarditis  usually  precedes  pericar- 
ditis. The  murmurs  present  must  be  called  accidental  if  the  area  of  car- 
diac dulness  is  normal,  the  second  pulmonary  sound  not  accentuated,  and 
if  the  murmur  be  heard  only  at  the  pulmonary  cartilage,  or  at  this  point 
and  at  the  apex,  and,  at  any  rate,  more  distinctly  at  the  pulmonary  car- 
tilage (Leube-).  The  elimination  of  old  endocarditis  or  chronic  valvular 
disease — a  matter  of  importance — may  be  accomplished  by  attention  to  the 
character  of  the  murmur  in  acute  endocarditis,  as  well  as  to  its  limited 
area  of  diffusion,  and  by  the  absence  of  the  signs  of  hypertrophy  and  of 
marked  accentuation  of  the  second  pulmonary  sound. 

A  relative  insufUciency  distinguishes  itself  by  a  pure  systolic  murmur, 
loud  and  not  invariably  uniform,  by  a  weak  cardiac  impulse,  a  slight  ac- 
centuation of  the  second  pulmonary  sound,  and  a  comparatively  small  and 
often  irregular  pulse.  It  is  met  with  in  excessive  dilatation  of  the  left 
ventricle,  in  anemia,  "  and  particularly  in  certain  changes  of  the  valvular 
muscles,  due  to  myocarditis"  (Leube). 

Prognosis.  —  The  immediate  dangers  are  few.  and  depend  largely 
upon  the  primary  disease.  In  many  instances,  however,  acute  endocar- 
ditis initiates  permanent  lesions  of  the  valves. 

Treatment. — Prophylaxis. — The  prevention  of  acute  endocarditis  in 
rheumatism  has  been  dealt  with  in  discussing  the  latter  disease.  Xo  known 
direct  measures  can  prevent  the  development  of  this  condition  in  the  course 
of  the  specific  fevers,  though  absolute  rest  in  bed  and  protection  of  the  body 
against  "  cold  "  may  diminish  somewhat  the  tendency  to  it. 

The  Attack. — The  sick-room  should  be  free  from  draughts.  thou<?h 
well  ventilated,  and  flannel  is  to  be  applied  to  the  chest.  The  diet 
may  be  liberal,  but  should  be  composed  chiefly  of  milk  and  other  light 
nutritious  substances.     Stimulants  are  required  in  most  instances,   and 

^  DeiUsch.  Arckivf.  Min.  Med.,  Nov.  5,  1896.  -  Loc.  cit. 


592  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

in  abundance  should  the  heart  be  failing.  Digitalis  is  to  be  employed 
cautiously  if  at  all.  When  the  myocardium  is  involved,  its  use  is 
not  without  danger ;  under  these  circumstances  the  drug  increases  the 
sufferings  of  the  patient  by  throwing  the  inflamed  and  weakened  car- 
diac muscle  into  firm  contractions.  The  salts  of  ammonium,  particu- 
larly the  carbonate,  should  be  given  continuously  with  a  view  to  obvi- 
ating intracardial  coagulation  of  blood  ;  and  should  the  latter  accident 
occur  despite  all  efforts  to  prevent  it,  the  carbonate,  together  with  stiych- 
nin  and  alcoholic  stimulants,  should  be  freely  administered.  I  am  con- 
vinced that  in  endocarditis  due  to  acute  articular  rheumatism  it  is  wise  to 
continue  the  exhibition  of  the  salicylates,  though  in  moderate  doses,  pro- 
vided that  the  heart  is  guarded  by  the  use  of  stimulants.  During  con- 
valescence from  an  acute  endocarditis  the  patient  should  be  kept  at  rest, 
so  as  to  minimize  the  strain  upon  the  affected  valves ;  even  after  he  has 
apparently  recovered,  and  particularly  should  the  murmur  still  be  present, 
perfect  quiet  is  to  be  enjoined  for  a  period  of  several  weeks. 

ULCERATIVE   ENDOCARDITIS. 
(MaUf/nant  or  Infectious  Endocarditis.) 

Malignant  endocarditis  is  variously  characterized,  though  usually 
either  by  perforative  ulceration,  by  suppuration  of  the  valves,  or  by  both, 
giving  rise  to  the  physical  signs  of  acute  endocarditis.  These  develop 
amid  the  symptoms  of  some  severe  primary  infectious  or  septic  disease. 
There  is  at  hand  sufficient  clinical  evidence  to  warrant  the  assumption 
that  ulcerative  endocarditis  also  occurs,  though  very  rarely,  as  a  primary 
affection. 

Pathology. — (a)  Valvular  Endocarditis. — In  its  early  development 
the  valves  are  the  seat  of  vegetations  (such  as  are  met  Avith  in  simple 
acute  endocarditis)  which  later  undergo  necrosis.  The  latter  process 
manifests  a  tendency  to  spread,  destroying  more  or  less  of  the  endo- 
cardium. In  the  interior  of  the  vegetations  the  process  of  suppuration 
not  infrequently  takes  place,  and  the  abscesses  thus  formed  rupture  and 
produce  various  lesions  according  to  their  size  and  situation.  The 
vegetations  take  on  a  grayish-  or  yellowish-green  appearance.  Histo- 
logically, they  are  composed  of  granulation  tissue,  veiled  by  granular  and 
fibrillated  fibrin  that  contains  numerous  micro-organisms.  At  the  base 
there  is  usually  developed  more  or  less  reactionary  inflammation.  After 
rupture  the  blood-current  may  enter  the  abscess-cavity,  and,  if  there  be 
no  complete  perforation,  the  endocardium  will  be  pouched  out,  and  an 
aneurysmal  dilatation  of  the  valve  will  result.  Ulcerative  lesions  are 
most  frequently  observed.  They  may  be  mere  erosions  of  the  endo- 
cardium, but,  as  a  rule,  are  penetrating  in  character  and  often  result  in 
complete  perforation.  I  have  seen  repeated  instances  in  which  the  three 
classes  of  lesions  above  depicted  were  all  present.  Osier,  in  an  analysis 
of  209  cases  examined  by  him  with  a  view  to  ascertaining  approximately 
the  relative  frequency  with  which  the  different  parts  of  the  heart  were 
affected,  obtained  this  result :  Aortic  and  mitral  valves  together,  41 ; 
aortic  valves  alone,  53;  mitral  valves  alone,  77;  tricuspid  in  19,  pul- 
monary valves  in  15,  and  the  heart-wall  in  33  instances.  In  9  instances 
the  right  heart  alone  was  involved.' 

1  Text- Book  of  Medicine,  p.  631. 


ULCERATIVE  ENDOCARDITIS.  593 

(h)  Malignant  mural  endocarditis  gives  the  same  set  of  changes  as 
the  valvular  form  ;  indeed,  the  latter  may  be  combined  with  the  former 
throughout.  It  is  a  comparatively  rare  condition,  as  is  shown  by  the 
foregoing  figures  of  Osier.  The  ulcerative  process  may  invade  the 
chordae  tendinese  and  the  valves,  and  may  perforate  the  septum  or  even 
the  ventricular  wall  itself.  The  vegetations  are  detached  in  small  or  large 
masses,  and  are  conveyed  by  the  circulating  medium  to  various  distant 
organs,  especially  to  the  spleen  and  kidneys,  less  frequently  the  intestines, 
meninges  of  the  brain,  and  the  skin.  Their  site  is  determined  largely  by 
their  size,  and  they  may  be  so  large  as  to  plug  vessels  of  the  caliber  of 
the  external  iliac.  When  found  in  the  lungs  they  may  originate  in  endo- 
carditis affecting  the  right  heart.  These  emboli,  containing,  as  they  do, 
the  agents  of  inflammation,  form  suppurative  infarcts  that  may  be  either 
white  or  red  in  color.  The  detached  vegetations  are  sometimes  so  laden 
with  irritants  as  to  cause  rapid  softening  of  the  coats  of  the  vessel  at  the 
point  where  they  become  arrested,  with  consequent  aneurysmal  dilatation 
directly  opposite  their  seat.  As  to  number,  the  infarcts  vary  greatly  in 
different  cases  ;  thus  there  may  be  only  one  or  two,  as  in  a  case  in  my 
own  knowledge  in  which  the  spleen  alone  contained  two  small  infarcts,  or 
there  may  be  more  than  a  thousand  minute  abscesses  widely  scattered 
throughout  the  body. 

etiology. — It  is  to  be  kept  in  remembrance  that  the  condition  is, 
with  few  exceptions,  most  probably  a  secondary  one.  This  explains 
why  the  lesions  peculiar  to  simple  acute  endocarditis  usually  precede 
and  accompany  those  of  the  ulcerative  form. 

Bacteriology. — The  specific  irritant  is  probably  the  streptococcus  pyo- 
genes (Frankel  and  Sanger) ;  hence  the  diseases  in  which  ulcerative  en- 
docarditis occurs  as  a  complication  merely  furnish  the  opportunity  for 
the  invasion  of  the  streptococcus.  The  bacillus  diphtherige,  however, 
as  well  as  the  staphylococcus,  the  bacillus  coli,  the  bacillus  anthracis, 
the  pneumococcus,  the  gonococcus,  and  other  organisms,  have  been  found 
in  some  cases  in  the  absence  of  the  streptococcus. 

In  purely  septic  diseases  ulcerative  endocarditis  forms  but  a  part  of 
the  serious  general  condition.  Here  the  cardiac  element  serves  to  facil- 
itate the  generation  and  rapid  diffusion  of  the  poison  ;  and,  since  the 
latter  is  prone  to  attack  the  valve-segments,  the  morbid  lesions  within 
the  heart  not  rarely  constitute  the  chief  pathologic  factor  in  septico- 
pyemia. Instances,  however,  are  met  with  in  Avhich  the  segments  pre- 
sent slight  changes. 

Predisposing  Affections. — The  malignant  form  occurs,  in  connection 
with  acute  articular  rheumatism,  in  about  10  per  cent,  of  the  cases  in 
which  acute  endocarditis  appears.  In  lobar  pneumonia  the  ulcerative 
type  is  common,  occurring  almost  as  frequently  as  the  simple  variety, 
and  was  found  by  Osier  in  11  out  of  23  cases.  The  septic  processes 
that  arise  from  the  puerperal  state  or  from  gonorrheal  infection  may  also 
be  complicated  with  ulcerative  endocarditis.  Among  many  other  diseases 
that  furnish  occasional  instances  of  this  serious  complication  are  measles, 
scarlet  fever,  typhoid  fever,  erysipelas,  small-pox,  chorea,  tuberculosis, 
and  chronic  Bright's. 

Clinical  History. — That  form  of  ulcerative  endocarditis  which  is  a 
more  or  less  prominent  factor  in  septic  diseases  has  been  considered  in 

38 


594  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

connection  with  septicemia.  Malignant  endocarditis  being  usually  a 
secondary  event,  its  clinical  features  must  not  be  confounded  with  those 
of  the  primary  affection.  It  is,  however,  often  impossible  clearly  to 
separate  the  symptoms  of  the  former  from  those  of  the  intercurrent 
aftection.     I  shall  describe  first  the  common  typhoid  form. 

Local  si/mptonis  are  often  entirely  wanting,  or,  when  present,  consist 
merely  in  slight  precordial  pain  and  oppression,  and  are  not  sufficiently 
well  pronounced  to  arrest  attention.  Subjective  symptoms  are,  however, 
connected  with  other  organs  than  the  heart,  and  are  due  to  the  irritating 
effects  of  emboli  that  occupy  the  various  organs  of  the  body.  Gastro-intes- 
tinal  disturbance,  as  shown  by  the  occurrence  of  vomiting  and  diarrhea, 
is  common.  Pain  that  is  ascribable  to  local  peritonitis  over  the  spleen, 
and  sometimes  also  over  the  liver,  is  observed.  Hematuria  and  dimness 
of  vision  are  also  frequent  concomitants,  and  are  due  to  renal  and  retinal 
hemorrhages.  The  urine  may  be  scanty  and  albuminous.  The  more  gen- 
eral feattires  that  are  the  result  of  the  local  embolic  processes  and,  in 
part,  of  the  valvular  lesions,  are  serious  and  for  the  most  part  typhoid 
in  character.  The  onset  is  usually  signalized  by  a  severe  rigor  that 
may  be  repeated  at  intervals  varying  from  one  to  several  daj's,  and  the 
disease  often  presents  an  irregularly  continued  fever-curve,  often  touch- 
ing a  high  mark  (105°  or  106°  F— 40.5°  or  41.1°  C).  I  saw  a  case 
recently  in  which  the  febrile  movement  pursued  the  continued  type  for 
seven  weeks.  The  pulse  is  rapid  and  irregular,  though  frequently  be- 
coming slow  within  a  brief  period.  The  patient  rapidly  emaciates,  and 
from  the  earliest  development  is  profoundly  prostrated,  and  nervous  symp- 
toms., as  headache,  mild  delirium,  followed  by  somnolence,  and  sometimes 
even  coma,  appear.  Profuse  sweating  sets  in  and  persists,  and  as  a  result 
the  skin  may  be  covered  by  sudamina.  An  ecchymotic  eruption  due  to 
cutaneous  emboli  is  also  common,  this  being  often  found  associated  with 
a  papular  or  a  diffused  roseolar  rash. 

Physical  Signs. — These  may  be  negative  as  regards  the  heart.  In  the 
majority  of  instances,  however,  a  systolic  murmur  is  present,  which, 
when  associated  with  other  clinical  indications  that  point  to  this  affection, 
is  valuable  for  diagnosis,  and  especially  so  if  developed  while  the  patient 
is  under  treatment  for  the  primary  attack.  The  second  sound  is  some- 
times accentuated  even  when  no  organic  lesions  have  previously  existed. 
The  physical  signs  of  pneumonia  and  pleuritis  (particularly  the  latter) 
may  not  infrequently  be  noted.  Cases  occur  in  which  gangrenous  in- 
farcts of  the  right  lung  give  rise  to  signs  of  localized  consolidation  ;  the 
spleen  becomes  considerably  swollen,  as  can  be  easily  demonstrated  by 
palpation,  and  is  quite  tender  as  a  rule  ;  and  the  liver  is  likewise  mode- 
rately enlarged  and  slightly  sensitive. 

Cerebral  Variety. — In  a  small  though  decisive  percentage  of  the  cases 
all  the  clinical  features  of  acute  suppurative  meningitis  are  presented, 
and  sometimes  to  the  almost  total  exclusion  of  symptoms  pointing  to  the 
primary  disease  or  to  the  more  typical  typhoid  form  of  ulcerative  endo- 
carditis. For  a  description  of  the  symptoms  that  characterize  the  cere- 
bral form  the  reader  is  referred  to  the  discussion  of  Purulent  Meningitis. 

Recxirrent  Malignant  Endocarditis.— ^\  this  term  is  meant  an  acute 
ulcerative  endocarditis  coming  on  in  the  course  of  chronic  valvular  dis- 
ease.    As  has  been  pointed  out,  simple  acute  recurrent  endocarditis  is 


ULCERATIVE  ENDOCARDITIS.  595 

common,  though  difficult  of  recognition.  The  latter  condition,  as  well 
as  the  lesions  in  chronic  valvular  disease,  predisposes  to  secondary  infec- 
tion by  the  streptococcus  and  other  organisms.  The  onset  is  usually 
abrupt  and  marked  by  a  chill.  The  patient  has  fever,  "vvhich  may  be 
quite  high  (104°  F. — 40°  C,  or  over),  and  may  present  either  an  irreg- 
v.larly  intermittent  or  a  truly  intermittent  curve.  The  latter  is  often  asso- 
ciated with  recurring  chills.  In  either  of  the  above  groups  the  course  is 
likely  to  be  acute.  In  some  cases  the  character  of  the  pre-existing  mur- 
mur is  changed,  becoming  louder  and  more  decidedly  blowing  ;  in  many 
other  instances,  however,  there  is  no  appreciable  alteration  in  the  murmur. 
The  condition  may  ai-ise  suddenly,  amid  the  signs  of  failing  compensa- 
tion, as  in  a  fatal  case  reported  by  Dr.  H.  P.  Loomis,^  in  which  the 
patient  was  semi-conscious,  cyanotic,  and  suffering  from  intense  dys- 
pnea and  general  dropsy.  It  was  impossible  to  diagnosticate  the  cardiac 
lesions  by  the  murmur  present.  Occasionally  these  severe  intercurrent  feb- 
rile attacks  end  in  recovery,  and  such  cases  probablj^  belong  to  the  benign 
form,  though  closely  simulating  the  malignant  in  their  clinical  characters. 

There  is  a  third  group  of  cases  that  run  a  subacute  or  even  chronic 
course,  with  more  moderate  elevations  of  temperature,  or,  as  rarely  hap- 
pens, none  at  all.  Mullin  of  Hamilton  has  reported  a  case  that  lasted 
more  than  a  year.  Here  the  other  clinical  phenomena,  especially  those 
referable  to  the  heart,  are  often  scanty  and  indefinite. 

Diagnosis. — It  is  of  paramount  importance  to  consider  the  previous 
history  and  all  the  circumstances  under  which  individual  cases  occur. 
These  points,  together  with  the  symptoms  attending  the  onset  and  the 
first  three  or  four  days  of  illness,  more  particularly  the  severe  rigor, 
early  high  temperature,  and  profound  prostration,  the  sweatings,  the 
various  embolic  phenomena,  and  the  presence  of  cardiac  symptoms,  are 
often  adequate  for  a.  certain  diagnosis.  With  a  clear  history  and  the 
presence  of  the  more  characteristic  general  symptoms  (in  particular,  the 
signs  of  embolism),  a  correct  diagnosis  is  possible,  even  though  cardiac 
murmurs  be  absent.  Instances  in  which  no  data  can  be  found  to  explain 
the  occurrence  of  the  disease  are  especially  puzzling,  and  these  will  re- 
main unrecognized  if  at  the  same  time  the  lesions  in  the  heart  fail  to  be 
manifested  by  special  symptoms.  The  existence  of  a  chronic  valvular 
affection  would,  in  itself,  under  the  latter  circumstances  afford  strong 
probability  of  the  presence  of  recurrent  malignant  endocarditis  if  the 
other  significant  clinical  symptoms  mentioned  above  were  present. 

Differential  Diagnosis. — There  is  a  group  of  cases  in  which  either  the 
history  fails  to  furnish  the  essential  causal  factors  on  the  one  hand,  or 
there  is  an  absence  of  definite  heart-symptoms  on  the  other  ;  this  group 
cannot  sometimes  be  separated  from  cases  of  tyj^hoid  fever.  The  sub- 
joined table  will,  I  feel,  be  found  valuable  as  an  aid  in  eliminating  the 
latter  disease  from  the  typhoid  form  of  malignant  endocarditis  : 

Ulcerative  Endocarditis.  Typhoid  Fever. 

Previous  or  associated  disease,  as  acute  Previous   healtli   good.      History   of  an 

rheumatism  or  pneumonia.  epidemic. 

Very    rarely   a   primary   affection.      No  Always    idiopathic,    with    a    prodromal 

prodromes  observable.  stage. 

^  Traiisaction^  of  the  New  York  Pathological  Society,  1890. 


596  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Ulcerative  Endocarditis.  Typhoid  Fever. 

Ushered   in  suddenly  by  a  severe  rigor,  Invasion    marked    by   slight    recurring 

which  may  recur.  chilly  sensations.      (Severe  chill  very 

rarely.) 

The  fever  rises  rapidly.  More  gradually,  in  step-like  fashion. 

Profound  prostration   as  early   as  third  Profound    prostration    not    earlier    than 

day.  seventh  day. 

The   fever  is   markedly  irregular    from  Less  so,  especially  in  the  first  week. 

time  of  onset,  as  a  rule. 

Embolic  symptoms  (hemiplegia,  etc.)  may  Extremely  rare. 

appear. 

Cardiac  symptoms,  especially  loud  sys-  Sometimes  a  soft  systolic  murmur. 

tolic  murmur,  often  present. 

The  blood  usually  shows  signs  of  septic  The  blood  shows  a  decrease  in  the  num- 

leukocytosis.  ber  of  leukocytes. 

Widal  reaction  and  characteristic  erup-  Both  symptoms  usually  present  and  diag- 

tion  absent.  nostic' 

Prognosis. — Most  cases  that  run  an  acute  course  terminate  in  death, 
and  when  supposed  instances  of  malignant  endocarditis  recover  they  are 
usually  to  be  regarded  as  being  of  benign  character.  Subacute  or  chronic 
varieties,  however,  such  as  are  most  frequently  met  with  in  connection 
with  organic  heart-disease,  sometimes  reach  a  favorable  issue. 

Treatment. — This  is  largely  supportive.  The  feeding  is  to  be 
pushed  vigorously,  and  concentrated  forms  of  liquid  food  should  be  given 
at  regular^  brief  intervals.  Arterial  stimulants  in  liberal  quantities  are 
also  demanded,  and  in  addition  quinin,  sodium  salicylate,  and  antiseptics 
may  be  tried.  For  the  embolic  symptoms  the  salts  of  ammonium  give 
slic^ht  promise  of  beneficial  results,  and  I  prefer  the  carbonate  for  this 
purpose.  Antistreptococcic  serum  has  recently  been  used,  and  has  proved 
efficacious  in  certain  cases.  It  is  obviously  of  no  avail  in  instances  in 
which  the  streptococcus  is  not  the  causative  agent.  Moritz  treated  a 
case  with  antistaphylococcic  serum,  with  a  favorable  issue. 

CHRONIC   ENDOCARDITIS. 
{Clironic  Interstitial  Endocarditis.) 

Two  clinical  varieties  are  met  Avith — one  following  the  acute  form,  the 
other  beginning  as  a  chronic  inflammation. 

Pathology. — The  lesions  may  be  limited  to  the  valvular  endocardium 
(their  most  common  seat),  orthe  mural  endocardium  may  also  be  involved. 
In  not  a  few  instances  the  lesions  are  confined  to  the  edges  or  bases  of 
the  segments,  and  when  seen  in  the  early  stages  there  may  frequently  be 
observed  merely  a  slight  thickening  of  the  free  border  of  the  leaflets ; 
in  most  cases  small  prominences  appear  near  their  free  margins.  The 
endocardium  looks  opaque  and  its  normal  elasticity  is  lost  quite  early. 
When  the  auriculo-ventricular  valves  are  affected  the  primary  seat  of 
inflammation  is  the  auricular  face,  but  when  the  semilunar  valves  are  dis- 
eased the  morbid  changes  begin  on  the  ventricular  side  and  implicate  the 
Aurantian  body.  Extension  of  the  morbid  process  to  other  and  all  parts 
of  the  valvular  curtain  is  common,  and  it  is  in  cases  of  this  sort  that  the 
greatest  degree  of  shrinking  and  crumpling  occurs.  The  most  character- 
istic lesions  consist  of  inflammation  and  exudation,  which  produce  cohe- 

^  The  septic  form  may  simulate  malaria  in  its  general  course.  The  points  of  dis- 
similarity may  be  found  in  the  discussion  of  Septicemia. 


CHRONIC  ENDOCARDITIS.  597 

sion  of  the  segments,  roughen  the  surfaces,  and  lead  to  the  deposit  of 
fibrin  upon  them.  The  Jmtologic  alterations  consist  in  a  proliferation  of 
the  endothelial  and  a  round-cell  infiltration  of  the  subendothelial  connective 
tissue.  Organization  of  these  products  of  inflammation  into  connective 
tissue,  "with  resulting  induration  and  contraction,  is  the  necessary  subse- 
quent pathologic  event.  In  old  cases  calcification  of  the  diseased  struc- 
ture is  frequent.  The  fibrinous  deposits  in  acute  endocarditis  may  be- 
come calcareous  "  at  the  same  time  that  the  sclerotic  processes  are  tak- 
ing place  in  the  valve  "  (Stengel).  The  shrinking  shortens  the  curtains 
or  curls  their  free  edges,  and  produces  insufiiciency  in  either  case,  since  on 
dropping  into  the  plane  of  the  valvular  orifice  they  fail  to  close  it  perfectly. 
Valves  thus  deformed  may  also  obstruct  the  blood-stream.  As  before 
mentioned,  cohesion  of  the  invaded  segments  take  place,  particularly  at 
their  bases,  and  may  extend  upward  for  a  considerable  distance,  leading 
to  constriction  or  stenosis. 

Involvement  of  the  semilunar  (aortic)  segments  in  the  ways  previously 
described  opposes  an  obstruction  to  the  outflowing  blood-current  on  the 
one  hand,  and,  owing  to  the  inability  of  the  segments  to  effect  perfect 
closure  of  the  aortic  orifice,  allows  on  the  other  hand  a  diastolic  reflux  of 
blood  into  the  left  ventricle.  The  aortic  ring  to  which  the  semilunar 
segments  are  normally  attached  becomes  sclerosed,  and  finally  the  seat  of 
atheromatous  changes,  either  fatty  or  calcareous.  Again,  chronic  inflam- 
mation of  the  intima  of  the  aorta  produces  a  similarly  thickened  condi- 
tion of  this  layer  in  spots,  followed  by  atheroma.  These  changes  are 
most  prone  to  take  place  in  the  course  of  the  ascending  arch  of  the  aorta 
or  just  above  the  aortic  segments.  From  the  aorta  and  subvalvular 
ring  tJie  diseased  processes  before  described  may  extend  to  the  coronary 
arteries.  Hence  sclerotic  and  atheromatous  alterations  in  the  blood- 
vessels are  found  frequently  in  association  with  organic  valvular  defects. 

Much  less  commonly  similar  lesions  are  noted  at  the  orifice  of  the  pul- 
monary artery.  A  similar  involvement  of  the  auriculo- ventricular  valves 
also  causes  regurgitant  and  obstructive  deformities  at  the  mitral  orifice, 
and  in  advanced  cases  the  chordae  tendineae,  and  even  the  papillary 
muscles,  are  almost  invariably  invaded  by  direct  extension  from  the 
valves.  As  these  structures  undergo  marked  thickening  with  subsequent 
contraction,  they  become  shortened  and  rigid,  causing  an  actual  narrowing 
of  the  cardiac  orifice.  In  mitral  stenosis  during  the  early  stages  or  in 
the  mildest  types  a  more  or  less  complete  ring  of  vegetations  encircles  the 
mitral  orifice  on  its  auricular  aspect.  The  margins  of  the  orifice  also 
become  hardened  and  roughened,  these  changes  frequently  extending  to 
the  valvular  curtains  and  the  chordae  tendineae.  Under  such  circum- 
stances the  thickened  valve  could  not,  during  the  ventricular  diastole,  be 
forced  back  against  the  ventricular  wall,  but  would  occupy  a  nearly  cen- 
tral position.  Owing  to  cohesion  of  the  free  edges  of  the  valvular  struc- 
tures and  to  contraction  of  the  chordae  tendineffi  drawing  the  leaflets  toward 
the  apex  of  the  heart,  the  transition  from  this  condition  to  the  formation 
of  a  hollow  cone  {funnel  mitral)  is  accomplished  by  natural,  easy  stages. 
Extensive  union  of  the  segments  along  their  free  margins  may  reduce 
the  aperture  to  a  mere  button-hole  slip  (hutton-hole  mitral)  as  viewed 
from  the  auricular  aspect.  The  last  two  forms  of  lesions  are  far  less 
commonly  met  with   at  the   aortic   orifice,  though   they  occur  rarely  in 


598  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

moderate  degree ;  on  the  other  hand,  curling  of  the  valvular  edges  is  far 
more  commonly  seen  at  the  aortic  than  at  the  mitral  orifice,  if  we  except 
the  cases  that  occur  in  children.  The  curtains  of  the  thick,  rigid  valves 
may  also  permanently  occupy  the  plane  of  the  orifice,  presenting  a  small 
ring-like  opening  {annulcu-  mitral). 

Fatty  degeneration  leading  to  the  formation  of  necrotic  (atheromatous) 
ulcers  is  common  ;  and  calcareous  deposits  are  frequently  seen  in  old  cases, 
either  in  localized  areas  or  coextensive  with  the  diseased  tissue,  converting 
the  entire  valve  into  a  calcified  mass,  Avith  loss  of  the  valvular  outlines. 

In  cJironie  mural  endocarditis  the  lesions  exhihited  are  grayish-white, 
slightly  elevated  patches  that  are  usually  found  to  invade  the  underlying 
muscular  structure  to  a  greater  or  a  less  extent.  Under  such  conditions 
of  the  valves  the  deposit  of  fibrin  would  be  greatly  favored,  and  the 
presence  of  an  ulcerative  surface  or  of  a  fibrous  deposit  on  the  valves 
affords  a  ready  and  satisfactory  explanation  of  the  occurrence  of  embo- 
lism in  these  cases.  Emboli  may  also  become  detached  from  cardiac 
thrombi  or  from  thrombi  formed  in  the  peripheral  veins.  For  anatomic 
reasons  the  favored  seats  of  embolic  processes  are,  as  in  acute  endocar- 
ditis, the  spleen,  brain,  and  kidneys,  and  irritants  that  cause  acute  endo- 
carditis find  here  a  tissue-soil  whose  capacity  for  resistance  to  invasion  is 
greatly  lowered.  Chronic  mural  endocarditis  and  chronic  myocarditis 
are,  as  a  rule,  due  to  the  extension  of  the  inflammation  from  the  valves, 
though  the  ventricular  endocardium  may  be  invaded  independently  of  the 
valvular  affection.  In  one  instance  of  mitral  stenosis  I  observed  an 
enormous  calcareous  mass  partly  in  the  subvalvular  tissue  and  partly  in 
the  wall  of  the  ventricle,  the  segments  remaining  altogether  intact.  In 
advanced  stages  of  most  cases  of  chronic  endocarditis  myocardial  degen- 
eration occurs.  It  takes  the  form  of  fibroid  change  or  fiitty  degeneration, 
or  both.  Aortic-valve  involvement,  especially  when  complicated  with  ath- 
eromatous change  in  the  coronary  arteries,  is  most  prone  to  these  forms 
of  myocardial  disease.  Chronic  endocarditis  may  be  said,  with  the  rarest 
exceptions,  to  persist  until  death,  although  Musser  has  reported  two 
cases  in  which  the  murmur  of  chronic  endocarditis  disappeared  during 
life.  The  effect  of  valvular  deficiencies  upon  the  several  cardiac  cham- 
bers and  the  muscular  structure  of  the  heart  will  be  most  advantageously 
studied  when  the  individual  lesions  of  the  segments  are  considered. 

Btiology. — There  can  be  no  doubt  that  most  cases  of  organic  heart- 
disease  occurring  in  children  and  young  adults  are  caused  by  primary  acute 
rheumatic  endocarditis  ;  and,  although  the  latter  affection  cannot  in  truth 
be  said  to  terminate  invariably  in  chronic  endocarditis,  it  probably  does  in 
most  instances.  This  result,  in  my  opinion,  is  more  frequent  in  children 
suffering  from  acute  endocarditis  than  in  adults.  On  the  other  hand,  not 
a  few  cases  of  chronic  endocarditis  originate  in  a  very  mild  grade  of  acute 
valvular  inflammation,  which  may  be,  though  itself  mute,  reinforced  by  a 
rheumatic  diathesis.  Indeed,  acute  endocarditis  may  be  the  sole  expression 
of  rheumatic  disease.  Not  less  than  one  half  of  all  cases  of  organic  val- 
vular disease  are  caused  by  rheumatism,  and  more  than  one  half  of  the 
total  number  occur  between  twenty  and  tliirty  years  of  age.  Acute  endo- 
carditis complicating  other  acute  infectious  diseases  than  rheumatism 
(e.  g.  measles,  chorea,  pneumonia)  may  also  be  followed  by  the  chronic 
variety  ;  but  it  is  quite  questionable  whether  this  occurs  as"  frequently  as 
in  the  case  of  acute  endocarditis  of  rheumatic  origin. 


AORTIC  lyCOMPETENCY.  599 

The  second  variety,  in  which  slow  interstitial  changes  occur  from  the 
beginning,,  is  dependent  upon — (a)  biologic  irritants  (e.  g.  syphilis,  malaria, 
and  chronic  rheumatism) ;  (h)  chemical  irritants  (uric  acid,  alcohol,-  lead)  ; 
and  (e)  mechanical  influences.  Doubtless  the  influence  of  repeated  strain- 
ing efforts  is  the  most  potent  cause  of  this  class  of  cases.  Heavy  muscular 
labor  increases  constantly  the  tension  in  the  arterial  system,  and  this  acts 
injuriously  upon  the  valve-segments,  setting  up  a  gradual  sclerotic  change. 
In  like  manner,  arterial  sclerosis  and  Bright' s  disease  may  cause  chronic 
interstitial  endocarditis  by  maintaining  a  persistent  increase  in  the  vas- 
cular tension,  though  the  fact  that  these  affections  may  in  turn  result 
from  the  action  of  some  of  the  leading  causes  of  organic  heart-disease 
must  also  be  recollected.  Trauma  has  produced  in  valves  previously 
healthy  a  sudden,  incontestable  proof  of  valvular  paresis  or  laceration 
that  has  persisted  in  a  few  well-attested  cases.  This  accident  is,  of  course, 
much  more  frequent  in  cases  in  which  the  valves  have  been  already  dis- 
eased, and  particularly  if  they  have  been  the  seat  of  ulcerative  processes. 

The  predisposing  causes  of  organic  valvular  disease  may  be  discussed 
briefly.  Hereditary  influence,  as  pointed  out  by  Virchow,  is  especially 
potent  in  persons  in  whom  there  is  hypoplasia  of  the  heart  and  aorta  {e.  g. 
in  chlorosis).  It  may  be  said  that  any  malformation  of  a  valve  is  certain 
to  throw  an  undue  strain  upon  certain  portions,  and  hence  is  likely  to  be 
followed  by  interstitial  change.  Osier,  in  17  cases  of  bicuspid  aortic 
valve,  has  reported  the  segments  to  be  uniformly  sclerosed.  The  cases  of 
supposed  hereditary  transmission  are  doubtless,  however,  for  the  most  part, 
due  to  the  causes  mentioned  above,  and  particularly  to  rheumatism.  Age 
exerts  a  predisposing  influence,  its  eflfects,  however,  varying  with  the 
valve  implicated.  During  fetal  life  this  is  on  the  right  side  of  the  heart 
in  a  vast  majority  of  cases;  during  childhood,  adolescence,  and  early 
adult  life,  when  the  infectious  diseases  and  rheumatism  are  frequent,  it  is 
the  mitral  valve  in  most  instances  ;  and  finally,  during  middle  and  espe- 
cially during  advanced  life  the  aortic  segments  are  especially  involved. 
I  have,  however,  found  aortic  disease  to  be  more  common  in  young  adults 
than  most  writers  are  ready  to  admit,  and  that  it  is  favored  especially  by 
an  occupation  involving  muscular  strain  (e.  g.  blacksmiths,  draymen,  sol- 
diers during  campaigns).  Sex  jjer  se  has  little  if  any  effect,  though,  owing 
to  the  greater  frequency  of  certain  well-known  causes  of  valvular  disease 
(chorea  and  rheumatism)  in  girls  and  young  women,  females  may  be 
more  frequent  sufferers  than  males. 


AORTIC  INCOMPETENCY. 

{^AodiC Insufficiency  :  Aortic  RegurgitoMon.) 

Definition. — The  failure  of  the  aortic  valves  to  prevent  a  return  flow 
of  blood  into  the  ventricle,  owing,  as  a  rule,  to  a  diseased  condition  of  the 
aortic  leaflets  (sclerosis)  that  is  followed  by  crumpling  and  attended  with 
contraction,  shortening,  or  curling  of  the  edges,  and  finally  calcification. 

Pathology. — The  aortic  orifice  may  be  enlarged  (relative  insuf- 
ficiencyj,  and  here  the  normal  cusps  fail  to  effect  complete  closure  of  the 


600  DISEASES   OF  THE  CIRCULATORY  SYSTEM 

orifice.  The  cusps  of  the  diseased  aortic  valves  sometimes  adhere  to  the 
intima  of  the  aorta,  and  laceration  of  the  semilunar  segments,  which  are 
the  seat  of  diseased  processes  (particularly  ulceration),  is  sometimes  found 
post  mortem,  and  may  be  the  chief  factor  in  determining  the  develop- 
ment of  the  condition.  This  accident  may,  though  rarely,  occur  as  a 
result  of  a  severe  straining  effort  in  the  case  of  valves  previously  healthy. 
Occasionally,  also,  the  principal  factor  in  the  production  of  this  valvular 
lesion  is  a  congenital  malformation  of  the  segments  whereby  they  are 
rendered  very  prone  to  chronic  endocarditis  in  consequence  of  the  undue 
strain  to  which  they  are  subjected.  The  lesions  that  give  rise  to  stenosis 
may  coexist  with  simple  aortic  incompetency,  and,  though  the  latter  con- 
dition frequently  occurs  alone,  stenosis  is  often  combined  with  regurgi- 
tation. 

Mechanical  Influence  of  the  Lesion. — The  reflux  current  passes  from 
the  aorta  backward  through  the  imperfectly  closed  semilunar  valve  into 
the  left  ventricle  during  the  diastole  of  the  heart  or  while  the  left  ventri- 
cle is  being  filled  by  the  normal  blood-flow  from  the  auricle.  It  is  clear 
that  over-distention  of  the  left  ventricle  must  result  at  once  from  two 
simultaneous  influx  currents  of  blood,  with  a  tendency  to  an  increasing 
dilatation,  especially  since  the  lesion  itself  is  steadily  progressive.  To 
expel  the  increased  amount  of  blood  from  the  left  ventricle  demands  in- 
creased cardiac  power,  and  the  over-exertion  causes  dilatation,  followed 
by  a  compensatory  hypertrophy.  Dilatation  and  hypertrophy  of  the  left 
ventricle  develop  pari  passu  until  the  left  ventricle  reaches  enormous 
dimensions,  forming  the  eor  bovinum,  which  weighs  1000  grams  or  more 
(30  to  50  ounces).  Under  these  circumstances  the  arterial  system  is 
overfilled  at  each  ventricular  systole.  In  the  very  early  stage  the  reflux 
of  blood  from  the  aorta  into  the  ventricle  tends  to  lessen  the  volume  of 
the  circulating  medium  in  the  arterial  tree,  but  this  depleting  influence  is 
successfully  counterbalanced  by  the  augmented  column  of  blood  thrown 
from  the  ventricle  during  cardiac  systole.  Hence  the  requirements  for 
bodily  nutrition  are,  for  a  longer  or  shorter  time,  satisfied.  The  abnor- 
mally large  amount  of  blood  that  is  thrown  into  the  arteries  with  undue 
force  subjects  them  to  increased  tension,  and  as  a  result  arterio-scle- 
rosis,  leading  sometimes  to  atheroma,  is  commonly  developed,  and  pre- 
sents its  ulterior  dangers  (aneurysm,  apoplexy).  The  coronary  arteries  are 
similarly  involved,  their  caliber  being  reduced,  and  particularly  at  the 
point  of  origin.  Soon  or  late  the  blood-supply  to  the  heart-muscle  may 
become  inadequate,  and  nutritional  disturbances  now  manifest  themselves 
in  fatty  and  fibroid  degeneration  of  the  cardiac  muscles :  these  pathologic 
changes  are  attended  with  secondary  dilatation,  which  soon  predominates 
over  the  hypertrophy.  The  imperfect  blood-supply  to  the  ventricular 
tissue  may  be  accounted  for,  in  great  measure,  by  the  narrowed  lumen 
of  the  coronary  vessels,  and  also  in  part  by  the  inelasticity  of  the  Avails  of 
the  latter  and  by  the  inefficiency  of  the  aortic  recoil.  Furthermore,  it  is 
to  be  recollected  that,  in  obedience  to  the  laws  of  nature,  overuse  of  any 
single  group  of  muscles,  while  productive  of  marked  hypertrophy  in  the 
first  instance,  is  followed  eventually  by  atrophy  and  loss  of  power.  In 
consequence  of  the  increased  tension  to  which  they  are  constantly  sub- 
jected the  mitral  leaflets  may  become  the  seat  of  sclerotic  endocarditis, 
and  this  may  lead  to  the  development  of  mitral  insufficiency  (usually  of 


AORTIC  INCOMPETENCY.  601 

mild  grade);  or  there  may  be  a  displacement  of  the  mitral  segments  in  the 
direction  of  the  auricle,  thus  creating  incompetency  at  this  orifice.  There 
is  to  be  observed  in  many  instances  a  marked  degree  of  fatty  degeneration 
of  the  papillary  muscles,  which  also  exhibit  more  or  less  flattening.  Again, . 
secondary  dilatation  may  produce  relative  insufficiency  at  the  mitral  ori- 
fice. When  incompetency  has  been  established  here,  impeded  pulmo- 
nary and  general  venous  circulation,  together  with  the  secondary  lesions 
in  the  left  auricle,  pulmonary  vessels,  and  right  ventricle  that  are  cha- 
racteristic of  mitral  incompetency,  are  the  necessary  result.  The  blood- 
current  through  the  mitral  ring  may  be  retarded,  owing  to  the  simultane- 
ous influx  into  the  left  ventricle  from  the  aorta,  thus  causing  pulmonary 
congestion  without  organic  change  in  the  segments. 

Special  Etiology. — (1)  Acute  Endocarditis. — Incomplete  resolution  of 
the  acute  form  of  endocarditis  leads  to  progressive  chronic  valvular  dis- 
ease. In  the  young  it  is  caused  with  comparative  frequency  by  rheu- 
matic endocarditis.  Aortic  regurgitation  may  also  arise,  though  rarely, 
in  the  course  of  acute  endocarditis,  as,  for  example,  when  the  latter  is 
attended  with  destructive  ulceration.  Such  instances  usually  terminate 
in  speedy  death. 

(2)  Chronic  Infectious  Irritants. — I  have  found  syphilis  to  be  a  factor 
(though  rarely  the  sole  cause)  in  a  considerable  percentage  of  cases. 
Aortic  regurgitation  is  a  frequent  complaint  in  sailors  and  soldiers,  among 
whom  it  is  worthy  of  notice  that  syphilis  is  particularly  common. 

(3)  Chemical  Irritants. — {a)  Uric  Acid. — In  chronic  and  irregular 
forms  of  gout  the  irritating  qualities  of  uric  acid  give  rise  to  interstitial 
endocarditis  and  arterial  sclerosis.  It  is  quite  probable  that  chronic 
rheumatism  has  a  similar  influence,  though  brought  about  in  a  somewhat 
different  manner,  (b)  By  favoring  the  accumulation  of  uric  acid  in  the 
blood,  lead-2}oisoning  may  be  indirectly  responsible  for  the  disease,  (c) 
Alcohol  by  its  persistent  irritant  action  may  excite  chronic  valvulitis. 

(4)  Augmented  Aortic  Tension. — The  excessive  functional  activity 
of  the  heart  occasioned  by  the  immoderate  use  of  cardiac  stimulants 
(alcohol)  tends  to  raise  the  blood-pressure  above  the  normal  point,  and 
thus  sclerotic  endocarditis  may  be  developed  very  slowly.  The  efl'ect  of 
occupation  in  causing  this  disease,  by  increasing  the  vascular  tension,  is 
more  notable  than  in  the  case  of  alcohol,  though  both  of  these  factors 
are  found  not  infrequently  to  be  present  in  the  same  case.  It  is  unde- 
niably true  that  strong-bodied  men  in  the  middle  period  of  life  and 
engaged  in  such  occupations  as  entail  strain — "  not  a  sudden,  forcible 
strain,  but  a  persistent  increase  of  the  normal  tension  to  which  the  seg- 
ments are  subject  during  the  diastole  of  the  ventricle  "  (Osier) — are  the 
most  frequent  sufl"erers  from  aortic  incompetency. 

(5)  From  personal  observation  I  feel  convinced  that  chronic  endo- 
carditis (afl"ecting  the  aortic  valves)  may  be  secondary  to  aortic  end- 
arteritis as  the  result  of  direct  extension.  It  must  be  borne  in  mind,  how- 
ever, that  arterio-sclerosis  is  also  often  secondary  to  chronic  valvulitis. 

(6)  Relative  insufficiency  is  caused,  in  rare  instances,  by  pronounced 
dilatation  of  the  ascending  portion  of  the  arch  near  to  the  valve,  or  by 
an  aneurysm  just  beyond  the  aortic  orifice. 

Among  the  more  efiective  predisposing  factors  are  age  and  sex.  The 
disease   occurs  much  more   often  in  males  than  in  females,  chiefly  on 


602  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

account  of  the  fact  that  a  greater  percentage  of  the  former  than  of  the 
latter  are  engaged  in  occupations  that  are  causally  related  to  the  dis- 
ease. As  to  age,  a  preponderating  proportion  of  the  cases  arise  during 
advanced  middle  life,  and  a  comparatively  smaller  number  at  a  more 
advanced  period  than  in  young  adult  life. 

Symptoms. — So  long  as  the  hypertrophy  of  the  left  ventricle  suc- 
cessfully overcomes  the  otherwise  injurious  consequences  of  the  valvular 
defect  the  harmonious  balance  of  forces  is  maintained,  and  there  is  an 
almost  entire  absence  of  symptoms.  I  have  observed,  moreover,  that 
compensation  does  not  fail  so  early  in  young  subjects  as  in  those  more 
advanced  in  years,  or  at  a  period  of  life  when  aortic  incompetency  is 
often  a  sequel  of  atheroma  combined  with  hypertrophy  and  dilatation 
of  the  left  ventricle.  With  the  development  of  marked  hypertrophy 
severe  muscular  exertion  and  strong  mental  excitement  will,  by  exciting 
over-action  of  the  poAverful  heart,  bring  on  a  train  of  symptoms  as  throb- 
bing headache,  vertigo,  and  tinnitus  aurium.  The  clinical  manifestations 
of  arterial  anemia,  particularly  of  the  brain,  and  also  those  of  general 
ai'terio-sclerosis,  frequently  coexist.  The  patient's  countenance  exhibits 
pallor,  and  he  complains  of  headache,  ftasJies  of  light  before  the  eyes, 
and  dizziness.  Dilatation  of  the  peripheral  vessels  often  leads  to  hot 
flushes  and  drenching  sweats.  Cases  exhibiting  the  latter  symptoms 
have  been  mistaken  for  phthisis.  Dizziness  is  often  distressing,  and  is 
most  marked  upon  rising  quickly  from  the  recumbent  to  the  erect  post- 
ure. Shortness  of  breath  may  come  on  early,  but  this  rarely  happens 
except  upon  inordinate  exertion  or  great  mental  excitement — conditions 
that  cause  strong  cardiac  action  and  prohibit  the  discharge  of  blood 
from  the  left  auricle  into  the  left  ventricle,  thus  causing  pidmonary 
congestion.  Oppression  in  the  precordial  region  and  cardiac  palpi- 
tation are  commonly  present,  as  is  a  dull  aching  fain;  the  most 
constant  seat  of  the  latter  is  the  precordia,  but  it  radiates  not  infre- 
quently to  the  shoulders,  and  thence  down  the  arms,  particularly  the 
left.  Genuine  angina  pectoris  may  be  a  concomitant.  I  have  seen 
instances  of  aortic  regurgitation  in  which  severe  poin  Avas  located  in  the 
left  shoulder-joint,  the  condition  simulating  rheumatism. 

FolloAving  immediately  upon  failure  of  compensation  the  cardio-pul- 
monary  circulation  is  retarded,  and  there  is  increased  dyspnea,  the  latter 
symptom  being  greatly  intensified  by  undue  exertion  and  at  night. 
There  may  be  cough,  and  not  rarely  hemoptysis,  though  less  frequently 
than  in  simple  mitral  disease.  Later  on,  general  venous  congestion  of  a 
moderate  grade  follows  pulmonary  congestion,  and  the  dyspnea  now 
becomes  severe.  It  is  nocturnal,  and  often  compels  the  patient  to 
assume  a  semi-erect  posture  in  bed.  In  the  later  stages  the  symp- 
toms, particularly  those  of  venous  stasis  as  shown  by  cyanosis  and 
malleolar  dropsy,  are  due  to  mitral  incompetency,  followed  by  fail- 
ure of  compensation.  Marked  enlargement  of  the  liver  due  to  passive 
congestion  may  now  ensue  and  give  rise  to  the  suspicion  of  a  new 
growth.  Edema  of  the  feet  rarely  goes  on  to  general  anasarca. 
In  aortic  incompetency  a  higher  grade  of  symptomatic  ane7nia 
is  reached  than  in  any  other  cardiac  lesion — a  recent  blood- 
count  showing  2,800,000  red  corpsucles  to  the  c.mm.  Hence  slight 
edema  of  the  feet  may  be  due  solely  or  in  part  to  anemia.      The  in- 


AORTIC  INCOMPETENCY.  603 

tercurrence  of  acute  endocarditis,  as  evidenced  by  prostration  and 
irregular  fever,  is  observed,  and  not  infrequently  as  a  terminal  condition. 
The  symptoms  of  cerebral,  splenic,  and  renal  embolism  may  arise.  Prob- 
ably sudden  death  ensues,  as  the  result  of  involvement  of  the  coronary 
arteries,  with  greater  frequency  in  this  than  in  all  other  forms  of  val- 
vular disease  combined  ;  and  yet  this  accident  is  by  no  means  frequent. 
Instances  of  aortic  incompetency,  in  which  nervous  phenomena^  as 
peevishness,  irritability,  or  melancholia,  manifest  themselves,  are  too 
common  to  be  looked  upon  as  mere  coincidences.  Many  patients  are 
led  to  commit  suicide  because  of  their  cardiac  lesion  when  other  and  er- 
roneous explanations  are  given  to  account  for  their  acts. 

Physical  Signs. — Inspection  brings  to  light  an  enlarged  area  of  the 
apex-beat ;  this  is  displaced  dowuAvard,  being  visible  in  the  sixth  and 
seventh  interspaces  and  to  the  left,  and  most  marked  between  the 
mammary  and  anterior  axillary  lines.  The  entire  precordial  zone  may 
be  distended,  particularly  in  young  subjects,  and  the  systolic  pulsation 
is  usually  more  or  less  heaving  in  character.  The  carotids  throb  for- 
cibly, as  do  the  temporals,  brachials,  and  radials,  though  less  vio- 
lently. These  abnormal  pulsations  are  due  chiefly  to  hypertrophy  of 
the  left  ventricle,  though  frequent  factors  of  lesser  influence  are  asso- 
ciated— an  arterio-sclerosis  and  a  regurgitant  blood-stream  from  the 
aorta  into  the  left,  ventricle.  The  impulse  becomes  difiused  and  wavy 
with  the  progressive  enfeeblement  of  the  left  ventricle,  and  venous  pul- 
sation due  to  tricuspid  insufliciency  may  be  associated  with  arterio-pul- 
sation  later  in  the  afi"ection.  Epigastric  throbbing  may  also  be  noticed, 
and  on  gently  rubbing  a  spot  upon  th«  forehead  an  alternate  paling  and 
blushing  appear  [Quincke's  capillary  pulse);  this  may  also  be  noted  in 
the  finger-nails.  It  is  not  peculiar  to  aortic  insufliciency,  however,  and 
may  be  observed  in  cases  of  decided  neurasthenia  and  in  anemia.  Very 
rarely  the  pulse-wave  is  propagated  from  the  capillaries  to  the  veins  of 
the  hand  and  back  of  the  foot,  giving  rise  to  a  visible  venous  pulsation. 
L.  Webster  Fox  informs  me  also  that  the  retinal  vessels  are  often  seen 
to  pulsate  in  this  disease. 

On  palpation  a  forcible  heaving  impulse  is  usually  felt.  When,  how- 
ever, dilatation  predominates  over  hypertrophy,  the  impulse  is  weak 
and  undulating.  A  diastolic  thrill  just  to  the  left  of  the  mid-sternum 
may  be  detected  in  many  instances,  and  a  presystolic  thrill  is  also  dis- 
coverable very  rarely.  The  pulse  is  characteristic  ;  it  is  quick,  jerking, 
and  full,  but,  upon  striking  the  finger,  recedes  abruptly,  and  is  known 
as  the  Corrigan  or  ivater-hammer  pulse.  This  sudden  collapse  of 
the  pulse  is  most  decided  when  the  arm  is  held  in  a  vertical  position. 
Its  distinctive  characters  are  not  always  appreciable  after  compen- 
sation is  lost.  A  glance  at  the  sphygmographic  tracing  will  show 
a  sudden  rise  and  fall,  with  absence  or  delay  of  the  secondary  wave 
{vide  Fig.   50). 

Percussion. — Cardiac  dulness  is  coextensive  with  the  impulse,  ex- 
tending downward  to  the  eighth  rib,  and  to  the  left  as  far  as,  or  even 
beyond,  the  anterior  axillary  line.  Later,  enlargement  of  the  left 
auricle  may  cause  dulness  upAvard  and  to  the  left  of  the  sternum.  En- 
largement of  the  right  ventricle  causes  an  increase  of  dulness  to  the 
right.     When  the  dilatation  exceeds  the  hypertrophy  the  area  of  dul- 


604  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

ness  will  be  much  extended  transversely  and  slightly  upward,  the  apex 
now  being  more  rounded.^ 

On  auscultation  a  diastolic  murmur  with  its  seat  of  greatest  pronuncia- 
tion is  audible  at,  or  a  little  below  and  to  the  left  of,  the  aortic  cartilage 
and  is  transmitted  down  along  the  left  edge  of  the  sternum ;  this  is  pro- 
duced in  the  left  ventricle.     From  the  xiphoid  it  may  be  transmitted  to 


Fig.  49.— Xormal  pulse-tracing. 

the  left  as  far  as  the  spinal  column.  It  may  be  heard  in  the  vessels  of 
the  neck  and,  very  rarely,  in  the  radials.  A.  Borgherini  affirms  that 
the  special  direction  taken  by  the  regurgitant  current  determines  largely 
the  variable  position  of  the  murmur  and  the  variable  size  of  the  heart. 
The  rhythm  of  the  murmur  can  be  most  readily  determined  by  auscul- 
tating over  the  base,  for   while  the   pulmonic  second  sound  is  usually 


Fig.  50.— Pulse-tracing  in  a  case  of  aortic  regurgitation  (William  Hoffman). 


audible  at  the  apex  (the  murmur  appearing  to  follow  it),  it  is  not  so 
when,  as  sometimes  happens,  the  murmur  is  quite  loud.  The  first  ^und 
is  often  dull,  indefinite,  and  widely  diffused,  OAving  to  hypertrophy  of  the 
left  ventricle..  In  qiialitj/  this  murmur  is  usually  soft,  blowing  (long- 
drawn),  and  frequently  musical ;  sometimes,  however,  it  is  somewhat 
rough  and  loud.  Associated  murmurs. — In  most  instances  a  systolic 
murmur,  brief  and  harsh  in  character  and  transmitted  into  the  vessels 
of  the  neck,  is  also  discovered  over  the  aortic  region  {double  aortic). 
The  presence  of  the  murmur  with  the  first  sound  is  not  diagnostic  of 
actual  aortic  stenosis.  It  is  more  often  due  to  a  mere  roughening  of 
the  semilunar  segments  or  of  the  intima  of  the  aorta.  In  advanced 
cases  a  soft  systolic  murmur  is  commonly  heard  at  the  apex  ;  it  is  readily 
distinguished  from  the  diastolic  murmur  by  its  rhythm,  and  is  occasioned 
in  most  instances  by  a  relative  mitral  incompetency.  Still  another  mur- 
mur, of  rare  occurrence,  is  rolling  in  character  and  generally  presystolic 
in  time,  and  may  be  heard  at  the  apex  over  a  limited  surface-area.  This 
may  be  accounted  for  by  the  presence  of  excessive  dilatation  of  the  left 

'  A  dilated  .lorta  with  thickened  walls— a  condition  sometimes  associated  with  aortic 
rep;urgitation — may  also  give  rise  to  abnormal  dulness  under  the  manubrium  and  to  the 
left  of  the  sternum. 


AORTIC  STENOSIS.  605 

ventricle,  in  consequence  of  which  the  mitral  leaflets  must  remain  free 
in  the  blood-stream  during  the  diastole,  and  here  they  set  up  vertiginous 
movements  that  cause  the  presystolic  (Flint)  murmur.  Duroziez  dis- 
covered a  double  murmur  in  the  arteries  (femoral),  which  is  quite  fre- 
quently present,  but  this  may  be  noted  occasionally  in  the  absence  of 
aortic  regurgitation.  Traube  has  described  another  arterial  phenomenon 
— a  systolic  sound  in  the  leg,  somewhat  resembling  a  heart-sound,  but 
exceedingly  short  and  sharp.  It  is  probably  due  to  sudden  systolic 
distention  of  vessels  that  were  previously  empty. 

The  diagnosis  demands  the  presence  of  a  diastolic  murmur,  the 
signs  of  left  ventricular  hypertrophy,  the  peculiar  arterial  pulsations, 
and  the  characteristic  water-hammer  or  Corrigan  pulse.  The  diastolic 
murmur  may  be  absent. 

For  the  differential  diagnosis  see  Aneurysms  of  the  Arch,  Hyper- 
trophy, Dilatation  of  the  Heart,  etc. 


AORTIC  STENOSIS. 

Definition. — A  narrowing  or  stricture  of  the  aortic  orifice,  due  to 
thickening  or  adhesion  of  the  valve-segments,  and  causing  an  obstruc- 
tion to  the  flow  of  blood  into  the  aorta. 

Simple  aortic  stenosis  may  be  met  with,  though  it  is  a  great  rarity. 
Its  development  is  soon  followed  by  more  or  less  valvular  incompetency, 
and  hence  these  affections  often  coexist.  It  may  be  secondary  to  aortic 
insufficiency ;  but  this  is  rare,  the  conditions  in  the  latter  disease  being 
unfavorable  to  the  development  of  the  former. 

Special  Ktiology. — Rarely  rheumatic  endocarditis,  and  still  less 
commonly  other  forms  of  acute  endocarditis,  cause  union  of  the  semi- 
lunar segments,  with  resulting  stenosis.  The  most  common  immediate 
causative  factor  is  a  slow  sclerosis  of  the  aortic  valve,  followed  by  cal- 
careous deposits.  The  more  or  less  immobile,  rigid  valves  obviously 
narrow  the  aortic  orifice  and  oppose  a  barrier  to  the  outflowing  blood- 
current  from  the  left  ventricle  into  the  aorta.  The  aortic  ring  may 
be  the  seat  of  changes  similar  to  those  just  described,  resulting  in  a 
moderate  grade  of  stenosis,  though  the  leaflets  themselves  remain  intact. 
The  lesions  are  most  frequently  to  be  regarded  as  a  part  of  the  general 
process  of  arterial  sclerosis,  which  is  most  marked  in  the  region  of  the 
thoracic  aorta;  and  sometimes,  as  Peter  contends,  they  are  distinctly 
secondary  to  sclerotic  changes  at  the  root  of  the  aorta.  The  coronary 
arteries  may  be  the  seat  of  changes  similar  to  those  noted  in  aortic 
regurgitation.  The  condition  is  also  rarely  congenital.  Males  who 
have  reached  advanced  years  are  especially  prone  to  aortic  stenosis,  for 
the  reason  that  atheromatous  processes  belong  peculiarly  to  that  sex 
and  period  of  life. 

Mechanical  Influence  of  the  Lesion. — To  propel  the  normal  volume  of 
blood  through  the  constricted  aortic  orifice  requires  increased  strength 
on  the  part  of  the  left  ventricle,  and,  as  a  consequence,  the  latter  hyper- 
trophies.   This  hypertrophy  develops  very  slowly,  and  keeps  pace  with  the 


606  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

progress  of  the  valvular  lesions.  The  undue  ventricular  tension  sometimes 
induces  more  or  less  sclerotic  change  in  the  mitral  valves.  Hypertrophy 
of  the  left  ventricle  eventually  gives  way  to  extreme  dilatation,  and  also 
to  relative  mitral  incompetency  with  its  unfavorable  influence,  first  upon 
the  pulmonary  and,  secondly,  upon  the  general  venous  circulation. 

Symptoms. — The  symptoms  date  from  the  commencement  of  failure 
of  compensation,  often  many  years  after  the  onset  of  the  disease.  Their 
first  appearance  will  be  found  to  follow  some  unusual  muscular  effort  or 
the  operation  of  some  depressing  influence,  as  the  too  free  use  of  to- 
bacco or  alcohol.  They  are  due  to  disturbances  of  circulation  arising 
from  a  gradual  secondary  dilatation  of  the  left  ventricle,  which  is  noAv 
unable  to  propel  the  normal  quantity  of  blood  into  the  arterial  tree. 
Hence  anemia,  especially  of  the  brain  and  peripheral  parts  of  the  body, 
becomes  pronounced,  and  is  evidenced  by  such  symptoms  as  sr/ficojye, 
dizziness,  headache,  and  pallor.  Since  aortic  incompetency  usually  mani- 
fests itself  secondarily,  the  clinical  features  of  both  affections  are  sooner 
or  later  variously  commingled.  In  cases  in  which  mitral  lesions  develop 
they  are  overcome  by  compensatory  enlargement  of  the  right  ventricle : 
the  latter  chamber  may  at  a  later  period  become  dilated,  in  which 
event  tricuspid  regurgitation  and  the  symptoms  of  general  venous 
engorgement  appear.  As  in  the  case  of  aortic  regurgitation,  so  in  an 
aortic  constriction,  slight  edema  of  the  feet  is  common  as  a  terminal 
symptom ;  marked  dropsy,  however,  is  uncommon.  From  the  fibrous 
deposits  on  the  segments,  as  well  as  from  any  small  clots  behind  the 
valves,  emboli  are  apt  to  become  dislodged  by  the  forcible  blood-stream 
and  be  conveyed  to  the  brain  (cerebral  embolism),  to  the  spleen  (splenic 
embolism),  to  the  kidneys  (renal  embolism),  or  to  other  organs. 

Physical  Signs. — Inspection. — The  apex-beat  is  gradually  displaced 
downward  and  to  the  left,  owing  to  left  ventricular  hypertrophy.  It  is, 
as  a  rule,  slow,  forceful,  and  heaving,  but  less  frequently  it  may  be  lack- 
ing in  strength.  It  may  be  enfeebled,  diminished  in  area,  or  even 
absent,  owing  to  associated  emphysema. 

Palpation  discloses  the  forcible  and  heaving  impulse-beat,  unless 
emphysema  be  present,  when  the  heart  and  its  movement  may  be  con- 
cealed and  the  apex-beat  become  impalpable.     A  marked  systolic  thrill, 


Fig.  51.— Sphygmogram  of  aortic  stenosis,  from  a  man  aged  sixtj-  years. 

with  the  seat  of  greatest  intensity  in  the  aortic  region,  is  quite  gener- 
ally present.  I  have  frequently  felt  this  thrill  in  the  apex  region, 
though  not  so  intensely  as  at  the  base.  The  pulse,  in  this  disease,  is 
small,  regular,  not  compressible,  and  of  normal  or  slightly  lessened  fre- 
quencv.  The  sphygmographic  tracing  shows  slowness  of  the  ascending 
curve  and  a  gradual  formation  of  the  descending  line  {vide  Fig.  51). 


MITRAL  INCOMPETENCY.  607 

Percussion. — Although  hypertrophy  of  the  left  ventricle  is  present, 
the  area  of  cardiac  dulness  is  almost  entirely  dependent  upon  the  degree 
of  emphysema  associated.  In  the  absence  of  this  condition  the  dulness  is 
increased  to  the  left  and  downward,  and  especially  so  when  insufficiency 
of  the  valve  supervenes  or  compensation  fails. 

Auscultation. — A  systolic  murmur,  harsh  in  quality,  most  audible  at 
the  aortic  cartilage  (the  second  right),  and  transmitted  into  the  carotids, 
is  present  in  typical  aortic  stenosis.  When  non-compensation  is  ad- 
vanced the  murmur  is  neither  so  rough  nor  so  loud,  and  quite  late  it 
may  be  missing  altogether.  The  second  sound  is  faint  or  inaudible  on 
account  of  the  diminished  blood-tension  in  the  aorta  and  the  character 
of  the  valvular  lesion.  As  aortic  incompetency  is  commonly  associated, 
a  regurg-itant  or  diastolic  murmur  is  also  heard,  forming  a  double  or  see- 
saiv  murmur,  the  stenotic  bruit  more  or  less  completely  masking  the 
regurgitant.  A  soft,  bloAving  apical  murmur  (with  the  systole)  is  not 
infrequent  in  the  advanced  stage  or  after  relative  insufficiency  of  the 
mitral  valves  has  appeared. 

The  diagnosis  demands  the  concurrence  of  the  following  signs  :  a 
systolic  thrill,  most  marked  at  the  base  ;  a  tense,  small,  somewhat  slow 
pulse ;  indications  of  left  ventricular  hypertrophy  (unless  emphysema 
be  present) ;  a  rough,  loud,  systolic  murmur  at  the  aortic  cartilage  and 
propagated  into  the  vessels  of  the  neck. 

Differential  Diagnosis. — A  calcareous  plate  lying  on  the  intima  of  the 
aorta  and  a  markedly  roughened  condition  of  the  aortic  segments  are 
conditions  frequently  mistaken  for  aortic  stenosis,  since  they  give  rise 
to  a  mui^mur  possessing  many  of  the  characteristics  of  the  one  above 
described.  These  murmurs,  however,  are  seldom  musical,  while  the 
murmur  of  aortic  stenosis  is  often  distinctly  so ;  moreover,  the  second 
sound  is  decidedly  accentuated,  while  in  aortic  stenosis  it  is  faint  or 
absent.  In  clironic  BrigMs  disease  with  arterial  sclerosis  and  left 
ventricular  hypertrophy  a  murmur  of  maximum  intensity  may  be  devel- 
oped at  the  base  ;  but  here  the  urinary  symptoms,  together  with  inten- 
sification of  the  second  sound  and  a  more  rapid  pulse,  are  sufficient  for 
a  discrimination.  In  aortic  regurgitation  a  systolic  murmur  frequently 
coexists,  but  it  cannot  be  reckoned  as  indicating  actual  stenosis  unless 
it  has  a  musical  quality  and  a  systolic  thrill  can  be  felt  on  palpa- 
tion. In  cJilorosis  and  other  forms  of  anemia  basic  murmurs  are  con- 
stant concomitants  ;  the  anemic  murmurs  are  soft  and  distant,  and  not 
harsh ;  the  intense  thrill  and  ventricular  hypertrophy  are  absent  also. 
The  venous  hum  may  also  be  heard  in  the  veins  of  the  neck. 


MITRAL  INCOMPETENCY. 

{Mitral  Regurgitation ;  Mitral  Insufficiency^ 

Definition. — Imperfect  closure  of  the  mitral  valve  due  to  rupture 
or  contraction  of  the  mitral  leaflets.  It  is  also  caused  by  dilatation  of 
the  left  ventricle  and  by  a  diseased  condition  of  the  chordae  tendineee. 

Pathology. — This  is  the  most  frequent  form  of  organic  disease  of 


608  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  heart.  Thomas  Gr.  Ashton,'  from  clinical  observation  of  1012  cases 
of  heart-affection,  comprising  all  the  different  varieties,  found  that  5.4.4 
per  cent,  were  instances  of  mitral  regurgitation.  The  predominating 
lesions  are  of  three  kinds :  (a)  Acute  or  chronic  endocarditis,  leading  to 
contraction  and  deformity,  particularly  curling,  of  the  margins  of  the 
valve ;  (b)  contraction  or  weakening  of  the  chordae  tendinese ;  and  (c) 
relative  insufficiency  from  excessive  dilatation  of  the  left  ventricle  (the 
seorments  beins:  healthv).  Adhesion  of  a  segment  Avith  the  walls  of 
the  ventricle  occurs  rarely,  but  may  result  in  incompetency. 

Mechanical  Influence  of  the  Lesion. — The  mitral  leaflets  normally  close, 
and  prevent  the  reflux  of  the  blood  from  the  left  ventricle  into  the  left 
auricle  with  each  cardiac  systole.  Hence  incomplete  closure  of  the 
mitral  segments  allows  a  portion  of  the  blood  to  return  into  the  left 
auricle  during  the  systole.  This  regurgitant  wave  meets  and  offers  an 
obstacle  to  the  normal  blood-current  coming  simultaneously  from  the 
pulmonary  veins  into  the  left  auricle.  It  is  clear  that  vertiginous  move- 
ments must  result  under  these  circumstances  and  give  rise  to  a  murmur. 
The  double  blood-current,  entering  the  left  auricle  during  the  systole 
of  the  left  ventricle,  causes  over-filling  (hence  dilatation)  of  the  left 
auricle,  and  thus  induces  compensatory  hypertrophy  of  its  walls  since 
its  labor  has  been  increased.  During  the  next  diastole  the  abnormally 
large  contents  of  the  auricle  stream  under  increased  pressure  into  the 
left  ventricle,  producing  over-distention  (dilatation)  of  that  chamber. 
This  increased  volume  of  blood  in  the  ventricle  is  not  all  expelled  into 
the  aorta,  but  a  portion  of  it  returns  into  the  left  auricle.  Thus  the 
left  ventricle,  in  consequence  of  its  increased  labor,  becomes  hypertro- 
phied  as  well  as  dilated.  Under  these  circumstances  the  volume  of  blood 
that  is  poured  into  the  aorta  remains  about  normal,  and  hence  the 
arterial  tension  for  a  longer  or  shorter  period  is  also  normal.  Soon  the 
cardio-pulmonary  circulation  becomes  impeded.  The  blood  that  returns 
into  the  left  auricle  must,  by  reason  of  pressure,  offer  increased  obstruc- 
tion to  the  outflow  of  blood  from  the  pulmonary  veins,  and  the  pressure 
in  the  latter  must,  in  turn,  be  similarly  increased.  The  current  of  the 
blood  through  the  pulmonary  capillaries  and  branches  of  the  pulmonary 
artery  is  thus  retarded,  owing  to  the  gradual  accumulation  that  takes 
place  in  a  backward  direction.  The  Avails  of  the  lung- vessels  are 
the  seat  of  a  sclerotic  process,  and  present  an  abnormal  obstacle  to 
the  passage  of  the  systolic  wave  from  the  right  ventricle  to  the  distal 
end  of  the  cardio-pulmonary  arc ;  in  consequence  of  this  the  right  ven- 
tricle becomes  dilated  and  hypertrophied.  The  abnormally  increased 
tension  in  the  pulmonary  vessels  is  shoAvn  by  the  accentuated  pulmonic 
second  sound.  Thus  the  right  heart  compensates  the  lesion  in  the  left, 
though  to  supply  an  adequate  amount  of  blood  to  the  peripheral  arteries 
the  left  ventricle  must  maintain  its  proper  degree  of  hypertrophy.  As 
soon  as  this  harmonious  balance  is  disturbed,  either  as  the  result  of  in- 
crease in  the  degree  of  incompetency  or  of  f\iilure  of  muscular  power, 
the  progress  of  the  blood  from  the  right  auricle  to  the  right  ventricle  is 
hindered.  Increased  pressure  in  the  right  auricle  produces  dilatation 
of  its  chamber,  with  subsecjuent  general  venous  congestion  as  a  natural 
backward  effect  {vide  Tricuspid  Regurgitation).  It  is  now  seen  that 
1  Medical  Neus,  June  30,  1894. 


MITRAL  INCOMPETENCY.  609 

when  the  right  heart  fails  a  lessened  amount  of  blood  reaches  the  left 
ventricle,  and  hence  an  abnormally  small  amount  finds  its  way  into  the 
aorta ;  this  fact  explains  the  presence  of  the  low  arterial  tension  late  in 
the  disease.  Hypertrophy  of  the  left  ventricle  in  this  disease  has  also 
been  attributed  in  part  to  the  augmented  tension  in  the  general  capillary 
vessels  that  is  occasioned  by  the  venous  stasis. 

Special  il^tiology. — {a)  Rheumatic  endoca7^ditis  is  the  most  fre- 
quent cause,  though  mitral  regurgitation  also  results  less  frequently 
from  acute  endocarditis  due  to  other  causes.  (6)  It  may  be  a  part  of  a 
general  arteriosclerotic  process,  this  group  of  cases  being  caused,  not 
rarely,  by  syphilis  and  alcohol,  (c)  A  diseased  condition  of  the  columnce 
carnece  or  chordoe  tendinece,  if  it  contracts  them  or  weakens  their  struct- 
ures so  that  the  free  edges  of  the  segments  pass  beyond  the  plane  of 
the  orifice,  produces  insufficiency,  (d)  It  rarely  arises  in  the  course  of 
aortic  valvular  disease  (a  secondary  mitral  affection),  and  is  then  excited 
mainly  by  undue  tension  of  the  blood  in  the  left  ventricle.  Here  the 
lesion  is  of  a  mild  grade,  as  a  rule,  (g)  It  is  frequently  occasioned  by 
enlargement  of  the  left  auriculo-ventricidar  ring,  resulting  from  excessive 
dilatation  of  the  left  ventricle,  as  in  aortic  incompetency,  aortic  stenosis, 
long-continued  fevers,  and  the  graver  anemias  (relative  incompetency).  (/) 
Ulcerative  endocarditis,  either  by  perforating  or  producing  rupture  of  the 
valve-curtains  or  by  destroying  the  chordae  tendinese,  may  bring  about 
mitral  incompetency.  Among  jjredispo sing  factors  age  and  sex  are  worthy 
of  special  mention,  the  incompetency  occurring  with  greatest  relative  fre- 
quency in  young  adults  (from  twenty  to  thirty  years  of  age,  according  to 
Ashton's  figures),  and  somcAvhat  more  commonly  in  males  than  females. 

Symptoms. — During  Compensation. — In  healthy  persons  the  com- 
pensatory forces  keep  pace  with  the  valvular  lesions  for  an  indefinite 
and  usually  lengthy  period,  during  which  time  there  may  be  an  entire 
absence  of  symptoms.  When  present  they  are  dependent  upon  dis- 
turbances of  the  cardio-pulmonary  circulation  that  are  occasioned  by  trivial 
causes,  such  as  excitement,  going  up  stairs,  or  other  forms  of  active 
physical  exertion.  Under  these  circumstances  the  force  of  the  regurgi- 
tant current  is  increased  (by  the  hypertrophied  left  ventricle),  thus  pro- 
ducing more  or  less  pulmonary  congestion  that  may  proceed  to  edema 
of  the  lungs  or  hemoptysis.  The  condition  is  usually  a  temporary  one, 
and  is  attended  by  dyspnea,  palpitation  of  the  heart,  a  short,  hacki7ig 
cough,  and  expectoration  of  a  frothy  serum  that  may  be  blood-stained. 
The  relation  existing  between  the  severity  of  the  dyspnea  and  the 
degree  of  active  physical  exertion  is  positive  and  vital.  Shortness  of 
breath  may  be  the  sole  feature  during  a  long  period.  The  rational 
symptoms  rarely  warrant  a  suspicion  of  the  existence  of  mitral  disease 
until  compensation  has  failed,  but  the  patient's  appearance  often  indicates 
heart-disease.  The  face  is  pale  and  the  features  peaked,  the  eyes,  lips, 
and  ears  are  dusky,  and  the  minute  vessels  of  the  cheeks  are  prominent. 
Clubbing  of  the  finger-nails  is  observed  most  frequently  in  the  young. 

After  Failure  of  Compensation. — Failure  of  compensation  implies 
failure  of'  the  right  ventricle  to  cope  efficiently  with  the  augmented  ten- 
sion in  the  pulmonary  circulation,  with  accompanying  congestion  of  the 
lungs,  followed  by  engorgement  of  the  systemic  veins.  The  latter  process 
begins  at  the  right  heart  and  proceeds  toward  the  periphery,  involving 
39 


610  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  viscera,  mucous  membranes,  and  extremities  until  it  is  universal. 
The  pulmonic  symptorns  above  detailed  are  noAv  more  marked,  particu- 
larly the  dyspnea  (which  may  be  constant),  cough  (with  expectoration 
of  alveolar  epithelium  containing  brown  pigment-granules),  and  cardiac 
palpitation  Avith  arrhythmia.  Pain  is  rare  unless  stenosis  coexists. 
General  venous  engorgement  manifests  itself  by  an  enlargement  of  the 
liver  and  of  the  spleen,  in  the  features  of  gastro-intestinal  catarrh,  in 
hemorrhoids,  in  marked  cyanosis  of  the  surface,  and  in  the  passage  of 
a  scanty  albuminous  urine  containing  tube-casts  and  blood-corpuscles. 
Dropsy  follows,  beginning  in  the  feet  and  progressing  upward,  until 
finally  the  trunk  and  the  serous  sacs  are  involved.  By  stimulation  the 
heart  may  be  reinforced,  and  all  of  the  unfavorable  symptoms  disappear 
in  conse([uence,  but  this  is  not  for  long,  as  a  rule.  I  have  at  present 
under  observation  a  case  in  which  not  less  than  half  a  dozen  instances 
of  broken  compensation  have  occurred  at  intervals  of  six  to  eight 
months,  all  of  which  have  been  successfully  overcome.^  In  all  cases, 
however,  there  comes  a  time  Avhen  compensation  cannot  be  restored,  and 
the  end  is  reached  by  an  uninterrupted  downward  course. 

Physical  Signs. — Inspection. — The  precordia  is  prominent,  particu- 
larly in  children,  and  the  area  of  the  apex-beat  is  enlarged,  later  becom- 
ing diftVise  and  wavy.  It  is  carried  to  the  left  and  downward,  corre- 
sponding with  the  degree  of  hypertrophy  of  the  left  ventricle.  A  pul- 
sating epigastrium  is  in  frequent  association,  particularly  after  dilata- 
tion of  the  right  ventricle  appears.  With  the  failure  of  the  right  heart 
also  come  wavy  pulsations  in  the  cervical  veins,  and  occasionally  a  mild 
grade  of  jaundice. 

Palpation  sometimes  discovers  a  tlirill  at  the  scat  of  the  apex-beat, 
that  is  synchronous  Avith  the  first  sound.  Tlie  impulse  during  the  stage 
of  full  compensation  is  forceful  and  heaving,  but  Avith  the  beginning  of 
failure  of  compensation  it  grows  feeble  and  irregular,  and  late  in  the 
aifection  is  excessively  Aveak  and  arrhythmic.  The  pulse  bears  a  defi- 
nite relation  to  the  apical  impulse ;  it  is  commonly  regular  and  full 
during  the  compensatory  period  (though  at  times  the  tension  is  slightly 
loAvered),  but  becomes  small,  easily  compressible,  and  exceedingly  irreg- 
ular during  the  period  of  broken  compensation.  One  meets  Avith  cases 
in  which  irregularity  appears  during  the  period  of  fair  compensation. 

Percussion. — The  dull  area  is  increased  to  the  left,  extending  fre- 
quently to  the  anterior  axillary  line ;  and  also  to  the  right,  frequently 
from  ^  to  1  inch  (1.2-2.5  cm.)  beyond  the  right  sternal  margin.  Dila- 
tation of  both  ventricles  exerts  a  Avidening  influence  ;  hence  cardiac 
dulness  is  increased  more  laterally  than  vertically. 

Auscultation  reveals  a  systolic  murmur,  Avith  greatest  intensity  at 
the  apex  (see  Fig.  52).  Occasionally,  this  murmur  is  also  conducted 
to  the  tricuspid  and  pulmonary  valves.  It  is  rarely  loudest  in  the  fourth 
or  third  space  in  the  vertical  nipple  line.  Balthazar  Foster  first  called 
attention  to  the  fact  that  the  murmur  of  mitral  regurgitation  may  be 
loudest  at  the  base  of  the  heart,  and  at  times  audible  only  in  that  situa- 
tion— an  occurrence  that  has  since  been  confirmed.  It  is  sometimes 
audible  in  the  recumbent  posture  and  inaudible  in  the  erect.     From  the 

*  Neglect  of  liygienic  precautions  and  intercurrent  complaints  of  various  sorts  often 
determine  the  occurrence  of  failure  of  compensation. 


MITRAL  INCOMPETENCY. 


611 


apex  it  is  transmitted  to  the"  left  as  far  as  the  angle  of  the  scapula,  with 
progressively  diminishing  clearness.  It  has  a  blowing  quality,  and  fre- 
quently ends  in  a  musical  tone.  Loudness  implies  strength  of  con- 
traction (Broadbent).  Over  the  third  left  costal  cartilage,  and  fre- 
quently at  the  apex,  there  is  heard  the  accentuated  pulmonic  second 
sound,  due  to  the  increased  tension  in  the  pulmonary  vessels  that 
is  engendered  by  the  hypertrophy  of  the  right  ventricle.  Comhined 
murmurs  may  be  heard,  and  not  infrequently  a  rough,  rolling,  or  rum- 
bling presystolic  murmur  is  detected.  A  frequent  late  occurrence  is  the 
secondary  dilatation  of  the  right  ventricle,  causing  relative  tricuspid 
insufficiency  with  its  characteristic  soft,  low-pitched,  systolic  murmur, 
keard  best  at  the  ensiform  cartilage.     A  spurious  diastolic  murmur  may 


Fig.  52. — 1,  Seat  of  greatest  intensity;  2,  direction  of  cMef  transmission ;  3,  boundary  line  of  rela- 
tive dulness ;  4,  boundary-line  of  absolute  dulness  (modified  from  Sahlij. 

be  noted,  though   rarely,  when  the  sounds  are  timed  with  the  pulse. 
This  is  due  to  a  weak  systole  that  fails  to  cause  a  radial  pulse. 

Diagnosis. — In  the  presence  of  the  following  group  of  features  the 
diagnosis  is  set  at  rest:  A  marked  broadening  of  the  area  of  cardiac 
dulness ;  a  systolic,  apical  murmur  that  is  conveyed  to  the  left  axilla 
and  may  be  heard  even  at  the  back ;  and  a  decided  accentuation  of  the 
pulmonary  sound.  Obviously,  the  latter  sound  becomes  feeble  after 
dilatation  of  the  right  ventricle  has  occurred.  A  systolic  thrill  is 
of  the  highest  diagnostic  importance,  but  is  unfortunately  absent  in 
perhaps  a  majority  of  the  cases.  Free  regurgitation  through  the  mitral 
orifice  may  be  safely  inferred  when  the  following  signs  are  concurrent : 


612  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

(a)  An  absence  of  the  sound  of  mitral-valve  tension,  a  murmur  replacing 
the  first  sound ;  {h)  accentuation  of  the  pulmonic  second  sound ;  {c) 
an  enlarged  area  of  the  left  cavity ;  {d)  an  enlarged  area  of  the  right 
cavity  (Sansom). 

Differential  Diagnosis. — There  are  two  organic  lesions  of  the  heart 
that  are  sometimes  mistaken  for  mitral  incompetency,  since  both  are  ac- 
companied by  a  systolic  murmur — the  one  aortic  stenosis,  and  the  other 
tricuspid  regurgitation.  How  to  distinguish  mitral  from  tricuspid  in- 
competency is  a  (juestion  that  will  receive  due  attention  when  the  latter 
disease  is  considered.  Aortic  stenosis  generates  a  systolic  murmur,  but 
it  is  loudest  over  the  base,  and  is  transmitted  through  the  great  vessels 
of  the  neck ;  while  the  mitral  systolic  is  most  intense  over  the  apex  and 
is  transmitted  far  to  the  left.  In  mitral  incompetency  the  pulmonary 
second  sound  is  accentuated ;  in  aortic  stenosis  it  is  not.  In  mitral  in- 
competency both  ventricles  are  enlarged,  as  shown  by  percussion  and 
other  signs ;  in  aortic  stenosis  the  left  is  chiefly  enlarged  during  almost 
the  entire  course.  In  mitral  incompetency  a  thrill,  most  marked  over 
the  apex-beat,  may  be  felt ;  in  aortic  stenosis  a  thrill,  rough  and  having 
its  chief  seat  at  the  base,  is  common.  Additional  minor  points  of  dis- 
tinction are  furnished  by  the  peculiarities  of  the  jjulse,  the  age  of  the 
patient,  and  other  ctiologic  factors. 

Functional  and  other  harmless  murmurs  are  often  confounded  Avith 
mitral  insufficiency.  The  considerations  on  which  the  greatest  depend- 
ence is  to  be  placed  in  the  differentiation  are  to  be  found  in  the  sub- 
joined table : 

MiTRx\L  Incompetency.  Functional  and  Harmless  Murmurs. 

History. 

Previous  history  of  rheumatism  or  other      History  of  causative   factors   of  one  or 
disease  causally  related.  other  form  of  anemia,  of  debility,  or 

of  Graves'  disease. 

Frequently  there  is  definite  knowledge  of       No  such  association, 
rheumatisin  and  organic  heart-disease, 
in  combination  in  the  same  individual. 

Physical  Signs. 

Inspection. — Dusky  lips,  cars,  etc. ;  later  Pallor  of  skin  and  mucous  surfaces  com- 

wavy  pulsation  in  veins  of  neck.  mon. 

Palpation. — Finger-tips  placed  over  apex-  Finger  not  lifted  by  the  impulse,  which 

beat  forcil)ly  lifted.  Pulse-tension  some-  often  cannot  be  felt.    Pulse-tension  pro- 

Avhat  lowered  and  not  prolonged.     Im-  longed  and  arterial  pressure  increased 

pulse  displaced.  generally.     Impulse  not  displaced. 

Percussion. — Evidence   of   dilatation   of  Dilatation  of  right  auricle,  but  only  in 

both  ventricles.  about  one-half  of  the  cases,  giving  rise 

to  dulness  al)ovc  or  to  the  right  of  the 
right  edge  of  sternum. 

Auscultation. — A    systolic    apex-murmur  Soft  systolic  murmur  at  apex  (often  late — 

(often  musical),  with  characteristic  area  systolic   rarely  transmitted  to  axilla), 

of  transmission.     This  murmur,  unlike  usually  preceded  by  or  associated  with 

the  functional,  is  often  heard   })eliind,  a  basic  systolic  murmur  and  a  venous 

between  the  spine  and  the  scapula.  hum  in  the  veins  of  the  neck. 

To  differentiate  the  murmur  of  relative  mitral  incompetency  is  diffi- 
cult, though  in  many  instances  it  can  be  accomplished  with  reasonable 
certainty.     It  rests  u])on  two  points :  (a)  the  character  of  the  murmur. 


MITRAL  STENOSIS.  613 

which  is,  as  a  rule,  softer  and  less  intense  than  that  due  to  valvular 
lesions  ;  and  (5)  the  antecedent  history  of  the  patient.  Thus,  relative 
insufficiency  of  the  mitral  segments  probably  exists  in  patients  in  the 
middle  period  of  life,  in  whom  the  previous  history  furnishes  such 
etiologic  factors  as  chronic  gout,  syphilis,  or  alcoholism ;  or  in  persons 
who  exhibit  arterio-sclerosis  or  organic  disease  of  the  aortic  valve  and 
an  apex-systolic  murmur.  On  the  other  hand,  if  the  signs  of  mitral 
regurgitation  occur  in  a  younger  subject  or  in  one  who  has  been  afflicted 
with  acute  rheumatism,  it  is  highly  probable  that  the  mitral-valve  seg- 
ments are  the  seat  of  chronic  endocarditis  of  rheumatic  origin.  Again, 
if  present  in  chronic  renal  disease,  with  concurrent  symptoms  of  high 
arterial  tension  and  of  left  ventricular  hypertrophy — accentuation  of  the 
aortic  second  sound,  a  mitral  systolic  murmur — it  is  to  be  ascribed  to 
relative  insufficiency.  Oompression  of  the  edge  of  the  left  lung  by  the 
ventricular  systole  may  produce  a  spurious  murmur.  I  believe  that  a 
rare  sequel  of  mitral  incompetency  is  mitral  stenosis,  owing  to  the  con- 
traction of  the  mitral  orifice,  with,  in  some  instances,  cohesion  of  the 
free  edges  of  the  cusps. 


MITRAL  STENOSIS. 


Definition. — Constriction  of  the  left  auriculo-ventricular  orifice, 
due  to  either  thickening  or  adhesion  of  the  segments.  With  few  ex- 
ceptions adhesions  of  the  free  borders  of  the  valve  or  of  the  chordge 
tendinese  obtain. 

Special  Pathology  and  Btiology. — It  is  to  be  recollected  that 
the  constriction  may  be  almost  inappreciable,  and  yet  an  uneven,  rough- 
ened surface  be  presented,  producing  a  murmur  as  the  blood-stream 
enters  the  ventricle ;  on  the  other  hand,  a  high  degree  of  constriction 
may  be  encountered.  Thus,  in  the  funiiel-shaped  form  of  mitral  stenosis 
the  aperture  may  be  so  small  as  scarcely  to  admit  the  passage  of  a  goose- 
quill.  When  moderate  in  degree  the  tip  of  the  index  finger  is  admissi- 
ble ;  in  the  button-hole  form  the  slit  may  be  so  narrow  as  not  to  allow  an 
object  larger  than  a  shirt-button  to  pass  through  it.  The  funnel  variety 
is  common  in  children,  and  is  occasionally  a  congenital  condition  (possibly 
hereditary),  while  the  button-hole  variety  is  comparatively  rare  in  child- 
hood. In  adults,  however,  the  funnel-shaped  constriction  is  rare,  while 
the  button-hole  valve  is  quite  common ;  in  62  postmortem  examinations 
only  3  showed  funnel-form  contraction  (Hayden  and  Fagge).  Mitral 
stenosis  is,  as  a  rule,  dependent  upon  a  mild  or  limited  endocarditis  that 
is  usually  of  rheumatic  origin.  It  is  more  common  in  young  adults  and 
in  children  after  the  fifth  year  than  in  older  persons,  and  a  greater  inci- 
dence is  shown  in  females  than  in  males,  for  the  reason  that  the  affec- 
tions that  are  causally  related  to  endocarditis  are  more  frequent 
in  females  (rheumatism,  chorea,  chlorosis).  The  endocarditis  of 
measles  and  scarlatina  may  also  lead  to  narrowing  of  the  mitral  orifice, 
and  I  quite  agree  with  Osier  in  the  belief  that  whooping-cough,  owing 
to  the  great  strain  that  it  imposes  upon  the  heart-valves,  may  be  account- 


614  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

able  for  certain  cases.  In  adults  arteriosclerosis  and  chronic  nephritis 
may  act  as  causes.     Ball-tlirombi  have  been  found  in  the  auricle. 

Mechanical  Influence  of  the  Lesion. — On  account  of  the  obstruction 
of  the  blood-stream  at  the  mitral  orifice  during  diastole  the  task  of  the 
left  auricle  becomes  greater  than  normal,  and  in  consequence  of  this  its 
Avails  hypertrophy.  They  may  be  found  to  be  one-fourth  or  even  one- 
half  inch  (1.2  cm.)  in  thickness,  the  normal  thickness  being  only  three- 
tAventieths  of  an  inch  (3.7  mm.).  Dilatation  of  the  auricle  comes  on 
early,  since  this  chamber  cannot  take  on  much  hypertrophy  OAving  to 
lack  of  muscular  structure,  and  in  the  later  stages  its  Avails  become 
extremely  thin.  For  a  varying  period  of  time  the  increased  poAver  due 
to  hypertrophy  of  the  left  auricle  and  the  increased  resistance  to  the 
circulation  that  is  the  result  of  the  mitral  lesion  are  exactly  balanced. 
At  a  comparatively  early  period,  hoAvever,  the  auricle  can  no  longer  main- 
tain this  equilibrium  ;  and  then,  owing  to  retardation  of  the  current  from 
the  pulmonary  veins  to  the  auricle,  the  vascular  tension  in  the  lungs  and 
right  ventricle  is  increased.  The  right  ventricle,  in  seeking  to  overcome 
the  obstruction,  becomes  greatly  hypertrophied  and  dilated,  and  late  in 
the  disease  tricuspid  incompetency  supervenes  Avith  its  usual  sequences. 
The  hypertrophy  of  the  latter  chamber  counterbalances  the  lesion  during 
the  greater  part  of  the  period  of  compensation.  For  a  brief  time  the 
left  ventricle  exhibits  no  abnormal  proportions.  Later  and  at  autopsies 
its  cavity  is  found  smaller  and  its  walls  thinner  than  the  normal,  these 
conditions  being  due  to  its  abnormally  light  labor.  The  apex  of  the 
heart  is  formed  almost  exclusively  by  the  greatly  enlarged  right  ven- 
tricle. If  the  left  ventricle  be  hypertrophied,  it  is  owing  to  the  existence 
of  associated  mitral  incompetency. 

Sj^mptoms. — The  subjective  symptoms  are  scanty  and  of  slight 
value  in  forming  the  diagnosis.  During  the  period  of  full  compensation 
there  may  be  an  entire  absence  of  symptoms  except  on  going  up  stairs 
or  on  attempting  some  unusual  muscular  effort,  Avhen  dyspnea  appears. 
Fragments  of  fibrinous  coagula  dislodged  from  betvN'een  the  musculi 
pectinati  of  the  auricle  or  swept  from  the  valves  may  give  rise 
to  the  phenomena  of  cerebral  embolism  (aphasia  and  hemiplegia).  The 
same  conditions  may  arise,  and  in  the  same  Avay,  from  recurring  endo- 
carditis, to  Avhich  such  patients  are  specially  liable.  The  patient  in 
Avell-marked  cases  presents  an  anemic  appearance :  a  stitch-like  pain  in 
the  apex-region  is  freijuently  present,  and  active  exertion,  by  overtax- 
ing the  left  auricle,  induces  cardiac  palpitation  and  dyspnea. 

After  failure  of  compensation  the  symptoms  referable  to  the  pulmo- 
nary system  are  almost  identical  Avith  those  manifested  in  mitral  incom- 
petency. OAving  to  the  pulmonary  engorgement  the  djispnea  is  constant, 
and  is  increased  by  exertion.  After  severe  or  prolonged  physical  exer- 
cise congestion.,  folloAved  by  edema  of  the  lungs,  may  supervene,  attended 
by  a  copious  blood-stained,  serous  expectoration.  True  hemoptysis  may 
arise  from  time  to  time.  The  increased  tension  in  the  pulmonary  vessels 
being  practically  constant,  sclerosis,  followed  by  atheromatous  degenera- 
tion of  their  Avails,  is  a  frequent  occurrence,  and  may  accidentally  result 
in  pulmonary  apoplexy.  IntercxwYeut  febrile  attacks  (due  usually  to  re- 
curring endocarditis)  are  common,  particularly  in  the  later  stages,  and 
are  attended  Avith  marked  aggravation  of  the  circulatory  disturbances. 


MITRAL  STENOSIS. 


615 


Mitral  stenosis  differs  from  mitral  incompetency  in  that  general  anasarca 
is  rare,  though  marked  enlargement  of  the  liver  and  other  evidences  of 
portal  congestion  (including  ascites)  are  commonly  present. 

Physical  Signs. — Itispection. — The  apex-beat  is  not  displaced  un- 
less there  be  excessive  enlargement  of  the  right  ventricle  or  associated 
hypertrophy  of  the  left.  There  is  usually  present  a  visible  pulsation  in 
the  second  left  intercostal  space,  and  sometimes  in  the  third  and  fourth 
interspaces,  occasioned  by  increased  tension  in  the  pulmonary  artery ; 
and  there  is  also  a  diffuse  impulse  along  the  right  border  of  the  sternum. 
Epigastric  pulsation  is  common.  A  prominence  having  its  seat  over  the 
fifth  and  sixth  left  costal  cartilages  and  the  lower  half  of  the  sternum  is 
observed,  particularly  in  children.  After  failure  of  compensation  the 
impulse  is  feeble  and  undulates,  "with  engorgement  and  pulsation  of  the 
jugular  veins. 

Palpation  discovers  a  presystolic  thrill  in  a  great  proportion  of 
cases.  In  certain  instances  active  physical  exertion  may  render  this 
appreciable,  or  Avhen  in  the  recumbent  posture  on  the  left  side  the  ele- 
vation of  the  arms  may  accomplish  the  same  result.  It  is,  however, 
absent  in  rare  instances  before  failure  of  compensation  occurs,  and  more 
frequently  by  far  after  the  latter  event.  This  fremitus  is  best  felt  over 
the  third  and  fourth  (less  frequently  the  fifth)  interspaces,  just  within 
the  nipple,  and  during  expiration.  It  commences  after  the  second  sound 
(during  the  diastole)  as  a  purring  fremitus,  increasing  steadily  in  volume 
and  intensity,  and  terminates  abruptly  with  the  severe  shock  of  the  new 
impulse.  The  fremitus  and  systolic  shock  are  pathognomonic,  and  may 
be  relied  upon  in  the  absence  of  the  murmur.  The  heart's  impulse  is 
most  forcible  over  the  lower  portion  of  the  sternum  and  along  the  right 
border,  being  due  to  the  enlarged  right  ventricle;  in  a  smaller  propor- 


FiG.  53.— Sphygmograms  in  a  case  of  mitral  stenosis  treated  by  extract  of  convaUaria,  and  sub- 
sequently by  digitalis :  A,  before  treatment,  showing  the  interpolated  pulsations  ;  B,  after  treat- 
ment (Sansom). 


tion  of  cases,  in  the  third,  fourth,  and  fifth  interspaces  to  the  left  of  the 
sternum.  The  radial  pulse  is  small,  compressible,  and  markedly  ir- 
regular as  the  propulsive  power  of  the  right  ventricle  diminishes.  The 
sphygmographic  tracing  is  notably  irregular  {vide  Fig.  53). 

Percussion  shows  an  extension  of  heart-dulness  to  the  right,  fre- 
quently  5  centimeters  (2  inches)  beyond  the  sternal  margin,  as  a  result 
of  hypertrophy  of  the  right  ventricle,  and  upward  as  high  as  the  sec- 


616  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ond  rib  on  either  side  of  the  sternum.  Increase  in  the  cardiac  dulness 
to  the  left  also  occurs  not  infrequently,  and  is  attributable  to  excessive 
enlargement  of  the  right  ventricle,  though  more  often  of  the  left  ven- 
tricle in  consequence  of  associated  mitral  insufficiency. 

Auscultation  reveals  a  rough,  presystolic  murmur,  Avhich  may  be 
characterized  as  churning  or  rolling,  acquiring  increased  intensity. 
It  occurs  synchronously  with  the  thrill.  Its  point  of  greatest  pronun- 
ciation is  just  above  and  about  one  inch  within  the  normal  apex-beat. 
The  area  of  transmission  is  generally  quite  limited,  not  exceeding  a 
couple  of  inches  in  any  direction.  Griffith,  however,  has  shown  that 
the  murmur  is  not  seldom  Avidely  transmitted.  This  murmur  sometimes 
exhibits  atypical  characters :  it  may  be  brief  and  low-toned,  and  may 
be  audible  on  one  occasion  and  then  disappear  for  a  considerable 
period.  After  the  right  ventricle  becomes  weak,  the  murmur  may  ab- 
sent itself  either  temporarily  or  permanently,  and  lose  its  peculiar  ter- 
mination. In  most  cases  the  clear,  accentuated  first  sound  is  retained, 
even  though  the  murmur  disappears.  Improvement  in  the  muscular 
power  of  the  heart  as  the  result  of  judicious  treatment  may  cause  the 
murmur  to  reappear,  and  I  have  seen  such  an  occurrence  in  a  case  asso- 
ciated with  mitral  incompetency  at  the  Philadelphia  Hospital.  For 
purposes  of  diagnosis,  nothing  is  so  vitally  important  as  the  time  or 
rhythm  of  the  murmur,  and  in  his  examination  the  observer  must  there- 
fore palpate  the  heart,  and  not  the  radial  pulse,  while  practising  aus- 
cultation. The  finger  as  well  as  the  ear  will  thus  become  sensible  of 
the  systolic  shock  which  replaces  the  cardiac  impulse,  and  it  will  be 
noted  that  the  murmur  terminates  at  the  same  moment.  In  cases  in 
which  the  impulse  cannot  be  felt  the  finger  should  be  placed  over  one  or 
other  carotid,  since  here  the  pulse  is  practically  synchronous  with  the 
systole.  In  most  cases  the  murmur  occupies  only  the  latter  half  of  the 
diastole,  though  occasionallv  the  whole  of  it.  In  some  cases  it  is  heard 
in  the  middle  of  the  long  pause.  Owing  to  the  presence  of  right 
ventricular  hypertrophy  the  pulmonic  second  sound  is  greatly  accent- 
uated, being  distinctly  audible  at  the  apex,  while  the  aortic  second 
sound  is  often  absent  or  feeble.  Reduplication  of  the  second  sound  is 
not  rare,  and  is  characteristic. 

Secondary  Murmurs. — As  previously  ])()inted  out,  the  murmur  of 
mitral  stenosis  may  succeed  that  of  mitral  incompetency,  but  this  is 
comparatively  rare.  Mitral  stenosis  may  folloAv  aortic  valvular  disease, 
but  in  the  vast  majority  of  instances  it  is  a  primary  affection.  Secondary 
murmurs  are  not  uncommon,  however.  Among  these  the  bruit  of  mitral 
incompetency  is  relatively  freijuent.  After  com])ensation  is  ruptured 
the  murmur  of  tricuspid  insufficiency  usually  becomes  audible  at  the 
loAver  end  of  the  sternum  and  persists  until  the  end. 

In  so-called  '■^relative  mitral  stenosis"  associated  with  primary 
dilatation  of  the  left  ventricle,  which  holds  the  orifice  open,  there 
occurs  also  a  mitral  regurgitant  murmur,  while  that  of  stenosis  may 
be  absent. 

Diagnosis. — The  distinctive  features  of  mitral  stenosis  are — (1)  A 
presystolic  thrill  at  the  apex.  (2)  An  increase  in  the  precordial  dul- 
ness upward  and  to  the  right.  (3)  A  murmur  which  [a)  has  its  seat 
above,  yet  near,  the  normal  apex-beat ;  [h)  is  usually  localized ;  (e)  is 
presystolic  in  time,  terminating  abruptly  with  the  systolic  shock  (sharp 


TRICUSPID  INCOMPETENCY.  617 

impulse) ;  and  (d)  is  rough  and  vibratory  in  character.  (4)  A  marked 
accentuation  of  the  pulmonic  second  sound. 

Differential  Diagnosis. — When  the  murmur  of  mitral  stenosis  is  very 
brief,  it  is  difficult  to  eliminate  a  mere  rougJieniny  without  valvulitis. 
In  the  latter  condition,  however,  there  is  no  increase  in  intensity  of 
the  murmurs  on  exertion  or  when  the  arms  are  uplifted,  they  are 
not  vibratory  in  character,  and  there  is  no  right  ventricular 
hypertrophy.  From  simple  mitral  stenosis  the  lesion  of  mitral  incom- 
petency is  easily  distinguished  by  its  systolic  rhythm,  greater  area  of 
transmission,  and  by  the  soft,  more  blowing  character  of  its  murmur. 
A  combination  of  the  two  lesions,  however,  is  a  more  frequent  occur- 
rence than  that  of  pure  mitral  stenosis ;  and  under  such  circumstances 
it  is  with  great  difficulty  that  the  two  murmurs  are  separated.  The 
presence  of  the  systolic  murmur  is  distinguishable  by  its  synchronism 
with  the  impulse  or  carotid  pulse,  and  by  its  area  of  transmission  to  the 
left  as  far  as  the  axilla.  If  now  the  stethoscope  be  applied  just  above 
and  to  the  right  of  the  normal  apex,  a  limited  superficial  area  will  be 
found  where  a  presystolic  murmur  is  distinctly  heard.  Points  can  also 
usually  be  found  where  a  continuous  bruit,  covering  a  portion  of  the 
period  of  diastole  and  of  systole,  is  audible. 

In  aortic  regurgitation  the  presence  of  a  presystolic  thrill  and  mur- 
mur has  rarely  been  recorded,  and  Fisher,  Phear,  and  others  have  called 
attention  to  their  presence  in  adhesive  pericarditis  as  well  as  in  simple 
dilatation.  When,  as  is  usual,  a  purely  diastolic  murmur  is  also  present 
in  the  aortic  area,  together  Avith  strong  correlative  evidence  of  aortic 
regurgitation,  the  diagnosis  of  mitral  stenosis  must  be  made  with  ex- 
treme caution  and  reserve. 


TRICUSPID  INCOMPETENCY. 

( Tricuspid  Regurgitation.) 

Definition. — An  imperfect  closure  of  the  tricuspid  valve,  due  either 
to  a  dilatation  of  the  right  ventricle  that  is  secondary  to  mitral  or  lung- 
disease,  or,  less  frequently,  to  an  inflammatory  shortening  of  the  valves. 

Pathology  and  Ktiology. — As  a  primary  disease  tricuspid  in- 
competency is  rare.  It,  however,  is  not  uncommonly  due  to  chronic 
organic  changes,  though  originating  in  fetal  endocarditis.  After  birth 
this  variety  is  most  common  during  childhood,  and  the  frequency  of 
occurrence  is  in  inverse  ratio  to  the  age.  At  any  period  of  life,  how- 
ever, chronic  affections  of  the  lungs  or  organic  disease  of  the  left  side 
of  the  heart  may,  by  augmenting  the  tension  in  the  right  ventricle,  pro- 
duce chronic  interstitial  changes  in  the  tricuspid  segments.  These  lat- 
ter, however,  are  usually  of  mild  grade.  I  have  observed  in  autopsied 
cases  of  chronic  bronchitis  associated  with  emphysema,  and  in  pulmonary 
tuberculosis,  that  the  chief  reason  why  extensive  lesions  of  these  valves 
are  seen  so  rarely  is  to  be  found  in  the  fact  that  dilatation  of  the  right 
ventricle  is  soon  followed  by  relative  insufficiency,  and  thus  the  strain 


618  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

is  in  great  part  removed  from  the  valves  themselves.  And  yet,  accord- 
ing to  the  statistical  studies  of  Byron  Bramwell,  the  tricuspid  valve  is 
implicated  in  50  per  cent,  of  all  cases  of  acute  endocarditis,  notwith- 
standing the  rarity  of  sclerosis  of  these  segments.  He  suggests  that 
the  acute  form  frequently  results  in  cure  because  of  the  relatively  dimin- 
ished right  intraventricular  tension.  In  rare  instances  one  of  the  leaflets 
has  been  ruptured  by  straining.  The  relative  tricuspid  insufficiency, 
produced  in  a  manner  analogous  to  relative  mitral  insufficiency,  is  an 
exceedingly  common  secondary  condition  in  affections  of  the  lungs  and 
heart  that  cause  hypertrophy  and  dilatation  of  the  right  ventricle  (mi- 
tral incompetency  and  stenosis,  emphysema,  sclerosis  of  the  lung). 

Physiologic  Pathology. — In  tricuspid  leakage  every  systole  of  the 
right  ventricle  is  accompanied  by  a  reflux  of  venous  blood  through  the 
imperfectly  closed  tricuspid  orifice  into  the  auricle,  and  thence  into  the 
veins.  This  causes  venous  stasis  and  gives  rise  to  visible  pulsation,  and 
in  this  manner  the  engorged  pulmonary  circulation  is  relieved  to  some 
extent.  A  necessary  unfavorable  consequence,  however,  on  account  of 
the  reflux  current  from  the  right  ventricle,  is  the  lessened  blood-supply 
to  the  pulmonary  arteries,  even  though  the  latter  are  found  to  be  en- 
gorged. The  already  hypertrophied  and  dilated  right  heart  now  under- 
goes further  enlargement  in  the  same  manner  as  in  the  hypertrophy  of 
the  left  ventricle  following  mitral  incompetency,  though  not  to  the  same 
extent.  In  mitral  incompetency  the  right  ventricle  compensates  the 
mitral  lesion  after  failure  of  the  left  auricle,  but  there  can  be  no  such 
effective  compensatory  mechanism  after  failure  of  the  right  auricle  in 
tricuspid  incompetency,  since  the  right  heart  is  not  reanimated  by  a 
fellow  as  is  the  left.  The  blood-stream  flowing  into  the  right  ventricle 
during  the  period  of  diastole,  however,  is  abnormally  large,  owing  to 
moderately  increased  tension.  When  the  right  ventricle  fails  to  main- 
tain the  pulmonary  circulation,  progressive  dilatation  of  its  chamber 
occurs,  Avith  a  proportionate  thinning  of  its  walls  until  its  dimensions 
are  enormous. 

Symptoms. — In  most  instances  the  indications  of  the  primary  or 
causal  aftection  must  be  noted,  though  these  are  often  more  or  less 
screened  by  the  more  characteristic  features  of  the  disease  under  con- 
sideration. The  symptoms  of  tricuspid  incompetency  point  to  passive 
congestion  of  the  lungs  and  engorgement  of  the  systemic  veins,  and 
they  have  been  described  in  connection  with  mitral  lesions.  Cardiac 
dropsy  is  common,  though  present  in  by  no  means  all  cases.  Frederick 
Taylor  ^  contends  that  ascites  is  absent  frequently,  because  the  liver  acts 
as  a  diverticulum  to  accommodate  the  excess  of  venous  blood. 

Physical  Signs. — Inspection. — Venous  pulsation,  caused  by  the  back- 
ward blood-wave  from  the  right  ventricle  at  each  systole,  is  a  path- 
ognomonic sign.  It  is  confined  to  the  lower  portion  of  the  jugular 
veins  so  long  as  the  valve  that  lies  above  the  jugularis  remains  closed, 
but  soon  this  yields,  and  then  the  veins  seem  to  pulsate  through  their 
entire  course  with  each  cardiac  systole.  Tliis  is  best  seen  Avhen  the 
patient  is  in  the  semi-recumbent  posture,  and  is  more  marked  in  the 
right  than  in  the  left  side.  The  subclavian  and  axillary  veins  may  also 
be  seen  to  pulsate,  but  rarely.     The  veins  appear  to  be  everywhere  en- 

1  Lancet,  Nov.  22,  1890,  p.  1126. 


TRICUSPID  INGOMPETENQY.  619 

gorged,  producing  a  cyanosis  that  is  more  noticeable  if  the  breath  be 
held  when  in  full  respiration.  Tricuspid  incompetency  may  be  shown 
by  pressing  on  the  vein  with  the  finger  rather  firmly,  commencing  just 
above  the  clavicle  and  passing  upward,  thus  emptying  it  of  blood.  If, 
now,  the  right  ventricle  be  capable  of  producing  a  return  wave  suffi- 
ciently powerful  to  overcome  the  valve  in  the  external  jugular,  pulsation 
is  seen  to  take  place — also  from  below — in  the  vessel  slowly  and  in- 
creasingly until  the  vein,  as  far  as  the  point  compressed,  becomes  filled. 
The  vein  fills  "by  jets  synchronous  with  the  heart-beat"  (Sansom). 
Again,  an  impulse  may  be  communicated  to  the  jugulars  from  the 
underlying  carotid  artery ;  if  this  be  the  true  explanation  in  any  given 
case,  the  light  pressure  upon  the  vein  below  does  not  arrest  the  pulsa- 
tion above,  as  is  the  case  in  tricuspid  incompetency.  ISTot  rarely  there  is 
noticeable  a  feeble  presystolic  venous  pulse,  due  to  the  weaker  contrac- 
tion of  the  right  auricle  as  compared  with  that  of  the  right  ventricle 
{anadicJirotic  venous  pulse).  The  area  and  seat  of  the  apex-beat  vary 
with  the  nature  of  the  primary  afi'ection :  in  mitral  incompetency,  for 
example,  the  beat  is  displaced  to  the  left  and  downward,  while  in  un- 
complicated mitral  stenosis  no  appreciable  displacement  occurs.  To  the 
right  of  the  sternum  an  undulatory  pulsation  is  seen,  due  to  contraction 
of  the  right  auricle  and  ventricle,  but  this  is  not  characteristic,  since  it 
may  take  place  in  simple  mitral  stenosis  without  tricuspid  regurgitation. 
Epigastric  pulsation  is  almost  invariably  observed. 

Palpation  detects  the  heaving  impulse  of  the  right  ventricle  in  the 
upper  epigastric  region.  Rhythmic  expansile  pulsation  of  the  veins 
of  the  liver  is  quite  diagnostic  and  is  usually  detectable.  To  obtain 
this  sign  the  patient  should  lie  on  the  back  with  the  arms  raised,  and 
the  examiner  should  place  the  palm  of  his  left  hand  over  the  right  mid- 
axillary  region,  and  that  of  the  right  hand  over  the  upper  abdomi- 
nal region.  He  will  thus  be  enabled  to  feel  an  expansile  pulsation  of 
the  liver  synchronously  with  the  ventricular  systole.  This  is  to  be 
carefully  distinguished  from  mere  systolic  depression  of  the  organ  due 
to  the  impulse  of  an  enlarged  right  ventricle,  transmitted  through  the 
diaphragm  and  left  lobe  of  the  liver  to  the  epigastrium. 

Popofi"  and  others  have  also  noted, an  inequality  in  the  radial  pulses 
in  tricuspid  regurgitation.  This  is  probably  due  to  the  pressure  of  the 
enlarged  auricle. 

Percussion. — The  extent  and  form  of  precordial  dulness  are  variable 
according  to  the  nature  of  the  causative  disease,  but  a  dulness  extending 
far  beyond  the  right  edge  of  the  sternum  is  especially  characteristic. 

Auscultation. — A  systolic  murmur  having  its  seat  of  greatest  inten- 
sity at  the  base  of  the  ensiform  cartilage  {vide  Fig.  54)  is  almost  con- 
stantly audible.  The  area  in  Avhich  it  is  best  heard  varies  according  to 
the  intensity  of  the  murmur.  It  is  clearly  conveyed  to  the  left  one  inch 
beyond  the  left  sternal  margin,  and  to  the  right  and  upward  for  an  equal 
distance  beyond  the  limit  of  cardiac  dulness.  It  is  soft  in  character, 
short,  and  often  faint.  If  the  heart  be  weak,  it  may  be  absent.  Ad- 
ditional murmurs,  due  to  primary  lesions,  are  often  heard,  and  usually 
at  other  orifices.      The  pulmonic  second  sound  is  accentuated. 

Diagnosis. — I  believe  that  the  most  valuable  symptom  for  diag- 
nosis is  the  venous  pulse,  whether  observed  clearly  in  the  neck  or  de- 


620 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


termined  positively  by  bimanual  palpation  of  the  liver,  as  before 
described.  Either  of  these  signs  alone  suffices.  The  murmur  is  gen- 
erally audible,  and  when  so  is  a  most  valuable  aid  to  the  diagnosis. 
The  differential  diagnosis  between  mitral  and  tricuspid  regurgitation  is 
easy  when  either  exists  alone,  if  it  be  remembered  that  the  seat  of 
greatest  pronunciation,  the  area  of  transmission,  and  the  acoustic  char- 
acter of  the  respective  murmurs  are   widely  different.     But  it  is  ex- 


FiG.  54.— 1,  Seat  of  greatest  pronunciation ;  2,  chief  direction  of  conveyance ;  3,  boundary -line  of 
absolute  dulness;  4,  boundary-line  of  relative  dulness  (modified  from  Sahli). 

tremely  difficult  to  discern  precisely  a  faint  tricuspid  murmur  when  it 
develops  secondarily  to  the  more  pronounced  murmur  of  mitral  incom- 
petency. If  a  careful  observation  of  the  murmur  fails  to  establish  the 
diagnosis  of  tricuspid  insufficiency,  as  sometimes  is  the  case,  absolute 
reliance  should,  in  my  opinion,  be  placed  upon  the  venous  pulse  when 
present,  and  the  absence  of  the  latter  sign  should  exclude  this  disease. 


TRICUSPID   STENOSIS. 

This  is  a  rare  condition,  occurring  as  a  congenital  and  an  ac(|uired 
disease  with  about  ecjual  frequency.  As  a  primary,  independent  dis- 
ease tricuspid  stenosis  is  very  rare,  being  usually  seen  in  association 
with  organic  disease  of  the  left  side  of  the  heart.  The  lesions  of  mitral 
and  tricuspid  stenosis  are  observed  to  be  combined  most  frequently, 


PULMONARY  INCOMPETENCY.  621 

while  those  of  tricuspid  stenosis  and  aortic  insufficiency  coexist  less 
frequently.  The  morbid  changes  are  practically  identical  with  those  of 
mitral  stenosis,  the  right  auricle  becoming  dilated,  and  this  being  fol- 
lowed by  general  venous  stasis.  The  effect  of  tricuspid  stenosis  upon 
the  right  ventricle  is  the  same  as  that  of  mitral  stenosis  upon  the  left 
ventricle.  The  right  ventricle,  however,  is  usually  hypertrophied, 
owing  to  the  obstruction  in  the  pulmonary  circulation  that  results  from 
the  combined  valvular  deficiencies. 

Special  Etiology. — The  fact  that  mitral  and  tricuspid  stenosis  fre- 
quently have  a  common  cause,  acting  concurrently,  can  scarcely  be 
doubted  in  view  of  their  frequent  association  and  pathologic  identity. 
Hence  the  statement  that  rheumatic  antecedents  are  furnished  by  the 
history  in  from  30  to  40  per  cent,  of  the  cases  of  tricuspid  stenosis  need 
excite  no  surprise.  As  in  mitral  stenosis,  so  in  tricuspid,  sex  is  a  po- 
tent factor,  the  statistics  of  Bedford,  Fenwick,  Herrick,  and  of  Leudet 
(which  embrace  a  total  of  160  cases)  showing  a  ratio  of  5  to  1  in  favor 
of  the  female  sex. 

Symptoms. — The  symptoms  are  those  of  the  combined  affections. 

Physical  Signs. — Inspection  sometimes  reveals  a  feeble  venous  pulse 
in  the  jugulars,  due  to  right  auricular  systole,  and  hence  presystolic 
in  time.  Palpation  may  detect  a  presystolic  thrill  over  the  body  of 
the  right  ventricle.  Percussion  may  enable  the  observer  to  indicate 
the  enlarged  right  auricle.  Auscultation  gives  ^usually  an  audible  pre- 
systolic rolling  murmur,  which  is  best  heard  over  the  lower  sternum  and 
along  its  right  border.  The  above  physical  signs  are  to  be  relied  upon 
in  imcomhined  cases,  which  are  exceedingly  rare.  On  the  contrary,  it 
is  difficult  in  the  extreme  to  differentiate  the  signs  of  tricuspid  stenosis 
from  those  of  the  lesions  with  which  it  is  almost  uniformly  associated — 
viz.  mitral  stenosis  and  aortic  insufficiency. 


PULMONARY   INCOMPETENCY. 

{Pulmonary  Regurgitation.) 

This  is  an  exceedingly  rare  complaint  that  results  from  acute  (ma- 
lignant) or  chronic  endocarditis  after  birth ;  it  is  also  rarely  due  to  a 
congenital  malformation.  In  the  latter  form  union  of  two  of  the  seg- 
ments is  often  observed  ;  in  the  former,  the  usual  sclerotic  processes, 
with  the  occasional  adhesion  of  one  or  more  segments  with  the  pulmo- 
nary artery  wall,  may  be  noted.  The  effect  of  the  lesion  is  to  cause 
hypertrophy  and  dilatation  of  the  right  ventricle.  The  physical  signs 
furnish  no  diagnostic  characteristics.  There  is  developed  a  diastolic 
murmur  which  is  most  audible  in  the  second  pulmonary  interspace,  and 
is  transmitted  to  the  lower  sternal  region,  simulating  the  murmur  of  aortic 
regurgitation.  The  water-hammer  pulse  and  marked  hypertrophic  dila- 
tation of  the  left  ventricle  are  present  in  the  latter  complaint,  however, 
and  are  absent  in  pulmonary  regurgitation.  In  pulmonary  insufficiency, 
on  the  other  hand,  hypertrophy  and  dilatation  of  the  right  ventricle  en- 
sue. Preble  reports  a  case  of  relative  insufficiency  of  the  pulmonary 
cusps ;   at  the  autopsy  aortic  and  mitral  insufficiency  were  also  found. 


622  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


PULMONARY  STENOSIS. 

A  QUITE  frequent  form  of  congenital  malformation  of  the  heart  is 
the  narrowing  of  the  pulmonary  orifice.  In  the  rarest  cases  it  is  of 
post-natal  date,  and  may  result  in  induration,  contraction,  and  fusion  of 
the  segments.  In  one  of  Osier's  cases  the  orifice  "  was  only  two  milli- 
meters in  diameter,  with  vegetations  of  acute  endocarditis  on  the  seg- 
ments." I  saw  one  case  in  which  the  pulmonary  artery  near  the  valve 
was  contracted  to  one-half  its  normal  caliber.  Myocarditis  with  result- 
ing contraction  of  the  conus  arteriosus  may  cause  pulmonary  stenosis, 
and  some  of  the  cases  that  originate  during  adolescence  and  later  in  life 
are  due  to  atheromatous  change,  while  others  possibly  are  the  result  of 
chronic  endocarditis,  direct  violence,  and  ulcerative  endocarditis.  The 
lesion  is  compensated  by  an  hypertrophy  of  the  right  ventricle,  follow- 
ing which  dilatation  and  tricuspid  incompetency  may  appear. 

Symptoms. — Cyanosis  and  distention  of  the  systemic  veins  are 
observed. 

Physical  Signs. — A  systolic  tJirill  may  be  felt  at  times  over  the  base. 
There  is  considerable  enlargement  of  the  right  ventricle,  as  elicited  by 
percussion  and  palpation^  and  a  systolic  murmur  of  greatest  distinct- 
ness is  audible,  as  a  rule,  in  the  third  left  space  near  the  sternum.  It 
is  harsh,  superficial,  and  transmitted  a  short  distance  upward  and  to  the 
left.  Occasionally  this  murmur  is  heard  best  at  the  aortic  valve,  but  it 
is  never  conveyed  to  the  vessels  of  the  neck,  and  hence  is  easily  distin- 
guished from  the  aortic  systolic  murmur.  Its  harsh  character  and  loud- 
ness would  serve  to  obviate  confusion  ys'iih.  functional  or  anemic  murmurs 
that  are  sometimes  heard  here.  The  pulmonic  second  sound  is  weak, 
and,  not  rarely,  there  is  a  diastolic  murmur  of  the  same  character,  indi- 
cating pulmonary  regurgitation.  Broadbent  asserts  that  a  temporary 
systolic  murmur  due  to  severe  exertion  may  be  observed,  and  I  have 
noted  a  systolic  murmur  in  the  pulmonary  area  in  young  adults  of 
remarkably  vigorous  build  and  unusual  endurance.  Sansom  holds  that 
disease  of  the  pulmonary  artery  (contrary  to  other  forms  of  organic 
heart-disease)  predisposes  markedly  to  pulmonary  tuberculosis.  I  have 
at  present  under  my  care  a  tuberculous  patient  in  whom  there  is  a 
double  murmur  audible  at  the  pulmonary  orifice. 


COMBINED  FORMS  OF   CARDIAC  DISEASES. 

It  may  be  asserted  safely  that  in  more  than  one-half  of  all  the  cases 
combined  lesions  or  murmurs  are  exhibited  before  the  fatal  termination. 
As  I  have  already  stated,  stenosis  of  an  orifice  when  due  to  valvular 
disease  is  associated  with  incompetency  of  the  corresponding  valve. 
Thus  aortic  stenosis  is  constantly  combined  with  or  followed  by  aortic 
incompetency,  and  in  like  mannei'  mitral  stenosis  by  mitral  incom- 
petency. The  association'may  also  have  reference  to  lesions  at  two  or 
more  different  valves  ;  and  according  to  the  table  of  F.  J.  Smith,  the 


CHRONIC   VALVULAR   DISEASE.  623 

relative  frequency  of  the  chief  murmurs  found  in  combination  is  as 
follows : 

Aortic  diastolic  and  systolic  and  mitral  systolic,  16.55  per  cent. 

Aortic  stenosis  and  mitral  stenosis,  6.12         " 

Aortic  diastolic  and  mitral  systolic  (common  in  children),  5.21         " 

Aortic  diastolic  and  systolic  and  mitral  presystolic  and  systolic,    3.77         " 

When  two  lesions  coexist  at  the  same  valve,  the  one  may  compensate, 
in  part  at  least,  for  the  other,  as,  for  example,  in  the  case  of  aortic  ste- 
nosis in  association  with  aortic  regurgitation.  Here  the  stenotic  deficiency 
lessens  the  reflux  current  from  the  aorta  into  the  left  ventricle  during  the 
diastole ;  hence  the  latter  receives  a  correspondingly  diminished  amount 

of  blood.     During  the  contraction  of  the  ventricle  the  distendinsc  force 

...  .      ^ 

in  the   aorta  is  diminished,  both  on   account  of  the   narrowing-  at  the 

aortic  orifice  and  the  relatively  lessened  contents  of  the  hypertrophied 
ventricle.  Similarly,  in  dominating  mitral  incompetency  an  associated 
mitral  stenosis  by  lowering  the  strength  of  the  regurgitant  current  ren- 
ders the  conditions  more  favorable.  Relative  insufficiency  at  the  mitral 
valve,  following  aortic  insufficiency, 'may  prove  salutary  by  preventing 
over-distention  of  the  left  ventricle,  and  also  the  over-filling  of  the  ar- 
terial tree  and  the  possible  rupture  of  a  blood-vessel.  On  the  other 
hand,  when  mitral  incompetency  is  secondary  to  aortic  stenosis,  the 
latter  defect  may  hasten  the  unfavorable  tendencies  in  the  former. 

Relative  tricuspid  incompetency,  secondary  to  mitral  disease  (a  fre- 
quent combination),  usually  results  in  the  development  of  a  serious 
impediment  to  the  systemic  venous  circulation,  and  often  heralds  a 
speedily  fatal  issue.  It  is  probable  that  in  advanced  mitral  disease 
the  occurrence  of  a  slight  leakage  at  the  tricuspid  valve  may  be  the 
means  of  obviating  disastrous  consequences  to  the  right  ventricle  in 
case  of  undue  strain. 

Physical  Signs. — These  are  confusing,  but  a  systematic  analysis  often 
leads  to  the  correct  inference.  That  one  of  the  valvular  lesions  pre- 
dominates over  all  others  is  a  fact  of  paramount  importance  for  the  solu- 
tion of  these  cases.  The  chief  lesions  can  usually  be  determined  by 
noting  the  seat.,  the  area  of  transmission,  and  the  character  of  the  most 
pronounced  murmur ;  and  more  important  still  is  the  correct  timing  of 
any  murmurs  that  may  be  audible.  When  a  murmur  occupies  both  the 
aortic  and  mitral  areas  the  student  will  note  two  points  of  maximum  in- 
tensity, and  that  each  grows  weaker  as  the  stethoscope  is  moved  to- 
ward the  mid-prsecordial  region.  The  secondary  alterations  in  the 
heart  frequently  coincide  with  the  predominating  murmur,  and  observers 
should  recollect  the  familiar  fact  that  mitral  murmurs  are  often  secondary 
to  aortic,  and  that  tricuspid  murmurs  point  to  accompanying  mitral  dis- 
ease. Unquestionably,  a  single  observation  of  these  cases,  however 
carefully  made,  is  often  profitless. 

Complications  of  Valvular  Disease. — Most  of  these  have 
already  been  spoken  of  at  sufficient  length,  but  to  restate  them  col- 
lectively in  this  connection  may  prove  useful  to  the  student  and  phy- 
sician. They  are — (1)  acute  endocarditis  (including  the  ulcerative 
form);  (2)  acute  pericarditis;  (3)  pleurisy ;  (4)  pneumonia;  (5)  nephritis, 
followed  by  uremia ;  (6)  local  or  general  arterial  sclerosis ;  (7)  chronic 


624  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

gastric  or  intestinal  catarrh  with  intercurrent  acute  attacks ;  (8)  embolic 
processes :  (9)  angina  pectoris ;  (10)  edema  of  the  lungs ;  (11)  hysteria, 
neurasthenia,  epilepsy,  and  insanity  ;  (12)  rupture  of  the  skin  of  the  ex- 
tremities in  consequence  of  excessive  edema,  with  erysipelatous  inflam- 
mation ;  (13)  synovitis,  a  not  uncommon  complication,  fever,  swelling 
of  one  or  more  of  the  joints,  and  pain  are  the  usual  symptoms.  The 
muscles  of  the  extremities  may  also  be  involved  simultaneously.  It  is 
highly  probable  that  these  manifestations  are  to  be  ascribed  to  rheuma- 
tism, though  they  are  also  met  Avith  in  ulcerative  endocarditis.  (14) 
Febrile  paroxysms  occur  at  varying  intervals  of  time,  and  are  due  to  a 
variety  of  causes,  as  rheumatism,  acute  endocarditis,  and  pericarditis. 
Ulcerative  endocarditis  may  also  occur  and  be  attended  with  an  irregular 
type  of  fever. 

Course  and  Duration. — When  valvular  disease  consists  in  rupture 
of  a  segment  the  course  is  brief  and  usually  proves  quickly  fatal.  Apart 
from  these  exceptional  instances  the  duration  is  measured  by  months,  or 
more  often  by  years  or  even  decades.  Statements  applicable  to  all  cases 
cannot  be  made,  however,  owing  to  the  wide  differences  in  different 
cases.  Among  the  circumstances  affecting  the  duration  I  would  men- 
tion in  particular  the  patient's  mode  of  life,  the  hygienic  conditions 
under  which  he  lives,  his  occupation,  mental  condition,  and  the  severity 
of  the  morbid  processes.  Every  experienced  physician  has  doubtless 
met  with  a  small  class  of  cases  that  have  terminated  fatally  in  from  six 
months  to  a  year,  having  developed  in  that  period  all  of  the  serious 
phenomena  and  complications  of  the  more  chronic  forms  of  organic 
heart-disease.  In  the  preponderating  proportion  of  cases,  however,  the 
course  is  exceedingly  slow,  and  often  cases  have  existed  many  years 
before  they  have  finally  been  recognized.  In  numerous  instances  the 
patient  follows  his  usual  avocation,  which  may  even  be  laborious,  for 
years,  and  without  discomfort.  In  other  cases  the  symptoms,  as  dysp- 
nea on  exertion,  are  so  slight  as  not  to  excite  suspicion. 

Facts  such  as  these  render  it  obvious  that  while  the  period  of  com- 
pensation is  long,  its  exact  limits  are  indeterminable.  In  12  instances 
of  chronic  endocarditis  that  have  developed  under  my  observation  (some 
having  lasted  ten  or  twelve  years)  only  3  have  reached  the  stage  of 
■  broken  compensation.  The  progi'ess  after  failure  of  compensation  is 
more  definitely  known,  since  frequent  opportunities  for  observation  are 
afforded.  At  "this  time  the  cases  also  exhibit  wide  differences  respecting 
their  duration ;  in  my  own  experience  they  have  varied  from  two  to 
three  months  to  as  many  years  (rarely  even  longer),  depending  much  on 
the  patient's  mode  of  living.  The  course  may  be  shortened  by  severe 
external  injury,  intercurrent  acute  illness  (especially  febrile  disease), 
vicious  habits,  straining  efforts,  and  the  like. 

Prognosis. — The  detection  of  a  cardiac  murmur  should  not  alone 
lead  to  a  gloomy  prognosis.  Says  Osier:  "With  the  apex-beat  in  the 
normal  situation  and  regular  in  rhythm,  the  auscultatory  phenomena 
may  be  practically  disregarded."  Individual  cases  require  separate  and 
careful  consideration.  It  is  well  not  to  advance  positive  assertions 
until  all  the  circumstances  that  may  influence  the  prognosis  of  any 
given  instance  have  been  well  weighed.  Observation  of  a  case  for 
some  Aveeks  and  months  enables  the  physician  to  speak  with  greater 


CHRONIC  VALVULAR  DISEASE.  625 

confidence  and  knowledge  concerning  the  probable  outcome.  Prior  to 
the  occurrence  of  disturbances  of  compensation  the  prognosis  is  meas- 
urably favorable.  After  this  pivotal  event  the  prognosis  as  to  life 
becomes  wholly  unfavorable  in  direct  proportion  to  the  extent 
of  the  degenerative  changes  of  the  myocardium.  Disturbances  of 
compensation  that  are  attended  with  marked  arrhythmia,  urgent 
dyspnea,  and  general  dropsy  may  admit  of  com.plete  relief.  Later,  restora- 
tion of  the  balance  of  forces  becomes  only  partial,  and  finally  the  above- 
mentioned  symptoms  become  more  pronounced  ;  Cheyne-Stokes'  breath- 
ing may  then  develop,  and  after  a  prolonged  and  distressing  struggle 
for  breath  the  patient  succumbs.  Death  may  also  occur  suddenly  from 
cardiac  paralysis.  Among  ominous  and  yet  common  complications  and 
intercurrent  affections  may  be  cited  again  extensive  edema  of  the  lungs, 
pneumonia,  typhoid  fever,  embolic  processes,  ulcerative  endocarditis, 
acute  endocarditis,  obstinate  gastritis,  and  nephritis.  On  the  contrary, 
favorable  indications  are  sound  general  health,  good  external  condi- 
tions (absence  of  poverty,  hunger,  etc.),  strong  and  regular  action  of 
the  heart,  absence  of  arterio-sclerosis,  of  excessive  hypertrophy,  of 
rheumatic  antecedents,  and  any  vices  of  life.  Age  influences  the  prog- 
nosis to  some  extent.  In  children  under  ten  years  the  lesions  are  usu- 
ally somewhat  more  rapidly  progressive  than  in  adults,  and  the  compen- 
satory hypertrophy  is  developed  with  corresponding  rapidity ;  hence  the 
period  of  failing  compensation  is  reached  earlier.  This  may  be  said  to 
be  a  broad  general  rule,  and  I  have  found  that  it  is  one  to  which  there  are 
many  exceptions.  Among  other  reasons  for  the  more  gloomy  prospect 
when  heart-disease  occurs  in  young  children  are  the  following :  the 
mitral  valve  is  generally  implicated,  the  liability  to  rheumatic  inter- 
currences  is  great,  and  children,  unless  carefully  controlled,  overtax  at 
play  the  reserve  cardiac  power  when  indulging  in  running  and  other 
forms  of  exercise.  After  the  twelfth  year  the  prognosis  becomes  more 
favorable.  Sex  is  also  a  modifying  prognostic  factor,  women  bearing 
valvular  lesions  better  than  men,  apart  from  the  influence  of  childbear- 
ing,  though  even  this  is  an  influence  the  significance  of  which  has  been 
greatly  magnified  by  many  writers.  To  explain  the  more  favorable  out- 
look in  women  we  have  two  main  facts — viz.  a  less  laborious  as  well  as 
a  more  quiet  life,  and  a  diminished  liability  to  arterio-sclerosis  and  in- 
volvement of  the  coronary  vessels.  The  particular  valve  involved  has 
some  influence  on  the  prognosis. 

Aortic  regurgitation  gives,  on  the  whole,  a  rather  favorable  prognosis, 
particularly  in  those  cases  that  begin  in  early  adult  life,  granting,  of 
course,  that  the  patient  regulates  wisely  his  manner  of  living.  Under 
such  circumstances  the  lesion  may  be  compensated  for  many  years  or 
even  decades.  The  increased  vigor  of  the  left  ventricle  as  compared  with 
the  right  is  conducive  to  longevity  in  this  disease.  After  failure  of 
compensation,  the  prognosis  is  less  satisfactory  in  aortic  regurgitation 
than  in  mitral  regurgitation,  since  restoration  of  compensation  is  not 
as  readily  accomplished  in  the  former  as  in  the  latter  variety.  In 
the  lesion  under  consideration  a  chief  danger  arises  from  associated 
arterio-sclerosis — a  rather  frequent  occurrence  in  advanced  life — and 
from  implication  of  the  coronary  arteries.  Much  depends  upon  the 
condition  of  the  latter  vessels.     When  their  lumen  is  narrowed  starva- 

40 


626  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

tion  of  the  heart-muscle  quickly  ensues,  followed  by  myositic  degenera- 
tion. Blocking  of  one  of  the  branches  of  the  coronary  artery  is  the 
most  frequent  cause  of  sudden  death  in  this  affection.  In  aortic  stenosis 
equally  favorable  predictions  are  warrantable  when  the  disease  is  un- 
complicated. 

Mitral  regurgitation,  when  a  primary  lesion,  is  propitious,  except  in 
the  very  young,  and  not  infrequently  the  progress  of  the  morbid  process 
is  apparently  arrested.  In  a  considerable  proportion  of  cases  the  dis- 
ease does  not  materially  shorten  the  life  of  the  sufferer.  In  a  larger 
percentage,  however,  there  is  special  liability  to  a  renewal  of  the  causa- 
tive affections  (e.  g.  rheumatism)  and  to  pulmonary  conditions  of  serious 
import,  producing  exacerbations  and  permanent  aggravations  of  the 
disease.  The  gravity  of  these  intercurrent  complaints  is  also  increased 
by  the  existence  of  the  cardiac  lesion.  Failure  of  compensation  at  once 
renders  the  prognosis  decidedly  unfavorable.  In  mitral  stetiosis  com- 
pensation of  the  right  heart  fails  somewhat  earlier  than  in  mitral 
insufficiency,  and  hence  the  accidents  and  conditions  referable  to  the 
lung  (diffuse  pulmonary  apoplexy,  edema)  are  not  so  long  delayed 
as  in  the  latter  disease :  this  is  also  true  of  the  later,  more  serious 
manifestations.  I  have  learned  by  experience  that  mitral  stenosis  is 
better  borne  by  women  than  by  men,  and  better  during  adolescence  and 
early  adult  life  than  during  more  advanced  years.  The  congenital 
forms  are  comparatively  benign.  It  should  not  be  forgotten  that  mitral 
stenosis  causes  sudden  death  more  frequently  than  any  other  form  of 
organic  disease  of  the  heart  except  aortic  regurgitation.  Tricuspid 
incompetence^,  whether  secondary  to  disease  of  the  lung  or  of  the  left 
side  of  the  heart,  is  extremely  grave.  It  is  usually  indicative  of  dila- 
tation following  hypertrophy  of  the  right  ventricle.  Compensatory  hy- 
pertrophy, however,  can  be  re-established,  and  sometimes  repeatedly. 

Treatment. — This  falls  naturally  into  three  subdivisions  :  (1)  pro- 
phylaxis ;  (2)  management  during  the  stage  of  compensation  ;  (3)  treat- 
ment of  the  stage  of  non-compensation. 

(1)  Prophylaxis. — It  can  scarcely  be  doubted,  as  shown  by  the  statis- 
tics of  Sibson,  that  complete  rest  and  protection  of  the  surface  during 
an  attack  of  acute  articular  rheumatism  lessen  the  average  percentage 
of  cases  in  which  acute  endocarditis  develops.  When  the  latter  com- 
plication occurs  in  acute  rheumatism  the  patient  should  keep  to  his  bed 
for  some  time  after  all  rheumatic  symptoms  have  disappeared  (two  to  six 
weeks)  or  until  the  improvement  in  the  cardiac  condition  has  ceased 
absolutely.  This  precautionary  measure  will  often  lessen  the  extent  of 
the  ensuing  chronic  endocarditis,  and  also  increase  the  proportion  of 
perfect  recoveries.  Suitable  dietetic  and  medicinal  treatment  must 
necessarily  be  combined.  When  the  physician  is  cognizant  of  hered- 
itary predisposition  to  organic  heart-disease,  or  has  to  deal  Avith  the 
artliritic  diathesis  (gouty  or  rheumatic)  or  the  alcoholic  habit,  he  can 
frequently,  by  timely  advice  and  hygienic  suggestions,  direct  his  pa- 
tient to  adopt  measures  that  will  obviate  the  occurrence  of  valvular 
disease.  All  persons  predisposed  by  heredity  or  otherwise  should  be 
told  of  the  probable  effect  of  muscular  strain,  alcohol,  and  other  excit- 
ing factors ;  too  often,  however,  when  he  sees  his  patient  for  the  first 
time  the  physician  is  confronted  by  an  incurable  malady. 


CHRONIC  VALVULAR  DISEASE.  627 

(2)  Management  during  the  Stage  of  Compensation. — Three  main  ob- 
jects are  to  be  accomplished :  {a)  The  avoidance  of  every  agency  that 
tends  to  aggravate  or  maintain  the  lesion  or  lesions.  Under  this  head  the 
detection  and  removal  of  all  causal  factors  is  imperative.  Thus,  if  the 
patient's  avocation  entails  undue  muscular  effort,  it  must  be  aban- 
doned ;  violent  exercise,  as  running  up  flights  of  stairs,  heavy  lifting, 
or  straining  at  stool,  is  also  dangerous  and  must  be  prevented.  If 
alcohol  has  been  a  factor,  it  must  be  discontinued  ;  if  syphilis,  it  must 
be  treated  specifically.  If  there  be  present  a  rheumatic  or  gouty  taint 
of  the  system,  it  must  be  overcome  as  far  as  possible  by  special  meas- 
ures. Fatigue  and  exposure  must  be  avoided,  particularly  if  the 
patient  be  comparatively  young.  Emotional  excitement  and  mental 
over-exertion  injuriously  affect  the  cardiac  lesion  ;  therefore  tranquillity 
of  mind  should  be  insisted  upon,  though  moderate  and  systematic 
mental  exercise  has  no  risks  for  the  patient.  In  the  case  of  children 
at  school  careful  supervision  of  their  studies  as  well  as  of  their  recrea- 
tive exercises  is  essential.  Fright  and  sudden  emotion  must  be  avoided 
if  possible.  The  use  of  tea,  coffee,  and  tobacco  should  be  rigidly  pro- 
hibited.     In  mitral  disease,  bronchitis  is  to  be  especially  guarded  against. 

ih)  The  diet  of  the  patient  demands  careful  regulation.  Only  a  very 
moderate  amount  of  food,  composed  for  the  most  part  of  readily  digested 
albuminous  articles  (milk,  eggs,  the  lighter  forms  of  meats,  and  stewed 
fruits),  is  to  be  taken,  since  overloading  the  stomach  will  disturb  the 
action  of  the  heart ;  particularly  is  this  true  at  night.  The  carbohy- 
drates may  be  allowed  only  in  limited  quantities,  since  they  are  apt  to 
decompose  and  form  gases  that  distend  the  stomach  and  intestines.  For 
the  same  reason  the  coarser  and  more  indigestible  food-stuffs  should  be 
avoided.  Small  meals  at  brief  periods  is  a  plan  of  feeding  that  I  can 
highly  commend.  The  amount  of  liquids  taken  should  not  exceed  the 
actual  requirements  of  the  patient,  inasmuch  as  over-filling  of  the  blood- 
vessel system  increases  the  work  of  the  already  overburdened  cardiac 
forces.  Alcoholic  beverages  should  not  be  used  as  a  rule ;  but  if  the 
patient  has  been  moderate  in  the  use  of  alcohol,  and  particularly  if  he 
be  advanced  in  years,  light  wines  may  be  allowed  in  moderate  quantity 
to  aid  digestion,  (c)  Carefully  regulated  exercise  is  beneficial,  but  it  must 
be  gentle  and  should  be  taken  out  of  doors.  As  before  intimated,  a 
good  general  muscular  development  is  an  aid  of  no  mean  value  to  the 
conservative  powers  of  the  heart.  Oertel,  with  a  view  to  assisting  the 
compensatory  forces  of  the  heart,  has  recommended  graduated  physical 
exercise ;  he  advises  that  patients  be  instructed  first  to  ascend  low  ele- 
vations, and  later  mountains  of  a  considerable  height,  the  object  being  to 
bring  about  full  compensation.  Great  caution  is  to  be  exercised  by  the 
physician,  however,  since  this  method  has  been  found  to  be  inapplicable 
to  a  large  percentage  of  cases.  Cardiac  distress,  palpitation,  and  dys- 
pnea are  complained  of  by  this  large  group  of  patients  if  other  than  the 
gentlest  forms  of  exercise  be  undertaken.  With  respect  to  exercise, 
then,  the  sensations  and  experiences  of  each  patient  must  be  consulted 
before  the  physician  can  advise  judiciously.  Woollens  should  be  worn 
next  to  the  skin  during  both  the  warm  and  the  cold  seasons.  The  skin 
should  be  kept  clean  by  daily  sponge  baths,  and  if  these  be  followed 
by  friction  of  the  surface,  the  bodily  nutrition  will  be  improved  and  the 


628  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

liability  to  intercurrent  attacks  of  bronchitis  greatly  lessened.  The 
bowels  should  be  moved  each  day,  and  usually  the  use  of  steAved  fruits 
suffices  to  accomplish  this  end ;  if  not,  salines,  Rochelle  or  Carlsbad 
salts,  and  the  bitter  waters  (Friedrichshall,  Hunyadi-Janos)  must  be 
brought  into  requisition.  In  winter  a  Avai'm  climate  may  prove  ad- 
vantageous, though  long  journeys  are  often  illy  borne,  owing  to  the 
fatigue  induced  thereby.  If  the  patient  becomes  anemic  or  his  nutri- 
tion is  notably  impaired,  a  suitable  change  of  air,'  or  the  use  of  quinin, 
arsenic,  small  doses  of  mercury,  and  cod-liver  oil,  is  to  be  recommended. 
Digitalis  should  not  be  employed  when  compensation  can  be  preserved 
in  other  ways.  We  should  train  the  heart  up  to  the  amount  of  work 
required  of  it  (Bruntou). 

(3)  Treatment  of  the  Stage  of  Non-compensation. — The  principal  object 
to  be  kept  in  view  in  this  stage  is  the  reinvigoration  of  the  exhausted 
cardiac  muscle,  and  thus  to  relieve  the  impeded  circulation.  Sudden 
death  may,  though  rarely,  occur  from  the  blocking  of  a  branch  of  the 
coronary  artery  or  from  acute  dilatation.  Failure  of  compensation, 
however,  begins  gradually  as  a  rule,  the  condition  often  existing  without 
marked  or  characteristic  symptoms ;  but  its  early  recognition  is  import- 
ant from  the  stand-point  of  therapy.  Increased  dyspnea  on  exertion, 
and  nocturnal  seizures  of  shortness  of  breath  and  irregular  action  of  the 
heart  [arrhythmia),  are  among  the  earliest  clinical  features.  The  latter 
symptom  may  have  been  present  before,  and  particularly  during  active 
exercise  in  mitral  disease,  but  now  it  is  more  marked,  and  may  be  con- 
stant. The  patient's  nutrition  often  suffers,  and  he  is  pale  and  rather 
feeble.  Absolute  (juiet,  liberal  feeding  with  suitable  food,  and  iron 
may  in  a  little  while  restore  the  impaired  cardiac  tone.  If  this  treat- 
ment fails,  by  the  end  of  a  fortnight  a  small  dose  of  digitalis  should 
also  be  exhibited  (5  minims — 0.333 — of  the  tincture  three  times  daily); 
the  latter  should  be  promptly  withdrawn  upon  the  disappearance  of  the 
symptoms.  Decided  indications  of  lost  compensation  are  marked  dys- 
pnea and  arrhythmia;  the  canter  rhythm  :  an  irregular,  small,  compres- 
sible pulse ;  and  cyanosis,  with  or  without  the  presence  of  dropsy.  The 
object  now  is  the  maintenance  of  the  blood-pressure  at  an  adequate  height 
by  the  following  means :  (a)  Absolute  rest  in  bed.  This  diminishes 
greatly  the  Avork  of  the  heart,  and  thus  enables  it  to  regain  largely  its 
former  vigor.  Rest  joined  with  massage  and  careful  yet  liberal  feeding 
and  attention  to  the  bowels  Avill  often  restore  disturbed  compensation 
in  from  one  to  two  weeks.  In  4  cases  recently  treated  at  the  Medico- 
Chirurgical  Hospital  this  method  succeeded  admirably. 

{b)  Cardiac  stimulants  and  tonics.  Of  these,  when  occasion  demands, 
the  most  important  is  digitalis,  and  this  may  be  tried  in  any  case  in  which 
dilatation  exists.  By  stimulating  the  pneumogastric,  by  increasing  the 
blood-supply  to  the  heart-muscle,  by  causing  the  systole  to  be  more  com- 
plete and  the  period  of  diastole  to  be  lengthened,  digitalis  becomes  an  in- 
valuable aid  to  the  nutrition  of  the  cardiac  muscles.  In  addition,  the 
heart  contracts  more  regularly  and  the  blood-pressure  in  the  peripheral 
circulation  is  raised.     As  a  result  of  the  use  of  this  drug  the  tissue-calls 

1  Observation  and  experience  have  contirnieil  my  helief  that  sea-air  during  the  warm 
season  and  high  altitudes  at  ail  times  are  injurious  in  their  etiects  in  valvular  disease  of 
the  heart. 


CHRONIC  VALVULAR  DISEASE.  629 

upon  the  cardiac  forces  from  the  outlying  portions  of  the  body  are  satis- 
fied and  the  reserve  energies  of  the  heart-muscles  are  maintained. 

In  mitral  disease  the  influence  of  digitalis  is  most  beneficial,  the  pulse 
becoming  slower,  of  better  tension,  and  more  regular  while  the  urine 
increases  in  amount.  In  mitral  incompetency  its  good  efi"ects  are  ascrib- 
able  in  part  to  the  powerful  contractions  of  the  left  ventricle,  whereby 
the  normal  blood-stream  from  the  ventricle  to  the  aorta  is  greatly  in- 
creased. On  the  contrary,  the  patient's  condition  is  occasionally  aggra- 
vated by  the  drug,  because  "  the  leak  is  increased  as  much  as  the  normal 
flow  "  (Hare).  Digitalis  exercises  its  most  beneficial  influence  by  ren- 
dering the  systole  of  the  right  ventricle  more  energetic,  the  blood-press- 
ure being  raised  in  the  pulmonary  circuit  and  left  auricle ;  this  fills  the 
left  ventricle  better  during  diastole  and  "  resists  reflux  through  the  mi- 
tral orifice  in  the  systole  "  (Broadbent).  In  mitral  stenosis  digitalis,  by 
lengthening  the  period  of  diastole,  allows  time  for  the  blood  to  pass  from 
the  auricle  through  the  narrowed  mitral  orifice  into  the  ventricle.  Slight 
toxic  efi'ects  may  sometimes  result  from  digitalis,  the  pulse  becoming 
thread-like  and  irregular,  and  the  urine  scanty.  Under  these  circum- 
stances the  drug  should  be  discontinued. 

In  aortic  regurgitation  digitalis  exercises  as  great,  if  not  as  wide,  an 
influence  as  in  mitral  disease  :  the  theoretic  view,  however,  that  by  pro- 
longing the  diastole  digitalis  causes  overfilling  of  the  left  ventricle  rests 
on  too  slender  a  foundation  to  be  regarded  as  a  valid  objection  to  its 
use.  It  may,  however,  produce  excessive  hypertrophy,  in  which  case  it 
should  be  promptly  withheld.  The  symptoms  due  to  secondary  mitral 
regurgitation  digitalis  meets  by  reinforcing  the  ventricles, 'particularly 
the  right.  In  all  forms  of  organic  heart-disease,  though  most  frequently 
in  aortic  regurgitation,  nausea  and  vomiting  sometimes  follow  the  ad- 
ministration of  digitalis :  when  this  is  the  case  it  should  be  stopped  and 
other  cardiac  stimulants  substituted  or  the  dose  reduced  to  the  point  of 
tolerance,  when  it  may  be  continued  if  adequate  to  maintain  a  proper 
efi'ect.  When  secondary  dilatation  comes  on  in  aortic  stenosis  digitalis 
is  needed  to  increase  left  ventricular  power.  The  dose  is  to  be  calcu- 
lated according  to  the  degree  of  existing  dilatation.  When  tricuspid 
incompetency  is  secondary  to  mitral  disease  striking  results  are  obtained 
from  the  use  of  digitalis  (supra) ;  but  when  it  exists  alone — e.  g.  folloAV- 
ing  emphysema  or  cirrhosis  of  the  lung — digitalis  often  fails.  The 
cardiac  contractions,  if  they  have  previously  been  irregular,  may  become 
somewhat  more  regular,  but  the  precordial  distress  will  often  be  increased, 
while  the  circulatory  disturbance,  as  evidenced  by  the  objective  signs, 
will  remain  unrelieved.  If  dropsy  be  slight  or  absent,  10  minims  (0.666) 
of  the  tincture  or  2  to  3  drams  (8.0-12.0)  of  the  infusion,  three  or  four 
times  daily,  will  sufiice.  If  symptoms  of  decidedly/  unfavorable  import 
be  present,  including  marked  dropsy,  the  dose  should  then  be  larger 
(of  the  tincture,  minims  x  to  xv — 0.666  to  0.999;  of  the  infusion,  sss — 
16.0 — every  two  or  three  hours)  for  two  or  three  days,  when  the  dose 
must  be  diminished  or  given  at  longer  intervals.  Quantitative  estima- 
tions of  the  urine  should  be  made  during  the  use  of  the  drug,  and  if  the 
effect  be  good  the  daily  amount  will  often  be  greatly  increased ;  if  bad, 
there  will  be  a  diminution  rather  than  an  increase  in  the  amount.  There 
are  not  a  few  patients  in  whom  the  symptoms  of  commencing  failure  of 


630  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

compensation  recur  as  soon  as  the  drug  is  discontinued.  To  such  digi- 
talis may  be  administered  continuously  or  until  toxic  symptoms  are  mani- 
fested. I  believe  that  the  solid  preparations  (powder  and  extracts)  can 
be  taken  for  longer  periods  than  the  liquid  forms  without  exciting  unto- 
ward symptoms.  This  suggestion  should  be  followed  particularly  in  cases 
that  are  seen  at  long  and  irregular  intervals  of  time.  Evidences  of  fatty 
degeneration  and  atheroma  are  not  contraindications  to  its  use,  but  are 
signals  for  the  observance  of  extreme  caution.  It  should,  however,  be  a 
rule  never  to  be  broken  to  discontinue  the  digitalis  when  the  symptoms 
of  disturbed  circulation  have  vanished.  When  it  fails  of  its  effect  or  is 
not  well  borne,  and  when,  as  often  happens,  the  arrhythmia  is  not  favor- 
ably influenced  by  it,  the  physician  is  compelled  to  resort  to  other  car- 
diac stimulants.  These  are  numerous,  and,  whilst  their  good  effects  are 
not  comparable  to  those  of  digitalis  in  every  respect,  some  of  them  seem 
to  meet  certain  indications  that  are  not  met  by  this  drug.  Among  the 
more  important  are  nitroglycerin,  strophanthus,  strychnin,  cocain,  spar- 
tein,  and  caffein.  Nitroglycerin  in  small  doses  is  at  the  same  time  a  car- 
diac stimulant  and  an  arterial  relaxant,  and  hence  is  more  often  useful  in 
aortic  than  in  mitral  valvular  disease.  In  larger  doses,  Avhen  left  ven- 
tricular hypertrophy  is  excessive,  as  may  occur  when  general  arterio- 
sclerosis is  associated  with  aortic  regurgitation  and  also  (though  rarely) 
aortic  stenosis,  it  is  highly  useful,  widening  the  blood-paths,  and  causing 
less  powerful  contractions  of  the  heart.  Strophanthus  should  be  em- 
ployed in  instances  in  which  digitalis  must  be  interrupted,  since  the 
action  of  these  two  remedies  upon  the  heart-walls  is  very  similar.  The 
tincture  is  usually  employed,  the  dose  (varying  with  the  indications  of 
each  case)  being  from  4  to  10  minims  (0.266-0.666)  every  three  or  four 
hours,  and  in  controlling  the  irregularity  or  intermittency  of  cardiac 
action  it  is  sometimes  better  in  its  influence  than  digitalis.  Many  cases 
of  marked  arrhythmia  will  not  yield  to  either  when  but  one  is  given  ;  and 
in  such  I  have  occasionally  obtained  good  results  from  digitalis  and  stro- 
phanthus in  combination.  Caffein  citrate  is  also  a  good  cardiac  stimu- 
lant, but  is  superior  as  a  diuretic.  It  should  be  stated  that,  rarely,  stro- 
phanthus, like  digitalis,  does  harm  rather  than  good,  being  sometimes 
badly  borne  by  the  stomach.  Under  these  circumstances  I  have  em- 
ployed, both  in  hospital  and  private  practice,  the  following  combination : 


I^.   Caffein.  citrat.,                      z] 

(-t.O): 

Strychninfe  sulphat.,            gr. 

i  (0.021); 

Spartein.  sulphat.,                 gr. 

ij  (0.129). 

Ft.  capsulge  No.  xij. 

One  every  three  or  four  hours. 

Sig. 

The  above  prescription  is  not  only  a  good  heart-tonic  and  stimulant,  but 
also  an  equally  good  diuretic.  Spartein  is  a  potent  diuretic  and  heart-stim- 
ulant when  employed  in  doses  of  gr.  ^  to  ^  (0.010-0.016)  every  four  to  six 
hours,  and  is  especially  serviceable  in  organic  heart-affections  when  dropsy 
as  a  symptom  and  nephritis  as  a  complication  exist.  Strychnin,  when 
given  hypodermically  in  full  dose,  gr.  ^-^  to  ylg-  (0.002-0.004),  is  the  most 
efiicient  cardiac  stimulant  known  to  medical  science.  It  should  be  em- 
ployed in  this  manner  in  cases  in  which  there  is  sudden  failure  of  heart- 
power  with  the  development  of  serious  symptoms.     Given  in  doses  of 


CHRONIC  VALVULAR  DISEASE.  631 

average  size,  per  os,  its  effects  in  chronic  valvular  disease  are  not  very 
striking.     Atropin  may  be  advantageously  combined  with  it. 

When  the  indications  are  urgent  and  the  above  agents  are  not  avail- 
able, diffusible  stimulants,  as  ether  or  ammonium,  may  be  used  until  more 
suitable  remedies  can  take  effect.  Cocain  simulates  strychnin  in  its 
action.  The  dose  is  gr.  J  (0.016)  every  four  hours,  and  the  drug  may 
be  given  with  digitalis  in  pill-form.  Later,  systemic  tonics  are  often  de- 
manded by  the  anemia  and  other  constitutional  indications,  and  here  iron 
and  quinin  should  be  joined  with  strychnin.  Unquestionably,  the  value 
of  iron  in  full  doses  as  an  aid  to  the  completion  of  the  work  of  restoring 
broken  compensation  has  been  and  is  still  scarcely  appreciated  by  the 
profession  at  large.  When  iron  disagrees,  arsenic  may  be  given  instead. 
In  many  cases  of  failure  of  compensation  the  restoration  of  the  balance  of 
the  cardio-systemic  circulation  can  be  greatly  assisted  by  depleting  the 
over-filled  venous  system.      There  are  two  ways  of  attaining  this  end  : 

(a)  Venesection. — When  the  right  heart  is  over-distended,  as  shown 
by  its  very  feeble  efforts  at  contraction,  and  the  whole  venous  system  is 
intensely  engorged,  as  shown  by  marked  cyanosis  and  orthopnea,  bleeding 
directly  from  a  vein  is  not  only  warrantable,  but  often  imperatively  de- 
manded in  order  to  save  life.  From  16  to  30  ounces  (473.0-887.0)  may 
be  removed  safely,  and  the  heart's  action  will  almost  immediately  be 
observed  to  gi'ow  stronger  and  more  regular,  and  the  pulse  fuller  and  of 
better  tension.  As  before  intimated,  the  form  of  dilatation  of  the  right 
ventricle  that  follows  emphysema  is  disinclined  to  yield  to  digitalis.  In 
such  instances,  following  the  suggestion  of  Osler,^  I  have  obtained  bril- 
liant results  from  free  bleeding-s. 

(h)  Dejoletion  hy  purgation  affords  less  pronounced  relief  to  the  heart, 
though  it  is  of  the  greatest  value  in  cases  in  which  a  moderate  grade  of 
cyanosis  and  dropsy  exists.  As  in  the  case  of  venesection,  a  feeble, 
irregular  pulse  is  not  a  contraindication  to  the  use  of  purgatives,  since  the 
latter  remove  directly  a  considerable  portion  of  the  heart's  burden.  The 
purgative  to  be  used  will  vary  with  different  cases.  I  select  at  the  outset 
Rochelle  or  Epsom  salts,  employing  them  after  the  method  of  Matthew 
Hay — i.  e.  from  1  to  2  ounces  (32.0-64.0)  of  Rochelle  or  1  to  1^  ounces 
(32.0—48.0)  of  Epsom  salts,  in  concentrated  solution,  to  be  given  from  a 
half  to  one  hour  before  breakfast.  Watery  evacuations  (three  to  six  in 
number  daily)  usually  follow  the  administration  of  the  saline  ;  but,  unfor- 
tunately, one  meets  with  many  patients  in  whom  it  produces  symptoms 
of  marked  catarrhal  irritation.  Next  to  salines,  the  most  satisfactory 
results  have  been  obtained  from  the  use  of  elaterium  ;  I  often  combine 
this  with  podophyllin  and  belladonna.  I  have  never  seen  good  results 
from  the  use  of  mercurials  when  the  object  has  been  to  procure  venous  de- 
pletion, but  they  are  of  service  in  dropsy,  and  particularly  in  ascites. 

Schott  of  Nauheim  has  introduced  a  special  plan  of  treatment  that  is 
applicable  to  most  forms  of  valvular  disease,  simple  dilatation,  and  nervous 
affections  of  the  organ.  The  beneficial  effects  are  principally  attribu- 
table to  the  salt,  which  acts  as  a  cutaneous  stimulant,  and  to  a  slighter 
deg-ree  to  the  gaseous  ingredients  of  the  bath.  Greene^  regards  the 
warmth  and  moisture  as  the  important  features.     Twenty-one  baths  are 

1  For  illustrative  cases  from  Prof.  Osier  s  wards,  see  article  by  Leufler,  Medical  News, 
July,  1891.  -  Jour.  Amer.  Med.  Assoc,  Oct.  15,  1898. 


632  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

given  in  one  month,  dropping  one  every  fifth,  fourth,  third,  and  second 
days.  The  water  contains  sodium  chlorid,  calcium  chlorid,  and  carbon 
dioxid,  and  the  temperature  ranges  from  82°-95°  F.  (27.7°-35°  C)- 
The  first  bath  lasts  seven  or  eight  minutes ;  the  time  is  then  gradually 
lengthened,  the  temperature  lowered,  and  the  carbon  dioxid  increased. 
After  the  bath  the  patient  is  rubbed  and  allowed  to  rest  for  an  hour. 

Artificial  Nauheim  baths  are  successfully  employed  in  certain  Ameri- 
can hospitals  at  the  present  time.  They  are  prepared  as  follows :  Five 
pounds  of  sodium  chlorid  and  eight  ounces  of  calcium  chlorid  are  dissolved 
in  one  half  bath  (30  gals. — 114  liters),  the  temperature  of  the  water  being 
95°  F.  (35°  C).  In  a  few  days  the  bath  is  charged  with  carbon  dioxid 
by  adding  sodium  bicarbonate  (1  lb. — 153.6)  and  HCl  (|- lb, — 226.8),  the 
latter  just  before  the  bath  is  taken.  The  eifects  are  to  lower  the  pulse- 
rate,  to  decrease  the  size  of  the  heart,  to  stimulate  the  nerves,  and,  indi- 
rectly, the  cardiac  nutrition.  There  is  also  a  tendency  toward  improve- 
ment of  the  skin  and  an  increase  of  the  urine. 

Gentle  resistance  exercises  (consisting  of  all  the  more  reasonable  move- 
ments that  a  person  naturally  makes,  and  resisted  by  an  attendant)  form 
an  important  element  of  the  treatment,  since  they  tend  to  stimulate  the 
muscles  and  nerves  and  propel  the  blood  from  the  congested  veins.  The 
Nauheim  treatment  is  not  suitable  in  aortic  regurgitation,  aneurysm,  or 
fatty  degeneration  of  the  heart,  although  the  movements  alone  are  bene- 
ficial in  these  conditions  and  may  be  employed  to  the  exclusion  of  the 
baths. 

Individual  symptoms  frequently  become  so  conspicuous  as  to  demand 
special  treatment. 

(1)  Dyspnea  and  Orthopnea. — When  these  conditions  are  caused  by 
engorgement  of  the  pulmonary  vessels,  the  cardiac  stimulants  above 
detailed  usually  afford  relief.  Frequently  the  patient  cannot  lie  down, 
in  which  case  a  suitable  bed-rest  often  gives  immediate  comfort  and 
support.  For  the  severe  attacks  of  nocturnal  dyspnea  (amounting  some- 
times to  orthopnea),  particularly  when  accompanied  by  cardiac  palpita- 
tion, the  subjoined  formula  has  proved  itself  of  great  benefit : 

I^.  Sodii  bromidi,  gr,  xv    (0.972); 

Tr.  opii  deod.,  mx-xv  (0.666-0.999).— M. 

Sig.   To  be  taken  in  one  dose  at  bed-time. 

In  the  late  stages  of  heart-disease  morphin,  given  hypodermically,  is  to  be 
preferred  in  combating  this  symptom,  and  is  entirely  free  from  the  usual 
objections  to  the  habitual  use  of  the  remedy.  Its  influence  for  good  is 
inestimable.  Dyspnea  may  also  be  produced  by  associated  bronchitis, 
edema,  emphysema,  and  hydrotborax — conditions  that  must  be  treated 
according  to  the  customary  rules.  Frecjuent  physical  explorations  of 
the  chest  should  not  be  omitted.  Hydrotborax  demands  aspiration,  and 
this  repeatedly  in  some  instances.* 

In  valvular  disease  (particularly  aortic),  owing  probably  to  coronary 
arterio-sclerosis,  paroxysms  of  severe  dyspnea  {cardiac  asthma)  are  apt 
to  arise.  These  are  best  overcome  by  nitroglycerin  in  ascending  dosage 
in  combination  with  sodium  bromid  at  bed-time,  to  be  repeated  as  needful. 

'  When  the  chambers  of  the  heart  are  greatly  dilated  care  must  be  exercised  in  insert- 
ing the  aspirating  needle,  lest  the  left  ventricle  be  entered. 


CHRONIC  VALVULAR  DISEASE.  633 

(2)  Oough. — Cough  is  common  after  failure  of  compensation,  and  is 
due  to  bronchitis  resulting  from  stasis  in  the  pulmonary  vessels.  In 
mitral  disease  it  may  come  on  before  the  rupture  occurs.  Beyond  the 
treatment  directed  to  the  causal  condition  (the  cardiac  failure)  nothing 
is  needed  to  relieve  the  cough.  These  subjects,  however,  are  prone  to 
suffer  from  catarrhal  bronchitis  due  to  cold,  and  this  impairs  the  com- 
pensatory mechanism.  J.  Weiss  extols  heroin  in  cases  that  are  not  re- 
lieved by  the  ordinary  remedies. 

(3)  Hemorrhage  may  take  place,  and  generally  from  the  lungs,  though 
it  may  also  proceed  from  the  nose,  stomach,  bowels,  or  uterus.  In  a 
recent  case  of  double  aortic  and  relative  mitral  insufficiency  attended 
with  marked  dropsy,  rather  copious  hemorrhages  occurred  from  the 
bowel,  but  with  apparent  relief  to  the  patient.  The  hemoptysis,  which 
is  a  rather  frequent  accompaniment  of  mitral  lesion,  is  rarely  excessive, 
and  is  probably  always  beneficial.  I  would  advise  against  active  treat- 
ment unless  the  hemorrhage  is  actually  copious  in  amount. 

(4)  Palpitation  may  be  due  to  different  causes,  the  recognition  of 
which  in  each  case  is  important.  At  times  undue  hypertrophy  maintains 
a  constant  throbbing  and  distress  in  the  precordial  region,  the  former 
being  distinguished  by  the  strength  of  the  impulse  and  by  the  full,  tense 
pulse  at  the  wrist.  Palpitation  is  best  met  by  the  use  of  the  tincture 
of  aconite,  TTLj-iv  (0.066-0.266,  every  four  hours.  With  the  aconite  I 
frequently  associate  the  bromid  with  excellent  effect.  An  ice-bag  to 
the  precordia  is  Avorthy  of  recommendation.  Unless  the  patient's  dis- 
comfort is  significant,  however,  this  symptom  does  not  call  for  active 
treatment.  The  administration  of  a  saline  purge  not  infrequently  serves 
to  quiet  the  heart.  The  patient  may  suffer  from  pure  nervous  palpitation, 
in  which  case  the  diet  and  the  condition  of  the  stomach  must  be  care- 
fully looked  to,  while  for  the  throbbing  the  bromids  of  ammonium  and 
sodium,  together  with  preparations  of  valerian,  are  the  most  reliable. 

(5)  Anginose  Pains. — These  are  seen  in  aortic  incompetency  accom- 
panied by  sclerotic  vessels,  and  more  especially  in  mitral  stenosis.  When 
dependent  upon  rigid  blood-vessel  walls  nitroglycerin  should  be  tried ; 
if  the  attacks  be  severe,  amy!  nitrite  by  inhalation  deserves  a  trial,  and, 
this  failing,  morphin  and  atropin  may  be  employed  hypodermically.  The 
latter  measures,  as  a  rule,  promptly  relieve  the  patient's  suffering.  Local 
measures  alone  are  sometimes  sufficient  when  the  pain  is  only  moderately 
intense,  and  the  ice-bag  or  Leiter's  coils  may  be  tried.  The  sedative 
effect  of  a  blister  (4  by  6  in. — 10  by  15  cm.)  has  more  often  proved 
effectual  in  my  experience,  though  its  use  should  be  limited  to  patients 
whose  general  strength  is  not  materially  impaired. 

(6)  Pain  referred  to  the  stomach,  and  less  frequently  to  the  abdomen 
also,  occasionally  assumes  prominence  and  is  relieved  with  great  diffi- 
culty. It  is  dependent,  in  part  at  least,  upon  obstinate  subacute  gas- 
tritis, and  I  have  quite  recently  seen  an  instance  of  the  sort  verified  by 
autopsy.  Among  many  drugs  tested  in  this  case,  opium  alone  gave 
relief.  Usually  the  pain  results  from  gaseous  distention  of  the  stomach 
and  bowels,  and  is  not  intense,  a  mild  laxative  frequently  bringing 
relief.  Should  this  fail,  however,  trial  should  be  made  of  the  carmin- 
atives in  combination  with  some  antiseptic  agent,  as  salol  or  creosote. 

(7)  Gastric  Symptoms. — Soon  after  compensation  is  broken  the  ap- 


634  DISEASES   OF  THE  CIRCULATORY  SYSTE^f. 

pearance  of  mild  symptoms  of  catarrh  of  the  stomach  may  be  said  to 
be  the  rule,  and  these  yield  to  simple  measures  in  addition  to  the  cardiac 
stimulants  and  laxatives  already  indicated.  But  there  are  not  a  few 
instances  in  which  such  symptoms  as  gastric  distress  and  uneasiness, 
constant  nausea  with  frequent  vomiting,  particularly  after  food,  occur 
and  assume  a  distressing  phase.  Such  patients  cannot,  as  a  rule,  take 
digitalis  or  strophanthus  by  the  mouth ;  they  sometimes,  however,  do 
well  on  the  capsules  before  adduced  composed  of  strychnin,  spartein, 
and  caffein.  When  the  latter  cannot  be  borne  I  employ  hypodermically 
digitalin  and  strychnin  or  caifein  citrate,  the  latter  being  made  soluble 
bv  the  addition'  of  sodium  benzoate  in  solution.  Cases  of  this  class 
reach  an  early  fatal  termination,  as  a  rule.  The  symptoms  may  be 
partly  due  to  gastric  catarrh  coupled  with  hepatic  engorgement,  and 
partly  to  uremic  intoxication. 

(8)  Nervom  Symptoms. — Insomnia  and  internal  restlessness  are 
almost  constantlv  present  at  some  period  in  the  course  of  heart-disease, 
and  notably  in  the  more  advanced  stages.  The  restiveness  is  rendered 
more  distressing  on  account  of  hideous  dreams  and  cardiac  palpitation 
on  awaking.  For  these  phenomena  stimulation  often  answers  a  better 
purpose  than  sedation.  Hoffman's  anodyne  (3J — i-0 — well  diluted), 
spirits  of  chloroform  (TTLxv — 0.999),  or  ether  (sss — 2.0),  taken  in  whis- 
key (5j — 32.0)  are  serviceable.  The  elixir  of  ammonium  valerianate  is 
also  of  value  when  given  in  full  doses.  I  formerly  employed  sulfonal  in 
combination  with  camphor  monobromate  when  a  hypnotic  was  required 
to  afford  sleep.  Recently,  the  use  of  trional  (grs.  xv)  in  combination 
with  sodium  bromid  (grs.  xx)  was  found  more  satisfactory.  Paralde- 
hvd  and  chloralamid  are  among  the  remedies  of  choice  in  the  treat- 
ment of  this  symptom,  but  I  have  had  no  experience  with  their  employ- 
ment. 

In  the  later  stages  there  is  no  objection  to  the  use  of  morphin  hypo- 
dermicallv.  Headache  due  to  uremia  may  frecjuently  be  a  troublesome 
symptom  in  connection  with  sleeplessness,  and  in  such  cases  morphin  is 
the  remedy  par  excellence ;  it  is  to  be  supplemented  by  free  purgation 
and  cardiac  stimulants.  Should  the  right  heart  be  found  flagging, 
venesection   may  be  practised. 

(9)  ]Jrops<y. — Among  the  symptoms  requiring  special  treatment  in 
advanced  valvular  disease  drop.sy  easily  assumes  the  lead.  As  above 
pointed  out,  rest  with  attention  to  the  diet  and  state  of  the  bowels  will 
often  restore  defective  compensation  even  when  accompanied  by  a  mod- 
erate degree  of  dropsy.  In  the  severe  grades  of  failure  of  the  balancing 
forces  the  cardiac  stimulants  and  purgatives  before  mentioned  often 
suffice  to  remove  the  dropsy  for  a  considerable  period  of  time.  Later, 
however,  it  becomes  obstinate,  and  refuses  to  yield  to  any  of  the  known 
methods  of  treatment.  The  therapeutic  indications,  so  far  as  the  symp- 
tom under  consideration  is  concerned,  are  for  the  use  of  diuretics  and 
purgatives.  Diaphoretics,  particularly  the  hot-air  and  vapor  baths,  are 
not  to  be  thought  of,  since  they  tend  to  depress  the  already  weakened 
heart.  While  describing  the  action  of  digitalis  as  a  cardiac  stimulant, 
inci<lental  allusion  was  also  made  to  its  action  as  a  diuretic.  In  view 
of  the  fact  that  it  raises  the  blood-pressure  in  the  peripheral  vessels  and 
capillaries  by   contracting  their   walls,  and  because  of  its  stimulating 


CHRONIC  VALVULAR  DISEASE.  635 

effect  on  the  heart,  digitalis  in  large  doses  becomes  a  most  efficient  diu- 
retic in  cardiac  dropsy.  When  the  renal  secretion  is  not  free -under  its 
use,  or  when  for  some  good  reason  it  cannot  be  taken,  I  have  frequently 
found  that  a  combination  of  strychnin,  spartein,  and  caffein  {vide  supra) 
will  excite  free  diuresis.  Nitroglycerin  may  also  be  prescribed,  espe- 
cially in  cases  presenting  evidences  of  advanced  arterio-sclerosis.  An 
unirritating  yet  highly  effective  diuretic  mixture  in  these  cases  is  the 
following : 

^.  Potassii  acetatis,  3J    (4.0) ; 

Inf.  digitalis,  gij  (64.0).— M. 

Sig.  5ss  (16.0)  every  three  hours. 
Purgatives  are  of  the  utmost  value.  Frequently,  after  a  few  copious 
watery  evacuations  as  the  result  of  the  action  of  hydragogue  cathartics, 
a  free  discharge  of  urine  can  be  established,  when  before  the  latter  event 
it  has  been  impossible.  Salines  and  elaterium,  with  podophyllin  and 
belladonna,  are  agents  that  have  been  already  recommended  as  purga- 
tives (to  deplete  the  venous  system),  and  these  should  be  first  employed 
in  the  order  named.  Compound  jalap  powder  may  also  be  combined 
with  the  elaterium.  A  course  of  calomel,  followed  by  salines  until  free 
catharsis  is  set  up,  is  valuable  from  time  to  time.  Mercury  is  especially 
applicable  when  the  liver  is  much  enlarged  and  ascites  is  a  marked  fea- 
ture, or  when  the  history  of  syphilitic  infection  is  obtainable.  It  may 
be  combined  with  cardiac  stimulants  and  other  diuretics  as  follows: 
^.  Pulv.  digitalis, 

Pulv.  scillse,  aa.  gr.  xij     (0.777); 

Hydrarg.  mass.,  gr.  xxiv  (1.555); 

Ext.  bellilllonnse,  gr.  ss       (0.0324). 

M.  et  ft.  pil.  No.  xij. 
Sig.   One  every  three  or  four  hours. 

When  efforts  at  relieving  the  dropsy  by  means  of  medicines  fail,  then 
the  most  dependent  parts  of  the  body,  or  those  most  swollen,  should  be 
scarified  under  strict  aseptic  precautions.  Fine  silver  trocars  with 
rubber  tubes  attached  (Southey's  tubes)  may  be  inserted  and  the  liquid 
allowed  to  drain  off  in  a  gradual  manner. 

Means  to  Prevent  Recurrence  of  Broken  Compe^isation. — When  the 
compensation  has  been  successfully  established,  the  after-treatment  must 
be  prosecuted  with  vigor  for  at  least  a  year.  The  cause  of  the  rupture 
of  compensation  is  most  probably  fibroid  and  fatty  degeneration  of  the 
cardiac  muscle,  and  hence  the  mere  restoration  of  the  compensatory 
power  of  the  heart  does  not  imply  a  complete  cure  of  the  impaired  mus- 
cular structure  of  that  organ.  Much  can  be  done,  however,  to  overcome 
the  tendency  to  degeneration  by  the  peristent  use  of  hematinics  and 
other  tonics,  as  cod-liver  oil  and  mercuric  chlorid,  the  latter  in  small 
doses.  I  have  obtained  excellent  results  from  the  use  of  the  followino; 
prescription  m  these  cases  : 

^,.  Liq.  arsenici  chlor.,        TTLxlviij  (3.186); 

Tinct.  ferri  chlor.,  gss  (16.0); 

Hydrarg.  bichloridi,       gr.  ss      (0.0324); 

Glycerini,  q.  s.  ad  faiij         (96.0). — M. 

Sig.  3j  (4.0)  after  each  meal,  well  diluted. 


636  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

This  preparation  may  be  taken  indefinitely  with  occasional  brief  inter- 
ruptions. .  The  patient  should  lead  a  very  quiet  life,  and  follow  rigidly 
all  hygienic  rules  that  tend  to  prevent  the  production  of  valvular  disease. 
Appropriate  diet,  it  should  be  emphasized,  is  not  inferior  to  appropriate 
medication  in  its  salutary  effect.  Should  the  faintest  evidence  of  failure 
of  the  right  ventricle  manifest  itself,  the  patient  must  be  put  to  bed 
immediately,  and  the  foregoing  treatment  is  to  be  carried  out.  I  am 
inclined  to'the  view  that  the  plan  herein  advocated  not  only  renders  the 
course  of  recurring  attacks  of  failing  compensation  milder,  but  that,  in 
a  considerable  proportion  of  the  cases,  the  much-dreaded  recurrence  is 
thus  prevented. 


CARDIAC  THROMBOSIS. 

Pathology. — True  cardiac  thrombi  are  seen  most  frequently  on  the 
right  side  of  the  heart,  in  the  auricular  appendices,  and,  less  commonly, 
in  the  right  ventricle  near  the  apex.  They  are  of  firm  consistence,  and 
are  tightly  adherent  to  the  endocardium,  considerable  force  being  re- 
(juired  to  dislodge  them.  The  color,  while  generally  grayish-brown  or 
red,  varies  with  the  age  of  the  thrombus,  being  more  colorless  as  it  be- 
comes older.  Cardiac  thrombi  may  be  pedunculated  or  sessile,  and  their 
contour  is,  as  a  rule,  more  or  less  rounded.  Recklinghausen  and  others 
have  observed  globular  masses,  the  so-called  "  i>all-thrombi,"'  in  the  auri- 
cles, without  the  slightest  endocardial  attachment.  They  vary  greatly 
in  size,  from  a  mustard-seed  to  a  hen's  egg,  and  sometimes  exhibit  cal- 
careous degeneration.  Cardiac  thrombi  may  occur  singly  or  in  groups 
of  considerable  numbers.  From  the  cavity  in  which  they  have  their 
primary  seat  they  may  project  into  other  chambers  of  the  heart,  or  from 
the  left  ventricle  into  the  aorta  for  a  considerable  distance.  It  is  evi- 
dent that  fragments  detached  by  the  blood-stream  from  these  cardiac 
blood-concretions  will  tend  to  lodge  in  various  viscera  and  in  the  per- 
ipheral tissues,  and  set  up  embolic  processes.  Examined  microscopically, 
degenerate  round  cells  and  detritus  are  revealed,  but  pus-cells  are  not 
seen.  Secondary  degenerative  changes,  and  later  softening,  may  take 
place  in  the  central  portions  of  a  thrombus,  and  these  areas  may  contain 
a  reddish-brown  licjuid. 

Htiology. — The  causes  of  cardiac  thrombosis  are  to  be  found  chiefly 
in  some  previously  diseased  or  injured  condition  of  the  endocardium, 
though  sometimes  alterations  of  the  blood  constitute  a  factor  of  consid- 
erable importance.  The  condition  may  occur  in  the  course  of  both 
acute  and  chronic  diseases,  in  which  the  intracardiac  conditions  favor 
the  formation  of  a  blood-clot.  Hence  it  is  seen  in  connection  witli 
organic  diseases  of  the  heart  in  which  the  valvular  and  often  the  mural 
endocardium  are  roughened,  and  the  obstructive  and  regurgitant  lesions 
at  the  various  valves  cause  retardation  in  the  blood-current.  Chronic 
obstruction  in  the  lungs  may  contribute  to  the  result  by  slowing  the  cir- 
culation in  the  heart.     Cardiac  thrombosis  has  been  observed  in  many 


CARDIAC  THROMBOSIS.  637 

of  the  acute  affections,  and  almost  invariably  there  is  a  loss  of  endocar- 
dium, due  to  inflammatory  action  (endocarditis)  at  some  point  in  the 
cavities  of  the  heart.  This  becomes  the  seat  of  the  fibrinous  deposit 
which  is  subsequently  imperfectly  organized.  Among  the  most  import- 
ant of  these  acute  primary  diseases  are  rheumatism,  dijjJitJieria,  lobar 
pneiunonia,  and  pyemic  and  lyuerijeral  conditions.  It  may  be  questioned 
whether,  given  a  healthy  endocardium,  as  contended  by  some  writers, 
slowing;  of  the  circulation  alone  suffices  to  cause  true  cardiac  thrombi. 

Sytnptoms. — These  will  depend  very  much  upon  the  rapidity  with 
which  the  thrombus  is  formed,  as  well  as  upon  its  seat  and  dimensions. 
Thrombi  invariably  lack  definiteness,  and,  as  their  effects  are  largely 
mechanical,  signs  of  obstruction  to  the  cardiac  circulation  and  failure 
(more  or  less  gradual)  of  the  cardiac  muscle  are  developed.  The  pulse 
becomes  weak,  rapid,  and  irregular  ;  dyspnea,  vertigo,  and  attacks  of 
syncope  are  frequent;  and  later  cyayiosis  may  appear.  It  is  probable 
that  at  times  the  liquefied  products  of  a  clot  may  be  absorbed,  producing 
blood-poisoning.  When  the  thrombus  is  formed  rapidly  the  symptoms 
are  suddenly  developed  and  the  course  is  rapid.  Rarely  a  valvular  ori- 
fice, an  efferent  vessel,  or  the  coronary  artery  may  become  blocked  and 
instant  death  folloAv.  Since  the  right  heart  is  the  most  frequent  seat 
of  these  thrombi,  pulmonary  embolism,  attended  with  its  usual  symp- 
toms, is  a  common  event.  When  portions  of  a  clot  are  broken  off  and 
swept  into  the  systemic  circulation,  the  clinical  phenomena  of  cerebral, 
splenic,  or  renal  embolism  are  exhibited. 

The  physical  signs  consist  of  a  feeble  impulse  with  marked  arrhyth- 
mia ;  the  area  of  dulness  is  somewhat  increased  to  the  right,  and  often 
upward  ;  and  the  heart-sounds  are  greatly  enfeebled  and  quite  irregular, 
with  marked  change  in  any  murmurs  that  may  previously  have  been 
audible.     A  systolic  pulmonary  murmur  may  rarely  be  engendered. 

Differential  Diagnosis. — It  is  important  to  distinguish  true  car- 
diac thrombi,  such  as  are  above  described,  from  the  less  dense  and  usu- 
ally darker  clots  that  are  formed  either  immediately  before  or  after 
death.  .  The  latter  may  seldom  show  an  attempt  at  a  very  low  grade  of 
organization,  and  may  present  a  somewhat  decolorized  appearance,  but 
they  do  not  adhere  firmly  to  the  endocardium.  Moreover,  antemortem 
and  postmortem  clots,  as  the  latter  may  be  appropriately  termed,  have  a 
different  causation  from  true  thrombi.  For  instance,  they  are  apt  to 
form  in  diseases  in  which  the  fibrin-factors  of  the  blood  are  greatly 
increased,  as  in  pneumonia.  Perhaps  a  more  potent  causal  element  is 
the  progressive  weakening  of  the  heart-muscle,  resulting  in  partial  ex- 
pulsion of  the  contents  of  the  right  ventricle;  the  blood  that  remains 
in  the  chamber  is  merely  whipped  up,  and  the  deposition  of  its  fibrin 
must  thus  be  greatly  favored.  Such  heart-clots  may  be  generated  if  the 
endocardium  be  healthy,  and  cannot  be  separated  positively  from  true 
cardiac  thrombi  by  clinical  observation. 

The  prognosis  is  uniformly  bad  and  sudden  death  may  be  expected. 

Treatment. — Beyond  measures  calculated  to  meet  the  symptomatic 
indications  nothing;  can  be  sugfgested. 


638  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

HYPERTROPHY  OF  THE  HEART. 

[Hypertrophia  Cordis.) 

Definition. — Hypertrophy  is  an  increase  in  the  muscular  structure 
of  the  heart,  evidenced  usually  by  an  increased  thickness  of  its  walls. 
It  is  almost  invariably   associated  with   dilatation   of  the  chambers. 

Pathology. — When  the  two  processes — hypertrophy  and  dilatation 
— coexist,  they  cause  great  enlargement  of  the  organ.  To  this  condition 
the  term  ^'■eccentric  hypertrophy'''  has  been  given.  Hypertrophy  with- 
out dilatation  receives  the  name  "  simple  hypertrophy,"  and  hypertrophy 
with  diminution  in  the  size  of  the  cavities  was  formerly  described  as 
^'■concentric  hypertrophy,"  but  this  term  should  now  be  regarded  as  ob- 
solete, inasmuch  as  the  condition  is  due  to  postmortem  contraction  of 
the  ventricles. 

The  increase  in  size  may  affect  either  the  whole  heart,  one  chamber 
on  either  side,  one  whole  side,  or  but  a  single  cavity  {^general  and  partial 
]iypertrop>hy).  The  process  may  also  be  limited  to  a  minute  division  of 
the  heart  {circumscribed  hypertrophy).  Owing  to  its  important  physio- 
logic function  the  left  ventricle  is  more  fre(i[uently  enlarged  than  the 
right,  and  oppositely  the  right  auricle  is  more  frequently  involved  than 
the  left.  The  loeiyht  of  the  normal  heart  in  a  man  of  average  size  is 
approximately  9  ounces  (255.0);  in  a  woman  it  is  8  ounces  (226.0).  In 
bilateral  hypertrophy,  however,  the  weight  of  the  heart  may  be  greatly 
increased  ;  hearts  weighing  from  15  to  25  ounces  (425.0-710.0)  are  seen 
in  moderate  grades  of  hypertrophy,  and  those  from  40  to  50  ounces 
(1134.0-1420.0)  in  extreme  cases  {cor  bovinum).  Measurements  show- 
ing the  thickness  of  the  walls  also  indicate  the  degree  of  hypertrophy  ^ 
and  the  exact  scat  of  the  enlargement  when  not  general.  The  normal 
diameter  of  the  left  ventricular  wall  is  from  8  to  12  mm.  {\—^  in.) ;  that 
of  the  right  ventricle,  from  5  to  7  mm.  {\-\  in.) ;  that  of  the  left  auri- 
cle, about  3  (1  in.),  and  of  the  right,  2  mm.  (^  in.).  Suffice  it  to  state 
in  this  connection  that  under  conditions  of  cardiac  hypertrophy  the 
normal  thickness  of  the  various  cavity-walls  is  usually  doubled,  not  in- 
frequently trebled,  and,  rarely,  even  quadrupled.  In  cases  in  which 
there  is  a  concomitant  dilatation  the  walls  may  appear  thinned,  while 
the  measurement  will  show  them  to  be  in  reality  thickened. 

The  shape  of  the  heart  is  also  altered  according  to  the  seat  and  ex- 
tent of  the  hypertrophy.  If  both  ventricles  are  enlarged,  the  apex  is 
widened  and  appears  flattened  ;  if  only  the  left  ventricle  is  involved, 
the  apex  is  lengthened  and  is  more  or  less  pear-shaped  ;  and  if  the 
right  ventricle  alone  is  hypertrophied  (as  in  mitral  stenosis),  it  may  form 
the  largest  part  of  the  apex,  Avhich  Avill  be  less  conical  than  in  health. 

The  papillary  muscles  and  columns  carnete  are  greatly  thickened, 
and,  particularly  in  the  eccentric  form  of  hypertrophy,  they  are  often 
decidedly  flattened.  In  this  form  the  septum  fretjuently  shows  increased 
thickness — a  condition  that  I  have  never  observed  in  simple  hypertrophy. 
The  muscular  trabeculne  generally  assume  greater  prominence  on  the 
right  than  on  the  left  side.     The  muscular  structure  is  usually  of  a 

'  Measurements  should  not  be  attempted  until  the  rigor  mortis  has  been  overcome  bv 
soaking  the  organ  in  water. 


HYPERTROPHY   OF  THE  HEART.  639 

deeper  red  color  and  also  firmer  than  normally.  The  hypertrophied 
left  ventricle  can,  as  a  rule,  be  lacerated  readily,  while  the  right,  as  first 
pointed  out  by  Rokitansky,  may  be  tough  and  leathery.  As  the  heart 
continues  to  enlarge  it  sinks  lower  in  the  chest-cavity ;  this  is  not, 
however,  owing  to  an  increase  in  size  alone,  but  more  particularly  to  an 
increase  in  weight.  In  hypertrophy  of  the  heart  there  is  a  multiplica- 
tion of  muscular  fibers,  to  which  alone  the  enlargement  of  its  walls  is 
attributable. 

Ktiology. — Hypertrophy  of  the  left  ventricle  (sometimes  termed 
general  hypertrophy)  results  from  obstructions  to  the  arterial  circula- 
tion of  whatever  sort.  These  may  be  classified,  according  to  their  seat, 
into — (1)  Lesions  of  the  Heart. — (a)  Aortic  incompetency  and  aortic 
stenosis  ;  {h)  Mitral  insufficiency  ;  {c)  The  fibroid  form  of  myocarditis ; 
((i)  Pericardial  adhesions,  particularly  in  the  young.  Late  in  life  the 
heart  may  become  atrophied.  In  such  cases  the  adherent  pericardium 
exerts  a  counter-traction  force  during  the  systole,  and  thus  the  work  is 
increased  beyond  the  capacity  of  the  normal  heart,  with  consequent 
hypertrophy.  In  valvular  disease  the  augmented  tension  in  the  ven- 
tricle induces  the  hypertrophy. 

(2)  Abnormal  Conditions  of  the  Blood-vessels. — (a)  Narrowing  of  the 
aorta — e.  g.  congenital  stenosis,  external  pressure,  and  the  development 
of  an  aneurysm  ;  (5)  General  arterio-sclerosis,  by  raising  the  pressure  ;  {c) 
Increased  arterial  pressure,  due  to.  contraction  of  the  peripheral  vessels 
in  consequence  of  the  local  action  of  certain  chemical  and  biologic  irri- 
tants (lead,  Bright's  disease,  gout,  syphilis).  Hassenfeld  ^  has  recently 
shown  that  hypertrophy  of  the  left  ventricle  occurs  only  when  the  vis- 
ceral arteries  exhibit  an  extreme  degree  of  sclerosis,  or  when  the 
thoracic  aorta  is  sclerotic.  In  cases  of  pure  contracted  kidney  all  the 
chambers  of  the  heart  are  hypertrophied  ;  but  when  extreme  arterio- 
sclerosis is  present  also  the  left  ventricle  is  disproportionately  enlarged. 
In  all  of  these  cases,  whether  the  blood-pressure  is  raised  in  larger  or 
smaller  vessels,  increased  cardiac  action  is  essential  to  meet  the  demands 
of  the  system-circulation. 

Attention  should  be  called  to  the  causes  of  the  so-called  "  primary  idio- 
pathichypertrophy."  The  main  causal  conditions  are — (1)  Prolonged  physi- 
cal exertion,  as  in  certain  occupations  (blacksmiths,  locksmiths,  dray- 
men, and  athletes).  (2)  Constant  over-distention  of  blood-vessels,  as  in 
the  case  of  excessive  beer-drinkers  (beer-heart).  Here  the  direct  action 
of  the  alcohol  upon  the  heart-muscle  must  also  be  taken  into  account. 
(3)  Functional  disturbances  (neuroses),  constant  over-action  of  the  heart, 
and  even  paroxysmal  tachycardia,  tea,  coff'ee,  and  alcohol  may  give  rise 
to  primary  and  general  hypertrophy.  Idiopathic  hypertrophy  of  the 
heart  is  undoubtedly  due  to  increased  activity,  which  may  be  due  to  a 
variety  of  irritating  influences  acting  upon  the  heart-muscle  (De  Domen- 
icis  ^).  Excessive  bicycling  causes  hypertrophy,  particularly  if  arterio- 
sclerosis exists.  Primary  congenital  hypertrophy  of  the  heart  is  attribu- 
table either  to  circulatory  disturbance  (Simmonds  ^)  or,  as  Virchow 
holds,  to  a  diffuse  myomatous  neoplasia  of  congenital  origin. 

Hypertrophy  of  the  right  ventricle  develops  secondarily  to  any  condi- 
tion that  offers  obstruction  to  the  pulmonary  circulation  or  to  the  blood- 

1  Deutsch.  Arch.f.  Min.  Med.,  Dec.  9,  1897  ;  Phila.  Med.  Jom-n.,  Jan.  22,  1898. 

^  Wien.  Min.  WocL,  May  22,  1897.       =*  Munchener  med.   WocL,  1899,  No.  4,  S.  108. 


640  DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

current  through  the  right  ventricle.  Among  them  may  be  mentioned — 
(1)  mitral  incompetency  and  stenosis ;  (2)  emphysema,  bronchitis,  col- 
lapse of  a  portion  of  the  lung,  contraction  of  a  lung  from  pleural  ad- 
hesions, and  cirrhosis  of  the  lung  ;  (3)  right-sided  valvular  lesions,  par- 
ticularly obstruction  at  the  pulmonary  orifice  ;  (4)  it  is  doubtful  whether, 
on  account  of  the  normal  situation  of  the  right  ventricle,  pericardial 
adhesions  induce  hypertrophy  of  this  chamber. 

Hypertrophy  of  the  Auricles. — Hypertrophy  with  dominant  dilatation 
of  the  left  auricle  occurs  in  mitral  disease,  and  especially  in  mitral  ste- 
nosis. The  right  auricle  hypertrophies,  though  not  invariably,  when  the 
blood-pressure  in  the  pulmonary  vessels  is  pronounced  from  any  cause. 
Stenosis  of  the  tricuspid  orifice  is  occasionally  the  sole  cause  of  thicken- 
ing of  the  right  auricular  wall,  which  also  becomes  hypertrophied  in  tri- 
cuspid incompetency. 

Symptoms. — There  is  usually  an  entire  absence  of  subjective  symp- 
toms when  compensation  is  efficient.  When  present,  their  intensity 
varies  with  the  degree  of  the  hypertrophy,  which  is  then  pronounced, 
as  a  rule,  and  often  already  attended  by  incipient  dilatation.  They 
may  be  local  entirely,  though  frequently  general  as  Avell.  Of  the  former, 
precordial  discomfort  and  uneasiness  from  the  violence  of  the  impulse 
occur.  They  are  most  annoying  when  the  patient  is  in  the  recumbent 
posture  on  the  left  side  and  when  the  hypertrophy  is  dependent  upon 
nervous  causes.  Pain  and  palpitation  are  seldom  complained  of  except 
by  neurasthenics  and  patients  suffering  from  enlargement  due  to  tobacco 
or  excessive  muscular  exertion.  Decided  aggravations  of  the  local  mani- 
festations may  follow  the  operation  of  influences  that  create  a  demand 
for  increased  cardiac  action,  such  as  undue  mental  emotion  or  excite- 
ment, physical  exhaustion,  active  bodily  exercise,  and  gourmandizing. 

The  general  symptoms,  when  present,  may  fluctuate  or  even  intermit. 
Those  most  frequently  observed  are  fulness  in  the  head,  often  amounting 
to  actual  headache.,  tinnitus  aurium,  carotid  pulsations,  flushing  of  the 
face,  flashing  of  light  before  the  eyes,  and  often  prominent  eyeballs.  These 
symptoms  are  attributable  to  the  increased  \ngor  of  the  cerebral  circulation. 

Remote  Effects. — General  or  total  hypertrophy  promotes  high  ten- 
sion throughout  the  arterial  tree.  Endarteritis  and  arterio-sclerosis  are, 
as  a  conseijuence,  frequent  consentaneous  developments  in  advanced 
cases,  especially  when  the  cause  of  the  enlargement  has  been  increased 
tension  in  the  peripheral  vessels,  as  in  Bright's  disease.  With  a  circu- 
lation too  forcibly  carried  on,  as  in  hypertrophy,  the  sclerotic  vessels 
are  overstrained,  and  are  apt  to  rupture.  The  break  often  occurs  in  the 
brain  {apoplexy)  or  in  the  lung  {pulmomary  apoplexy),  and  hemorrhage 
from  the  lung  (hemoptysis),  due  to  left  ventricular  hypertrophy,  is  more 
common.  I  believe,  than  is  supposed.  Some  of  the  symptoms  are  due  to 
the  cause  or  causes  of  the  hypertrophy. 

Physical  Signs  in  Left-sided  Hypertrophy. — Inspection. — In  females 
and  in  childrL'n  with  soft,  yielding  ribs  there  is  visible  bulging.  The 
intercostal  spaces  are  much  broadened  and  the  apex-beat  covers  an  in- 
creased area,  the  extension  being  downward  and  to  the  left.  The  whole 
body  of  the  patient,  and  even  the  bed  on  which  he  may  be  lying,  may 
share  visibly  in  the  cardiac  impulse. 

Palpation. — In  pronounced  grades  the  impulse  may  be  felt  as  low 


HYPERTROPHY  OF  THE  HEART.  641 

down  as  the  seventh  interspace  and  as  far  to  the  left  as  the  axilla.  In 
simple  hypertrophy  it  is  carried  downAvard  to  the  sixth  intercostal  space 
and  outward  to  a  point  near  the  anterior  axillary  line.  The  impulse  is 
sloAv,  forcible,  and  heaving,  the  "thrust"  lifting  the  fingers  of  the  ex- 
aminer. In  eccentric  hypertrophy  (hypertrophy  with  dilatation),  though 
heaving  and  forcible,  it  is  someAvhat  more  abrupt,  as  in  cardiac  dilata- 
tion. Over  the  aortic  orifice  a  short  diastolic  impulse  may  also  be  felt 
occasionally  (double  impulse).  Pressing  the  fingers  into  the  second  and 
third  right  spaces  will  detect  an  impulse  if  the  aorta  be  dilated.  The 
pulse  in  pure  hypertrophy  is  full,  strong,  regular,  and  of  normal  rate  ; 
it  is  also  prolonged,  owing  to  increased  tension.  In  eccentric  hyper- 
trophy it  is  more  abrupt,  soft,  full,  and  somewhat  accelerated. 

Percussion. — This  defines. only  approximately  the  degree  of  enlarge- 
ment, as  the  hypertrophy  may  take  a  backward  direction  or  there  may 
be  more  than  the  usual  overlapping  of  the  heart  by  the  lung.  Traced 
upward,  dulness  may  terminate  in  the  second  interspace,  Avhilst  to  the 
left  it  may  extend  1  or  2  inches  (2.5-5  cm.)  beyond  the  mid-clavicular 
line.  When  hypertrophy  is  of  moderate  extent  the  left  limit  of  dulness 
corresponds  with  the  results  of  palpation  and  inspection ;  but  when  it 
is  of  immoderate  extent  the  extension  of  dulness  does  not  keep  pace 
with  the  systolic  impulse,  which  is  diffused  to  points  beyond  the  limits 
of  contact  of  the  heart  with  the  thoracic  wall.  If  concomitant  hyper- 
trophy of  the  right  ventricle  be  present,  dulness  will  also  extend  to  the 
right  {vide  infra). 

Auscultation. — The  sounds  vary  with  the  grade  of  the  morbid  proc- 
ess and  the  variety.  In  simple  hypertrophy  of  marked  type  a  pro- 
longation of  the  first  sound  is  always  appreciable,  and  usually  it  is 
duller  than  the  normal.  The  second  sound  (aortic)  is  intensified,  clear,  and 
often  ringing.  The  degree  of  accentuation  depends  partly  upon  the 
vigor  of  the  left  ventricle,  though  chiefly  upon  the  condition  of  the 
blood-vessels.  Reduplication  of  the  second  sound,  due  to  high  tension, 
is  common  (e.  g.  in  Bright's  disease).  The  first  sound  may  also  be  du- 
plicated. In  dilated  hypertrophy  the  first  sound  is  clearer  and  more 
abrupt,  while  the  second  is  less  marked  or  even  faint.  Modification  of 
these  sounds  occurs  when  hypertrophy  is  due  to  chronic  valvular  disease. 

Hypertrophy  of  the  Right  Ventricle. — One  or  more  of  the  causal  fac- 
tors that  produce  augmented  tension  in  the  pulmonary  vessels  are  pres- 
ent, and,  if  properly  appreciated,  Avill  throw  light  upon  the  condition. 
There  may  be  an  absence  of  all  symptoms  if  the  hypertrophy  exactly 
balances  the  result  of  the  obstructive  forces,  and  this  state  may  be  main- 
tained for  a  long  period  of  time.  Undue  exertion,  how^ever,  soon  leads 
to  temporary  dyspnea  in  many  cases.  When  secondary  to  emphysema 
or  cirrhosis  of  the  lung  the  symptoms  occasioned  by  the  latter  diseases, 
such  as  cough  and  dyspnea,  may  completely  veil  any  symptoms  that 
may  be  due  to  the  hypertrophy.  Discomfort  in  the  cardiac  region 
should,  however,  arouse  suspicions  of  the  existence  of  the  latter  con- 
dition. When  dilatation  of  the  ventricle  supervenes,  as  is  usual,  and 
the  clinical  evidences  of  tricuspid  incompetency  develop,  then  pulmo- 
nary symptoms,  due  to  venous  congestion,  are  prominent ;  these  are 
bronchial  catarrh,  shortness  of  breath,  and  the  like.  Later,  general 
cyanosis  and  edema  appear.     As  pointed  out  in  the  discussion  of  Mitral 

41 


642  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Stenosis  with  permanently  heightened  tension  and  overgrowth  of  the 
right  ventricle,  the  lung-vessels  become  atheromatous  and  the  lung- 
tissue  the  seat  of  brown  induration.  Owing  to  the  fact  that  the  scle- 
rotic vessels  are  easily  ruptured,  hemoptysis — a  not  uncommon  event 
after  sudden  great  exertion — is  to  be  expected ;  intense  pulmonary 
congestion  and  apoplexy  may  also  be  met  with  in  hypertrophy  with 
dominant  dilatation. 

Physical  Signs. — These  have  been  in  the  main  detailed  in  speaking 
of  aflfections  of  the  mitral  valve.  Inspection  discloses  bulging  of  the 
sixth  and  seventh  left  costal  cartilages  and  of  the  lower  sternum.  In 
the  angle  between  the  ensiform  cartilage  and  the  seventh  rib  an  epigas- 
tric impulse  may  be  visible,  but  more  commonly  the  impulse  is  in  the 
sixth  interspace,  close  to  the  left  edge  of  the  sternum.  It  is  also  very 
generally  seen  to  the  right  of  the  sternum,  in  the  third  and  fourth 
interspaces,  and  particularly  is  this  the  case  in  eccentric  hypertrophy, 
forming  a  highly  characteristic  sign.  The  apex-beat  is  therefore  diffuse, 
the  radial  pulse  is  small,  and  in  dilated  hypertrophy  it  is  increased  in 
frequency,  and  is  small,  unsustained,  and  irregular. 

Percussion  shows  the  extension  of  cardiac  dulness  to  a  point  an  inch 
(2.5  cm.)  or  more  beyond  the  right  sternal  border.  When  there  is  great 
increase  transversely,  dilatation  is  most  probably  associated  and  may 
predominate  over  hypertrophy.  The  auscidtatori/  signs  are  not  distinct- 
ive unless  dilatation  also  exists,  when  the  first  sounds  ai'e  clear  and 
sharp.  In  simple  hypertrophy  the  first  sound  is  slightly  prolonged  and 
lower  than  in  health.  Owing  to  the  high  vascular  tension  throughout 
the  lungs  the  second  sound  at  the  pulmonary  valve  is  accentuated,  and 
reduplication  of  the  second  sound  may  occur  for  the  same  reason. 

It  must  be  kept  in  remembrance  that  w^hen  advanced  emphysema  is 
present  all  the  physical  signs  will  be  greatly  modified,  and  may  even  be 
entirely  negative,  though  the  heart  be  of  large  size.  Under  these  cir- 
cumstances venous  pulsation  in  the  neck  would  be  diagnostic  of  dilated 
hypertrophy  of  the  right  ventricle. 

Hypertrophy  of  the  Left  Auricle. — This  may  be  assumed  to  occur  in 
mitral  stenosis  and  incompetency  in  order  to  compensate  for  these 
lesions  :  it  cannot,  however,  be  recognized  positively  by  physical  signs. 
When  the  chamber  is  at  the  same  time  extensively  dilated,  the  dulness 
may  be  extended  upward  to  the  left  of  the  sternum,  passing  over  the 
third  and  even  second  interspaces.  At  this  point — the  second  inter- 
space— a  presystolic  wave  may  now  be  noticeable. 

Hypertrophy  of  the  right  auricle,  associated  with  dilatation,  is  per- 
haps more  common  than  its  counterpart  on  the  left  side.  It  is  secondary 
to  tricuspid  incompetency  (rarely  stenosis)  and  enlargement  of  the 
right  ventricle,  and  hence  has  the  same  etiology  as  the  latter  conditions. 

The  phi/sica!  sifpis  a,re — systolic  jugular-pulsation,  sometimes  a  pre- 
systolic wavy  pulsation  over  the  third  and  fourth  interspaces  to  the  right 
of  the  sternum,  extension  of  cardiac  dulness  to  the  same  interspaces, 
and  other  signs  of  tricuspid  regurgitation. 

Diagnosis. — The  recognition  of  cardiac  hypertrophy  is  possible 
only  by  attention  to  the  physical  signs.  Next  to  these,  in  point  of 
diagnostic  value,  come  the  causes,  which  should  therefore  be  diligently 
searched  for ;  the  rational  symptoms  are  least  in  value,  though  usually 


HYPEBTBOPHY  OF  THE  HEABT.  643 

corroborative.  It  is  difficult  to  establish  a  diagnosis,  even  approx- 
imately, wben  extensive  emphysema  coexists.  As  before  pointed  out, 
venous  pulsation  in  the  neck  would  point  indisputably  to  right  ventric- 
ule  enlargement. 

.  Diflferential  Diagnosis. — Conditions  that  cause  an  increase  in  the  pre- 
cordial area  of  dulness,  except  hypertrophy,  must  be  eliminated.  (1) 
Pericardial  Effusion. — A  careful  analysis  of  the  physical  signs  and  the 
history  will  suffice.  (2)  Aneurysm.— In  this  affection  the  enlargement 
is  altogether  upAvard  and  to  the  left  or  right.  This  fact,  joined  with 
the  other  evidences  of  aneurysm,  should  obviate  error.  (3)  Mediastinal 
growths  also  enlarge  the  dull  space  mainly  upward  and  to  the  right  or 
left,  though  the  point  of  cardiac  contact  may  be  increased  and  the  heart 
carried  forward.  (4)  Displacement  of  the  heart  does  not  give  a  heaving 
impulse  nor  an  increased  area  of  dulness ;  moreover,  it  usually  furnishes 
its  special  cause  (pleural  effusion).  (5)  Abnormally  narrow-chested 
persons  present  a  considerably  increased  superficial  zone  of  dulness, 
partly  owing  to  the  position  assumed  by  the  lungs  and  partly  (perhaps 
chiefly)  to  their  imperfect  development.  Since  there  is  usually  an 
entire  absence  of  all  other  physical  signs  of  hypertrophy,  ordinary 
caution  will  exclude  the  latter  complaint.  (6)  Affections  of  the  Lungs 
and  Pleurce. — Left-sided  pleurisy  with  retraction  may,  by  exposing  a 
large  part  of  the  anterior  surface  of  the  heart,  give  rise  to  signs  of 
moderate  hypertrophy.  The  presence  of  the  former  condition,  the  lack 
of  lung-expansion  on  deep  inspiration,  the  displacement  of  the  heart  to 
the  left  and  upward,  and  an  absence  of  the  causes  of  hypertrophy  should 
lead  to  a  correct  conclusion.  (7)  Phthisis  and  cirrhosis  of  the  lung.,  with 
or  without  pleurisy,  may  in  like  manner  produce  apparent  enlargement 
of  the  heart.  It  must  also  be  remembered  that  cirrhosis  of  the  lung  is 
one  of  the  causes  of  right-sided  hypertrophy,  and  that  the  latter  condi- 
tion may  therefore  be  present. 

Prognosis  and  Course. — The  course  that  will  be  pursued  depends 
largely  upon  the  stage  at  which  the  case  has  arrived  and  the  character 
of  its  special  cause.  I  have  repeatedly  found  postmortem  evidence  of  a 
moderate  grade  of  hypertrophy  in  persons  who  died  of  other  affections, 
and  with  especial  relative  frequency  in  those  who  had  constantlv  fol- 
lowed manual  pursuits.  Simple  cardiac  hypertrophy,  being  compensa- 
tory as  a  rule,  exerts  in  nearly  all  instances  a  salutary  influence,  and 
if  the  processes  that  constitute  the  causal  factors  are  not  steadily  pro- 
gressive, life  may  not  only  not  be  curtailed,  but  be  greatly  lengthened 
by  its  existence.  Even  in  organic  valvular  disease  of  the  heart  hyper- 
trophy prolongs  life  by  overcoming  the  ill  effects  of  the  valve-lesion 
and  by  maintaining  the  normal  circulatory  equilibrium.  But  since  in 
this  class  of  cases  the  lesion  is  progressive  despite  treatment,  a  limit  is 
reached  sooner  or  later  beyond  which  the  increased  vigor  on  the  part  of 
the  heart  cannot  be  maintained.  The  nutritive  functions  become  inade- 
quate in  obedience  to  a  natural  law,  and  muscular  degenerations  then 
occur,  followed  by  disturbances  of  the  circulation  due  to  cardiac  weak- 
ness and  secondary  dilatation.  It  must,  however,  be  recollected  that 
the  heart  may  at  no  time,  in  the  course  of  certain  cases,  fully  compen- 
sate for  the  causal  condition — e.  g.  as  when  a  valve  ruptures  with  start- 
ling suddenness.     Failure  of  the  cardiac  nutrition  at  once  renders  the 


644  DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

prognosis  unfaA^orable.  The  cardiac  sounds  now  give  notice  that  the 
hypertrophy  no  longer  meets  the  requirements  of  the  case.  The  sys- 
tolic pause  grows  longer  (with  abbreviation  of  the  first  sound),  and  the 
diastolic  shorter.  Occasionally,  as  the  result  of  undue  muscular  exer- 
cise, acute  dilatation,  followed  by  a  speedy  termination  of  life,  is 
observed.  I  believe  that  hypertrophy  of  the  left  ventricle  warrants  a 
more  favorable  prediction  than  can  be  made  in  hypertrophy  of  the  right, 
and  this  for  two  reasons  :  first,  the  increased  capacity  for  work  of  the 
left  ventricle ;  second,  the  milder  character  of  the  many  factors  that  are 
productive  of  left  ventricular  hypertrophy,  as  compared  with  those  of 
the  right.  In  special  instances,  however,  the  reverse  may  obtain,  as 
when  left-sided  hypertrophy  is  associated  with  or  caused  by  general 
arterial  degeneration.  It  may  be  of  advantage  to  the  student  and  junior 
physician  to  recapitulate  here  a  few  of  the  chief  points  that  are  prog- 
nostically  favorable  as  well  as  those  that  are  unfavorable :  Favorable 
Conditions. — (1)  When  the  hypertrophic  development  fully  compensates 
the  causal  lesion;  (2)  when  the  causes  are  removable  or  more  or  less 
amenable  to  treatment ;  (3)  when  the  external  conditions  under  which 
the  patient  lives,  his  habits,  and  general  nutrition  are  good.  Unfavor- 
able.— (1)  When  signs  of  imperfect  nutrition  of  the  heart  arise ;  (2) 
when  evidences  of  advancing  cardiac  dilatation  (dyspnea,  rapid,  irregular 
pulse,  edema)  show  themselves;  (3)  when  poverty,  poor  food,  intemperate 
habits,  and  an  unhygienic  environment  are  all  combined  ;  (4)  when  appar- 
ent cardiac  vigor  suddenly  gives  place  to  dilatation  and  great  cardiac 
weakness. 

The  treatment  lias  for  its  prime  objects  the  establishment  of  full, 
and  the  prevention  of  failure  of,  compensation  {vide  Chronic  Valvular 
Disease). 

Over-hypertrophy,  as  indicated  by  certain  cerebral  and  thoracic 
symptoms,  may  require  the  employment  of  measures  to  reduce  the  con- 
tractile energy  of  the  left  ventricle,  although  direct  cardiac  depressants 
(aconite,  and  the  like)  are  rarely  needed.  It  requires  careful  dietetic 
and  hygienic  management.  Briefly,  the  diet  should  be  nutritious,  but 
the  more  concentrated  forms  of  food  should  be  used  very  sparingly,  and 
the  daily  quantity  should  be  slightly  less  than  that  required  in  health. 
It  must  be  non-stimulating,  and  tea,  coff"ee,  alcohol  in  all  forms,  and 
smoking  must  be  prohibited.  The  physical  exercise  should  be  moderate 
in  amount  and  of  the  gentlest  sort ;  and  if  the  patient's  occupation  tends 
to  stimulate  the  heart,  it  must  be  immediately  abandoned.  A  mild 
saline  purge  (sij  to  5ss — 8.0  to  16.0 — of  Rochelle  salts  once  daily)  is 
quite  beneficial. 

For  relief  of  the  cerebral  symptoms  (tinnitus  aurium,  vertigo, 
fulness)  and  the  precordial  discomfort  the  physiologic  relaxants  of  the 
capillaries  and  the  arterioles  are  of  great  service,  particularly  when 
arterio-sclerosis  is  a  traceable  cause.  Among  them  nitroglycerin  in  full 
doses  and  veratrum  viride  are  most  useful :  the  efiicacy  of  both  may  often 
be  enhanced  by  the  addition  of  the  bromids.  In  cases  of  nervous  origin 
the  bromids,  with  preparations  of  valerian,  are  the  most  valuable  agents. 
Nothing,  however,  is  of  higher  importance  than  the  determination  and 
removal  of  the  cause  when  possible.  After  compensation  has  failed  the 
further  treatment  is  identical  with  that  of  cardiac  dilatation. 


DILATATION  OF  THE  HEART.  645 

DILATATION  OF  THE  HEART. 

Definition. — By  dilatation  of  the  heart  is  meant  an  enlargement  of 
its  various  cavities.  The  walls  of  the  chambers  may  in  consequence  be 
thinner  than  in  health,  but  much  more  commonly  they  are  thicker,  as  in 
dilatation  ivitJi  hypertrophy.  Both  hypertrophy  and  dilatation  are  rela- 
tive terms,  but  the  latter  has  reference  to  that  condition  in  which  the 
cavities  are  distended  out  of  proportion  to  the  diameter  of  their  walls. 

Varieties. — (1)  Dilatation  tvith  Hypertrophy. — Here  there  is  a  pro- 
gressive increase  in  the  capacity  of  the  chambers  until  they  attain  to 
large  dimensions.  The  cardiac  walls  continue  of  abnormal  thickness, 
yet  the  vigor  of  the  divisions  affected  may  be  relatively  diminished  to  a 
remarkable  degree,  owing  to  the  weakening  influence  of  the  degenerative 
processes  that  attack  the  hypertrophied  muscles.  In  eccentric  hvper- 
trophy  the  heart-cavities  are  dilated,  but  the  hypertrophied  cardiac  walls 
are  sufficiently  vigorous  to  meet  the  demands  of  the  circulation.  This 
condition  should  not  be  regarded  as  identical  with  dilatation  with  hyper- 
trophy., but  frequently  merges  into  the  latter,  the  size  of  the  cavities 
now  being  proportionately  greater  than  is  the  thickness  or  the  functional 
power  of  their  walls. 

(2)  Dilatation  tvith  Thinning  of  the  Heart-ivalls. — The  diminution  in 
the  diameter  of  the  cardiac  muscles  may  be  slight  if  the  capacity  of  the 
chambers  involved  be  only  moderately  increased.  Instances  of  this  sort 
are  sometimes  seen  to  follow  prolonged  fever  (typhoid).  On  the  other 
hand,  the  process  of  attenuation  may  reach  a  high  grade,  the  greatly 
thinned  cardiac  wall  being  scarcely  capable  of  holding  the  weight  of 
the  contained  blood. 

(3)  Dilatation  ivith  little  or  no  variation  from  the  normal  cardiac  loall 
has  also  been  described  by  some  authors.  It  is  to  be  observed,  however, 
that  stretching  of  a  cavity  whose  walls  are  of  normal  thickness  must  be 
attended  with  thinning  of  those  walls. 

Pathologfy. — Dilatation  with  hypertrophy  is  generally  secondary 
to  valve-lesions,  and  affects  more  than  one  cavity  as  a  rule.  It  may 
happen,  as  in  advanced  aortic  regurgitation,  that  all  the  divisions  are 
dilated.  The  right  ventricle  is  somewhat  more  frequently  dilated  than 
the  left,  however,  for  reasons  previously  adduced.  The  auricles  (espe- 
cially the  left)  are  more  frequently  expanded  than  the  ventricles  :  hence 
of  all  the  chambers  the  left  ventricle  is  least  apt  to  dilate.  The  extent 
of  the  relative  increase  in  the  capacity  of  the  cavities  is  variable,  and 
often  remarkable.  As  an  example  of  extreme  dilatation  of  a  chamber, 
the  left  auricle  in  cases  of  mitral  stenosis  may  be  singled  out ;  I  have 
seen  an  instance  in  which  this  auricle  was  capable  of  containing  twenty- 
two  ounces  of  blood.  The  septum  may  be  seen  to  bulge  when  one  ven- 
tricle only  is  stretched.  Extensive  dilatation  of  the  chambers  produces 
a  dilated  condition  of  the  auriculo-ventricular  rings,  which  in  turn  gives 
rise  to  relative  incompetency.  Other  cardiac  orifices  are  found  to  be 
similarly  dilated.  Dombrowski  ^  has  drawn  attention  to  the  fact,  first 
pointed  out  by  Wolf,  that  the  surface  of  the  mitral  leaflets  greatly  ex- 
ceeds the  orifice,  and  Kirschner  and  Garcin  contend  that  the  anterior 

1  "  Functional  Insufficiency  of  the  Valves  of  the  Left  Heart,"  Bevue  de  Medecine,  Sept. 
10,  1893. 


646  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

flap  alone  suffices  to  close  the  mitral  orifice,  "  even  when  the  left  heart 
is  considerably  dilated."  Dombrowski  believes  that  functional  incom- 
petency is  due,  in  many  cases,  '"to  muscular  dilatation,  producing  a 
separation  of  the  insertions  of  the  papillary  muscles,  which  in  systole 
cannot  approach  each  other  near  enough  to  allow  the  valves  to  close,  the 
contraction  of  the  papillary  muscles  only  increasing  the  difficulty." 
Great  dilatation  of  the  left  auriculo-ventricular  ring  is,  however,  prob- 
ably an  important  factor  in  the  causation  of  relative  mitral  incompetency. 
The  tricuspid  valves,  being  scarcely  competent,  normally,  are  unques- 
tionably incompetent  when  that  orifice  is  considerably  dilated. 

The  shape  of  the  heart  is  altered  according  to  the  seat  and  extent  of 
the  dilatation.  AVhen  all  the  cavities  are  dilated  the  organ  assumes  a 
globular  form,  while  dilatation  of  the  ventricles  only  produces  broaden- 
ing of  the  apical  region. 

Condition  of  the  Endocardium  and  Cardiac  Muscle. — The  muscular 
tissue  generally  exhibits  degenerations  (fibroid,  fatty,  or  parenchyma- 
tous). Important  as  is  the  part  played  by  the  ganglia  in  maintaining  the 
nutritive  integrity  of  the  heart  by  supplying  nervous  force,  our  knowledge 
of  the  alterations  that  may  occur  in  them  in  this  condition  is  as  yet  very 
imperfect.  Ott  and  others  have,  however,  found  them  to  be  degenerated. 
Opacity  and  patchy  roughening  of  the  endocardium  are  common.  The  pa- 
rietes  and  endocardium  may,  however,  have  a  normal  color  and  structure. 

Btiology. — Entering  into  the  causation  of  cardiac  dilatation,  there 
are  two  essential  factors:  (1)  increased  endocardial  tension;  (2)  dimin- 
ished resistance.  These  often  act  together.  Broadbent  contends  that  the 
special  feature  of  dilatation  is  the  imperfect  emptying  of  the  yentricles. 

(1)  Increased  Endocardial  Tension. — It  is  to  be  premised  that  a  pri- 
marv  and  a  secondary  form  occur,  the  latter  being  of  greater  importance 
clinically  than  the  former.  Primary  dilatation  occurs  from  a  recent  ob- 
struction to  the  circulation  of  considerable  magnitude  and  at  any  point 
throughout  the  blood-vessel  .system.  A  good  example  is  afforded  by 
aortic  constriction,  in  which  condition  the  obstruction  of  the  aortic  ring 
eno^enders  dilatation  of  the  left  ventricle  by  raising  the  intraventricular 
pressure ;  this  is  quickly  overcome  by  compensatory  hypertrophy.  In 
the  vast  majority  of  these  instances  the  nutrition  of  the  muscular  fibers 
eventually  suffers,  with  consequent  dilatation.  Angiospastic  dilatation 
is  a  condition  due  to  acute  transitory  spasm  of  the  vessels  (Jacob). ^ 

Other  causes  of  augmented  endocardial  pressure  have  been  considered 
in  the  discussion  of  Hypertrophy  and  Chronic  Valvular  Lesions.  In 
eccentric  hypertrophy  dilatation  is  a  com|)ensatory  arrangement,  until 
finally  the  cardiac  nutritive  functions  fail  and  dilatation  at  once  predom- 
inates (dilatation  with  hypertrophy).  Compensation  has  now  been  rupt- 
ured. Among  the  exciting  factors  that  may  precipitate  this  accident 
are — recurrent  endocarditis,  intercurrent  febrile  affections  Avhich  over- 
stimulate  the  heart  and  impair  its  muscular  tissue,  general  disturbances 
of  nutrition,  and  physical  and  mental  overstrain. 

Acute  primary  dilatation  may  be  brought  about  by  sudden,  great  ex- 
ertion, as  in  ascending  mountainous  elevations,  excessive  bicycling,  and 
the  like.  Under  these  circumstances  the  heart  palpitates  violently,  and 
there  are  epigastric  pulsation  and  often  pain  in  the  cardiac  region — evi- 
»  Zeiischr.f.  klin.  Med.,  Feb.  4,  1899. 


DILATATION  OF  THE  HEART.  647 

dences  of  dilatation  of  the  right  ventricle.  Although  the  heart's  reserve 
capacity  for  work  has  been  exceeded,  rest  folloAved  by  quite  moderate 
exercise  often  restores  the  conditions  to  the  normal.  I  have  seen  acute 
primary  dilatation  produced  by  strong  emotion ;  in  such  cases  sudden 
contraction  of  the  peripheral  vessels  occurs,  attended  -with  arrest  of  the 
heart's  action  ;  this  soon  gives  place  to  violent  palpitation,  and  rarely  to 
dilatation  (angiospastic  dilatation).      Sudden  fright  may  act  similarly. 

The  reraartable  endurance  of  the  athlete  and  the  gymnast  is  in  part 
owing  to  the  abnormal  amount  of  physiologic  cardiac  reserve  force 
■which  they  naturally  possess,  but  it  is  mainly  due  to  the  invigorating 
effect  of  training.  If,  however,  the  training  be  not  so  conducted  as  sym- 
metrically to  develop  the  entire  muscular  system,  or  if  the  exertion  be 
in  excess  of  the  reserve  functional  power  of  the  heart,  then  acute  dila- 
tation may  suddenly  arise.  From  this  accident  (cardiac  fatigue)  recov- 
ery may  take  place ;  sometimes,  however,  it  initiates  organic  valvular 
disease,  and  thus  prohibits  the  further  undertaking  of  unusual  feats. 
Acute  dilatation  has  been  made  conspicuous  by  recent  contributions,  in 
which  bicycling  is  assigned  as  the  cause. 

AiJparently  idiopathic  cases  of  cardiac  dilatation  of  indeterminate 
etiology  rarely  occur. 

(2)  Diminished  Eesistance  owing  to  Weakened  Cardiac  Walls. — The 
occurrences  that  weaken  the  cardiac  wall  are  numerous,  and  not  a 
few  lead  to  acute  primary  dilatation,  such  as  myocarditis  due  to  acute 
specific  fevers  (scarlatina,  typhoid,  malaria,  typhus).  It  is  especially 
prone  to  occur  in  rheumatic  endocarditis  and  jjericarditis.  B.  Robin- 
son ^  calls  forcible  attention  to  serious  dilatation  due  to  the  toxic  action 
upon  the  heart  muscle  of  the  rheumatic  poison.  The  chronic  degenera- 
tions (fatty,  fibroid)  impair  the  contractile  power  of  the  heart.  JVutri- 
tional  disturbances  of  varied  origin,  such  as  digestive  disorders,  ill- 
ventilation,  lack  of  open-air  exercise,  and  improper  or  defective  food- 
supply,  may  induce  enfeeblement  of  the  cardiac  muscle.  Dilatation 
is  met  with  also  in  diseases  of  the  blood  (chlorosis,  anemia,  leukemia). 

Clinical  History. — In  acute  dilatation  the  onset  is  sudden.  It  is 
accompanied  by  rapidly  augmenting  dyspnea  and  cardiac  palpitation,  a 
feeling  of  coldness,  and  frequently  by  pain  in  the  precordial  region. 

The  physical  signs  may  be  incontestable.  They  are  venous  pulsation 
in  the  neck,  a  rapid,  feeble  apex-beat,  and  a  systolic  7nurmur  at  the  tri- 
cuspid valves,  all  of  which  declare  the  presence  of  tricuspid  regurgita- 
tion. In  angiospastic  dilatation  the  pain  may  begin  in  the  extremities, 
and  the  second  heart-sound  may  be  louder  at  the  apex  than  the  first. 
Among  signs  of  subsidiary  value  are  a  venous  turgescence.  a  marked 
epigastric  pulsation,  and  a  sudden  extension  of  dulness  to  the  right ;  the 
pulse  is  small,  irregular,  and  exceedingly  rapid. 

In  the  more  chronic  form  which  arises  from  slowly-acting  causes,  or 
in  that  which  accompanies  eccentric  hypertrophy  or  follows  simple  hy- 
pertrophy due  to  left-sided  heart-  or  lung-trouble,  the  manifestations 
that  characterize  the  earlier  stages  are  not  at  all  striking.  They  indi- 
cate weak  heart-walls,  and  such  chambers  expel  their  contents  imper- 
fectly during  systole.  Hence  with  each  subsequent  diastole  the  abnor- 
mal amount  of  blood  contained  in  them  is  increased.     This  blood-stasis, 

1  American  Journal  of  the  Medical  Sciences,  Dec,  1899. 


648  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

as  previously  pointed  out,  often  extends  from  the  left  heart  to  the  pul- 
monary vessels,  from  the  latter  to  the  right  heart,  and  finally  to  the 
general  venous  system.  Both  in  the  acute  and  chronic  forms,  however, 
failure  of  the  right  ventricle  more  often  determines  rupture  of  compen- 
sation. Obviously,  the  symptoms  must  be  those  of  organic  diseases  of 
the  heart  (tricuspid  incompetency  in  particular).  Dilatation  of  the 
right  heart,  without  tricuspid  insufficiency,  is  a  frequent  complication  of 
pulmonary  tuberculosis  (Maisonneuve  ^). 

Physical  Signs. — Inspection  in  dilatation  of  the  left  ventricle  shows 
the  apex-beat  to  be  displaced  outward  and  downward,  and  a  diffuse, 
Aveak,  fluttering,  and  often  distinctly  undulating  impulse.  The  apex- 
beat  will  show  a  greatly  diminished  vigor  in  its  normal  area;  or  there 
may  be  no  recognizable  point  of  strongest  impulse  as  in  health.  Dis- 
tinct pulsation  in  the  second  left  interspace  is  not  rare.  Its  feebleness 
and  diffuse  character  are  confirmed  by  palpation.  It  may  be  quick  and 
sharp,  though  always  lacking  in  power.  Walsh  first  made  the  capital 
observation — since  abundantly  corroborated — that  the  impulse  may  be 
visible,  yet  not  palpable.  There  may  be  a  mere  vibration  or  an  utter 
absence  of  the  apex-beat  in  advanced  cases.  The  pulse  is  small  (rarely 
large),  short,  often  rapid,  and  irregular.  Percussion  shows  a  lateral 
increase  in  dulness  to  the  left,  to  or  even  beyond  the  raid-clavicular  line, 
upward  to  the  second  rib,  and  downward  as  far  as,  though  rarely  below, 
the  sixth  interspace,  except  perhaps,  in  rare  instances,  in  dilatation  with 
hypertrophy.     In  emphysema  the  lungs  unduly  overlap  the  heart. 

Dilatation  of  the  right  ventricle  demands  separate  consideration  so 
far  as  the  impulse  and  percussion-dulness  are  concerned.  The  normal 
impulse  is  largely  replaced  by  the  abnormal  apex-beat  of  the  right  ven- 
tricle, which  advances  to  the  anterior  chest-wall.  The  chief  impulse  is 
now  seen  and  feebly  felt,  as  a  rule,  below  the  xiphoid  cartilage,  or.  less 
commonly,  to  the  right  or  left  of  the  latter.  A  wavy  pulsation  is  seen 
to  the  left  of  the  sternum,  over  the  fourth,  fifth,  and  sixth  interspaces 
and  close  to  its  right  edge.  If  dilatation  of  the  right  auricle  be  asso- 
ciated, as  is  often  the  case,  a  distinct  pulsation  also  occurs  in  the  third 
right  interspace.  Dulness  reaches  to  a  point  1  inch  (2.5  cm.)  or  more 
beyond  the  right  sternal  border  on  a  level  with  the  fourth  interspace. 

On  auscultation  variable  results  are  obtained  accordinji  to  the  state 
and  diameter  of  the  cardiac  walls.  When  thin  and  not  much  disorgan- 
ized, the  first  sound  is  much  shorter,  sharper,  and  louder  than  in  health. 
In  advanced  cases  the  systolic  sounds  may  be  feeble,  though  almost 
always  audible  in  the  aortic  area  (unlike  the  first  sound  in  hypertrophy). 
The  first  closely  resembles  the  second  sound,  the  long  pause  being  short- 
ened, resembling  the  systolic  pause  (fetal  heart-sounds).  This  form  of 
arrhythmia  is  a  serious  indication  of  failure  of  the  ventricles.  The  can- 
ter rhythm  is  equally  common.  Irregular  and  intermittent  cardiac  action 
are  usual  phenomena.     Reduplication  may  occur,  but  is  not  fref|uent. 

Pre-existing  organic  murmurs  obscure  the  sounds  due  to  dilatation, 
and,  on  tlie  other  hand,  the  dilatation  may  also  alter  the  murmurs  (])re- 
viously  audible),  and  even  cause  them  to  disappear,  as,  for  example,  in 
mitral  stenosis.  Again,  dilatation  may  induce  relative  incompetency  or 
superadd  a  murmur,  as  in  cases  of  chronic  valvular  disease  at  the  auriculo- 

»  Gaz.  hebdom.  cle  Med.  et  de  Chir.,  Oct.  30,  1898,  No.  45 ;  Ann^e,  No.  87. 


DILATATION  OF  THE  HEART.  649 

ventricular  orifices.  It  is  interesting  to  recall  here  that  proper  treat- 
ment may  remove  a  murmur  due  to  relative  insufficiency,  and  that  this 
treatment  may,  in  turn,  reproduce  an  organic  murmur. 

Diagnosis. — This  is  made  readily  when  there  is  obtainable  a  clear 
history,  together  with  the  following  characteristic  features  :  a  weak,  irreg- 
ular heart-action  ;  an  extended,  wavy  impulse ;  a  small,  vigorless,  irreg- 
ular, and  intermittent  pulse ;  often  an  indistinct  apex-beat ;  an  outward, 
upward  increase  in  the  percussion-dulness  on  one  or  both  sides,  causing 
the  outline  to  resemble  a  square ;  and  a  brief,  sharp,  yet  feeble  first 
sound  that  strikingly  resembles  the   second,  which  is  itself  enfeebled. 

Differential  Diagnosis. — Hypertrophy.,  like  dilatation,  gives  rise  to  an 
extended  area  of  impulse  and  of  percussion-dulness ;  hence  by  the  care- 
less observer  these  conditions  are  sometimes  sadly  confounded.  From 
dilatations,  in  Avhich  the  diagnosis  rests  upon  the  points  above  enumer- 
ated, hypertrophy  is  to  be  distinguished  by  symptoms  of  an  opposite 
nature,  such  as  indicate  increased  energy  on  the  part  of  the  heart.  The 
latter  are — a  slow,  heaving  impulse  ;  a  full,  sustained,  regular  pulse ;  an 
increase  in  the  area  of  dulness,  chiefly  outward  and  downward  ;  abnor- 
mal position  of  the  apex-beat ;  and  the  prolonged,  dull  first  and  accen- 
tuated second  sounds.  To  determine  the  point  at  which  eccentric  hyper- 
trophy ends  and  dilatation  (with  hypertrophy)  begins  is  often  difficult ; 
but  a  careful  discrimination  must  be  attempted,  and  I  have  already  dis- 
cussed the  ushering-in  symptoms  of  dilatation  following  hypertrophy 
(chiefly  of  the  right  ventricle)  in  connection  with  Chronic  Valvular 
Disease.  Occurring  in  left  ventricle  hypertrophy,  dilatation  first  be- 
trays itself  by  a  change  in  the  position  of  the  visible  apex-beat  and  the 
palpable  impulse.  Thus,  the  maximum  point  of  the  apex-beat  of  hyper- 
trophy very  early  becomes  rounded  and  indefinite,  and  later  is  diffuse 
and  wavy.  The  strong,  heaving  thrust  of  the  impulse  gives  place  to  the 
shorter,  more  sudden  shock  of  commencing  dilatation,  indicating  weak- 
ness. These  signs,  together  with  a  reduction  in  the  strength  and  an  in- 
creased frequency  or  irregularity  of  the  pulse,  show  the  condition  to  be 
dilatation  with  hypertrophy. 

The  prognosis  is  bad,  as  a  rule,  and  may  be  said  to  be  that  of  the 
causative  factors. 

Treatment. — This  in  all  essential  particulars  is  identical  with  the 
treatment  of  organic  heart-affections  after  rupture  of  compensation.  The 
etiology  in  many  cases  differs  from  that  of  the  organic  valvular  affections 
of  the  heart;  and  next  to  rest  and  the  use  of  cardiac  stimulants,  the  re- 
moval of  the  remote  and  near  causes  of  the  dilatation  is  the  most  im- 
portant part  of  the  treatment.  Individual  cases  frequently  present 
special  indications ;  but  in  all  the  work  of  the  heart  is  increased  and 
the  propulsive  power  of  the  organ  diminished.  In  cases  of  non-valvu- 
lar origin  digitalis  and  other  heart-stimulants  may  be  omitted  early,  as 
a  rule ;  though  they  should  be  resumed  if  there  be  a  recurrence  of  seri- 
ous indications  of  dilatation.  When  the  dilatation  has  been  overcome 
careful  attention  is  to  be  bestowed  upon  all  the  details  of  the  patient's 
life  and  sanitary  surroundings  in  order  to  force  his  bodily  nutrition  to 
the  highest  point.  Every  precautionary  measure  having  for  its  aim  the 
prevention  of  a  recurrence  of  the  dilatation  must  also  be  advised  and 
enjoined. 


650  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

MYOCARDITIS. 

( Carditis.) 

Definition. — An  inflammation  of  the  muscle-substance  of  the  heart. 
It  may  be  acute  or  chronic. 

ACUTE   MYOCARDITIS. 

Pathology  and  Varieties. — (1)  Acute  Parenchymatous  Myocarditis. 

— This  is  characterized  by  a  granular  degeneration  of  the  muscular  fibers 
of  the  parenchyma  of  the  organ,  with  a  numerical  increase  in  their  nu- 
clei. The  muscle-structure  throughout  looks  pale,  is  turbid,  and  very 
soft.     Many  cases  of  a  severe  type  terminate  in  fatty  degeneration. 

(2)  Acute  Diffuse  Interstitial  Myocarditis. — Here  the  primary  altera- 
tions aff'ect  tlie  connective  tissue  of  the  myocardium ;  the  histologic 
changes  consist  in   round-cell  infiltration. 

(3)  Acute  Circumscribed  Myocarditis. — In  this  variety  the  degenerative 
processes  result  in  necrosis  of  the  tissues  over  large  or  small  areas,  with 
abscess-formation.  Though  usually  multiple,  these  abscesses  vary  con- 
siderably in  number,  and  may  rupture  either  into  the  various  cardiac 
chambers  or  into  the  pericardium.  Thus,  the  purulent  contents  of  the 
abscess,  when  there  is  established  a  fistulous  communication  with  an 
endocardial  chamber,  find  their  way  into  the  blood-stream  and  are  con- 
veyed to  all  parts  of  the  arterial  system,  frequently  setting  up,  here  and 
there,  embolic  processes  of  an  infectious  nature.  The  blood  in  turn 
enters  the  abscess-cavity,  exerting  pressure  on  the  walls,  and  may  either 
produce  an  acute  aneurysmal  dilatation  of  the  heart-wall  or  occasion 
fatal  rupture  into  the  pericardium.  More  frequently,  perhaps,  the  con- 
nective-tissue wall  of  the  abscess  yields  gradually  during  the  ventricular 
diastole,  when  the  cardiac  aneurysm  is  formed  with  corresponding  slow- 
ness. Occurring  in  the  vicinity  of  one  of  the  auriculo-ventricular 
valves,  abscesses  may  cause  mitral  or  tricuspid  incompetency.  Owing 
to  their  tendency  to  burrow,  they  may  perforate  the  interventricular 
septum,  thus  creating  a  fistulous  connection  between  the  two  sides  of 
the  heart,  and  resulting  in  an  intermingling  of  venous  and  arterial  blood. 
The  abscess  may  become  encysted,  then  caseous,  and  finally'  undergoes  a 
calcareous  process.     Multiple  abscesses  usually  affect  the  left  ventricle. 

Ktiology. —  The  causes  of  myocarditis  are — (a)  endo-  and  pericar- 
ditis in  the  course  of  rlieumatism  :  it  is  probable  that  rheumatic  myo- 
carditis may  also  exist  without  involvement  of  the  endo-  or  pericardium  ; 
(//)  the  infectious  processes  in  acute  specific  fevers;  (c)  infectious  emboli, 
lodging  in  the  branches  of  the  coronary  arteries  in  connection  Avith  sep- 
ticemia, pyemia,  and  acute  ulcerative  endocarditis,  and  commonly  termi- 
nating in  abscesses  (circumscribed  myocarditis).  The  first  two  of  these 
causes  give  rise  to  acute  diffuse  interstitial  and  acute  parenchymatous 
myocarditis  as  a  rule,  although  Freund  calls  attention  to  the  frequency 
with  which  circumscribed  myocarditis  is  associated  with  rheumatism  and 
diseases  of  the  joints.  As  compared  Avith  the  female  sex,  the  male 
suffers   much   more  fre(|uently. 

Symptoms  and  Diagnosis. — The  symptoms  are  practically  nega- 
tive.    They  point  merely  to  great  cardiac  enfeeblement.     When  cardiac 


CHRONIC  MYOCARDITIS.  651 

weakness,  as  shown  by  a  rapid,  small,  compressible,  and  irregular  pulse, 
and  by  attacks  of  cardiac  palpitation  and  Byncope.  comes  on  suddenly 
in  the  course  of  rheumatism,  septicemia,  or  other  causal  affections,  myo- 
carditis may  be  suspected.  Later,  signs  of  venous  stasis  appear.  The 
mental  symptoms  may  suggest  meningitis  or  salicylic-acid  poisoning. 
Koplik  ^  calls  attention  to  certain  symptoms  (pallor,  faintness,  vomiting, 
irregular,  teeble  heart-action,  disturbance  of  the  respiration  and  pulse- 
ratio)  that  should  arouse  suspicion  of  myocarditis  in  the  course  of  an 
infectious  disease  in  childhood. 

The  physical  signs  simulate  those  of  dilatation,  and  may,  indeed,  be 
largely  dependent  upon  the  presence  of  the  latter  condition.  Early  the 
action  of  the  heart  is  tumultuous  ;  the  sounds  on  auscultation  are  short, 
sharp,  and  finally  very  feeble.  Murmurs  in  myocarditis  are  not  rare,  and 
are  not  necessarily  dependent  upon  dilatation.  Kiehl's  work  shows  the 
dependence  of  the  valves  for  their  complete  closure  upon  a  normal  state 
of  different  portions  of  the  heart-muscles,  and  thus  explains  these  mur- 
murs. The  special  conditions  rendering  the  murmurs  audible  are  great 
dilatation,  softening  ofthe  papillary  muscle,  and  abscesses  near  the  valves. 

For  the  recognition  of  cardiac  aneurysm,  see  p.  660.  The  symp- 
toms of  visceral  or  cutaneous  embolic  processes,  combined  with  a  murmur 
and  a  septic  type  of  fever,  are  suspicious  of  the  existence  of  circum- 
scribed myocarditis.  Their  great  variability  as  to  presence  or  absence 
is  an  important  point,  especially  in  the  diagnosis  from  murmurs  due  to 
endocardial  changes.  The  latter  usually  coexist  with  a  more  marked 
accentuation  of  the  pulmonary  second  sound. 

Prognosis.- — The  diflFuse  forms  are  fatal ;  the  circumscribed  form 
may,  however,   end  in  recovery.     Myocarditis  may  end  life  suddenly. 

The  treatment  is  identical  with  that  indicated  for  endocarditis  and 
pericarditis — diseases  of  which  myocarditis  is  often  a  complication.  The 
effects  of  digitalis,  particularly  when  myocarditis  supervenes  upon  old 
heart-lesions,  are  quite  unsatisfactory.  When  myocarditis  is  suspected 
as  an  independent  condition  absolute  rest  must  be  enjoined,  the  general 
nutrition  maintained,  and  the  more  urgent  symptoms  relieved. 

CHRONIC   MYOCARDITIS. 

[Fibrous  Myocarditis.) 

Definition. — A  gradually  developing  inflammation  of  the  cardiac 
interstitial  connective  tissue,  resulting  in  induration. 

Pathology. — The  characteristic  changes  may  be  diffuse,  though 
most  frequently  they  are  confined  to  certain  portions  of  the  muscular 
structure,  the  left  ventricular  wall,  the  septum,  and  the  papillary  muscles 
being  the  three  favorite  seats  of  the  process.  This  is  sometimes  of  ante- 
natal development,  and  then  its  usual  seat  is  near  the  apex  of  the  right 
ventricle.  The  hardened  spots  take  the  form  of  more  or  less  rounded 
patches  or  broad  lines.  In  color  they  are  gray,  grayish-white,  or  gray- 
ish-yellow, the  latter  tint  being  due  to  the  intermingling  of  fibers  that 
have  undergone  fatty  degeneration.  Their  size  is  exceedingly  variable, 
some  being  so  minute  as  to  elude  detection  by  the  unaided'eve.  while 
others  measure  1  or  2  inches  (2.5-5  cm.)  in  diameter.  Inflamma- 
tory induration  (contraction,  of  the  conus  arteriosus  of  either  ventricle 
causes  narrowing  of  the  pulmonary  and  aortic  orifices,  with  the  usual 
^  Medical   News,  March  31,  1900. 


652  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

signs  and  symptoms.  Similar  changes,  by  disturbing  the  functions  of 
the  papillary  muscles,  produce  valvular  incompetency.  Compensatory 
hypertrophy  of  the  uninvolved  portion  of  the  heart  is  also  observed, 
both  the  size  and  weight  of  the  organ  thus  being  increased ;  the  hyper- 
trophic enlargement  may  frequently  be  accounted  for  in  pai't  by  an 
associated  chronic  endocarditis.  Sometimes,  however,  the  hypertrophy 
is  occasioned  mainly  by  general  arterial  sclerosis.  Dilatation  of  the 
ventricles  follows,  with  fresh  and  grave  disturbances  of  the  circulation. 

Chronic  iniiammation  usually  attacks  early  the  intima  of  the  coro- 
nary arteries,  and  leads  to  thrombosis,  Avith  the  formation  of  anemic 
infarcts  that  subsequently  undergo  sclerotic  changes  in  the  muscle- 
structure.  It  is  probable  that  most  cases  of  localized  fibrous  myocar- 
ditis have  their  origin  in  an  obliterating  endarteritis.  Pasquier  offers 
proof  that  fibroid  myocarditis  results  from  chronic  congestion  due  to 
stopping  of  the  vessels.  The  calloused  zone  may  yield  to  the  endocar- 
dial blood-tension,  and  thus  slowly  produce  saccular  dilatation  (aneur- 
ysm). Microscopically,  the  affection  is  characterized  by  hyperplasia  of 
the  interfibrillar  connective  tissue  with  subsequent  development  of  new 
fibrous  tissue.  Fatty  degeneration  and  atrophy  of  the  muscle-fibers  (the 
latter  in  consecjuence  of  compression)  are  also  observed.  Fragmentation 
of  the  muscle-fibers  has  also  been  observed.  This  occurs  as  sl  postvwrtein 
change,  and  is  due  to  a  softening  of  the  interfibrillar  substance  (the  etat 
segmentaire  of  Renant). 

iJ^tiology. — The  disease  is  most  commonly  traceable  to  the  action 
of  one  or  more  of  the  following  factors :  an  excess  in  the  use  of  alcohol 
or  tobacco,  lead-poisoning,  gout,  rheumatism,  diabetes,  chronic  nephritis, 
malaria,  and  syphilis.  Thus,  it  may  be  produced  by  many  infections 
and  chemical  irritants,  the  latter,  in  most  cases,  first  causing  a  sclerosis 
of  the  coronary  arteries,  to  which  the  patchy  fibroid  degeneration  is 
secondary.  Some  of  the  causes  of  acute  diffuse  interstitial  myocarditis 
may  by  their  more  slightly  irritant  effect  (oAving  to  the  minuteness  of 
the  dose  of  the  specific  poison)  lead  to  the  subsequent  development  of 
the  general  chronic  form  {e.  g.  rheumatism).  Certain  irritants  that  usu- 
ally engender  localized  lesions  of  chronic  myocarditis  may  also  affect 
the  entire  myocardium  (syphilis,  alcohol,  gout).  Chronic  myocarditis 
may  arise  in  consequence  of  a  direct  extension  of  the  infective  infiam- 
matory  processes  in  chronic  endo-  and  pericarditis ;  it  may  also  follow 
injuries  of  the  antero-lateral  thoracic  region.  Sex  and  age  possess  a 
predisposing  effect,  the  disease  being  more  common  in  males  than  in  fe- 
males, and  after  middle  life  than  before  that  period.  The  right  ventricle 
is  apt  to  be  the  seat  of  chronic  myocarditis  during  fetal  life,  if  at  all. 

Symptoms. — Extensive  indurated  myocarditis  has  been  met  with 
post  morteiu  in  numerous  instances  that  have  been  unattended  by  per- 
ceptible symptoms  during  life.  In  many  of  these  cases  the  presence  of 
compensatory  hypertrophy  accounts  for  the  absence  of  any  symptoms, 
and  it  may,  therefore,  be  inferred  that  mild  grades  that  fail  to  manifest 
themselves  must  freijuently  exist.  The  symptoms  when  present  are, 
almost  without  exception,  untrustworthy  for  diagnostic  purposes,  since 
they  bear  a  striking  resemblance  to  those  of  the  organic  valvular  dis- 
eases, minus  their  more  characteristic  physical  signs.  Among  the 
earliest  phenomena  that  point  merely  to  failing  heart-power  are  dys- 


CHRONIC  MYOCARDITIS.  653 

pnea,  and  sometimes  also,  on  exertion,  paljntation  and  a  sense  of  heavi- 
ness or  constriction  in  the  precordia.  The  patient  suffers  from  marked 
general  debility,  and  becomes  fatigued  in  consequence  of  the  slightest 
physical  exertion.  Mental  inertia  is  the  rule,  and  chronic  mania  may 
come  on  and  last  to  the  close.  Later,  more  positive  disturbances  of  the 
circulation  gradually  arise,  and  Avhen  the  breathing  becomes  more  diffi- 
cult (cardiac  asthma)  signs  of  venous  stasis  affecting  the  liver,  gastro- 
intestinal tract,   and  kidneys,  and  edema  finally  appear. 

Two  symptoms  that  are  frequently  manifested,  and  not  without  some 
diagnostic  import,  remain  to  be  mentioned :  (1)  Angina  pectoris,  which 
is  attributable  to  the  sclerosed  condition  of  the  coronary  arteries. 
( Vide  Symptoms  of  Angina  Pectoris,  p.  672.)  It  is  often  followed  by 
some  form  of  arrhythmia.  Cases  occasionally  occur  in  which  recurring 
paroxysms  of  angina  pectoris,  with  or  without  arrhythmia,  are  the  only 
phenomena  of  the  disease. 

(2)  Cardiac  Arrhythmia. — Brachycardia  is  associated  as  a  rule,  there 
being  a  reduction  in  the  pulse-rate  to  50  or  even  40  beats  per  minute. 
With  this  decreased  rate  intermittency  is  often  combined,  and  various 
other  forms  of  disturbed  rhythm  are  also  observed,  though  they  are  less 
frequent  and  less  significant.  Slowing  of  the  pulse  does  not,  how^ever, 
prohibit  the  cardiac  palpitation  that  is  especially  apt  to  arise  during 
anginal  attacks.  Disturbance  of  the  rhythm  may,  on  the  other  hand, 
be  entirely  absent. 

The  pulse  is  slow,  iiTegular,  and  of  low  tension  if  cardiac  atrophy  be 
present.  Should  fatty  degeneration  be  conjoined,  the  pulse  may  be 
quickened  and  irregular,  and  this  effect  likewise  obtains  when  the  patient 
escapes  sudden  death  and  the  usual  dilatation  supervenes. 

Chronic  myocarditis  may  be  the  sole  cause  of  the  pseudo-apoplectic 
seizures  that  often  terminate  life  abruptly.  Preceding  the  unexpected 
attack  the  patient,  usually  advanced  in  life,  may  have  experienced  from 
time  to  time  slight  vertigo,  syncope,  and  oppression.  These  seizures  may 
also  be  caused  by  a  heavy  meal  or  intense  mental  or  physical  exertion, 
and  may  consist  in  a  momentary  loss  of  consciousness,  paralytic  symp- 
toms then  being  usually  absent.  At  other  times  they  last  a  number 
of  hours,  and  are  accompanied  by  paralysis  which  outlasts  the  coma, 
as  a  rule,  by  a  few  hours  only.  Convulsive  twitchings  may  be  present. 
During  the  attack  cerebral  hemorrhage  occurs,  and  may  leave  the  patient 
hemiplegic.  It  is  highly  characteristic  of  these  pseudo-apoplectic  seiz- 
ures that  they  tend  to  recur,  sometimes  at  intervals  of  a  few  hours  for 
a  day  or  two,  but  more  commonly  at  longer  intervals  during  many 
weeks  or  months. 

Physical  Signs, — The  impulse  may  be  feebly  heaving  (sometimes  ab- 
sent) ;  the  apex-beat  is  displaced  downward  and  to  the  left,  while  the 
dull  area  is  enlarged  correspondingly  in  the  same  direction.  Quite 
early  the  heart-sounds  may  be  clear  and  strong,  but  subsequently  they 
become  weak  and  muffled.  A  contraction  of  the  papillary  muscles 
and  of  the  chordae  tendinese  may  cause  mitral  incompetency  with  its 
customary  murmur. 

With  the  occurrence  of  dilatation  also  comes  an  apical,  systolic  mur- 
mur (due  to  relative  incompetency),  with  a  gallop  rhythm  of  the  heart. 

Diflferential  Diagnosis.^ — (1)  Chronic  valvular  disease  can,  as  a 


654  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

rule,  be  eliminated  prior  to  the  occurrence  of  secondary  dilatation. 
During  this  period  murmurs  do  not  occur  unless  the  valvular  adnexa 
(the  chordas  and  papillary  muscles)  are  aftected.  In  the  latter  event  the 
secondary  alterations  in  the  heart,  the  symptoms,  and  whole  course  of 
the  complaint  are  the  same  as  in  certain  chronic  valvular  lesions. 

(2)  Hypertrophj  and  Dilatation. — In  chronic  myocarditis  hyper- 
trophy does  not  usually  reach  as  high  a  grade  of  development  as  in  the 
majority  of  the  organic  valvular  complaints  and  other  causal  conditions. 
But  after  the  occurrence  of  dilatation.,  following  indurated  myocarditis, 
the  differential  diagnosis  between  the  latter  and  eccentric  hypertrophy 
is  purely  conjectural. 

(3)  Fatty  overgroioth  must  be  distinguished  from  fibrous  myocarditis, 
and  is  met  with  chiefly  in  brewers,  publicans,  and  butlers.  The  disease 
is  also  found  to  be  specially  related  to  obesity,  and  sometimes  to  over- 
eating and  drinking,  combined  with  indolent  habits.  These  subjects 
suffer  more  frequently  from  bronchitis,  emphysema,  and  nocturnal  asthma 
than  patients  having  chronic  myocarditis  alone.  Slight  vertigo  is  com- 
mon, but  true  syncopal  attacks  are  rare,  according  to  my  observation. 
In  fatty  overgrowth  the  heart-sounds  are  weak  and  decidedly  muffled 
throughout ;  the  pulse  is  weak,  though  regular  as  a  rule.  Marked 
obesity,  however,  often  obscures  the  local   signs. 

Prognosis. — Chronic  myocarditis  is  a  fatal  disease.  Its  course  -and 
duration,  however,  are  subject  to  great  variations.  Among  unfavorable 
surroundings  are  certain  causal  and  associated  conditions,  particularly 
arterio-sclerosis,  chronic  interstitial  nephritis,  and  diabetes  mellitus.  On 
the  other  hand,  if  syphilis  has  been  the  cause,  hope  for  temporary  improve- 
ment, if  not  for  actual  cure,  may  be  reasonably  entertained.  Sudden 
death  may  result  from  a  blocking  of  a  vessel  that  is  the  seat  of  sclerosis. 

Treatment. — The  treatment  should  be  managed  according  to  the 
considerations  pointed  out  in  the  treatment  of  Organic  Valvular  Dis-. 
ease.  Rest  of  body  and  mind  is  imperative.  Next  to  this  come  the 
dietetic  and  hygienic  details.  Residence  in  a  mild  climate  in  winter 
and  a  change  to  the  country  or  to  a  moderate  elevation  in  summer  are 
matters  of  the  greatest  moment  to  the  welfare  of  the  patient.  Those 
rather  frequent  cases  that  present,  among  other  complications,  such 
closely  united  conditions  as  arterio-sclerosis,  gout,  and  chronic  nephritis 
sometimes  do  well  Avhile  sojourning  at  certain  mineral  springs,  such  as 
Marienbad,  Carlsbad,  Kissengen  abroad,  and  Bedford  or  Saratoga  at 
home.     These  waters  must,  however,  be  cautiously  used. 

When  dilatation  arises  cardiac  stimulants  are  called  for,  but  must  be 
used  Avith  an  unusual  degree  of  caution.  Strychnin  has  proved  itself 
to  be  valuable  if  perseveringly  exhibited,  and  here,  as  elsewhere,  digi- 
talis deserves  a  trial ;  its  careless  administration,  however,  may  give  bad 
results  if  the  pulse  be  much  retarded  or  arterio-sclerosis  coexist.  For 
the  angina  pectoris  morphin,  administered  hypodcrmically,  is  to  be  pre- 
ferred. Recurrences  of  this  distressing  symptom  may  be  averted  by  the 
cautious  use  of  nitroglycerin,  the  use  of  which  should,  however,  be 
limited  to  cases  that  seem  to  be  dependent  upon  arterial  degeneration 
with  high  tension.  Attacks  of  syncope  are  most  successfully  met  by  the 
hypodermic  use  of  the  diffusible  stimulants  (ammonia,  ether),  and  at 
the  same  time  by  putting  the  patient  at  rest  with  the  head  lowered. 


DISEASES  OF  THE  CORONARY  ARTERIES.  655 


DISEASES  OF  THE  CORONARY  ARTERIES. 

It  has  previously  been  noted  that  in  pyemia  and  allied  disorders 
septic  emboli  may  block  the  branches  of  the  coronary  arteries,  causing 
suppurative  infarcts  (acute  circumscribed  myocarditis). 

It  has  also  been  shown  that  one  of  the  chief  effects  of  sclerosis  affect- 
ing the  coronary  arteries  is  the  production  of  chronic  7nyocarditis. 
Sudden  blocking  of  one  coronary  artery  by  an  embolus  causes  instant 
death.  In  numerous  instances  in  which  death  has  occurred  suddenly 
either  thrombotic  or  embolic  obstruction  has  been  the  only  discoverable 
post-mortem  lesion.  In  others  the  pathologic  evidences  of  local  or  general 
atheroma  have  coexisted.  Ligation  or  plugging  of  the  coronary  vessels 
in  the  lower  animals  causes  arrhythmia  or  even  an  abrupt  arrest  of 
cardiac  action ;  a  partial  or  even  slight  reduction  in  the  lumen  of  the 
coronary  vessels  by  diminishing  the  supply  of  blood  to  the  heart-muscle 
induces  degenerations  in  the  latter.  Kronecker  found  that  occlusion  of 
the  coronary  arteries  by  injecting  paraffin  caused  the  heart  to  become 
irregular,  even  when  it  solidified  in  only  the  smaller  branches,  and 
stopped  almost  at  once.  The  anatomic  peculiarity  of  the  coronary 
arteries  in  that  they  are  end-arteries  is  to  be  noted,  since  it  affords  a 
ready  interpretation  of  the  usual  effects  following  total  or  partial  occlu- 
sion. According  to  F.  H.  Pratt,  however,  the  vessels  of  Thebesius, 
which  extend  from  the  auricles  and  ventricles  to  the  myocardial  capil- 
laries and  coronary  veins,  may  rarely  maintain  the  nutrition  of  the 
heart-muscles  even  after  occlusion  of  the  coronary  arteries. 

The  blocking  of  the  terminal  branches  by  emboli  or  by  the  more 
gradual  formation  of  thrombi  usually  produces  the  so-called  anemic 
necrosis  or  ivhite  infarct — a  condition  that  richly  deserves  brief  descrip- 
tion : 

Anemic  necrosis  {anemic  infarct)  is  met  with  most  frequently  in  the 
left  ventricle  and  septum,  which  receive  their  blood  from  the  ante- 
rior coronary  artery.  The  involved  areas  are  small  and  circumscribed, 
and  present  irregular  margins  that  project  slightly  above  the  surface. 
Rarely  the  infarct  is  wedge-shaped.  Its  color  is  grayish-white  or  gray- 
ish-red, while  the  central  portion  is  often  distinctly  white  and  firm ;  less 
frequently  it  breaks  down  into  a  soft  detrital  mass  {myomalacia  cordis). 
When  softening  does  not  occur  the  fibers  in  the  affected  area  lose  their 
nuclei,  becoming  first  hyaline  and  subsequently  sclerotic.  The  chief 
histologic  changes  are  of  two  sorts :  {a)  the  striae  of  the  muscle-fibers 
are  lost,  the  latter  becoming  granular  and  breaking  down ;  and  {h)  the 
fibers  assume  a  homogeneous  hyaline  appearance,  the  nuclei  having  dis- 
appeared. 

The  symptomatic  consequences  of  the  lesions  are  often  obscure  and 
unreliable.  Sudden  death  may  take  place,  and  rarely  this  accident 
may  be  due  to  rupture  of  the  heart.  Weak  and  irregular  action  of  the 
heart,  evidences  of  embarrassed  circulation  (especially  in  the  cardio- 
pulmonary circuit,  as  shown  by  cough  and  dyspnea),  and  finally  an- 
gina pectoris,  are  among  the  principal  features  observed.  Death  may 
ensue  in  the  first  attack.  The  paroxysms  are  presumed  to  be  due  to 
sudden  occlusion  of  a  branch  of  the  coronary  artery ;  but  it  should  be 


656.  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

stated  that  occasionally  in  fatal  instances  of  true  angina  pectoris  a  total 
absence  of  lesions,  including  emboli,  has  been  noted.  I  desire  to  lay 
stress  upon  the  medico-legal  importance  of  coronary  disease ;  it  may  be 
the  only  lesion  found  in  cases  of  quick  death. 


DEGENERATIONS  OF  THE  HEART. 

(a)  Fatty. — The  term  ••  fatty  heart  "  includes  two  pathologically  dis- 
tinct affections :  (1)  Fatty  degeneration,  in  which  the  cardiac  muscle- 
fibers  have  been  converted  into  fat ;  and  (2)  Fatty  overgrowth,  in  which 
an  abnormal  quantity  of  fat  is  deposited  in  and  about  the  heart. 

FATTY   DEGENERATION. 

Pathology. — The  condition  may  be  either  general  or  localized.  Its 
most  frequent  seat  is  in  the  left  ventricle,  the  papillary  muscles  and 
trabecule,  first  appearing  as  yellowish  spots  or  stripes  beneath  the  en- 
docardium. The  affected  portions  are  light  yellow  or  yellowish-brown 
(faded  leaf)  in  color,  due  to  an  associated  broAvn  atrophy ;  they  are  also 
soft  and  friable,  and  are  easily  lacerated.  The  heart  is  enlarged,  and 
often  decidedly  so  if  the  process  be  general,  and  its  walls  lack  firmness. 
The  microscope  reveals  characteristic  changes :  the  strire  and  nuclei 
begin  to  fade,  oil-drops  and  granules  appear  in  the  fibers,  and  finally  the 
latter  are  occupied  throughout  by  minute  globules. 

Ktiology. — Fatty  degeneration  has  already  been  mentioned  as 
occurring  in  both  the  primary  and  secondari/  forms  of  cardiac  hyper- 
ti-ophy.  It  is  found  also  in  association  with  fatty  change  in  other 
organs  in  severe  forms  of  primary  and  secondary  anemias.  It  is  most 
commonly  encountered,  however,  in  the  cachectic  states  produced  by 
such  chronic  diseases  as  carcinoma  and  phthisis,  and  in  the  course  of 
acute  infectious  diseases  of  intense  type,  all  of  which  may  produce 
the  condition.  In  poisoning  by  arsenic  and  phosphorus  and  in 
pernicious  anemia  it  advances  to  a  high  grade.  The  various  lesions 
of  the  coronary  arteries  previously  considered  bear  the  most  significant 
causal  relation. 

Predisposing  causes  are — (a)  aye — it  being  most  common  after  forty 
years  of  age ;  (6)  sex — it  occurs  somewhat  more  frequently  in  men  than 
in  women,  notwithstanding  the  fact  that  there  are  predisposing  influ- 
ences at  work  in  the  latter  that  do  not  obtain  in  the  male  sex,  such  as 
childbirth  and  amenorrhea  ;  and,  lastly,  (c)  whatever  may  be  its  apparent 
etiology,  it  is  invariably  preceded  by  a  defective  nutritive  supply  to  the 
muscle-cells :  this  may  be  dependent  upon  a  narrowing  of  the  lumen  of 
the  coronary  vessels,  or  upon  impairment  of  the  oxygen-carrying  power 
of  the  blood,  as  in  the  anemias.  An  excessive  supply  of  glucose,  gly- 
cogen, and  nuclein  may  be  a  factor. 

Symptoms. — The  disease  may  exist  in  an  advanced  form  without 
noticeable  symptoms,  though  the  conditions  under  wliich  it  is  most  liable 
to  occur  afford  secure  ground  for  suspicion.     The  evidences  of  cardiac 


FATTY  DEGENERATION  OF  TEE  HEART.  657' 

enfeehlement  are  usually  present,  but  in  pernicious  anemia  and  chlo- 
rosis the  pulse  may  even  be  full  and  regular. 

Dilatation  is  apt  to  supervene  early,  owing  to  the  weakened  state  of 
the  heart ;  and  hence  it  is  probable  that  many  of  the  symptoms  that 
have  been  ascribed  to  the  fatty  changes  are  in  reality  due  to  secondary 
dilatation.  Among  these  are  palpitation.,  dysimea,  a  small.,  irregular, 
and  somewhat  quickened  pulse,  and  cool  and  clammy  extremities.  The 
heart-sounds  are  weak,  as  a  rule,  and  the  action  of  the  heart  often 
irregular ;  later  the  physical  signs  of  dilatation  are  almost  invariably 
present.  Dropsy,  however,  is  rare  in  uncomplicated  cases.  Sometime's 
sudden,  great  physical  exertion  produces  equally  sudden  dilatation, 
whereupon  a  canter  rhythm  and  an  apical  systolic  murmur  speedily 
develop.  In  most  instances,  however,  the  symptoms  are  more  gradually 
brought  to  light.  Breathlessness  on  exertion  is  often  a  striking  feature, 
and  syncopal  attacks  are  sometimes  troublesome.  The  pulse,  in  conse- 
quence of  irritation  of  the  inhibitory  center  in  the  medulla,  often  be- 
comes greatly  retarded,  dropping  from  the  normal  rate  to  30  or  40  beats 
per  minute,  and,  in  rare  cases,  to  10  or  12  beats.  The  fatty  a7'cus 
senilis  is  devoid  of  diagnostic  value.  There  are  frequent  attacks  of 
cardiac  asthma  in  the  mornings,  and  these  are  apt  to  be  accompanied  at 
intervals  by  angina  pectoris.  Disturbance  of  the  intellect,  sometimes 
taking  the  form  of  maniacal  delusions,  may  come  on  and  persist. 
Syncopal  attacks  occur.  Pseudo-apoplectic  attacks,  such  as  have  been 
described  {vide  Chronic  Myocarditis),  may  occur.  Cheyne-Stokes 
breathing  is  among  the  later  manifestations.  It  happens  that  this 
symptom  and  pseudo-apoplectic  seizures  are  often  found  in  association ; 
they  are  more  apt  to  be  due  to  uremic  toxemia,  perhaps,  than  to  fatty 
degeneration  of  the  heart.  Epileptiform  attacks  resembling  petit  mat 
may  arise. 

The  diagnosis  is  sadly  obscure.  The  history,  the  age  of  the  patient, 
and  the  symptoms  of  cardiac  weakness  and  subsequent  dilatation, 
together  with  retardation  of  the  pulse,  apoplectic  attacks,  and  Cheyne- 
Stokes  breathing,  in  the  absence  of  precedent  hypertrophy  merely 
justify  a  probable  diagnosis.  With  a  clear  history  and  the  presence 
of  the  more  significant  symptoms,  including  the  signs  of  dilatation 
following  hypertrophy,  fatty  changes  may  be  inferred  with  some  de- 
gree of  assurance,  although  a  positive  opinion  should  be  withheld. 

The  prognosis  is  as  varied  as  the  etiology.  Death  may  come 
quickly,  the  process  being  commonly  associated  wuth  sclerosis  of  the  cor- 
onaries,  though  oftenerthe  end  is  reached  in  a  gradual  manner,  the  signs 
and  symptoms  of  advanced  dilatation  dominating  the  closing  scene. 

Treatment. — The  cause  in  each  individual  case  should  be  deter- 
mined with  as  much  precision  as  possible,  and  when  ascertained  a  bold 
attempt  should  be  made  to  remove  it.  This  course  often  places  the 
patient  in  the  most  favorable  position  for  the  successful  treatment  of  the 
cardiac  condition ;  and  the  method  embraces  many  hygienic  and  dietetic 
considerations  that  assist  in  improving  the  nutrition  of  the  cardiac 
tissue — one  of  the  cardinal  aims  of  a  proper  system  of  treatment.  An- 
emia in  one  form  or  other  plays  an  important  role  in  the  majority  of  the 
cases,  and  the  particular  variety  present  in  each  instance  must  deter- 
mine the  character  of  the  remedies  to  be  employed.     In  that  large  cate- 

42 


658  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

gory  of  cases  occurring  in  certain  cachexias  (cancerous,  tuberculous) 
hematinics,  arsenic  and  strychnin,  are  the  remedies  of  choice. 

A  frequent,  irregular  pulse  and  other  signs  of  cardiac  failure  indicate 
commencing  dilatation,  and  under  these  circumstances  digitalis  should 
be  employed  in  small  doses.  When  used  with  perseverance  it  is  of  the 
greatest  service,  and  in  the  form  of  the  powder  or  the  aqueous  extract 
it  may  be  conveniently  combined  with  the  above  prescription. 

I  believe  that  gentle  indulgence  in  physical  exercise  and  light  gym- 
nastics is  beneficial,  since  it  tends  to  invigorate  the  heart-muscle ;  it  is 
to  be  increased  in  proportion  to  the  manifest  improvement  in  the 
patient's  condition.  It  sometimes  happens,  however,  that  even  gentle 
exercise  is  badly  borne,  and  it  should  then  be  discontinued.  Kinesi- 
therapy,  particularly  the  milder  Swedish  method  of  gymnastic  exercises 
(alternating  movements  of  resistance),  increases  the  contractile  power 
of  the  heart  and  at  the  same  time  lessens  the  peripheral  resistan  ;e,  and 
should  be  accorded  a  careful  trial.  I  have  been  in  the  habit  of  advising 
daily  inhalations  of  oxygen  gas  in  this  class  of  cases  with  good  results. 
Recourse  to  massage  is  also  in  the  line  of  sound  practice,  but  the  sittings 
should  not  exceed  half  an  hour  in  duration  at  the  start.  The  more 
jwominent  symptoms  may  require  special  measures.  The  syncopal  and 
anginal  attacks  are  to  be  handled  in  the  manner  indicated  for  the  same 
symptoms  in  chronic  myocarditis.  For  the  pseudo-apoplectic  attacks 
rest  in  the  recumbent  posture,  with  the  head  slightly  elevated,  is  use- 
ful. Therapeutic  agents,  as  digitalis,  ammonia,  and  ether,  may  be 
used  hypodermically  to  stimulate  the  heart ;  it  is  also  good  practice 
to  withdraw  from  12  to  2-4  ounces  (355.0-710.0)  of  blood  directly 
from  a  vein.  If  the  arteries  be  hard  and  tense,  nitroglycerin  is  of 
distinct  service. 

A  strictly  horizontal  posture  and  the  application  of  ice  to  the  pre- 
cordial region  often  quickly  terminate  the  attacks  of  cardiac  asthma, 
and  spartein  sulphate,  with  nitroglycerin,  is  worthy  of  a  trial.  Hot  toddy 
and  other  diffusible  stimulants  are  valuable  adjuvants.  Should  these 
remedies  fail,  hypodermic  treatment  by  morphin  is  to  be  adopted. 

FATTY   OVERGROWTH. 

Pathology. — The  characteristic  change  consists  in  a  marked  in- 
crease in  the  normal  fat.  particularly  in  the  auriculo-ventricular  fur- 
rows. This  over-production  of  fat  takes  place  to  a  greater  or  lesser 
extent  in  every  obese  person,  and  may  become  so  excessive  as  to  form  a 
complete  enveloping  mantle  measuring  an  inch  or  more  in  thickness. 
In  these  extreme  grades  the  muscular  fibers  of  the  organ  may,  from  too 
great  pressure,  undergo  atrophy  and  thus  become  weakened. 

Ktiology. — The  principal  cause  is  general  corpulency.  (For  a 
consideration  of  the  factors  predisposing  to  fat  production  see  Obesity, 
p.  1225.)  In  the  cachexias  of  carcinoma  and  phthisis,  and  the  general 
atrophy  of  old  age,  fatty  overgrowth  and  fatty  degeneration  coexist. 

Symptoms. — The  condition  may  be  unaccompanied  by  any  symp- 
toms. The  muscle-fiber  is  weakened  (not  degenerated,  as  a  rule),  hence 
extra  labor  suddenly  thrown  upon  the  organ  excites  the  clinical  indica- 
tions of  a  weak   (dilated)   heart,    as  urgent  dyspnea,  vertigo,  syncope, 


FATTY  OVERGROWTH  OF  THE  HEART.  659 

palpitation,  and  cyanosis.  Later  recurrences  arise  on  every  provocation. 
Distressing  attacks  of  asthma  may  develop  after  a  full  meal  or  "without 
an  apparent  exciting  cause.  A  passive  form  of  bronchitis  may  supervene. 
The  cardiac  impulse  is  feeble  and  may  even  be  missing.  The  pulse 
is,  as  a  rule,  regular  and  moderately  tense.  Slight  intermittence  and,  in 
marked  heart-weakness,  decided  arrythmia  may  be  noted.  In  moderate 
grades  the  heart-sounds  may  be  clear  ;  in  marked  cases  with  ensuing 
dilatation  a  systolic,  apical  murmur  may  be  audible. 

The  diagnosis  rests  upon  the  combined  presence  of  marked  obesity 
and  cardiac  enfeeblement.     (For  the  differential  diagnosis,  see  p.  654.) 

Treatment. — I  wish  to  advocate  warmly  the  system  of  treatment 
introduced  by  Oertel,  as  I  have  seen  excellent  results  from  its  employ- 
ment. It  should  not  be  resorted  to  in  chronic  valvular  disease,  in  the 
stage  of  broken  compensation,  nor  in  marked  atheroma. 

Oertel's  method  comprises  three  parts :  (1)  The  reduction  of  the 
amount  of  liquid  taken  with  the  meals  and  during  the  intervals,  the 
total  for  each  day  being  36  ounces  (1064.0).  Frequent  bathing  (includ- 
ing the  Turkish  bath  in  suitable  instances)  and  pilocarpin  are  employed 
to  promote  free  diaphoresis. 

(2)  The  diet  is  composed  largely  of  proteids,  as  follows :  Morning. — 
A  cup  of  coffee  or  tea,  with  a  little  milk — about  6  ounces  (178.0)  alto- 
gether ;  bread,  3  ounces  (93.0). 

iVoow.— Three  to  4  ounces  (90.0-120.0)  of  soup  ;  7  to  8  ounces  (218.0- 
248.0)  of  roast  beef,  veal,  game,  or  poultry,  salad  or  a  light  vegetable, 
a  little  fish ;  1  ounce  (32.0)  of  bread  or  farinaceous  pudding ;  3  to  6 
ounces  (93.0-186.0)  of  fruit  for  dessert.  No  liquids  at  this  meal,  as  a 
rule,  but  in  hot  weather  6  ounces  (178.0)  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  (178.0)  of  coffee  or  tea,  with  as  much  water. 
An  ounce  of  bread  as  an  indulgence. 

Evening. — One  or  two  soft-boiled  eggs,  1  ounce  (32.0)  of  bread,  per- 
haps a  small  slice  of  cheese,  salad,  and  fruit ;  6  to  8  ounces  (178.0— 
236.0)  of  wine,  with  4  or  5  ounces  (120.0-148.0)  of  water  (Yeo). 

(3)  Graduated  exercise  up  inclines  of  various  grades.  The  distance 
to  be  undertaken  each  day  is  to  be  carefully  specified  and  frequently, 
though  gradually,  increased.  A  like  plan  is  to  be  pursued  with  refer- 
ence to  the  degree  of  inclination.  This  is  the  most  important  part  of 
the  system,  since  it  directly  invigorates  the  heart-muscles. 

(h)  Brown  Atrophy. — A  form  of  degeneration  in  which  accumulations 
of  yellowish-brown  pigment-granules  occur  in  the  muscular  fibers.  The 
color  exhibited  by  the  heart-muscle  is  a  reddish-brown,  and  in  pro- 
nounced cases  a  dark-red  brown.  Brown  atrophy  is  most  commonly 
seen  in  the  hearts  of  the  aged,  though  also  quite  often  in  cases  of 
chronic  valvular  disease  that  have  reached  an  advanced  stage. 

{c)  Calcareous  Degeneration  {Qalcification). — Calcareous  infiltration  of 
the  muscular  fibers  of  the  myocardium  has  been  noted,  though  very 
rarely.  Somewhat  more  common  are  the  bony  callosities  that  result 
from  myocardial  abscesses  {vide  Circumscribed  Myocarditis). 

{d)  Amyloid  Degeneration. — This  form  of  degeneration  is  rare.  It 
is  limited  to  the  blood-vessels  and  interstitial  connective  tissue ;  its 
causes  are  the  same  as  those  of  amyloid  degeneration  of  other  viscera. 


660  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

{e)  Hyaline  Degeneration, — This  is  sometimes  seen  in  association  with 
amyloid  change.  It  also  occurs  independently  in  prolonged  fevers 
{Jiyaline  transformation  of  Zeyiker).  The  fibers  are  swollen,  translu- 
cent, and  homogeneous,  and  their  strise  almost  entirely  disappear. 


CARDIAC  ANEURYSM. 

{Aneurysm  of  the  Heart.) 

A  CARDIAC  aneurysm  may,  in  the  first  place,  involve  the  whole 
diameter  of  the  myocardium  (aneurysm  of  the  walls).^  Secondly,  it 
may  merely  implicate  the  valves,  together  with  a  few  myocardial  fibers 
(valvular  aneurysm). 

Aneurysm  of  the  Walls. — This  is  not  of  frequent  occurrence.  Its 
most  common  seat,  however,  is  the  wall  of  the  left  ventricle  near  the 
apex ;  it  is  quite  generally  a  sequel  to  chronic  myocarditis,  which,  as 
before  stated,  occurs  oftenest  at  this  point.  Anything  that  produces  a 
decided  localized  weakness  of  the  ventricular  parietes  (other  forms  of 
degeneration  and  endocardial  and  pericardial  inflammations)  may,  how- 
ever, lead  to  its  development.  In  size  cardiac  aneurysms  are  exceed- 
ingly variable,  and  may  either  be  very  small,  or  as  large  as  the  average- 
sized  head  of  an  adult.  As  to  form,  two  types  should  be  recognized : 
(rt)  an  equable  dilatation  of  a  part  of  the  ventricular  wall,  and  (h)  the 
sacculated  form,  whicii  communicates  with  the  chamber  by  a  compar- 
atively small  orifice.  Layers  of  fibrin  are  often  found  in  these  aneur- 
ysmal dilatations  as  an  indication  of  Nature's  attempt  at  a  cure,  and 
occasionally  they  may  completely  efface  the  sac  when  the  attempt  is 
successful.  In  most  aneurysms  non-laminated  blood-clots  are  also 
found.  It  must  not  be  forgotten  that,  once  an  aneurysmal  distention 
has  begun,  a  straining  effort  may  cause  a  sudden  great  increase  of  the 
dimensions  or  even  rupture  it.  The  structures  adjacent  to  the  gradu- 
ally formed  aneurysm  exhibit  fibroid  overgrowth  and  other  kinds  of 
degeneration,  these  changes  being  secondary  and  most  probably  con- 
servative processes. 

Diagnosis. — Aneurysm  of  the  myocardium  has  no  characteristic 
features.  Usually  the  symptoms  and  local  signs  of  chronic  myocarditis 
or  dilatation  are  more  or  less  conspicuous,  but  the  presence  of  the 
aneurysm  is  not  even  suspected  unless  certain  physical  signs  develop  in 
the  coui'se  of  the  former  complaints.  Those  are — a  pulsating  prom- 
inence in  the  apex-region  that  may  even  perforate  the  chest-wall,  and  a 
coextensive  dulness.  The  abnormal  area  of  dulness  is  best  appreciated 
early  by  stethoscopic  percussion,  but  unless  peculiarly  circumscribed 
the  condition  cannot  be  distinguished  from  hypertrophy  or  dilatation. 
The  course  of  these  cases  is  unfiivorable,  death  ensuing  (rarely)  from 
rupture  of  the  sac  or  (more  frequently)  from  gradual  cardiac  exhaustion. 

Valvular  aneurysms  sometimes  arise  in  acute  ulcerative  endocarditis, 
which  destroys  the  segmented  endocardium  and  permits  of  dilatation  as 
the  result  of  the  intracardial  blood-pressure.     They  occur  Avith  much 

'  Of  87  cases  collected  by  Pelvet,  57  ^vere  in  this  situation,  and  of  90  collected  by 
Legg,  59. 


RUPTURE  OF  THE  HEART.  661 

greater  frequency  on  the  aortic  than  on  the  mitral  valves.  Thev  are 
spheroid  in  shape,  and  project  into  the  left  ventricle  when  found  at 
the  aortic  segments,  and  into  the  left  auricle  when  at  the  mitral.  Though 
usually  single,  they  are  multiple  in  a  few  instances.  Rupture  of  these 
aneurysms  is  common,  with  the  subsequent  development  of  extensive 
valvular  incompetency.      They  cannot  be  diagnosticated  during  life. 


RUPTURE  OF  THE  HEART. 

This  rare  and  serious  accident  may  either  be  complete  or  partial. 
The  term  partial  rupture  implies  laceration  of  the  trabeculje  ventriculi, 
whereby  the  chordte  tendine^e  are  liberated,  or,  more  seldom,  of  the 
papillary  muscle.  The  muscular  structure  may  be  involved  to  a  slight 
extent.  Valvular  incompetency  is  the  consequence  of  partial  rupture- 
Complete  rupture  consists  in  a  solution  of  continuity  of  the  total  diam- 
eter of  the  myocardium. 

Pathology. — The  chief  seat  of  rupture  is  the  anterior  wall  of  the 
left  ventricle,  though  it  may  also  occur  in  the  right  ventricle  and  in  the 
auricles,  but  Avith  great  rarity.  The  rent  runs  parallel  with  the  mus- 
cular fibers,  and  is  to  a  certain  extent  the  result  of  laceration,  though 
chiefly  of  a  separation,  of  the  fibers.  The  fissural  communication  pre- 
sents irregular  edges,  and  at  autopsy  is  seen  to  contain  blood-clots  ;  the 
pericardial  sac  is  also  occupied  by  coagula,  often  in  great  numbers. 
If  pericardial  adhesions  have  previously  obliterated  the  cavity,  the  es- 
caped blood-clots  may  occupy  the  pleural  cavity.  Histologic  examina- 
tion of  the  muscle-structure  surrounding  the  fissure  shows  the  charac- 
teristic changes  of  fatty  and  other  forms  of  degeneration. 

Ktiology. — Both  predisposing  and  exciting  causes  may  be  at  work. 
The  former  are  the  more  important  and  always  obtain,  and,  named  in 
the  order  of  their  frequency  of  occurrence,  the  predisposing  factors  are 
disease  of  the  coronary  arteries  (thrombotic  and  infectious  embolic  pro- 
cesses which  produce  anemic  necrosis  and  abscesses),  fatty  degeneration,^ 
chronic  myocarditis,  parietal  tumors,  and  parasites  in  the  heart-wall. 

The  influence  of  age  as  a  predisposing  factor  has  not  been  determined ; 
rupture  of  the  heart  usually  occurs  after  the  sixtieth  year  has  been  passed, 
however,  for  the  reason  that  the  myocardiac  changes  that  cause  rupture 
belong  to  that  period  of  life*  Males  suffer  somewhat  more  frequently 
than  females.  The  exciting  cause  is,  as  a  rule,  some  form  of  muscular 
exertion,  though  it  may  occur  spontaneously  during  sleejD. 

Symptoms. — In  the  majority  of  instances  rupture  of  the  heart  re- 
sults in  sudden  death.  Sometimes,  however,  the  patient  survives  the 
accident  for  several  hours  or  even  for  as  many  days.  The  symptoms 
are  those  oi  internal  bleeding,  in  addition  to  jyain  that  mav  be  agonizing 
and  is  referred  to  the  heart.  The  body-temperature  falls,  the  skin  sur- 
face becomes  pale  and  cool,  and  it  may  be  covered  with  cold  perspiration, 
while  the  pulse  grows  small,  very  frequent,  and  finally  almost  vanishes. 
Occasionally  gastro-intestinal  symptoms  and  syncope  tending  to  convul- 
*  According  to  Quain's  statistics,  about  75  per  cent,  of  the  cases  are  due  to  this  cause. 


662  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

sions  appear  in  consequence  of  the  irritation  of  the  vagus  centers  due  to 
cerebral  anemia.  The  phynical  signs  of  cardiac  failure  rapidly  develop, 
and,  if  the  leak  be  not  too  large,  those  of  pericardial  effusion  more 
gradually. 

Diagnosis. — A  certain  diagnosis  is  rarely  possible.  Heart-anguish, 
rapidly  j^rogressive  cardiac  failure,  the  evidences  of  internal  hemor- 
rhage, and  the  speedy  development  of  the  signs  of  pericardial  effusion 
should,  however,  always  excite  a  strong  suspicion  of  rupture,  and  in 
many  cases  suffice  for  a  correct  inference. 

The  prognosis  is  hopeless.  "When  immediately  fatal,  death  is  the 
direct  result  of  heart-shock  ;  when  delayed,  the  sad  issue  takes  place  in 
consequence  of  anemia  of  the  brain  or  of  compression  of  the  heart  by  the 
blood  that  pours  into  the  pericardial  cavity. 

Treatment. — Proplvilaxis  is  of  the  utmost  importance.  In  all 
conditions  of  the  cardiac  parietes  in  which  this  accident  is  liable  to  occur 
the  physician  should  not  fail  to  give  ample  warning  of  the  dangers  con- 
nected with  muscular  strain  of  whatever  sort.  If  rupture  has  occurred 
or  is  suspected  to  have  taken  place,  the  patient  must  be  put  at  complete 
rest  in  the  horizontal  position.  Full  doses  of  morphin  should  be  given 
hypodermically,  and  the  ice-bag  locally  applied.  Warmth  to  the  ex- 
tremities may  be  useful,  but  applied  to  the  heart-region  can  be  only 
harmful.  The  use  of  pure  cardiac  stimulants  Avill  be  attended  with  in- 
creased bleeding  from  the  rent,  but  agents  that  relax  the  peripheral 
arterioles,  such  as  nitroglycerin,  may  be  employed  with  a  view  to  dimin- 
ishing the  heart's  labor  without  diminishing  its  power.  Should  the  rup- 
ture be  partial  and  the  hemorrhage  slight,  the  patient's  life  may  be  pro- 
longed, or  even  saved,  by  keeping  him  at  absolute  rest  for  a  long  period 
or  until  Nature  effects  recovery. 


MINOR  AFFECTIONS  OF  THE  HEART. 

{a)  New  Growths. — Primary  carcinoma  or  sarcoma  is  rare  indeed. 
Metastatic  growths  occur,  but  are  very  rarely  sufficiently  large  (except 
perhaps  the  colloid  variety)  to  be  detected  by  physical  examination,  or 
to  give  rise  to  symptoms.  Very  large  tumors  may  weaken  the  heart- 
muscle,  but  this  must  be  an  extremely  rare  occurrence.  Kayserlink  re- 
ports a  case  of  lympho-sarcoma  with  well-marked  symptoms.  The  sep- 
aration of  portions  of  the  tumor  may,  if  of  considerable  size,  block  one 
of  the  valvular  orifices  and  cause  sudden  death,  or  more  minute  portions, 
becoming  released,  may  give  rise  to  embolism  in  distant  parts.  Tuber- 
culosis and  syphilis  have  been  considered  elsewhere. 

(6)  Parasites. — Four  forms  may  invade  the  heart-muscle — the  taenia 
echinococcus,  actinomyces,  cysticercus  cellulosse,  and  the  pentastomum 
denticulatum.  The  former  two  are  alone  productive  of  mischievous  re- 
sults. The  echinococcus  crrowths  mav  attain  to  considerable  dimensions 
and  are  often  multiple ;  they  are  secondary  to  echinococcus-cysts  in 
other  organs.  Their  effects  are  produced  in  a  purely  mechanical  man- 
ner unless  fragments  become  detached,  when  thev  mav  excite  embolic 


NEUROSES  OF  THE  HEART.  663 

lesions  at  different  points  in  remote  organs.  Embolic  abscesses  have 
occasionally  been  observed,  appearing  like  degenerations  due  to  the 
actinomyces  fungus. 

[e)  Misplacement  {Transposition  of  the  Heart). — During  intra-uterine 
life  the  heart  (and  rarely  all  the  other  thoracic  and  abdominal  viscera) 
may  either  be-  transposed  to  the. right  side  of  the  thorax,  or  the  fetal 
position — in  the  median  line — may  be  retained.  The  sternum  may  be 
missing  in  whole  or  in  part,  and  the  heart,  which  noAv  lies  immediately 
beneath  the  skin,  can  be  seen  and  felt  as  a  throbbing  tumor.  Recently 
a  man  of  about  forty  years  applied  at  the  Medico-Chirurgical  Hospital 
in  whom  the  lower  half  of  the  sternum  was  absent;  his  heart  occupied  a 
position  in  the  median  line  directly  underneath  the  skin,  where  its  strong 
pulsations  could  be  felt.  The  patient  stated  that  it  had  given  him  no 
inconvenience. 

Very  exceptionally  other  anomalous  positions  are  acquired  during 
ante-natal  development,  and  the  heart  may  become  displaced  upward  in 
the  chest-cavity  even  to  the  neck  or  downward  into  the  abdominal  cavity. 

{d)  Floating  Heart. — The  structures  that  serve  to  maintain  the  heart 
in  its  normal  anatomic  relations  may  become  weakened  or  unduly  lax, 
in  consequence  of  which  the  organ  may  exhibit  increased  motility. 


III.  NEUROSES   OF  THE   HEART. 
PALPITATION. 

Definition. — A  more  or  less  rapid  action  of  the  heart  that  is  per- 
ceptible to  the  patient,  and  usually  accompanied  by  an  increased  force 
of  the  cardiac  contractions  or  a  disturbance  of  the  rhythm,  and  often 
also  by  precordial  distress,  anxiety,  and  dyspnea. 

Htiology, — Chronic  valve-disease  and  other  organic  affections  of 
the  heart  seldom  produce  palpitation,  numerous  conditions  outside  of 
the  organ  being  more  frequently  related  causatively.  Among  these 
are — (1)  Mental  excitement,  depression  or  emotion ;  (2)  Anemia  (from 
the  local  irritant  action  of  the  altered  blood-state) ;  (3)  The  acute  in- 
fectious diseases,  in  which  the  toxins  in  the  blood  irritate  the  cardiac 
accelerating  nerves ;  (4)  Dyspepsia,  even  in  robust-appearing  persons 
(as  in  the  gouty)  who  willingly  or  unwillingly  commit  dietetic  errors. 
Special  articles  of  diet  may  excite  over-action  (e.  g.  strawberries,  shell- 
fish), the  palpitation  thus  arising  from  reflex  frritation  being  de- 
pendent upon  gastric  catarrh.  (5)  The  use,  and  more  especially  the 
abuse,  of  tea,  coffee,  alcohol,  and  tobacco.  These  agents  are  injurious 
largely  through  their  effects  upon  the  nerves.  (6)  The  female  sex  mani- 
fests a  greater  disposition  to  the  complaint  than  the  male,  especially 
about  the  period  of  puberty  and  the  menopause.  In  the  male  it  is  most 
common  at  or  after  the  middle  period  of  life,  a  time  when  the  effects  of 
the  work  and  worry  of  life  shoAv  themselves.  (7)  Disturbances  of  the 
ovaries  and  other  pelvic  organs  may  induce  palpitation  reflexly. 

Symptomatology. — Cardiac  over-action   may,  though   rarely,  be 


664  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

constant,  but,  as  a  rule,  it  displays  a  definitely  paroxysmal  character. 
The  onset  is  sudden,  and  immediately  preceding  the  attack  there  are 
often  a  blanching  of  the  face  and  a  slowing  of  the  cardiac  action,  symp- 
toms due  to  the  momentary  inhibitory  eiFect  of  the  nerve-aflfections  that 
cause  the  "palpitation."  The  patient's  jierception  of  increased  force 
and  rapidity  of  the  heart's  action  is  the  essential  symptom.  The  patient 
may  complain  of  throbbing  sensations  and  jxtljjitafion,  with  a  normally 
acting  heart,  the  symptoms  being  wholly  subjective  in  character.  Mental 
anxiety  is  common,  and  dyspnea,  the  latter  symptom  assuming  curious 
phases.  In  a  recent  case  of  my  own  the  patient  would  attempt  at  inter- 
vals of  three  to  five  minutes  a  forcible,  long-drawn  inspiration,  which 
Avould  sometimes  successfully  relieve  his  respiratory  difficulties  for  a  while. 

Physical  Signs. — Inspection  shows  the  impulse  to  be  somewhat  diffuse 
and  forcible.  Visible  throbbing  of  the  superficial  vessels  is  also  common. 
The  finyer-tips  easily  appreciate  the  increased  strength  of  the  impulse. 
At  the  wrist  the  pulse,  though  strong  and  full,  as  a  rule  is  rapid,  the 
rate  varying  from  120  to  160  per  minute.  Percussion  may  show  the 
area  of  cardiac  dulness  to  be  enlarged,  while  auscultation  re\eK\&\ond.ex 
sounds  than  the  normal.  The  attack  is  usually  of  brief  duration — but 
a  few  minutes — though  sometimes  it  may  last  for  hours  or  days. 

Attention  should  here  be  called  to  the  irritable  heart  described  by 
DaCosta — a  form  of  palpitation  common  among  young  soldiers  during 
the  late  Civil  War.  It  was  caused  partly  b}'  mental  excitement  and 
partly  by  inordinate  muscular  exertion.  A  minor  part  in  its  production 
was  also  played  by  the  diarrhea  that  was  so  often  present.  The  leading 
symptoms  were  palpitation,  a  very  frequent  pulse,  dyspnea,  and  cardiac 
pains  of  varying  intensity. 

Differential  Diagnosis. — Nervous  palpitation  must  be  distin- 
guished from  the  comparatively  rare  cases  in  which  the  heart  contracts 
rapidly  and  irregularly,  but  does  not  excite  subjective  sensations.  Some 
of  the  latter  instances  are  to  be  looked  upon  as  physiologic,  while  others 
are  due  to  exhaustion  and  other  causes.  They  do  not  constitute  cases 
of  palpitation,  since  they  are  unperceived  by  the  patient,  but  are  in 
reality  cases  of  either  tachycardia  or  arrhythmia. 

Palpitation  due  to  chronic  val re- disease  should  also  be  differentiated 
from  the  purely  nervous  form.  Here  chief  reliance  is  to  be  placed  upon 
the  presence  of  a  murmur  and  other  physical  signs  during  the  intervals 
between  the  attacks.  Anemic  murmurs  are  sometimes  present,  and  must 
not  be  confounded  with  those  of  organic  nature. 

Progfnosis. — The  condition  is  free  from  real  danger  to  life.  Most 
authors,  however,  a^e  agreed  that  cardiac  hypertrophy  may  be  a  sequel. 

Treatment. — The  chief  indications  for  treatment  are — (1)  The  arrest 
of  the  paroxysm.  The  patient  must  be  put  at  absolute  rest  in  bed  in  a 
large,  well-ventilated,  darkened  chamber,  and  his  clothing  loosened  so 
that  the  respiration  is  unimpeded.  Pressure  upon  the  vagus  in  the 
neck  or  upon  special  points  on  the  abdominal  parietes  (the  ovarian 
region  in  particular)  sometimes  arrests  the  attack  promptly.  In  my 
own  hands  the  best  results  have  been  obtained  from  the  application  of 
the  ice-bag  to  the  precordial  region.  If  this  does  not  succeed  in  cutting 
short  the  paroxysm  in  the  course  of  a  couple  of  hours,  the  ice-bag  should 
be  removed  every  third   hour.     In  conjunction  with   this  measure  the 


TACHYCARDIA.  665 

patient  should  be  told  to  take  large  draughts  of  cold  water  or  to  swallow 
bits  of  ice.  On  the  other  hand,  I  have  observed  a  few  instances  which 
were  speedily  relieved  by  the  ingestion  of  hot  and  somewhat  stimulating 
drinks.  It  is,  however,  not  possible  to  formulate  general  rules  that  will 
be  applicable  to  all  cases.  Kinnear  ^  treats  cardiac  palpitation  by  apply- 
ing cold  over  the  sympathetic  ganglia  of  the  spinal  cord. 

Among  the  many  therapeutic  measures  that  have  been  employed, 
morphin  alone  has  given  quite  constantly  good  results,  and  particularly 
when  administered  hypodermically.  However,  before  employing  morphin, 
other  sedatives  and  narcotics  should  be  tried,  such  as  the  bromids  (in 
large  doses),  hyoscyamus,  hyoscin,  and  camphor  monobromate.  In  neur- 
asthenic and  hysteric  subjects  the  bromids  and  the  preparations  of  vale- 
rian are  highly  serviceable.  The  tincture  of  valerian  or  the  elixir  of 
valerian  ammoniate  may  be  used,  and  I  have  found  the  following  cap- 
sule of  great  utility  : 

^.  Zinci  valerianat.,  gr.  x  (0.648); 

Strychninse  sulph.,  gr.  l  (0.0216); 

Ext.  sumbul.,  gr.  x  (0.648); 

Ext.  hyoscyami,  gr.  v  (0.324); 
M.  et  ft.  capsulge  No.  x. 
Sig.   One  after  meal-time. 

If  a  special  article  of  diet  or  an  overloaded  state  of  the  stomach  is 
the  cause,  an  emetic  may  be  given  and  the  attack  thus  speedily  con- 
trolled.    Oxygen-inhalations  have  been  warmly  advocated. 

(2)  To  prevent  a  recurrence  of  the  jjaroxysms^  the  causal  conditions, 
some  of  which  may  long  antedate  the  occurrence  of  palpitation,  must  be 
removed,  if  this  be  possible.  All  exciting  factors  must  also  be  avoided.  The 
use  of  tea,  coffee,  and  tobacco  must  be  discontinued,  and  alcohol  should 
be  allowed  only  in  small  amounts.  The  general  health  must  be  consid- 
ered, and  anemia,  chlorosis,  neurasthenia,  or  hysteria  must  each  receive 
appropriate  treatment  when  present.  When  cardiac  palpitation  occurs  in 
neurasthenia  and  hysteria  the  Weir  Mitchell  rest-cure  should  be  advised, 
its  results  often  being  strikingly  good  if  rigidly  practised.  Galvanism 
of  the  pneumogastric  is  sometimes  useful,  the  positive  pole  being  placed 
under  the  angle  of  the  jaw,  and  the  negative  lower  down,  over  each  side 
of  the  neck.  The  removal  of  certain  local  conditions  that  sustain  a 
causal  relation,  as  gastric  catarrh  or  intestinal  parasitic  diseases,  is  a 
question  that  must  not  be  overlooked.  If  the  heart  be  weak,  digitalis 
may  be  exhibited  for  a  long  time  in  small  dose.  I  have  observed  good 
effects  from  the  use  of  baths  (carbonated). 


TACHYCARDIA. 

( Tachycardia  Paroxysmalis  ;  Syncliopexia  ;  Rapid  Heart.) 

Definition. — A  rapid  movement  of  the  heart  occurring  in  parox- 
ysms of  variable  duration,  and  directly  dependent  upon  either  paralysis 
of  the  pneumogastric  or  stimulation  of  the  sympathetic  nerves.     It  is 

'  Med.  Rec,  July  16,  1898. 


6G6  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

not  dependent  upon  chronic  valvular  disease,  nor  upon  other  gross 
organic  lesions,  nor  is  it  generally  accompanied  by  notable  subjective 
sensations.  Martins  believes  that  the  condition  is  attributable  to  sud- 
den  dilatation. 

Pathology  and  Btiology. — It  occurs  as  a  physiologic  condition 
in  a  certain  proportion  of  the  human  family ;  in  such  cases  the  pulse  may 
range  from  90  to  100  beats  per  minute  or  over.  Certain  individuals  can 
increase  the  pulse-rate  by  their  own  volition.  The  pathologic  forms  are 
divisible  into — (1)  Essential  or  neurotic  tachycardia,  and  (2)  Symptom- 
atic tachycardia. 

(1)  Neurotic  Tachycardia. — The  causes  of  this  variety  are  identical 
with  many  of  those  that  excite  palpitation  ;  hence  these  cardiac  neuroses 
are  often  associated.  Thus,  among  disposing  factors  are  hysteria, 
anemia,  neurasthenia,  chlorosis,  and  toxic  agencies  (tea,  cofiFee,  tobacco, 
the  poisons  of  fevers).  Violent  exercise,  intense  mental  agitation, 
fright,  grief,  and  other  forms  of  shock  are  determining  influences.  Not 
a  few  cases  are  met  at  or  about  the  menopause. 

(2)  Symptomatic  Tachycardia. — The  lesions  that  induce  this  form  are 
— (a)  central  and  {b)  peripheral.  In  the  former  group  are  especially  to 
be  placed  tumors,  clots  (due  to  hemorrhage),  and  softening  of  the  me- 
dulla and  cord  ;  and  in  the  latter,  tumors,  aneurysms,  enlarged  lymph- 
glands  (which  paralyze  the  vagus  by  exerting  pressure  upon  it  either 
in  the  neck  or  thorax),  and  neuritis,  affecting  the  pneumogastric  nerve. 
The  latter  lesion  may  be  associated  Avith  polyneuritis  (alcoholic  or  infec- 
tious). Rapid  heart  may  be  due  to  reflex  irritation  (gastric,  intestinal, 
arterial,  uterine,  ovarian),  or  gastro-intestinal  intoxication. 

Symptoms. — The  clinical  picture  in  most  instances  of  the  com- 
plaint is  made  up  of  recurring  paroxysms  of  heart  hurry  {paroxT/smal 
tachycardia).  These  attacks  come  on  with  great  suddenness,  and,  as  a 
rule,  without  prodromes  or  forebodings.  If  the  latter  occur,  they  con- 
sist of  vertigo,  tinnitus,  and  a  sense  of  impending  danger,  and  some- 
times persist  to  the  end  of  the  attack.  With  the  onset  of  the  parox- 
ysms the  cardiac  movements  leap  to  150,   175,   200,  and  250,  or  even 


vJVAAAAA/\AA/W\A^/^AAAA/^AA^AA/^/^^A/^^ 


Fig.  55.— Kiulial  pulse  during  an  attack  of  paroxysmal  tachycardia. 

to  300  beats  per  minute.  The  puhe  is  feeble,  small,  readily  compres- 
sible as  a  rule,  and  sometimes  irregular  (Fig.  55).  Rarely  it  is  full, 
strong,  and  of  good  tension.  The  respiration  may  or  may  not  be  in- 
creased in  frequency,  but  dyspnea  is  not  common.  Respiratory  oppres- 
sion and  smothering  are  seldom  witnessed  in  genuine  tachycardia. 
At  first  pale,  the  skin  soon  becomes  flushed,  and  the  countenance  may 
wear  an  anxious  expression  ;  but  unless  "  palpitation  "  is  associated 
there  are  no  symptoms  present  that  denote  an  intense  degree  of  suff'er- 
ing.  In  many  cases  the  patient  is  not  conscious  of  palpitation,  or  there 
may  be  a  sense  of  slowing  of  the  heart,  when  in  reality  the  cardiac  con- 


BBACHYCABDIA.  667 

tractions  may  be  increased  to  200  or  more  ;  this  is  typical  tachycardia. 
In  a  clilorotic  girl  I  found  that  the  pulse-rate  increased  to  200  beats, 
and  lasted  for  a  few  minutes  at  each  visit  to  my  office.  During  the 
intervals  between  the  visits  the  pulse  was  apparently  normal  in  fre- 
quency. H.  C.  Wood  reports  a  truly  remarkable  case  occurring  in  a 
physician  in  his  eighty-seventh  year,  who  has  had  attacks  at  intervals 
since  his  thirty-seventh  year.  Following  a  sudden  onset,  the  pulse 
rises  quickly  to  200  beats  per  minute.  The  attacks  can  be  averted  by 
the  taking  of  ice-water  or  strong  coffee. 

Physical  Signs. — A  diffuse,  rapid,  and  sometimes  irregular  impulse 
may  be  observed  on  inspection  and  palpation^  but  seldom  is  there  an 
enlargement  of  the  heart.  The  sounds  are  slightly  modified,  the  first 
being  accentuated  and  the  second  aortic  greatly  diminished  in  intensity, 
owing  to  the  lessened  amount  of  blood  thrown  into  the  aorta  with  each 
ventricular  systole  ;  the  intensity  of  the  second  pulmonic,  however,  may 
be  increased.  An  apical  systolic  murmur  is  occasionally  audible.  The 
carotids  pulsate,  and  on  auscultating  over  them  a  murmur  is  sometimes 
heard.  The  duration  of  paroxysmal  tachycardia  varies  from  one  to  two 
or  more  decades. 

Diagnosis. — I  would  restate  the  fact  that  a  high  pulse-rate  (200  or 
over  a  minute)  and  an  absence  or  only  a  slight  sense  of  palpitation  or 
rapid  heart-action  are  the  distinctive  features  of  true  tachycardia.  In 
palpitation  (previously  considered)  the  pulse- rate  is  not  usually  so  high 
as  in  tachycardia,  while  the  associated  phenomena  of  dyspnea,  precor- 
dial constrictions,  smothering,  and  painful  anxiety  are  correspondingly 
more  pronounced. 

Prognosis. — In  the  majority  of  cases  no  serious  impairment  of  the 
general  health  follows,  though  the  course  is  exceedingly  chronic  and 
recoveries  are  comparatively  rare.  When  symptomatic  tachycardia  is 
due  to  lesions  that  are  removable,  it  is  often  curable,  though  not  invari- 
ably so.  In  sufferers  who  are  advanced  in  years,  however,  the  cerebral 
vessels  may  rupture.  Boveret  analyzed  a  number  of  cases,  4  of  which 
proved  suddenly  fatal  in  consequence  of  heart-failure.  In  forecasting  the 
issue  durincr  the  paroxvsm  these  serious  accidents  must  be  considered. 

The  treatment  is  to  be  conducted  on  precisely  the  same  lines  as 
those  advanced  for  "Palpitation  "  {vide  p.  664). 


BRACHYOARDIA. 

( Bradycardia.) 

Definition. — Slowness  of  the  pulse.  The  condition  may  be  physio- 
logic, the  rate  of  the  pulse  being  sometimes  60  or  less,  and  very  rarely 
as  low  as  40  per  minute  during  perfect  health. 

All  cases  of  pathologic  brachycardia  fall  naturally  and  conveniently 
into  two  groups  :  (1)  those  that  are  secondary  to  other  complaints  {symp- 
tomatic brachycardia) ;  and  (2)  those  that  are  due  to,  or  associated  with, 
a  neurosis. 

Pathology  and  Htiology. — Symptomatic  Brachycardia. — (a)  Aris- 
ing during  convalescence  from  acute  infectious  diseases,  especially  pie-u- 


668  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

monia,  typhoid,  diphtheria,  influenza,  and  acute  rheumatism.  Accord- 
ing to  Riegel,  who  analyzed  1047  cases  in  which  the  pulse-rate  was  less 
than  60,  the  acute  fevers  must  be  awarded  the  first  place  among  the 
causal  factors.  I  have  met  with  3  cases  of  diphtheria  in  which  the  pulse 
in  convalescence  fell  to  30  a  minute.  That  such  instances  are,  as  Traube 
contends,  due  to  exhaustion  is  true  of  some  cases,  but  not  of  all,  and 
doubtless  there  are  other  changes  in  a  certain  proportion.  The  slowing 
of  the  pulse  that  is  observed  after  premature  or  full-time  delivery  is  sim- 
ilarly ]jroduced.  (b)  The  second  place  belongs  easily  to  gastro-intestinal 
and  hepatic  disorders  (chronic  gastro-intestinal  catarrh,  ulcer,  or  carci- 
noma of  the  stomach),  {c)  Brachycardia  occurs  in  diseases  of  the  circu- 
latory system — in  coronary  disease,  fibroid  and  fatty  myocardial  change, 
most  frequently ;  and  chronic  valvular  disease  much  less  frequently, 
if  we  except  aortic  stenosis.  (fZ)  Pulmonary  complaints  (emphysema 
and  asthma),  (e)  Toxic  agencies,  as  in  jaundice,  blood-poisoning,  alco- 
holism, the  unwonted  use  of  tea,  coffee,  tobacco,  and  a  few  drugs  {e.  g. 
digitalis,  strophanthus).  (.f )  Constitutional  affections  (anemia,  chlorosis, 
gout,  diabetes),  {g)  Rarely  skin-diseases  and  affections  of  the  sexual 
organs,  and  commonly  myxedema,  are  associated  with  brachycardia.  In 
various  organic  nerve-affections  (apoplexy,  meningitis,  epilepsy,  tumors 
of  the  cerebrum,  and  the  medulla  in  particular,  injuries  and  diseases  of 
the  cervical  portion  of  the  cord).  In  such  cases  the  brachycardia  is  due 
chiefly  to  direct  or  reflex  irritation  of  the  center  or  of  the  peripheral 
portion  of  the  vagus  system.  Indeed,  brachycardia  is  produced  in  one 
or  other  of  these  ways,  except  in  those  cases  in  which  it  is  brought 
about  by  exhaustion  of  the  automatic  motor  apparatus  of  the  heart. 

(2)  Brachycardia  associated  with  a  neurosis  may  be  found  to  be 
marked  in  epilepsy ;  less  so  in  hysteria,  melancholia,  mania,  3Ljid  general 
paresis  of  the  insane.     It  precedes  palpitation. 

Symptoms. — The  sole  characteristic  symptom  is  the  slow  action  of 
the  heart,  and  this  may  either  be  temporary  or  permanent.  If  parox- 
ysmal, both  the  onset  and  termination  are  apt  to  be  sudden.  A  slow  emerg- 
ence is,  however,  more  common  than  a  slow  beginning,  though  a  small 
group  of  prodromes  a])pears,  comprising  vertigo,  tinnitus,  and  a  sense  of 
impending  danger.  During  the  paroxysm  the  patient  may  repeatedly 
suffer  from  syncopal  attacks  or  become  unconscious  for  hours  at  a  time ; 
physical  prostration  may  also  be  marked,  and  especially  when  secondary 
to  chronic  valve-disease.  The  pulse  is  weak  and  small,  and  the  beats 
per  minute  vary  from  50,  40,  30,  20,  to  10,  or  even  8.  When  the  con- 
dition arises  in  the  course  of  organic  valve-lesions  the  cardiac  contrac- 
lions..  as  a  general  rule,  may  be  increased  in  power,  though  greatly 
reduced  in  frequency.  Thus.  I  observed  this  occurrence  in  a  patient 
under  my  care  at  the  Philadelphia  Hospital  suft'ering  from  a  double 
mitral  lesion  and  aortic  constriction.  The  pulse  fell  from  70  to  28  per 
minute,  but  the  systole  was  more  powerful  than  before  brachycardia 
was  developed.  The  pulse  at  the  wrist  does  not  show  the  rate  of 
cardiac  contractions  (when  the  heart  is  weak),  since  the  latter  do  not 
always  emit  a  pulse-wave  that  can  be  detected  at  the  wrist ;  hence  the 
heart-action  must  be  noted  by  auscultation,  and  the  rate  compared  with 
that  of  the  peripheral  pulse.  The  impulse  and  the  heart-sounds  are 
feeble. 


ARRHYTHMIA.  669 

Diagnosis. — A  pulse  below  48  beats  per  minute,  with  correspond- 
ing slowness  of  the  systole,  suffices  for  a  certain  diagnosis. 

The  prognosis  is  governed  by  the  cause,  being  very  grave  in  cerebral 
and  advanced  cardiac  diseases.     When  fatal,  sudden  death  is  the  rule. 

Treatment. — Rest  in  the  lying  posture,  particularly  if  the  condition 
has  come  on  in  organic  heart-disease,  and  such  remedies  as  atropin, 
strychnin,  caffein,  nitroglycerin  (in  small  doses),  and  ammonia  are  to  be 
given  a  trial.  If  the  ventricular  contractions  are  very  feeble  and  not 
below  30,  small  doses  of  digitalis  will  be  found  useful,  though  the  efiFect 
must  be  closely  watched.  In  the  intervals  between  the  attacks  the  gen- 
eral health  must  be  improved  and  the  causal  states  eradicated. 


ARRHYTHMIA. 

{Irregular  Heart-  and  Pulse-beat.) 

(1)  The  irregularity  may  affect  only  the  volume  and  force  of  the 
pulse.  Here  the  intervals  between  the  beats  are  equal,  but  in  regard  to 
fulness  and  strength  the  beats  are  unequal.  Instances  of  irregularity 
in  the  volume  and  strength  of  heart-beats  may  give  rise  to  the  condition 
known  as  pulsus  altenians  (Traube),  in  Avhich  fuller  and  stronger  pulse- 
beats  regularly  alternate  with  those  of  lesser  volume  and  strength  (see 
Fig.  56).     (2)  Irregularity  in  Time, — (a)  Intermittent  heart-beat.     This 


Fig.  56.— Pulsus  bigeminus  alternans  (Eichhorst). 

is  but  an  exaggerated  degree  of  the  first  variety,  and  signifies  a  missed 
or  dropped  beat.  This  occurs  at  irregular  intervals  in  most  of  the  cases, 
though  sometimes  a  cyclical  irregularity  is  observed — /.  e.  every  second, 
fourth,  sixth,  or  eighth  beat  being  lost,  (b)  Twin-pulse  (coupled  beats, 
allorrliythmia).  When  two  beats  follow  each  other  quickly  (the  diastole 
being  shortened),  and  the  next  two  not  so  quickly  (the  diastole 
being  lengthened),  we  have  produced  the  pulsus  bigeminus.  The  first 
and  second  beats  may  be  of  equal  strength,  but  often  the  second  is  rela- 
tively feeble.  This  is  best  determined  by  auscultation  of  the  heart, 
since  the  second  systolic  contraction  (of  the  ventricle)  may  indeed  be  so 
weak  as  not  to  give  rise  to  a  palpable  beat  at  the  wrist.  I  have  fre- 
quently observed  the  pulsus  bigeminus  in  mitral  disease.     With  respect 


670  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

to  the  diastole,  the  approximated  pulsations  may  be  in  blocks  of  three 
(pulsus  trigetninus),  or  even  of  four  (pulsus  quadrigeminus).  (3)  Com- 
bined irregularity  of  time  and  volume.  Whilst  the  forms  of  irregularity 
described  above  should  be  distinguished  from  one  another,  this  is  not 
always  practicable,  particularly  in  the  last  stages  of  valvular  affections 
and  in  the  acute  infectious  diseases — conditions  in  which  the  heart- 
muscle  fails  in  consequence  of  degenerative  changes.  (4)  The  paradox- 
ical pulse  of  Kussmaul  also  consists  in  irregularity  of  volume,  strength, 
and  time,  though  not  indicative  of  so  great  peril  as  the  preceding.  It 
is  dependent  upon  the  act  of  inspiration — "normal  as  well  as  forced" 
— the  beats  during  inspiration  being  more  rapid,  though  weaker,  than 
during  expiration.  This  is  met  Avith  in  chronic  adhesive  pericarditis, 
in  cases  of  pressure  upon  the  root  of  the  aorta  by  bands,  in  pleuro-peri- 
carditis,  and  in  a  very  weak  heart.  (5)  Delirium  cordis  is  a  term  very 
appropriately  given  to  great  irregularity  and  ine(iuality  of  the  pulse-beats. 
It  is  seen  in  extreme  dilatation  and  advanced  exophthalmic  goiter.  (6) 
Embrocardia  or  Fetal  Heart-rhythm. — There  is  a  shortening  of  the  long 
pause  with  a  striking  similarity  of  the  first  and  second  sounds,  as  in  the 
fetal  heart.  I  have  already  pointed  this  out  in  connection  with  dilata- 
tion, though  it  also  sometimes  attends  the  advanced  stages  of  grave 
fevers.  (7)  Cantering  Rhjrtlim  (bruit  de  galop). — The  sounds  simulate 
the  triple  footfall  of  a  horse  at  a  canter.  The  interpolated  sound  is  due 
to  a  reduplication  of  the  second,  though  rarely  it  is  the  first  that  is 
doubled  instead.  It  is  developed  in  the  hypertrophy  of  arterio-sclerosis 
and  Bright's  disease,  in  profound  anemias,  and  in  the  myocarditis  of 
certain  acute  infectious  diseases.  (8)  Tremor  Cordis. — By  this  is  meant 
a  ventricular  systole  so  rapid  as  to  be  evidenced  by  mere  vibrations. 
Ktiology. — Baumgarten's  classification  of  the  causes  of  arrhythmia 
(quoted  by  Osier)  is  the  best,  and  is  here  given: 

(1)  Those  due  to  central — cerebral — causes,  either  organic  disease,  as 
in  hemorrhage  or  concussion,  or  more  commonly  psychical  influences. 

(2)  Reflex  influences,  such  as  produce  the  cardiac  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

(3)  Toxic  influences.  •  Tobacco,  coffee,  and  tea  are  common  causes  of 
arrhythmia.  Various  drugs,  as  digitalis,  belladonna,  and  aconite,  may 
also  induce  it. 

(4)  Changes  in  the  heart  itself,  (a)  In  the  cardiac  ganglia.  Fatty, 
pigmentary,  and  sclerotic  changes  have  been  described  in  cases  of  this 
sort,  and  these  may  have  an  important  influence  in  producing  disturb- 
ances in  the  rhythm,  but  as  yet  we  do  not  know  their  exact  significance. 
They  may  be  present  in  cases  that  have  not  presented  arrhythmia,  (h) 
Mural  changes  are  common  in  conditions  of  this  kind.  Simple  dilata- 
tion, fatty  degeneration,  and  sclerosis  are  most  commonly  present,  the  two 
latter  being  usually  associated  with  sclerosis  of  the  coronary  arteries.^ 

Symptoms. — Arrhythmia,  particularly  when  functional  or  of  reflex 
origin,  may  exist  for  years  together,  without  associated  symptoms  refer- 
able to  the  heart,  and  hence  is  often  discovered  accidentiilly.  When  it 
is  combined  with  palpitation  or  extreme  weakness  or  dilatation  of  the 
organ,  it  is  apt  to  arrest  not  only  the  attention  of  the  observer  in  many 
instances,  but  also  that  of  the  patient. 

^  Transactions  of  the  Association  of  American  Physicians,  vol.  iii. 


ANGINA  PECTORIS.  671 

Physical  Signs. — In  given  cases  the  cause  will  be  found  to  govern  the 
character  of  the  physical  signs,  which  are  often  scanty  or  sometimes 
practically  wanting.  Those  usually  present  have  been  indicated  in 
speaking   of  the   diiferent   varieties. 

Diagnosis. — Palpation  and  auscultation  of  the  heart  while  examin- 
ing the  pulse  are  matters  that  should  never  be  neglected  if  reliable  results 
are  to  be  obtained.  It  is  especially  in  this  class  of  cases  that  the  sphyg- 
mograph  renders  invaluable  aid.  Sphygmograms  will  often  show  the  kind 
and  degree  of  arrhythmia  when  all  other  means  of  examination  have  failed, 
and  also  distinguish  marked  dicrotism  from  irregularity. 

It  is  important  to  differentiate  functional  arrhythmia  or  that  of  reflex 
origin  from  arrhythmia  due  to  more  or  less  grave  myocardial  disease. 
Important  information  is  supplied  by  carefully  reviewing  the  varied  etio- 
logic  factors  that  produce  the  functional  form,  and  by  close  observation 
of  the  cardiac  symptoms. 

The  prognosis  is  variable.  A  gentleman  with  whom  I  am  ac- 
quainted was  rejected  by  a  life-insurance  company  twenty  years  ago  on 
account  of  occasional  slight  arrhythmia,  though  he  is  still  in  active  busi- 
ness life  and  apparently  in  vigorous  health.  When  the  myocardium 
becomes  involved,  as  occurs  in  chronic  valvular  or  coronary  disease  or 
in  the  acute  infectious  diseases,  the  prospect  is  gloomy ;  on  the  other 
hand,  when  it  is  functional  or  due  to  other  causes  outside  of  the  heart 
itself,  the  course  pursued  is  as  a  rule  favorable.  When  the  second  sound 
follows  closely  the  first  (marked  abbreviation  of  the  systolic  pause)  it  is 
a  serious  indication. 

Treatment. — There  are  many  cases  of  the  more  benign  form  in 
which  no  treatment  is  required  apart  from  methodic,  physical  training 
to  improve  the  strength  of  the  heart-muscle  and  the  general  systemic 
development.  Removal  of  the  causal  forces,  as  tea,  coffee,  alcohol,  in- 
digestible food-stuffs,  conditions  acting  in  a  reflex  manner,  must  be  ex- 
ecuted promptly.  When  the  condition  is  due  to  changes  in  the  heart- 
structures,  cardiants  in  addition  to  the  general  tonics  should  be  pre- 
scribed. I  prefer  strychnin,  arsenic,  and  the  dried  sulphate  of  iron  in 
combination.  Nitroglycerin  is  of  service  if  the  arterial  tension  be  high. 
If  the  arrhythmia  be  due  to  excessive  cardiac  dilatation,  digitalis 
should  be  employed.  In  purely  functional  cases,  in  which  there  is  a 
predominating  neurotic  element,  the  subjoined  formula  has  been  useful 
in  my  hands  : 

]^.  Ferri  valerianatis, 

Zinci  valerianatis,      da.  gr.  xxx  (1.94) ; 
Strych.  sulph.,  gr.  j       (0.0648) ; 

Pulv.  digitalis,  gr.   viij  (0.518).- 

Ft.  capsulse  No.  xxx. 
Sig.   Take  one  after  meal-time. 


ANGINA  PECTORIS. 

[Stenocardia^   Breast-pang.) 

Definition. — A  paroxysm  of  violent  precordial  pain  extending  into 
the  neck,  back,  and  arms,  and  at  times  attended  by  a  sense  of  impending 


672  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

death.  It  scarcely  deserves  to  be  classified  as  a  separate  disease,  being 
merely  symptomatic  of  several  cardiac  or  aortic  (?)  lesions. 

Pathology''. — Concerning  the  pathogenesis  of  angina  many  the- 
ories have  been  advanced,  but  conclusive  post-morte77i  evidence  in 
support  of  each  and  all  is  wanted.  Neither  does  any  single  hypothesis 
fit  the  grouping  of  symptoms  so  constantly  observed  in  cases  of  angina. 
It  is  to  be  recollected,  however,  that  it  is  a  neurosis  affectincr  the 
cardiac  sensory  filaments  that  are  given  off  chiefly  from  the  pneumo- 
gastric,  and  in  many  cases  the  vasomotor  apparatus  is  also  involved. 
Allbutt^  believes  that  the  symptoms  owe  their  origin  to  disease  in  the 
aorta — acute  and  chronic  aortitis.  Nothnagel  has  described  a  form 
distinct  from  the  above  in  which  the  vasomotor  apparatus  is  principally 
involved  (angina  pectoris  vasomotoria). 

Ktiology. — Cases  of  angina  unassociated  with  arterial  sclerosis, 
hypertrophy,  aortic  regurgitation,  or  adherent  pericardium,  are  rarely 
encountered.  It  is  quite  probable  that  witli  few  exceptions  sclerosis  of 
the  aorta  and  coronaries  is  present,  and  predisposes  to  the  disease  under 
discussion.  This  view  also  receives  some  degree  of  color  from  the  fact 
that  angina  usually  occurs  after  the  fortieth  year.,  and  principally  in  the 
male  sex.  It  may  be  a  sequel  of  influenza.  The  overuse  of  tobacco 
may  rarely  cause  true  anginiform  symptoms.  The  determining  factors 
of  the  attack  are  undue  exertion  and  mental  emotion. 

Symptoms. — The  jmroxysm  begins  quite  suddenly  during  the  action 
of  one  or  other  exciting  cause.  There  is  excruciating  pain  of  a  grip- 
like character,  affecting  the  entire  chest  and  rendering  the  body  motion- 
less. The  pain  radiates  most  frequently  to  the  left  shoulder,  though  also 
at  times  to  the  right,  and  thence  to  the  back,  neck,  and  down  the  arms 
to  the  fingers.  Coldness  and  numbness  of  the  fingers  or  in  the  precor- 
dial area  may  be  present.  Not  less  agonizing  than  the  pain  is  the  awful 
sense  of  impending  death.  The  countenance  is  frequently  pale,  and 
may  assume  a  leaden  hue,  and  is  usually  bathed  in  cold  perspiration. 
The  respirations  are  exceedingly  shallow  or  even  temporarily  arrested, 
and  the  patient's  anxiety  is  extreme.  The  heart's  action  may  be  regular, 
and  the  arterial  tension,  as  shown  by  the  pulse,  is  generally  increased. 
The  duration  of  the  paroxysm  varies  from  a  few  seconds  to  a  minute  or 
two,  and  after  the  pain  is  over  gaseous  eructations,  vomiting,  or  the  dis- 
charge of  a  large  amount  of  clear  urine  may  occur.  With  the  cessation 
of  the  attack  comes  instant  relief  from  the  cardiac  symptoms.  On  mak- 
inff  a  careful  examination  of  the  heart  subse(|uent  to  the  seizure  there 
may  be  an  utter  absence  of  signs,  and,  though  there  is  weakness,  this 
soon  disappears.  The  attacks  may  recur  at  intervals  varying  from  a  few 
days  to  many  years.  I  have  usually  found  that  cases  associated  with 
aortic  regurgitation   give   the   shortest  intervening  periods  as  a   rule. 

In  angina  vasomotoria  the  pain  in  the  heart-region  is  preceded  for  a 
few  minutes  by  pallor  of  the  face,  coldness  and  stiffness  of  the  limbs, 
due  to  spasm  of  the  peripheral  vessels. 

Pseudo-angina. — ^This  is  also  a  paroxysmal  affection,  that  may  be 
associated  with  hysteria,  anemia,  or  neuropathic  inheritance,  and  is 
occasionally  produced  by  infectious  diseases  and  poisons  (see  p.  672)'. 

Diagnosis. — The  characteristic  events  are  a  sudden,  most  intense 
'  Philadelphia  Medical  Journal,  June  30,  1900. 


ANGINA  PECTORIS.  673 

pain  in  the  substernal  and  left  parasternal  regions  Avith  marked  constric- 
tion of  the  chest,  the  peculiar  manner  of  radiation  of  the  pain,  and  the 
fear  of  death.  Less  diagnostic,  though  of  considerable  value,  are  the 
brevity  of  the  attack,  the  sudden  onset  and  cessation  of  the  pain,  the 
age  and  sex,  and  the  anxious,  moistened  features.  There  are  also  lighter 
forms,  in  which  one  or  more  of  the  diagnostic  phenomena  above  described 
are  absent.  If  they  occur  between  the  ages  of  forty  and  sixty  years  in 
persons  in  whom  either  arterial  sclerosis  or  aortic  regurgitation  is  present, 
this  disease  should  be  thought  of;  and  after  the  exclusion  of  certain  com- 
plaints in  Avhich  paroxysmal  pain  is  prominent,  such  as  gastralgia,  in- 
tercostal neuralgia,  and  locomotor  ataxia,  the  diagnosis  of  angina  be- 
comes reasonably  cei"tain. 

The  distinction  between  true  and  pseudo-angina  pectoris  rarely 
presents  formidable  difficulties  (see  table  below) : 

AxGiNA  Pectoris.  Pseudo-angixa. 

Etiology  indeterminate,  though  generally       The  causes  are — hysteria,  neurasthenia, 

associated   with    arterio-sclerosis    (in-  toxic  agents,  and  reflex  irritations. 

eluding    coronary   disease)    or    aortic 

I'egurgitation. 
Occurs  after  the  fortieth  j^ear,  usually  in       Occurs  at  any  age  (over  six  years),  and 

males.  usually  in  females. 

Paroxysms,  provoked  by  undue  exertion   .    Paroxysms  arise  spontaneously,  are  peri- 

or  mental  emotion,  are  rarely  periodic  odic  and  often  nocturnal. 

and  nocturnal. 
Pain  intensely  severe,  and  constricting,       Less  intense  pain,  more  diiFused  over  the 

its  chief  center  being  to  the  back  of  the  thoracic  region  :    sensation  of  cardiac 

mid-sternum  and  toward  the  left.  distention. 

Duration  of  attack  from  a  few  seconds  to       From  a  half  to  several  hours. 

one  or  two  minutes. 
Patient  silent  and  body  fixed.  Restlessness  and  emotional  symptoms  of 

causative  conditions  associated. 
Arterial  tension  increased  as  a  rule.  Usually  not  increased. 

Prognosis  unfavorable.  Entirely  favorable. 

The  vasomotor  form  of  angina  must  not  be  confounded  with  pseudo- 
angina,  which  is  infinitely  more  common. 

The  prognosis  is  bad,  yet  uncertain.  I  recall  two  instances  that 
occurred  ten  and  twelve  years  ago  respectively :  the  first  attacks  were 
survived  with  no  recurrence.  When  the  arteries  are  sclerosed  (partic- 
ularly the  coronaries)  life  is  often  suddenly  terminated  during  the  course 
of  the  attack.  Occasionally  the  sufferer  dies  of  syncope.  The  nature 
of  the  causal  and  associated  lesions  must  be  considered  in  estimating 
the  prospect  of  life.  In  the  vasomotor  angina  of  Nothnagel  the  out- 
look is  less  grave,  while  in  pseudo-anginal  attacks  it  is  bright. 

Treatment. — Prevention  of  the  attacks  in  persons  who  are  subject 
to  them  is  of  the  most  importance.  In  order  to  do  this  all  known  excit- 
ing factors  are  to  be  rigidly  avoided.  The  patient  should  be  instructed 
to  carry  constantly  in  a  convenient  pocket  such  agents  as  nitroglycerin 
and  amyl  nitrite,  beads  or  perhs  (strength  3  to  5  drops),  and  also  how 
to  use  them  with  judicious  care  immediately  upon  the  first  indication  of 
an  approaching  paroxysm. 

The  treatment  of  the  attack  must  be  prompt  and  energetic,  though 
carefully  conducted,  amyl  nitrite  being  inhaled  at  once  from  a  handker- 
chief in  doses  of  3  to  5  drops  according  to  the  severity  of  the  attack.  The 
patient  should  then  be  placed  in  a  cool  apartment  free  from  disturbing 

43 


674  DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

sounds.  Locally,  the  use  of  the  ice-bag  may  prove  efficacious  and  should 
be  tried  at  first.  Rarely,  hot  applications  (hot  cloths  or  siiiapism.s)  give 
better  results  than  cold.  If  the  pain  is  not  controlled  promptly  by  this 
method,  the  nitrite  should  be  reinforced  by  the  hypodermic  injection  of 
morphin  (gr.  \ — 0.0216)  combined  with  atropin  (gr.  yi^— 0.0005).  This 
usually  brings  speedy  relief,  and  is  best  suited  to  those  instances  in 
which  there  fs  no  increase  of  arterial  tension.  In  cases  exhibiting  high 
arterial  tension  the  tincture  of  nitroglycerin,  hypodermically,  should  be 
employed  (dose  TTLj — 0.066 — to  be  repeated  once  in  a  minute  if  needful). 
During  the  intervals  between  the  attacks  the  aim  should  be  not  only 
to  obviate  the  action  of  the  exciting  causes,  but  also  to  overcome  any 
predisposing  influences  that  may  exist.  Schott^  prefers  baths  (effer- 
vescent) and  passive  movements  to  drugs  or  other  methods.  In  true 
ano-ina,  gymnastic  exercises,  in  the  form  of  passive  movements  alone, 
should  first  be  performed  by  an  assistant,  but  later  may  be  safely  en- 
trusted to  the  patient.  In  cases  in  which  the  arterial  tension  is  habit- 
ually exalted,  nitroglycerin  in  increasing  doses  is  to  be  used  persever- 
ingly,  beginning  with  mj  (0.066)  and  increasing  by  TTLj  (0.066)  every 
five  or  six  days  until  the  physiologic  effects  are  produced.  Sodium 
nitrite  may  be  employed  similarly,  the  dose  being  gr.  j-iij  (0.0648- 
0.184)  three  or  four  times  daily.  Marked  arterial  sclerosis,  particularly 
if  there  be  a  syphilitic  history,  is  favorably  influenced  by  a  long  course 
of  potassium  iodid.  It  may  be  prescribed  in  doses  ranging  from  gr.  v 
to  XX  (0.324-1.296)  three  times  a  day.  When  hypertrophy  of  the  left 
ventricle  is  excessive,  the  use  of  the  following  is  effective : 

^.  Tr.  aconiti  rad.,  lUxlviij  (3.10) ; 

Sodii  bromidi,  .5ss  (16.0) ; 

Elix.  simplicis,  q.  s.  ad  siij  (96.0). — M. 
Sig.  3j  (4.0)  t.  i.  d. 

It  may  be  omitted  at  the  end  of  every  two  weeks  for  two  or  three  days. 
The  presence  of  a  gouty  diathesis  would  call  for  special  treatment. 

In  the  vasomotor  form  amyl  nitrite  and  nitroglycerin  are  most  valuable. 
Additionally,  hot  foot-baths, "followed  by  friction  of  the  extremities,  are 
also  of  the  highest  utility. 

The  treatment  of  pseudo-angina  must  be  directed  at  the  cause  of  the 
complaint — the  neurotic  condition. 


IV.  CONGENITAL  AFFECTIONS  OF  THE  HEART. 

These  result  from  two  leading  causes  :  (1)  Arrested  development,  and 
(2)  Fetal  endocarditis.      Occasionally,  both  these  factors  are  operative. 

(1)  Arrested  development  may  produce  a  great  variety  of  anomalies, 
some  of  which  may  be  briefly  enumerated  :  (a)  Acardia,  absence  of  the 
organ,  (h)  Cor  biloculare,  or  reptilian  heart,  in  which  the  septum  be- 
tween the  auricles  and  ventricles  is  absent,  thus  reducing  the  number  of 
chambers  to  two.  This  is  an  instance  of  reversion  to  a  lower  type,  (c) 
1  3Ied.  Re  J.,  March  11,  1899. 


CONGENITAL  AFFECTIONS  OF  THE  HEART.  675 

Absence  of  the  i7iter ventricular  se^jtum,  the  heart  consisting  of  three 
chambers  (cor  triloculare).  More  frequently  there  is  a  mere  perforation 
in  or  an  incomplete  development  of  the  septum,  and  this  is  usually  situ- 
ated in  the  upper  portion.  Obstruction  of  the  pulmonary  orifice  or  of 
the  conus  arteriosus  of  the  right  ventricle  are  frequently  conjoined  con- 
ditions, [d)  Patency,  or  incomjjlete  closure  of  the  foramen  ovale.  Per- 
sistence of  the  foramen  is,  in  the  majority  of  cases,  associated  with  ob- 
struction of  the  pulmonary  valve,  though  it  may  be  solitary,  (e)  An 
anomaly  known  as  ectopia  cordis  deserves  mention.  This  is  a  condition 
in  which  the  sternum  is  usually  divided  vertically,  and  the  heart  is  either 
entirely  exposed  or  beating  just  beneath  the  skin  in  the  cardiac,  thoracic,  or 
abdominal  region.  In  this  connection  another  and  the  most  common  form 
of  malposition  may  be  added — namely,  dextrocardia.  Here  the  heart 
occupies  the  right  side,  with  reversion  of  the  arch  and  displacement  of 
the  descending  aorta  to  the  right  of  the  spinal  column.  Transposition  of 
other  viscera  is  usually  associated.  (/)  Anomalies  of  the  valves. — There 
may  be  either  a  numerical  increase  or  decrease  of  the  cardiac  valves,  par- 
ticularly the  segments  of  the  semilunar  valves  of  the  aortic  and  pulmo- 
nary orifices.  Supernumerary  segments  are  usually  rudimentary,  and  at 
the  pulmonary  valve  one,  two,  or  more  are  most  commonly  seen.  A  de- 
crease in  the  number  of  segments  is  also  most  frequently  observed  at  the 
arterial  orifices,  the  aortic  and  pulmonic  semilunar  valves  then  being 
composed  of  two  segments  (bicuspid).  This  condition  may  be  due  to  de- 
fective development  on  the  one  hand,  or  to  endocarditis  with  resulting 
cohesion  of  segments  on  the  other. 

(2)  Fetal  endocarditis  leads  to  valvular  deficiencies  in  a  manner  sim- 
ilar to  what  occurs  during  the  whole  post-natal  period.  The  valve- 
lesions  originating  during  fetal  life  are  most  frequently  situated  on  the 
right  side,  probably  for  the  reasons  that  the  ante-natal  circulation  is 
more  actively  carried  on  in  the  right  than  in  the  left  heart,  and  that  the 
former  receives  the  oxygenated  blood  from  the  placenta.  They  may  occur 
at  the  pulmonic,  the  aortic,  or  the  auriculo-ventricular  orifices.  The 
changes  are  of  the  slow  sclerotic  form  as  a  rule,  and  their  character  is 
determined  largely  by  the  antecedent  anomalies  that  predispose  to  them. 
The  leaflets  present  smooth,  thickened,  and  contracted  borders.  Union 
of  the  mitral  segments  is  common,  and  the  chordae  tendinese  are  often 
thickened  and  contracted.  The  small  rounded  bodies  that  are  normally 
present  on  the  mitral  and  tricuspid  segments  {nodules  of  Alhini)  must  not 
be  confounded  with  pathologic  verrucosities. 

The  most  frequent  congenital  valvular  lesion  is  stenosis  of  the  pulmo- 
nary orifice  as  the  result  of  chronic  endocarditis.  Rarely,  it  is  due 
directly  to  defective  development,  and  perhaps  more  rarely  still  to  endo- 
carditis verrucosa.  Pulmonic  constriction  of  ante-natal  origin  may  be  an 
associated  lesion  in  other  forms  of  valvular  disease  in  the  young  adult. 
With  stenosis  at  the  pulmonary  orifice,  there  usually  coexist  stenosis  of 
the  conus  arteriosus  of  the  right  ventricle,  an  open  foramen  ovale,  and  a ' 
patent  ductus  arteriosus ;  according  to  Peacock,  "  in  86  per  cent,  of  the 
patients  with  congenital  heart-disease  living  beyond  the  twelfth  year  the 
lesion  is  at  this  orifice."  Atresia  of  the  pulmonary  orifice  occurs,  though 
less  frequently  than  stenosis. 

At  the  tricuspid  orifice  there  may  be  stenosis  or  contraction  of  the 


67G  DISEASES   OF  THE  CIRCULATORY  SYSTEM. 

valves,  producing  either  obstruction  or  regurgitation.  Similar  lesions  of 
the  aortic  orifice  are  infrequent.  Congenital  mitral  disease  also  occurs, 
but  only  exceptionally  ;  it  is  then  usually  associated  "with  tricuspid 
stenosis.  Boys  are  somewhat  more  liable  to  congenital  affections  of  the 
heart  than  girls. 

Symptoms. — There  is  an  almost  constant  and  strikingly  distinctive 
symptom  in  congenital  heart-disease — cyanosis.  The  tint  of  skin  ob- 
served is  variable,  being  at  one  time  a  general  duskiness,  at  another  a 
deep  violet,  and  rarely  almost  black.  This  coloration  is  most  notice- 
able about  the  lips  and  mucous  membrane  of  the  mouth,  the  nostrils, 
conjunctivae,  the  fingers,  toes,  and  lobules  of  the  ears,  and  as  a  rule  is 
general,  though  it  may  be  a  local  condition.  The  tint  may  grow  less 
distinct,  and  even  almost  vanish,  when  the  child  is  in  perfect  repose  or 
sleeping ;  excitants  or  efforts  at  coughing,  however,  increase  the  in- 
tensity of  the  discoloration.  The  cyanotic  hue  comes  on  almost  invari- 
ably during  the  first  week  of  life.  The  jingers  present  a  decidedly 
clubbed  appearance,  and  the  nails  are  thickened  and  curved  like  the 
claws  of  certain  animals.  The  temperature  is  subnormal,  while  the  ex- 
tremities are  cool  to  the  feel.  Dyspnea  on  exertion  and  couf/h  are  usual 
concomitants.  Cyanosis  may  be  due  to  various  causes  that  may  act 
either  singly  or  more  often  concurrently.  Yariot  reports  two  cases  Avith 
similar  cardiac  conditions — namely,  interventricular  perforation,  and 
narrowing  of  the  pulmonary  artery,  with  the  aorta  arising  from  both 
ventricles.  Cyanosis  was  absent  from  one  case,  and  "  this  disproves  the 
two  leading  theories  with  regard  to  the  origin  of  cyanosis — the  mixture 
of  the  two  bloods  and  the  obstruction  to  the  pulmonary  circulation." 

Physical  Signs. — In  the  very  young  the  impulse  is  feeble  (with  an  ab- 
sence of  a  palpable  thrill),  the  percussion-dulness  is  increased,  especially 
to  the  right,  and  a  loud  systolic  murmur  is  audible  at  the  pulmonary  ori- 
fice. When  the  auriculo-ventricular  valves  are  the  seat  of  endocarditis, 
the  murmur  may  be  apical.  In  pure  pulmonary  stenosis  the  second 
sound  is  feeble. 

In  older  children  the  area  of  t^M?Mc.s-s  is.only  slightly  extended,  partic- 
ularly to  the  left,  while  the  murmurs  heard  are  loud  and  often  musical. 

It  is  interesting  to  note  that  in  rare  instances  cerebral  abscess  is  an 
associated  condition. 

Differential  Diagnosis. — The  distinction  between  congenital  and 
acquired  lesions  in  children  may  be  assisted  by  a  reference  to  certain 
points  tabulated  below  : 

Congenital  Lesions.  Acquired  Lesions. 

History  of  almost  I'onstunt  cyanosis,  be-  Not   so  ;    history  of   endocarditis   or  of 

ginning  in  the  first  week  after  birth.  rheumatism    or    other    comph\ints   in 

which   endocarditis  occurs   as  a  com- 
plication. 

Slight  enlargement  of  the  heart.    It  is  of  Enlargement  marked,  frequently  involv- 

the  right  ventricle,  chiefly  non-progres-  ing  the  left  ventricle,  and  progressive, 
sive. 

Loud  and  musical  murmurs  present,  au-  Audible  over  apex  or  base  ;  definite  large 

dible  over  upper  third  of  sternum,  with  areas  of  transmission'.     Second  sound 

small  area  of  transmission  upward  and  frequently  accentuated, 
to  the  left;  second, sound  weak. 

Deficient  bodily  development.  Bodily  development  good,  as  a  rule. 

Mental  faculties  in  abeyance.  Mental  faculties  normal. 


DISEASES  OF  THE  ARTERIES.  677 

Prognosis. — The  prognosis  is  exceedingly  grave.  Many  succumb 
within  a  few  days  after  birth,  more  than  one-half  before  the  expiration 
of  one  year,  and  not  less  than  three-fourths  before  the  end  of  the  third 
year.  Few  survive  the  first  decade  of  life,  and  fewer  still  reach  full 
adolescence.  Among  the  forms  giving  the  most  favorable  prognosis  are 
pulmonary  stenosis,  especially  when  of  moderate  grade,  and  defective 
auricular  and  ventricular  septa.  In  those  instances  in  which  life  is 
spared  in  the  first  weeks  after  birth  there  is  a  disposition  to  affections  of 
the  lungs  (phthisis,  hemoptysis),  nerve-complaints  (convulsions,  cerebral 
hemorrhages). 

Treatment. — The  treatment  is,  in  the  main,  hygienic.  The  body 
must  be  warmly  clad,  flannels  being  worn  next  the  skin,  and  every  source 
of  cold  should  be  carefully  guarded  against.  The  diet  is  to  be  judiciously 
arranged,  yet  liberal,  preference  being  given  to  the  carbohydrates.  Gentle 
exercise  when  it  can  be  taken  is  valuable,  as  are  also  daily  spongings  of 
the  surface  followed  by  friction.  Special  thei'apeutic  indications  may 
arise,  and  must  be  met  in  accordance  with  general  principles,  while  tonics, 
such  as  iron,  arsenic,  quinin,  and  cod-liver  oil,  are  frequently  applicable. 


V.   DISEASES  OF  THE  ARTERIES. 

ACUTE  AORTITIS. 

Pathology. — The  morbid  changes  coincide  with  those  noted  in  acute 
endocarditis,  including  the  ulcerative  variety. 

^Etiology. — The  causes  are  not  clear,  but  the  condition  generally 
follows  the  acute  infectious  diseases  (typhoid  fever,  pneumonia,  miliary 
tuberculosis).  Alcoholism  and  syphilis  are  among  the  rarer  causes. 
Various  microorganisms  have  been  discovered  to  be  causal  irritants. 
Boinet  and  Romary  have  recently  shown  that  in  experimentally  pro- 
duced aortitis  a  point  of  lessened  resistance  (either  from  traumatism  or 
other  previous  arterial  lesion)  is  necessary. 

Symptoms. — The  symptoms  are  local  and  general.  Of  the  former, 
diffuse  thoracic  pain,  with  substernal  tenderness  under  pressure  and 
cardiac  palpitation,  are  the  chief.  The  pain  may  assume  the  type  of 
true  angina  pectoris.  Among  the  general  symptoms  a  moderate 
febrile  movement  is  almost  constant.  In  a  certain  percentage  of  cases 
embolism  is  betrayed  by  the  usual  signs,  as  rigors,  accompanied  by  a 
steep  temperature-curve.  These  forms  are  analogous  to  the  malignan,t 
variety  of  endocarditis.     A  cardiac  murmur  may  be  heard  over  the  base. 

Diagnosis. — All  that  the  best  clinicians  can  do  is  to  establish  a 
nrobable  diagnosis  even  in  the  presence  of  the  most  frankly  expressed 
features  of  the  affection.  From  acute  endocarditis,  aortitis  is  to  be  dis- 
criminated by  its  diffuse  pain  and  by  the  higher  seat  of  its  murmur. 

The  prognosis  is  serious,  owing  to  the  liability  to  infectious  emboli 
and  aneurysmal  dilatation  and  the  possibility  of  aortic  rupture. 

The  treatment  is  similar  to  that  of  acute  endocarditis. 


678  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ARTERIAL   SCLEROSIS. 

[Arteriosclerosis ;  Arterio-capillanj  Fibrosis:    Endarteritis  Chronica  Deformans; 

Atheroma.) 

Definition. — An  overgrowth  of  the  connective  tissue  of  the  artei'ial 
coats  (chiefly  and  primarily  of  the  intima).  followed  by  calcareous  deposi- 
tions.    The  elastic  tissue  of  the  intima  is  primarily  increased. 

Pathologfy. — The  most  frequent  seat  of  the  sclerotic  process  is  the 
aorta,  and  the  next  most  common  the  coronary  arteries.  Other  vessels 
implicated  are  the  arteries  of  the  brain,  the  temporals,  radials,  brachials, 
ulnars,  femorals.  and  iliacs.  On  the  other  hand,  certain  arteries,  as  the 
gastric,  hepatic,  and  mesenteric,  are  rarely  affected.  Two  forms  may  be 
recognized:   {a)  th<.'  circumscribed,  and  {h)  the  diffuse. 

(a)  Circumscribed  Arterio-sclerosis. — Naturally,  the  intima  presents  a 
smooth  internal  surface,  but  when  atheromatous  changes  occur  it  shows 
localized  areas  of  thickening.  These  patchy  prominences  are  often  hemi- 
spheric in  outline,  yellowish-white  in  color,  and  their  favorite  seats  are  the 
orifices  of  the  branches.  They  increase  in  depth  and  superficial  area,  and 
on  reaching  an  advanced  stage  their  interior  disintegrates  into  granulai' 
material  {atheromatous  abscess). 

In  circumscribed  or  nodular  atheroma  the  microscope  discloses  the  fact 
that  the  middle  and  external  coats  are  the  primary  seat  of  the  changes, 
which  consist  of  localized  infiltrations.  These  lesions  weaken  the  media 
and  adventitia,  and  then  (as  shown  by  Thoma)  compensatory  processes 
are  set  up  in  the  intima  which  lead  to  the  formation  of  the  so-called 
atheromatous  button.  The  latter  consists  in  a  hyperplasia  of  the  intima 
with  a  deposit  of  round  cells,  which  causes  a  gradual  increase  in  thickness  ; 
in  this  way  the  growing  Aveakness  of  the  middle  and  outer  coats  is  com- 
pensated. When  the  prominences  in  the  intima  undergo  softening  or 
liquefaction,  rapid  dilatation  [aneurysynal)  of  the  affected  vessels  is  apt 
to  occur.  The  same  accident  may  arise  early  or  before  the  intima  has 
reinforced  the  other  layers  by  its  increased  thickness  and  strength. 

(b)  Diffuse  Arterio-sclerosis. — In  this  form  the  morbid  process  is  dis- 
tributed throughout  the  greater  part  of  the  arterial  system,  the  nodular 
or  circumscribed  form  being  usually  combined  with  it  in  the  aorta.  Dila- 
tation of  the  aorta  and  of  its  branches  commonly  coexist.  Apart  from 
the  yellowish,  translucent,  elevated  areas,  the  intima  may  be  smooth  and 
the  naked-eye  appearances  almost  normal.  The  coats,  however,  and  par- 
ticularly the  intima,  are  very  much  thickened.  Microscopic  examination 
brings  to  light  an  extensive  proliferation  of  the  subendothelial  connective 
tissue  and  a  hyaline  transformation  of  the  entire  media,  particularly  in 
the  larger  vessels.  The  muscular  fibers  and  elastic  tissue  have  in  advanced 
cases  almost  totally  disappeared.  Necrotic  degeneration  of  the  media, 
especially  in  the  smaller  arteries,  is  also  observed,  and  calcareous  deposits, 
causing  rigidity  of  the  walls,  occur  among  the  later  changes.  This  is 
particularly  true  of  the  so-called  senile  arterio-sclerosis.  Atheromatous 
abscesses  that  burst,  forming  atheromatous  ulcers,  are  likewise  common 
pathologic  events  in  the  aged.  There  may  be  associated  atrophy  of  the 
heart,  liver,  and  kidneys,  due  to  a  lack  of  nutritive  supply  in  consequence 
of  the  narrowinsc  of  the  vessels.  More  commonlv,  however,  in  this,  and 
constantly  in  circumscribed  and  diffused  sclerosis,  the  heart  is  moder- 


ARTERIAL  SCLEROSIS.  679 

ately  hypertrophied.  When  coronary  disease  is  present,  fibrous  myo- 
carditis and  sclerosis  of  the  aortic  cusps  may  be  found  associated.  The 
kidneys  may  also  become  sclerotic — a  condition  that  will  be  described 
hereafter  {vide  Diseases  of  the  Kidneys). 

Sclerosis  of  the  pulmonary  artery,  previously  referred  to  in  the  dis- 
cussion of  the  Diseases  of  the  Heart,  exhibits  all  the  changes  observed  in 
connection  Avith  atheroma  of  the  systemic  arteries,  including  aneurysmal 
dilatation  of  the  trunk  and  rarely  of  the  main  branches.  From  the  ter- 
minal tributaries  the  process  may  extend  to  the  capillaries,  and  even  to 
the  pulmonary  veins  (angio-sclerosis). 

The  effect  of  arteriosclerosis  upon  the  physiologic  functions  of  the 
vessel-walls,  and  the  pathologic  and  clinical  results  are  of  the  utmost  im- 
portance. The  elastic  coat  is  destroyed,  and  hence  the  walls  cannot  bear 
the  blood-pressure  as  well  as  in  health.  This  predisposes  to  dilatation  of 
the  vessels  (aneurysm). 

Another  result  of  extensive  atheromatous  degeneration  of  the  vessels 
is  an  increase  in  the  resistance  to  the  blood-current,  and  a  consequent 
elevation  of  the  arterial  pressure.  Furthermore,  the  loss  of  elasticity  in 
the  coats  of  the  medium-sized  and  smaller  arteries  removes  an  important 
factor  in  the  propulsion  of  the  blood.  The  left  ventricle,  in  consequence 
of  this  fact,  almost  invariably  becomes  hypertrophied  in  cases  of  extensive 
arterio-sclerosis,  provided  the  general  nutrition  of  the  patient  is  still  well 
maintained  (Striimpell). 

The  reduction  of  the  lumen  of  the  vessel,  owing  to  the  thickening  of 
the  intima,  must  lessen  the  blood-supply  to  the  various  viscera,  and  thus 
in  part  are  explained  such  secondary  affections  as  fibrous  myocarditis, 
cirrhosis  of  the  kidneys,   and  cerebral  softening. 

Sclerosis  of  the  veins  {j)hleh a- sclerosis)  may  accompany  arterio- 
sclerosis. It  is,  however,  not  infrequently  found  in  association  with 
hepatic  cirrhosis  and  mitral  disease  when  the  portal  system  and  pul- 
monary veins  are  involved.  It  is  occasioned  by  increased  intravenous 
pressure.  Arterio-sclerosis  apart  from  sclerosis  of  the  peripheral  veins 
may  be  encountered,  though  rarely. 

■  Microscopically,  thickening  of  the  intima  and  atrophic  degenerative 
changes  in  the  media  are  commonly  observed.  Calcification  and  hyaline 
degeneration  of  the  layers  also  occur,  and  I  have  observed  them  in  one 
of  my  own  cases.     Moderate  dilatation  is-  not  exceptional. 

Ktiology. — The  diffuse  form  has,  in  part,  a  special  etiology.  It  may 
appear  in  the  young,  though  rarely ;  I  have  met  with  a  case  in  the 
Medico-Chirurgical  Hospital  in  a  man  aged  twenty-four  years.  It  is, 
however,  most  frequent  in  the  middle-aged  (who  are  able-bodied)  and  in 
the  aged.  At  an  earlier  period  it  occurs  as  a  result  of  alcoholism, 
syphilis  (the  overshadowing  factor),  lead-poisoning,  gout,  and  chronic 
nephritis — agencies  that  subject  the  vascular  system  to  undue  wear  and 
tear.  In  old  persons  atheroma  is  often  physiologic  and  characterizes 
the  natural  involution-period  of  life.  Heredity  may  play  no  inconspicuous 
part  in  arterio-sclerosis  dependent  upon  the  age.  This  fact  furnishes,  to 
some  extent  at  least,  the  reason  why  senile  changes  in  the  arteries  occur 
at  a  much  earlier  period  of  life  in  some  instances,  and  even  throughout 
whole  families,  than  in  others.  I^egroes  are  more  liable  than  ivhites  to 
this  form  of  atheroma,  and  males  than  females,  though  it  is  more  frequent 
in  the  latter  sex  than  the  circumscribed  variety. 


680  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

The  general  causes  may  be  thus  classified — (1)  Biologic  irritants, 
as  the  specific  micro-organisms  of  malaria,  rheumatism,  and  syphilis, 
(2)  Chemical  irritants  (chronic  alcoholism,  lead-poisoning,  uric  acid  in 
gout).  The  above  toxic  agents  produce  their  effects  partly  by  their 
direct  irritant  action,  and  partly  by  increasing  the  resistance  in  the 
peripheral  vessels  and  thus  raising  the  arterial  pressure,  (3)  BrighVs 
Disease. — It  must  be  admitted  that  there  is  a  class  of  cases  in  which 
arterio-sclerosis  is  secondary  to  Bright's  disease,  but  vhen  found  in  as- 
sociation the  former  is  more  frequently  the  primary  disease  than  the 
latter.  The  chief  causes  of  chronic  nephritis  are  also  capable  of  setting 
up  atheroma,  and  hence  it  must  not  be  forgotten  that  the  two  diseases  may 
develop  independently  of  one  another,  and  yet  simultaneously,  in  conse- 
quence of  the  action  of  a  common  cause.  (4)  Constant  overfilling  of  the 
blood-vessels,  resulting  from  excesses  in  eating  and  drinking,  in  the  opinion 
of  certain  authors,  also  causes  arterio-sclerosis.  (5)  Muscular  over-strain., 
which  augments  the  blood-pressure  while  at  the  same  time  obstructing 
the  peripheral  circulation,  is  a  leading  factor,  (6)  The  main  causes  of 
sclerosis  of  the  pulmonary  artery  are  mitral  disease  and  emphysema. 

Clinical  History. — The  disease  may  exist  for  years  without  becom- 
ing apparent :  or  it  may  be  discovered  incidentally  at  autopsy  while  pal- 
pating the  arteries  during  the  course  of  an  examination  for  some  sup- 
posed local  visceral  affection.  The  accessible  peripheral  vessels  (radial, 
temporal,  femoral,  and  brachial)  should  be  carefully  felt  when  the  pres- 
ence of  the  disease  is  suspected.  The  avails  of  the  affected  artery  feel 
hard,  and  the  pulse,  OAving  to  increased  tension,  is  incompressible ;  as  a 
result  of  this  rigidity  of  the  arterial  walls  the  degree  of  vascular  tension  is 
difficult  of  estimation.  In  marked  cases  the  pulse-wave  may  not  be 
detectable  on  palpation.  Again,  the  tension  may  be  high,  and  yet 
sclerosis  of  the  vessel-wall  be  slight  or  absent.  When  doubt  arises  as 
to  whether  or  not  sclerosis  exists,  the  pulse  should  be  palpated  by 
means  of  two  fingers.  If  noAv,  while  compression  of  the  pulse  is  made 
with  the  index-finger,  the  middle-finger  detects  a  pulse-wave,  arterio- 
sclerosis is  present.  Rarely,  however,  a  recurrent  pulse  may  be  felt 
notwithstanding,  but,  as  Ewart  points  out,  pressure  on  the  ulnar  artery 
at  once  arrests  it.  On  account  of  the  loss  of  elasticity  of  the  vascular 
walls  the  pulse  is  retarded,  and  the  sphygmogram  shows  a  short  sloping 
ascent,  a  wide  top,  and  a  slow,  gradual  descent,  with  almost  an  efface- 
ment  of  the  dicrotic  notch. 

The  opposition  of  the  increased  resistance  to  the  circulating  medium 
(due  to  the  rigid  vessel-wall)  in  the  outlying  portions  of  the  body  calls 
forth  a  correspondingly  increased  cardiac  action,  and  thus  hypertrophy  of 
the  left  ventricle  is  engendered,  with  its  customary  symptoms  and  physi- 
cal signs,  including  the  ringing,  accentuated  second  sound.  The  balance 
of  the  cardio-vascular  forces  may  thus  be  maintained  for  a  long  period  of 
time,  during  which  the  health  of  the  patient  often  remains  unimpaired. 
It  happens  sometimes  that  hypertrophy  preponderates  and  veils  com- 
pletely the  symptoms  of  arterio-sclerosis.  In  elderly  persons  suffering 
from  atheroma  the  first  sound  is  often  surprisingly  feeble.  3Iyocardial 
degenerations  frequently  come  on  in  the  later  stages,  when  dilatation  of 
the  left  ventriclie,  accompanied  by  a  mitral  systolic  murmur  and  marked 
rapidity  of  the  pulse,  may  supervene.  The  aorta  may  be  so  dilated  as 
to  give  rise  to  an  abnormal  area  of  dulness  in  the  upper  sternal  region. 


ARTERIAL  SCLEROSIS.  681 

Palpitation,  dyspnea  on  exertion,  a  feeling  oi precordial  constriction,  and 
\\g\ii  febrile  attacks  are  not  uncommon.  Angina  pectoris  is  an  infrequent 
symptom  except  in  coronary  atheroma. 

It  cannot  be  stated  absolutely  that  involvement  of  the  external  arteries 
implies  a  serious  involvement  of  the  aorta  and  its  main  branches.  On 
the  other  hand,  the  circumscribed  variety  is  not  attended  with  charac- 
teristic alteration  of  the  pulse.  The  patliologic,  and  more  particularly 
the  clinical,  events  above  described  may  be  more  pronounced  at  one  por- 
tion of  the  body  than  at  others,  and  this  fact  has  given  rise  to  several 
distinct  or  special  types  (apart  from  the  general  or  cardio-vascular  form 
first  depicted)  according  to  the  seat  of  the  most  marked  symptoms  and 
lesions.  Among  the  latter  I  would  mention  the  (r^)  cerebral,  (5)  pulmo- 
nary, (c)  renal,  and  {d)  peripheral  types. 

(a)  Cerebral  Type. — In  the  milder  grades  of  this  type  such  symptoms 
as  headache,  tinnitus,  vertigo,  syncopal  attacks,  and  local  palsies  are 
variously  blended  as  a  rule.  I  have  had  under  my  care  for  two  years  a 
case  of  marked  arterio-sclerosis  in  a  man  aged  eighty  years  in  Avhom  tin- 
nitus aurium  and  vertigo,  with  mild  melancholia,  are  the  only  constant 
symptoms ;  on  two  occasions  temporary  aphasia  was  superadded. 

Especially  in  the  aged,  the  condition  is  apt  to  lead  to  thrombosis  or 
cerebral  embolism,  small  emboli  being  detached  from  the  aortic  area  and 
conveyed  to  the  brain,  with  the  development  subsequently  of  the  symp- 
toms of  anemic  softening  of  the  latter.  The  loss  of  elasticity  of  the 
vessel-walls  in  atheroma  renders  them  more  liable  to  rupture  than  normal 
arteries,  while  the  tension  is  much  increased.  Under  these  circumstances 
the  danger  from  apoplexy  is  quite  obvious. 

(b)  Pulmonary  atheroma  is  considered  in  its  clinical  relations  in  con- 
nection with  the  diseases  of  the  heart  and  lungs.  ' 

(c)  The  renal  type  includes  those  instances  of  kidney-lesion  that  are 
associated  with  or  follow  general  arterio-sclerosis.  The  condition  is  essen- 
tially an  atrophic  nephritis,  due  to  the  diminution  of  the  blood-supply 
to  the  organs  in  consequence  of  the  narrowed  lumen  of  the  renal  arteries. 

(d)  In  the  peripheral  type  the  arteries  leading  to  the  extremities  be- 
come obliterated  to  such  an  extent  as  to  cause  starvation  of  the  tissue, 
with  resulting  gangrene. 

Diagnosis. — Hardened  arteries,  increased  arterial  tension,  left  ven- 
tricular hypertrophy,  and  marked  accentuation  of  the  aortic  second  sound 
form  a  grouping  of  clinical  characters  that  leaves  no  doubt  as  to  the  diag- 
nosis. Not  infrequently  it  is  the  occurrence  of  apoplexy,  acute  cardiac 
dilatation,  or  of  some  other  such  accident  that  leads  to  the  discovery  of 
general  arterial  sclerosis. 

Eaw  has  successfully  skiagraphed  the  arteries  by  a  special  method; 
and  C.  Beck^  and  others  have  found  that  the  ar-rays  are  useful  in  de- 
termining the  extent  of  arterio-sclerosis  (e.  g.  whether  local  or  general). 

To  differentiate  the  murmurs  of  dilatation  of  the  left  ventricle  follow- 
ing the  hypertrophy  of  this  disease  from  organic  valvular  lesions  is  only 
possible  by  the  history  or  the  results  of  treatment.  The  systolic  mur- 
mur over  the  aortic  area  in  atheroma  may  suggest  aortic  stenosis.  In 
such  cases,  however,  the  second  sound  is  loud,  and  the  pulse  more 
voluminous  than  in  aortic  constriction  (vide  Aortic  Stenosis). 
1  i^:  1'.  Med.  Journ.,  Jan.  22,  1898. 


682  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Prognosis. — Arterio-capillary  fibrosis  is  an  exceedingly  chronic, 
though  usually  a  progressive  disease,  and  freijuently  it  terminates  life. 
The  axiom  that  a  man  is  as  old  as  his  arteries  has  been  borne  out  by  the 
test  of  extensive  clinical  observation.  The  condition  may  prove  fatal 
either  with  great  suddenness,  as  when  it  occasions  apoplexy,  or  with  un- 
wonted slowness.  Very  rarely  the  aorta  ruptures  at  the  seat  of  an  athe- 
romatous ulcer,  causing  instant  death. 

Treatment. — Though  the  progress  of  the  disease  cannot  in  most  in- 
stances be  successfully  stayed,  it  can  be  retarded  frequently  by  correcting 
aggravating  habits  and  by  removing  the  influence  of  ascertainable  causes. 
The  syphilitic  taint,  if  present,  requires  the  liberal  use  of  the  iodids. 

The  dk'tmM&i  be  simple  and  free  from  stimulating  properties;  skimmed 
milk  is  excellent,  particularly  if  renal  symptoms  be  manifested.  Per- 
haps no  other  agent  is  so  generally  serviceable  in  all  cases,  especially  in 
the  earlier  stages,  as  potassium  iodid.  which  should  be  administered  for 
several  years,  combined  with  appropriate  gymnastics  to  regulate  the 
bodily  functions. 

For  the  increased  arterial  tension  nitroglycerin  or  the  other  nitrites 
should  be  employed.  The  former  should  be  given  in  increasing  doses 
until  an  impression  has  been  made  upon  the  blood-pressure,  after  which 
this  effect  should  merely  be  maintained. 

For  the  local  aortic  symptoms  (fever,  pain)  absolute  rest,  a  licjuid 
and  unirritating  diet,  and  a  small  blister  are  most  efficacious,  together 
with  internal  minute  doses  of  calomel,  quinin,  and  potassium  iodid. 


ANEURYSM. 


Definition. — A  true  aneurysm  is  a  circumscribed  dilatation  of  an 
artery,  formed  of  one  or  more  of  its  coats. 

Classified  according  to  their  form,  aneurysms  are — (1)  sacculated.  (2) 
cylindric,  and  (3)  fusiform.  They  are  termed  axial  when  the  complete 
circumference  of  the  vessel  participates  in  this  dilatation,  and  peripheral 
when   a  single  sac  is  confined  to  the  side  of  the  vascular  duct. 

Miliary  aneiiri/sms  occur  along  the  course  of  the  cerebral  vessels,  and 
are  so  termed  on  account  of  their  minute  size.  On  the  other  hand,  they 
may  attain  the  size  of  the  human  skull. 

By  a.  false  aneurysm  is  meant  one  in  which  the  coats  are  ruptured  and 
the  blood  is  found  in  the  adjacent  tissues. 

A  dissecting  aneurysm  is  one  that,  owing  to  laceration  of  the  internal 
coat,  dissects  between  the  layers  of  the  vessel-wall.  For  its  seat  it  usu- 
ally selects  the  aorta,  and  may  traverse  its  entire  length. 

An  arterio-venous  aneurysm  arises  from  a  direct  fistulous  connection 
between  an  artery  and  a  vein  {aneurysmal  varix),  or  an  aneurysmal  sac 
may  intervene  (raricose  aneurysm). 

Pathology  and  Pathogenesis. — The  Avail  of  the  aneurysm  is 
commonly  the  seat  of  arterio-sclerosis,  which,  according  to  Malkoff,^  is 
a  compensatory  arrangement.  The  intima  is  thickened,  and  to  a  less  ex- 
tent the  media  in  the  early  stages.  The  media  probably  weakens  first 
in  most  cases,  and  extreme  atrophy  of  both  the  intima  and  media  is  not 
uncommon  in  the  later  stages,  so  that  the  wall  of  the  sac  is  often  formed 

^  Ziegler's  BeitrdgCy  1899,  xxv. 


ANEURYSM.  683 

almost  exclusively  of  the  aclventitia.  The  intima  (as  in  Daland's  case 
of  aortic  aneurysm,  in  which  there  were  both  an  old  and  a  ncAv  trans- 
verse rent)  may  become  lacerated,  and  finally  the  media  and  adventitia 
tear  ;  this  results  in  rupture  unless  the  adherent  neighboring  structures 
compensate  for  the  natural  wall. 

The  blood  in  the  aneurysmal  sac  is  partly  fluid  and  is  composed  of  old 
and  new  thrombi.  The  latter  when  comparatively  recent  may  be  soft,  and 
when  old  may  be  firm  or  even  calcified,  yellowish  in  color,  and  adherent 
to  the  wall.  With  the  progressive  enlargement  of  the  aneurysm  sur- 
rounding organs  are  apt  to  be  compressed  and  their  functions  disturbed. 

Ktiology. — Among  recognized  causes  are — (1)  Arterio-sclerosis. — It 
follows  that  the  same  conditions  that  originate  the  latter  must  also  tend  to 
bring  about  aneurysms.  According  to  Rasch,  syphilis  was  present 
in  56  per  cent,  and  probably  in  82  per  cent,  of  25  aneurysms  of  the 
aorta  discovered  in  the  course  of  3165  necropsies  at  Copenhagen.  (2) 
Sudden  Great  Strain. — This  may  be  productive  of  aneurysm,  particularly 
in  the  early  stage  of  arterio-sclerosis  or  before  compensatory  endar-. 
teritis  occurs.  In  no  other  manner  can  the  fact  be  satisfactorily  ac- 
counted for  that  most  instances  of  aneurysm  occur  during  the  period 
of  greatest  bodily  activity  in  the  male  sex.  (3)  Embolic  plugging  of  a 
vessel,  if  complete,  may  cause  aneurysmal  dilatation  on  the  proximal 
side  of  the  point  of  obstruction.  The  development  of  aneurysm  may 
under  these  circumstances  be  facilitated  by  the  mechanical  effects  of  the 
embolus,  which  may  be  of  calcareous  hardness,  as  when  it  comes  from 
diseased  heart-valves.  Infectious  emboli  set  up  inflammation  and  soft- 
ening. (4)  Mycotic  Aneurysms. — That  aneurysms  sometimes  owe  their 
existence  to  mycotic  origin  was  first  pointed  out  by  Osier,  who  found  an 
abundant  groAvth  of  micrococci  in  the  aneurysmal  sacs..  They  are  met 
with  in  ulcerative  endocarditis,  and  are  often  small  and  usually  multiple. 
(5)  Traumatism. — Aneurysms  have  been  produced  experimentally  by 
traumatism  (Malkoff);  hence  it  is  obvious  that  it  may  become  one  of 
the  assignable  causes.  (6)  Age  and  Sex. — Aneurysms  are  most  frequent 
between  the  thirtieth  and  fiftieth  years,  this  being  the  period  of  great- 
est physical  exertion.  The  male  sex  is  more  frequently  aifected  than 
the  fejiiale,  owing  to  difi"erences  in  occupation. 

ANEURYSM  OF  THE  THORACIC  AORTA. 

{Aneurysma  Aortce.) 

The  thoracic  jjortion  of  the  aorta  is  involved  in  about  75  per  cent, 
of  the  cases,  and  the  abdominal  aorta  and  its  branches  furnish  about  25 
per  cent.  Within  the  thorax  nearly  60  per  cent,  of  the  cases  originate 
in  the  ascending  portion  of  the  aorta,  while  nearly  30  per  cent,  are  seated 
upon  its  arch  (Lyman). 

SymptoniS. — Intrathoracic  aneurysms  may  exist,  particularly  if 
they  are  small,  without  symptoms  or  noticeable  physical  signs.  When 
they  attain  to  any  considerable  dimensions,  however,  they  usually  excite 
characteristic  signs  and  distressing  symptoms,  the  latter  being  the  results 
of  dii'ect  pressure,  and  hence  varying  with  the  seat  and  direction  of  the 
progressive  enlargement.  In  a  few  instances  truly  diagnostic  symptoms 
are  present  in  the  absence  of  a  detectable  tumor  or  physical  signs. 
Finally,  the  more  characteristic  features — the  tumor  inclusive — may  be 


684  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

more  or  less  nearly  intermittent.  It  is  important  to  note  the  condition 
of  the  neighboring  organs  upon  which  pressure  is  exerted  by  the  growing 
aneurysm,  as  well  as  the  symptoms  and  signs  thus  occasioned.  Aneurysms 
of  the  ascending  portion  of  the  arch  usually  compress  the  vena  cava, 
causing  distention  of  tJte  veins  of  the  head  and  arms,  though  in  a  pro- 
portionately small  number  of  cases  the  subclavian  may  be  the  only  vein 
compressed,  with  resulting  enlargement  and  edema  of  the  right  arm.  The 
largest  aneurysms  may  even  compress  the  inferior  vena  cava,  causing 
edema  of  the  lower  extremities.  The  heart  is  displaced  outward  toward 
the  left  pleura,  usually  forward  and  upward,  and  rarely  causing  erosion 
of  the  ribs  and  sternum.  The  right  recurrent  laryngeal  nerve  may  be 
implicated,  giving  rise  to  dyspnea  and  aphonia.  Pain  is  a  constant 
feature.  When  a  tumor  appears,  it  occupies  the  upper  tAvo  or  three  in- 
tercostal spaces  near  the  right  border  of  the  sternum. 

Aneurysms  of  the  transverse  portion  of  the  aorta,  when  they  attain 
any  considerable  size,  cause  the  most  intense  symptoms,  oAving  to  the 
relatively  shorter  antero-posterior  diameter  of  the  chest  at  this  point,  in 
consequence  of  Avhich  greater  compression  of  the  neighboring  tissues  takes 
place.  By  protruding  backAvard  they  may  exert  pressure  upon  the 
trachea,  causing  paroxysmal  cough  and  dyspnea.,  or  on  the  esophagus, 
causing  dysphagia  ;  these  are  common  events.  The  pressure  may  fiill 
also  upon  the  bronchus,  inducing  dyspnea,  hronrhorrhea,  and  dilatation, 
the  latter  in  turn  sometimes  leading  to  circumscribed  abscess.  The  left 
recurrent  laryngeal  nerve  may  be  implicated,  with  resulting  aphonia. 

Upivard  extension  of  the  aneurysmal  process,  Avith  involvement  of  the 
coats  of  the  carotid  and  subclavian  on  the  left  side,  or  of  the  innominate 
and  carotid  on  the  right,  may  occur.  The  sympathetic  nerves  in  the  cer- 
vical region  may  be  irritated,  causing  dilatation  ;  or  they  may  be  para- 
lyzed, causing  contraction  of  the  pupils.  Compression  of  the  thoracic 
duct  may  occur,  Avith  resulting  rapid  emaciation.  A  tumor  may  appear 
in  the  jugular  fossa. 

The  aneurysm  may  grow  fonva7'd,  in  which  event  it  lies  directly  behind 
the  manubrium,  Avhich  from  the  pressure  becomes  eroded  and  may  finally 
disappear  in  part.  In  aneurysms  involving  the  transverse  portion  of  the 
arch,  lateral  pressure,  both  toAvard  the  right  and  the  left,  is  also  made, 
causing  recession  and  compression  of  tlie  lungs. 

When  the  descending  portion  of  the  arch  is  affected  the  pressure  is  ex- 
erted upon  the  spinal  column  to  the  right,  and  upon  the  tissues  as  far  as 
the  shoulder-blade  to  the  left.  As  a  consequence  of  destruction  and  ab- 
sorption of  the  vertebme,  compression  of  the  spinal  cord  may  ensue,  and  is 
an  intensely  painful  process.  Pressure  may  be  made  upon  the  esophagus, 
causing  dysphagia,  or  upon  the  left  bronchus,  causing  bronchiectasis,  with 
its  usual  sequeloi  (bronchorrhea,  fetid  bronchitis,  gangrene  of  the  lung). 

The  sac  may,  in  consequence  of  the  sIoav  ulcerative  process  that  attends 
its  progress,  rupture  e\'entually  into  the  bronchus,  the  pericardium  (Avhen 
situated  near  the  sinuses  of  Valsalva),  the  pleura,  the  superior  vena  cava, 
or  the  esophagus,  Avith  sudden  tleath  as  the  result.  Frequently  repeated 
small  hemorrhages,  due  to  Aveepings  from  the  thinned  Avails,  may  precede 
the  fatal  rupture.  I  saAv  a  case  of  aneurysm  of  the  transverse  portion 
in  Avliich  rupture  into  the  esophagus  resulted,  Avith  instantaneous  death. 

When  the  tumor  has  reached  the  subcutaneous  tissue  and  bulges  ex- 


ANEURYSM.  685 

ternally,  the  skin  covering  it  becomes  tense  and  shining,  and  Avith  in- 
creased pressure  the  surface  becomes  reddened  and  finally  necrotic.  The 
necrosed  area  is  covered  with  a  dry  brown  scab,  which  later  is  thrown 
off,  leaving  an  oozing  surface.     Rupture  soon  follows. 

Leading  Symptoms  in  Detail. — Among  these  jiain  stands  primarily, 
being  the  first  and  most  constant.  It  is  of  two  kinds :  (a)  due  to 
direct  pressure  upon .  and  stretching  of  the  nerves.  When  aneurysm 
is  developed  suddenly,  a  sharp,  excruciating  pain  is  felt  in  the  upper 
sternal  region,  accompanied  by  a  feeling  of  "something  giving  way." 
In  consequence  of  the  stretching  of  the  nerves  a  constant  pain  is  expe- 
rienced that  is  subject  to  exacerbations  when  the  intra-aneurysmal 
pressure  is  raised.  Pressure  against  the  bony  structures  causes  erosion, 
and  usually  produces  a  continuous  boring  pain.  In  a  recent  case  of 
aneurysm  shown  in  clinic  at  the  Medico-Chirurgical  College,  how- 
ever, a  tumor  that  had  eroded  the  right  half  of  the  sternum,  and  of 
the  size  of  a  goose's  egg,  had  given  rise  to  no  suffering  wdiatever.  In 
latent  aneurysm  there  is  an  absence  of  pain  until  the  growth  terminates 
life.  Anginose  attacks  sometimes  occur  when  the  sac  has  its  seat  near  to 
the  heart,  (h)  Reflected  pains  of  a  neuralgic  character  may  be  excited 
by  aneurysm.  This  is  true,  in  particular,  of  aneurysms  situated  in  the 
transverse  portion  of  the  aorta,  in  which  instances  pain  is  commonly  felt 
in  the  region  of  the  neck  and  occiput  and  down  the  left  arm.  When  the 
growth  is  situated  along  the  course  of  the  descending  aorta,  intercostal 
neuralgia  may  be  excited,  and  it  is  probable  that  pain  of  this  sort  is  due 
to  pressure  upon  the  nerve-trunks. 

Cough. — The  cough  is  paroxysmal,  and  frequently  has  a  peculiar 
brazen,  ringing  character  that  points  to  its  laryngeal  seat.  Pressure 
upon  the  windpipe  excites  a  paroxysmal  dry  cough.  Compression  of  a 
bronchus  may  lead  to  bronchiectasis,  and  the  cough  then  occurs  only  in 
long  and  severe  paroxysms  which  recur  at  intervals  of  a  day  or  even 
longer,  and  are  attended  with  copious,  thick,  ropy  expectoration  {vide 
Bronchiectasis). 

Dyspnea  is  a  conspicuous  symptom  in  aneurysm  of  the  transverse  por- 
tion of  the  aorta  (the  aneurysm  of  symptoms — Broadbent).  It  arises 
(a)  most  frequently  in  consequence  of  pressure  upon  the  recurrent  laryn- 
geal nerve,  (h)  direct  pressure  on  the  trachea,  and  (e)  from  pressure  on 
the  left  bronchus.     Marked  stridor  may  accompany  the  first  variety. 

Paralysis  of  the  vocal  bands  is  occasioned  by  compression  of  the  recur- 
rent laryngeals,  particularly  the  left,  while  a  slight  degree  of  compression 
or  irritation  of  the  same  nerve  causes  spasm  of  the  vocal  cords.  The 
symptoms  indicating  the  presence  of  these  conditions  are  hoarseness, 
cough,  and  aphonia  respectively.  The  laryngoscope  should  be  employed, 
since  paralysis  of  one  of  the  abductors  may  be  present  without  giving  rise 
to  appreciable  symptoms. 

Semorrhage  may  occur  as  a  slow  oozing,  either  from  the  point  of  com- 
pression in  the  trachea  or  externally ;  in  either  case  the  amount  of  blood 
lost  is  small.  Profuse  bleedings  (often  producing  sudden  death)  take  place 
in  consequence  of  rupture  of  the  sac  into  the  lung,  the  bronchus,  or  the 
trachea. 

Deglutition  may  be  difiicult,  owing  to  compression  of  the  esophagus. 
When  an  aneurysm  has  been  diagnosticated  or  even  suspected,  the  esoph- 


686  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ageal  sound  should  not  be  passed  for  purposes  of  exploration,  on  account 
of  danger  of  rupture  of  the  sac. 

Compression  and  irritation  of  the  sympathetic  system  of  nerves  cause 
pupillary  changes  that  have  already  been  mentioned.  With  dilatation 
of  the  pupil  there  may  be  observed  pallor  of  one  side  of  the  face,  due  to 
stimulation  of  the  vaso-dilator  fibers  ;  on  the  other  hand,  with  contraction 
of  the  pupil  (due  to  paralysis  of  the  dilator  fibers)  there  is  hyperemia  of 
one  side  of  the  face  and  unilateral  sweating. 

Clubbing  of  the  fingers  and  incurvation  of  the  nails  are  not  rarely  met 
with  in  thoracic  aneurysm. 

Physical  Signs. — Inspection. — Visible  pulsation  is  one  of  the  earliest 
appreciable  signs.  It  is  most  frequently  observed  at  the  right  side  of  the 
sternum,  above  the  level  of  the  third  rib  (second  interspace),  and  much 
less  frequently  on  the  left  side  over  a  corresponding  area.  In  aneurysm 
of  the  transverse  portion  pulsation  may  be  seen  at  the  episternal  notch, 
though  an  impulse  here  may  also  be  due  to  nervous  palpitation,  and  have 
no  connection  with  aneurysmal  growths.  The  pulsation  may  occur  in  the 
absence  of  the  slightest  bulging  ;  when  associated  with  swelling,  however, 
its  diagnostic  value  is  infinitely  greater. 

Involvement  of  the  innominate  artery  produces  pulsation  in  the  neck 
above  the  sterno-clavicular  junction,  or  less  commonly  above  the  sternum. 
Corresponding  to  the  site  of  visible  impulse,  there  is,  sooner  or  later, 
bulging  in  most  instances.  It  may,  however,  be  so  slight  as  to  elude  de- 
tection unless  the  keenest  observation  be  practised,  and  in  not  a  few 
instances  the  tumor  itself  is  invisible  from  the  front  of  the  body,  but  is 
recognizable  looking  from  behind  or  from  either  side.  Again,  on  allow- 
ing the  light  to  fall  obliquely  upon  the  chest  slight  prominences  may  be 
brought  to  view  that  would  otherwise  be  inappreciable. 

When  the  aneurysm  is  situated  in  the  ascending  part  of  the  arch,  the 
most  frequent  seat  of  the  bulging — which  varies  in  size  from  a  hen's 
egg  to  a  cocoanut — is  over  the  first  and  second  right  interspaces  near 
to,  and  frequently  involving,  a  portion  of  the  sternum  ;  when  seated  just 
beyond  the  aortic  orifice,  a  pulsating  prominence  may  occupy  the  third 
interspace  along  the  left  sternal  border  ;  situated  in  the  transverse  section 
of  the  aorta,  bulging  of  the  upper  part  of  the  sternum  is  a  frequent  event, 
or  a  projection  into  the  cervical  fossa  may  occur,  though  with  comparative 
rarity.  In  the  descending  portion  the  swelling,  when  present,  is  in  the 
second  and  third  left  interspaces  near  to  the  sternum,  or  very  rarelv  in 
the  left  scapular  zone.  The  skin  over  the  tumors  has  been  described. 
The  apex-beat  is  displaced  downward  and  outward,  chiefly  from  pressure, 
though  to  a  lesser  extent  also  from  hypertrophy  (functional). 

Palpation. — The  protrusion  presents  a  more  or  less  yielding  and 
elastic  mass,  and  when  superficially  seated  fluctuation  may  be  obtainable. 
The  degree,  and  the  rhythmic  expansile  character  of  the  pulsation  are 
to  be  noted,  and  also  the  fact  that  there  is  an  alternate  contraction  and 
dilatation  of  the  sac  in  every  direction — a  distinctive  feature. 

If  the  aneurysm  is  largely  concealed,  bimanual  palpation  should  be 
employed,  the  palm  of  one  band  being  placed  over  the  spine  and  that 
of  the  other  over  the  sternum.  In  an  inconsiderable  number  of  cases 
aneurysmal  pulsation  is  only  yielded  when  the  finger-tips  are  used,  and 
quite  rarely  only  at  the  end  of  expiration.     A  diastolic  shock  is  often 


ANEURYSM.  687 

perceived,  and  forms  a  physical  sign  of  no  little  value.  A  distinct  sys- 
tolic shock,  sometimes  accompanied  by  a  purring  fremitus,  can  also  be 
felt  over  the  aneurysmal  sac. 

Percussion. — If  the  growth  be  deep-seated,  percussion  may  give  neg- 
ative results ;  when,  however,  the  tumor  causes  bulging  or  comes  in  con- 
tact with  the  chest-wall,  a  proportionate  area  of  flatness  is  presented. 
The  abnormal  field  of  dulness  may  be  the  only  symptom  present,  as  in 
an  instance  of  suspected  aneurysm  that  recently  came  under  my  care. 
Aneurysms  of  the  ascending  arch  give  flatness  to  the  right  of  the  ster- 
num ;  those  of  the  transverse  arch,  over  the  upper  part  of  the  sternum 
and  to  the  left ;  while  those  of  the  descending  portion  are  revealed  by  a 
flat  area  between  the  spine  and  the  left  scapula.  With  flatness  of  the 
percussion-note  there  is  a  sense  of  increased  resistance.  There  is  gen- 
erally a  moderate  increase  in  the  area  of  cardiac  dulness.  Conversely 
the  left  ventricle  has  been  found  of  diminished  size  at  necropsy. 

Auscultatory  'percussion  (practised  after  the  method  of  Sansom  and 
Ewart)  quite  often  gives  valuable  results. 

Auscultation. — Since  murmurs  owe  their  origin,  in  great  part,  to  the 
presence  of  fibrin  in  the  sac,  they  may  often  be  absent,  and  this  even  in 
the  case  of  large  aneurysms.  When,  as  is  usual,  a  murmur  is  present,  it 
is  systolic  in  rhythm,  heard  with  greatest  intensity  over  the  flat  area  or 
body  of  the  tumor,  and  is  transmitted  in  the  direction  of  the  blood-stream, 
being,  therefore,  distinctly  audible  in  the  vessels  of  the  neck  and  along 
the  course  of  the  aorta.     The  murmur  has  a  booming  quality. 

Aortic  regurgitation  may  be  considered  as  associated  with  aneurysm 
near  the  aortic  ring  when  a  double  murmur  is  heard.  In  a  few  instances 
the  diastolic  bruit  is  alone  detectable.  A  much  intensified,  ringing  sec- 
ond sound  is  present  (unless  marked  aortic  regurgitation  coexists),  and  is 
a  sign  of  the  utmost  significance  for  diagnosis. 

The  Peripheral  Arteries. — The  pulse  in  the  vessels  beyond  the  aneurysm 
is  slowed.  Hence  the  two  radial  pulses  may  exhibit  differences  in  time. 
The  volume  of  the  pulse  beyond  the  aneurysm  is  also  lessened,  and  in  cases 


Fig.  57. — Sphygmogram  of  a  case  of  aneurysm  of  the  left  subclavian  artery  (Foster). 

of  aneurysm  of  the  abdominal  aorta  or  the  femorals  it  may  be  obliter- 
ated. Such  differences  as  these  will  not  only  point  to  the  existence  of 
thoracic  aneurysm,  but  also  may  indicate  its  seat.  Thus,  if  there  be 
dilatation  of  the  transverse  arch  with  no  implication  of  the  innominate, 
the  pulse  at  the  right  wrist  is  strong  and  almost  simultaneous  with  the 
cardiac  impulse,  while  that  on  the  left  side  is  small,  weak,  and  more  re- 
tarded. If  the  reverse  be  true,  then  the  aneurysm  may  be  near  to  or  in- 
volve the  innominate. 

The  sphygmogram  exhibits  a  slanting  up-stroke  with  obliteration  of  the 
secondary  wave  (Fig.  57),  though  its  characters  are  by  no  means  constant. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Tracheal  Tugging. — This  sign  may  be  practised  while  the  patient  is 
sitting  or  standing  with  the  chin  slightly  elevated.  The  cricoid  cartilage 
is  then  grasped  between  the  thumb  and  forefinger  and  pushed  gently  up- 
ward so  as  to  stretch  the  trachea.  The  patient  must  cease  breathing 
momentarily,  when,  if  this  sign  be  present,  there  will  be  a  downward 
drao-crinof  or  tugging  at  each  systole.  The  transmitted  pulsations  from 
the  cervical  vessels  must  not  be  confounded  with  the  up-and-down  move- 
ment of  the  trachea. 

A  new  method  of  eliciting  tracheal  tugging,  first  suggested  by  Ewart, 
has  been  pretty  widely  adoj)ted.  and  possesses  the  advantage  of  ensuring 
greater  delicacy  of  touch  than  the  old.  He  stands  behind  the  patient, 
supporting  the  head  of  the  latter  against  his  body,  and  the  cricoid  is  then 
grasped  firmly  between  the  tips  of  the  forefingers.  The  method  is  in 
other  respects  similar  to  that  previously  described. 

As  shown  by  Toulmin,  tracheal  tugging  may  be  present  in  health  and 
in  other  diseases.  The  sign  is  probably  one  of  less  value  tlian  has  been 
supposed. 

Diagnosis. — In  the  presence  of  the  following  points  the  existence 
of  thoracic  aneurysm  may  be  confidently  inferred  :  (1)  Antecedent  arterio- 
sclerosis (with  the  appropriate  causes  of  the  latter) ;  (2)  History  of  other 
etiologic  factors,  as  age  (between  thirty  and  forty-five  years)  and  occu- 
pation (such  as  entail  unusual  muscular  strain) ;  (3)  Pressure-symp- 
toms, as  pain,  dyspnea,  aphonia,  cough  (either  laryngeal  or  bronchial), 
bronchorrhea,  dysphagia,  edema,  vasomotor  disturbances ;  (4)  Physical 
signs  of  a  pulsating  tumor  (including  the  abnormal  area  of  dulness,  sys- 
tolic murmurs,  the  systolic  and  diastolic  shock,  and  tracheal  tugging) 
somewhere  along  the  course  of  the  arch  or  its  great  branches,  with  or 
without  differences  in  the  volume  and  time  of  radial  or  carotid  pulses. 
There  are,  however,  several  classes  of  cases  which  offer  difficulties  that 
are  sometimes  insurmountable :  («)  Those  in  which  the  aneurysm  is  small 
and  deep-seated.  Here  the  symptoms  and  physical  signs  are  indefinite. 
There  may  be  thoracic  oppression,  in  which  pain  may  radiate  to  the  left 
shoulder,  and  mild  pressure-symptoms — a  group  of  suspicious  features 
merely — sometimes  appear.  I  have  under  my  observation  now  a  patient 
suffering  fi'om  aneurysm  of  the  ascending  aorta  in  which  for  a  long  time 
left-sided  intercostal  neuralgia  was  the  only  symptom,  {b)  Aneurysm  of 
the  transverse  arch,  in  which  the  pressure-symptoms  are  more  or  less  pro- 
nounced, but  with  no  physical  signs.  In  such,  a  clear  history  suffices  to 
complete  the, diagnosis.  Pressure-symptoms,  on  the  other  hand,  without 
etiologic  factors  are  just  as  likely  to  be  due  to  other  causes,  (c)  Those 
cases  in  which  the  more  characteristic  features  are  manifested  intermit- 
tently. Fortunately,  a  proper  diagnosis  of  aneurysm  in  obscure  cases 
can  be  often  made  by  the  aid  of  the  a--rays.  The  disease  can  also  be 
excluded,  in  suspected  cases  in  which  it  is  not  present,  by  fluoroscopic 
examination. 

Extremely  obscure  are  many  of  the  cases  in  which  the  only  symptoms 
manifested  point  to  irritation  of  the  trachea  or  bronchial  tubes,  with  par- 
oxysmal cough,  bronchorrhea,  and  sometimes  the  signs  of  bronchiectasis. 
In  a  recent  case  of  this  sort  tracheoscopic  examination  revealed  com- 
pression of  the  windpipe,  making  clear  the  nature  of  the  affection.  In 
still  another  instance,  in  which  laryngeal  dyspnea  and  cough,  with  bron- 


ANEURYSM.  689 

chorrhea,  were  the  only  symptoms,  a  laryngoscopic  examination  determined 
tibe  diagnosis,  in  that  it  brought  to  view  bilateral  paralysis  of  the  abduc- 
tors of  the  vocal  bands. 

Differential  Diagnosis. — The  affections  from  which  intrathoracic  aneur- 
ysm must  be  distinguished  axe  pulsating  em'pyema,  pulmonary  tuberculo- 
sis, abnormal  pulsation  of  the  aorta,  and  solid  tumors.  Of  the  latter, 
those  simulating  aneurysm  are  carcinoma,  sarcoma,  and  enlarged  lymph- 
glands.  These  mediastinal  tumors  may  duplicate  all  of  the  pressure- 
symptoms,  though  they  are  less  apt  to  cause  bulging,  and  less  apt  still 
to  excite  abnormal  pulsation ;  when  pulsation  is  noted  it  is  observed  to 
be  quick,  and  not  deliberate,  heaving,  and  ex]Dansile,  as  in  aneurysm. 
Solid  growths  also  lack  the  characteristic  shock — both  systolic  and  dias- 
tolic— of  aneurysm.  The  cardio-vascular  symptoms  are  usually  want- 
ing in  the  case  of  solid  tumors,  especially  the  moderate  hypertrophy, 
accentuation  of  the  second  sound,  tracheal  tugging,  and  the  difference 
between  the  radial  pulses. 

Carcinoma  of  the  mediastinum  usually  gives  a  history  of  the  disease  in 
other  parts  of  the  body,  with  enlargement  of  the  axillary  or  other  super- 
ficial lymphatic  structures,  and  later  the  characteristic  cachexia,  this 
being  particularly  marked  in  carcinoma  of  the  esophagus. 

Abnormal  pulsation  in  the  aorta  is  noted  in  neurotic  subjects,  mostly 
females,  and  in  aortic  regurgitation ;  less  frequently  it  is  associated  with 
retraction  of  the  right  lung,  with  spinal  curvature,  and  with  displacement 
of  the  aorta.  In  the  case  of  the  latter  two  conditions  a  careful  considera- 
tion of  the  causal  states  and  the  absence  of  the  characteristic  physical 
signs  would  lead  to  a  correct  diagnosis.  Aortic  regurgitation  is  frequently 
associated  with  aneurysm  of  the  arch,  and  in  its  course  there  is  developed, 
not  infrequently,  a  dilatation  of  the  ascending  portion  of  the  aorta.  The 
diagnosis  of  aneurysm  of  the  arch  of  the  aorta  should  not  be  made,  even 
when  all  the  characteristic  physical  signs  of  aortic  regurgitation  are 
present  in  any  given  case,  unless  the  signs  of  the  pulsating  tumor  above 
the  heart  be  unmistakable.  Dynamic  pulsation  of  a  neurotic  origin  is 
seen  and  felt  in  the  episternal  notch,  as  a  rule,  and  a  correct  appreciation 
of  the  nervous  element,  whether  inherited  or  acquired,  will  prevent  the 
observer  from  committing  an  error. 

Pulsating  empyema  can  only  be  confounded  with  large  aneurysmal 
growths,  and,  as  pointed  out  by  Wilson,  it  does  not  have  the  same  definite 
relation  to  the  central  long  axis  of  the  body  as  do  aneurysms.  The 
abnormal  area  of  dulness  is  situated  at  the  base  of  the  lung  in  empyema, 
and  usually  extends  over  a  larger  superficial  area  or  is  less  circumscribed 
than  in  aneurysm.  In  empyema,  moreover,  the  pulsation  is  not  expansile, 
but  is  caused  by  pressure  on  the  respiratory  movements.  Auscultation 
in  empyema  renders  audible  neither  a  bruit  nor  the  double  shock  of 
aneurysm ;  the  pressure-symptoms  and  pulse-characters  are  also  entirely 
wanting. 

Pulmonary  tuberculosis  may  be  mistaken  for  thoracic  aneurysm.  When 
an  aneurysm  compresses  a  bronchus,  bronchiectasis,  attended  with  cough, 
bronchorrhea,  fever,  and  emaciation,  may  be  the  result ;  but  in  phthisis 
the  fever  and  emaciation  are  more  pronounced,  tubercle  bacilli  are  pres- 
ent, whilst  the  characteristic  cardio-vascular  signs  of  aneurysm  are 
absent. 

44 


690  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Prognosis. — The  occurrence  of  perforation  and  consequent  speedy 
death  in  unsuspected  cases  must  be  recollected.  In  other  instances  the 
end  is  approached  in  a  very  gradual  manner,  and  cases  in  which  rupt- 
ure does  not  supervene  sometimes  pursue  the  general  course  of  chronic 
valvular  affections  of  the  heart.  The  condition  ends  in  death  as  a  rule, 
and  the  immediate  causes  of  the  fatal  issue  are  as  follows :  (1)  Rupture 
of  the  aneurysm,  followed  by  hemorrhage  into  any  of  the  adjacent  cav- 
ities or  organs  (pericardium,  heart,  large  vessels,  mediastinum,  trachea, 
a  bronchus,  esophagus,  lungs,  pleura,  spinal  canal) ;  it  may,  though 
rarely,  rupture  externally,  in  w^hich  case  slight  hemorrhages  occur  and 
life  may  last  for  weeks ;  (2)  Gradual  asthenia ;  (3)  Direct  pressure  ;  (4) 
Independent  diseases,  either  primary  or  secondary  to,  and  induced  by, 
the  aneurysm.  Among  these  ])uhuonary  complications — fibrinous  pneu- 
monia, abscess,  gangrene,  tuberculosis — are  of  first  importance. 

Treatment. — There  are  two  objects  of  treatment  around  which  all 
others  center  in  the  management  of  this  disease — first,  the  promotion  of 
coagulation  of  the  blood,  and  secondly,  the  contraction  of  the  sac.  The 
clotting  of  the  blood  Avithin  the  growth  may  be  greatly  ftivored  by  retard- 
ing the  blood-current.  Nothing  so  well  accomplishes  this  object  as  abso- 
lute rest  in  the  recumbent  posture.  This  cannot  always  be  rigidly  en- 
forced, but  muscular  exertion  must  be  minimized,  and  mental  applica- 
tion and  emotional  excitement  avoided  ;  stimulants,  arterial  and  nervous, 
are  to  be  eschewed  for  like  reasons.  Palpitation  of  the  heart,  when 
present,  is  to  be  allayed  by  the  local  use  of  the  ice-bag.  The  coagula- 
bility of  the  blood  is  also  increased  by  removing  as  far  as  possible  the 
liquid  portion  of  the  diet. 

The  measures  already  indicated  tend  to  lessen  the  volume  of  blood 
and  the  intra-aneurysmal  pressure,  thus  inviting  contraction  of  the  sac 
as  well  as  consolidation  of  its  contents.  Among  medicinal  agents,  ergot 
and  potassium  iodid  have  been  employed,  the  latter  with  good  effects. 
The  exact  manner  in  which  the  iodid  produces  its  favorable  results  in 
these  cases  is  unknown,  though  most  probably  it  acts  upon  the  vascular 
Avails,  and  hence  would  be  most  efficacious  Avhen  the  disease  is  of  syphil- 
itic origin  ;  this  view  accords  Avith  my  OAvn  personal  experience.  I  Avould 
advise  against  the  internal  use  of  ergot,  Avhich  can  have  little  to  recom- 
mend it,  and  the  prolonged  use  of  Avhich  may  be  attended  Avith  un- 
pleasant effects.  Langenbeck  and  others  have  obtained  good  results 
from  the  direct  injection  into  the  sac  of  the  aqueous  extract  of  ergotin 
dissolved  in  Avnter  or  glycerin,  every  day  or  tAvo.  When  employed  in 
this  manner  ergotin  induces  contraction  of  the  smooth  muscles  in  the 
Avail  of  the  aneurysm.  Numerous  observers  have  resorted  to  the  use  of 
horse-hair,  fine  Avire,  fine  catgut,  slender  Avatch-springs,  Avith  a  vieAV  to 
coagulating  the  blood  as  it  comes  in  contact  Avith  these  foreign  bodies. 
Electrolysis  is  a  method  that  has  been  Avarmly  advocated  (Loreta). 

Combined  Aviring  and  electrolysis  (Corradi's  method)  has  been  suc- 
cessfully employed  by  Rosenstein,  Kerr,  D.  I).  StcAvart,  and  Hereby. 
The  details  of  the  method  are  briefly  as  follows : 

A  piece  of  fine,  slender  Avire,  several  feet  in  length,  is  passed  directly 
from  a  spool  through  a  hypodermic  needle,  so  that  the  wire  curls  up 
AVithin.  This  is  noAv  attached  to  the  positive  pole,  Avhile  the  negative  is 
connected  Avith  a  surfiice  pad  placed  over  the  abdomen  or  Avith  an  insu- 


ANEURYSM.  691 

lated  needle  inserted  into  the  sac,  and  the  current  is  then  passed 
through.  It  is  important  to  test  the  strength  of  the  current  beforehand 
by  inserting  the  needle  attached  to  the  positive  pole  into  the  white  of 
an  egg  and  observing  its  power  to  coagulate  albumin.  Each  applica- 
tion of  the  current  should  last  from  one  to  two  hours.  It  is  not,  how- 
ever, without  serious  dangers  (hemorrhage  and  embolism). 

After  the  same  method  galvano-puncture  has  long  been  resorted  to,  and 
in  the  hands  of  some  clinicians  with  encoui-aging  results.  The  cases  that 
receive  most  benefit  from  the  above  measures  belong  to  the  saccular  vari- 
ety ;  this  is  also  true  of  the  special  plan  first  commended  by  Tufnell,  which 
is  especially  applicable  in  the  earlier  stages.  Tufnell's  method  is  founded 
upon  two  main  principles — absolute  rest  in  the  recumbent  posture,  and  a 
much-restricted,  dry  diet.  With  physical  rest  a  quiet  mental  state  should 
be  conjoined.  The  diet  is  as  follows  :  Breakfast,  2  ounces  (64.0)  of  bread 
and  butter  and  2  ounces  (64.0)  of  milk  ;  for  dinner,  2  or  3  ounces  (64.0— 
96.0)  of  meat  and  3  or  4  ounces  (96.0-128.0)  of  milk  or  claret ;  for  supper, 
2  ounces  (64.0)  of  bread  and  2  ounces  (64.0)  of  milk. 

The  chief  advantages  growing  out  of  this  method  are  the  lessened 
number  and  decreased  force  of  the  heart-beats  in  consequence  of  the 
posture  and  bodily  rest,  and  the  diminution  of  the  blood-volume  in 
consequence  of  the  dietetic  restrictions.  It  should  be  persevered  in 
for  several  months.  His  bowels  should  be  regulated,  and  he  should  be 
told  not  to  strain  while  at  stool. 

A.  E.  Wright  has  particularly  insisted  upon  the  value  of  calcium 
salts  in  increasing  the  coagulability  of  the  blood  (gr.  x  to  xv — 0.648 
to  0.972,  t.  i.  d.,  may  be  given).  A.  E.  Taylor's  studies  show  that  if 
it  is  desired  to  saturate  the  body  with  calcium  salts,  water  should  be 
given  in  abundance. 

Injections  of  gelatin  in  aneurysm  have  a  specially  favorable  effect 
according  to  certain  observers.  Moyer  ^  reviews  the  literature,  and  in 
the  main  his  conclusions  are  :  Gelatin  solutions  are  of  some  value  in 
the  treatment  of  saccular  aneurysms,  ^but  not  of  the  diifused  forms. 
Solutions  not  stronger  than  1  per  cent,  should  be  used  ;  they  should  be 
kept  in  a  brood-oven  to  determine  bacterial  growth,  and  great  care 
should  be  taken  in  the  technique.  Absolute  rest  in  bed  should  be 
enjoined.  This  method  is  worthy  of  extended  trial,  but  great  caution 
and  watchfulness  must  be  exercised  in  its  administration. 

Special  Symftoms. — Pain  is  often  relieved  by  potassium  iodid.  When 
marked  arterial  sclerosis  is  present  I  have  seen  relief  from  pain  afforded 
by  the  internal  use  of  nitroglycerin  (tVLj  to  ij — 0.066  to  0.133,  three  or 
four  times  a  day).  In  the  later  stages  morphin  should  be  given  to  allay 
suffering.  When  there  is  bulging  the  pain  may  be  assuaged  by  the  local 
use  of  the  ice-bag  or  by  a  belladonna  plaster. 

Dyspnea  and  great  venous  congestion  are  to  be  met  by  free  bleedings 
from  a  vein,  and  tracheotomy  may  be  required  if  the  dyspnea  be  shown 
to  be  due  to  bilateral  paralysis  of  the  abductors.  In  dyspnea  arising 
from  pressure  on  the  trachea  or  bronchus,  however,  tracheotomy  would 
be  a  valueless  expedient.  When  the  aneurysm  forms  a  large  external 
tumor  the  application  of  an  elastic  bandage  to  the  chest  may  be  both 
agreeable  and  advantageous,  as  in  a  case  referred  to  by  Osier. 

1  Medicine,  March,  1899. 


692  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ANEURYSM   OF   THE  ABDOMINAL   AORTA. 

The  vicinity  of  the  celiac  axis  is  the  favorite  seat  of  abdominal 
aneurysm,  which  is  by  no  means  so  common  a  condition  as  intra- 
thoracic aneurysm,  though  not  rare.  It  may  assume  a  fusiform  or 
saccular  nature. 

Symptoms. — The  tumor  may  grow  backward ;  but  more  frequently 
its  growth  is  in  a  forward  direction.  VroJGCtmg  from  the  posterior  wall, 
it  usually  erodes  the  vertebrae,  and  compression  of  the  cord  is  apt  to  take 
place,  producing  paraplegia,  preceded  by  tingling  and  numbness  of  the 
legs. 

Pain  is  the  leading  symptom.  It  may  be  neuralgic  or  of  a  boring  or 
gnawing  character,  due  to  destruction  of  the  bone.  Rarely,  the  aneurysm 
perforates  the  diaphragm,  and  finally  ruptures  into  the  lungs  or  pleura. 
Arising  from  the  anterior  wall,  it  may  early  form  a  well-defined  tumor. 
It  may,  however,  when  situated  high  up  or  near  the  diaphragm,  conceal 
itself  until  it  has  attained  a  comparatively  large  size,  as  in  a  case  recently 
under  my  care  at  the  Medico-Chirurgical  Hospital.  Voiuiting  and  gas- 
tralgic  seizures  may  be  troublesome,  and  the  fact  that  embolism  of  the 
superior  mesenteric  artery  may  occur  and  give  rise  to  severe  colicky 
pains  must  be  recollected.     Jaundice  has  been  observed. 

Physical  Signs. — Epigastric  pulsation  may  be  visible,  and  occasion- 
ally an  epigastric  swelling.  The  palpating  hand  detects  a  heaving, 
expansile  pulsation  that  may  be  accompanied  by  a  thrill.  When  the 
tumor  hugs  the  diaphragm  the  pulsation  may  be  double.  The  femoral 
pulse  is  diminished  in  volume  and  delayed.  An  abnormal  area  of  dul- 
ness  may  be  present.  In  most  instances  a  soft  bruit  is  audible.  The 
diastolic  murmur  and  shock  of  intrathoracic  aneurysm  are  quite  usually 
absent. 

Diagnosis. — A  certain  diagnosis  demands  the  presence  of  a 
definite  growth  that  is  seizable  and  has  a  heaving,  expansile  pulsa- 
tion. Mere  pulsation  attended  with  a  thrill  and  a  systolic  murmur  are 
insufficient. 

Differential  Diagnosis. — A  throbbing  aorta,  as  met  with  in  neurotic 
females  and  in  anemia  (particularly  in  instances  of  the  traumatic  form), 
is  not  infrequently  distinguished  from  aneurysm  of  the  abdominal  aorta 
with  great  difficulty.  It  does  not,  however,  present  a  tumor  that  can 
be  held  in  the  grasp  and  possessing  an  expansile  pulsation,  as  in 
aneurysm. 

When  solid  growths  lie  upon  the  aorta  the  latter  may  manifest  pulsa- 
tion, a  thrill,  and  a  systolic  murmur,  but  the  very  general  absence  of 
pulsation,  owing  to  the  fact  that  the  tumor  falls  forward  when  the  patient 
is  placed  in  the  knee-elbow  position,  suffices  usually  to  diff'erentiate  the 
condition  from  genuine  aneurysm.  Again,  expansile  pulsation  is  not 
evinced  by  a  solid  growth. 

The  prognosis  is  very  gloomy.  Very  rarely,  hoAvever,  nature  effects 
a  cure  if  the  conditions  be  favorable.  "  Death  may  result  from  (a)  the 
complete  obliteration  of  the  lumen  by  clots ;  {b)  compression-paraplegia ; 
((?)  rupture  either  into  the  pleura,  retroperitoneal  tissues,  peritoneum,  the 
intestines,  or,  very  commonly,  into  the  duodenum  ;  {d)  embolism  of  the  su- 
perior mesenteric  artery,  producing  infarction  of  the  intestines"  (Osier). 


ANEURYSM.  693 

Treatment. — Apart  from  the  measures  indicated  for  thoracic  aneur- 
ysm, there  is  one  means  of  cure  that  may  be  tried  if  the  growth  be  low 
down — viz.  pressure.  This  must  be  maintained  for  twenty-four  hours  at 
least  under  an  anesthetic.  It  is  best  to  make  steady  pressure  on  the 
proximal  portion  of  the  vessel,  and  unless  practised  with  great  care  the 
sac  will  be  damaged  and  death  ensue. 

ANEURYSM   OP   THE   PULMONARY   ARTERY. 

Dilatation  of  the  pulmonary  artery  is  of  frequent  occurrence  in 
affections  that  oppose  obstruction  to  the  lesser  circulation  [e.  g.  mitral 
disease,  emphysema,  phthisis).  Very  rarely  extreme  dilatation  of  the 
vessel  is  followed  by  semilunar  incompetence,  when  a  diastolic  murmur 
at  the  pulmonary  orifice  (second  left  interspace)  becoines  audible. 

Aneurysms  involving  the  pulmonary  artery  are  quite  rare:  such  as 
occur  are  small  and  of  the  saccular  and  fusiform  varieties. 

The  symptoms  resemble  those  of  intrathoracic  aneurysm,  though 
they  are  rarely  well  marked,  owing  to  the  fact  that  they  remain  of  small 
size  as  a  rule. 

Physical  Signs. — Pulsation  (and,  rarely,  a  small  tumor)  is  detectable 
in  the  second  left  interspace.  Palpation  may  also  render  appreciable  a 
thrill  and  diastolic  shock.  Coextensive  with  the  area  of  pulsation  there 
may  be  dulness  on  percussion,  and  over  the  second  interspace  to  the  left 
of  the  sternum  Siloud  superficial  systolic  murmur  is  heard  on  auscultation, 
together  with  a  diastolic  shock.  Before  attaining  to  a  large  size,  these 
aneurysms  usually  rupture  into  the  heart  itself. 

The  prognosis  is  altogether  unfavorable,  the  treatment  having  refer- 
ence to  the  principles  that  are  appropriate  in  thoracic  aneurysm. 

The  coronary  arteries  may  be  the  seat  of  aneurysm,  though  exception- 
ally. The  condition  arises  in  consequence  of  weak  points  (due  to  arterio- 
sclerosis) in  the  course  of  the  vessels,  and  is  unrecognizable  during  life. 

ANEURYSM   OP   THE    CELIAC    AXIS. 

This  condition  is  sometimes  observed  in  combination  with  aneurysm 
of  the  upper  portion  of  the  abdominal  aorta. 

ANEURYSM    OF    THE    SPLENIC    ARTERY. 

This  branch  of  the  celiac  axis  is  occasionally  the  seat  of  aneurysmal 
dilatation.  It  may  be  single  or  multiple,  and,  whilst  it  is  small  as  a  rule, 
may  in  rare  cases  be  quite  large. 

The  symptoms  are  indefinite,  but  distressing.  Deep-seated  abdomi- 
nal pain,  which  shows  a  tendency  to  radiation,  forms,  with  vomiting,  and 
rarely  hematemesis,  the  main  features.  By  percussion  a  tumor  may  be 
mapped  out  in  the  left  hypochondriac  region,  the  dulness  merging  with 
that  of  the  spleen  and  the  left  lobe  of  the  liver.  Usually,  pulsation, 
and,  rarely,  a  tumor  can  be  felt,  and  systolic  murmur  is  often  heard. 
The  condition  may  be  confounded  with  gastric  ulcer. 

ANEURYSM  OF  THE  HEPATIC  ARTERY. 

This  is  exceedingly  rare,  the  total  number  of  cases  on  record  being 
about  20.  H.  B.  Schmidt  has  recently  reported  a  case  associated  with 
symptoms  of  gall-stones,  in  which,  as  shown  by  the  autopsy,  death  was 
caused  by  rupture  of  the  sac  into  the  bile-ducts.     Schmidt  found  records 


694  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  but  5  cases  of  this  mode  of  termination.     Osier  and  Eoss  have  reported 
an  instance  associated  Avith  multiple  hepatic  abscesses. 

The  symptoms  are,  in  the  main,  colicky  j) dins,  vomiting,  hemateme- 
sis,  and  obstructive  jaundice.  A  tumor  is  rarely  discernible,  though  an 
abnormal  area  of  pulsation  is  relatively  more  frequent.  The  recognition 
of  the  condition  during  life  is  entirely  conjectural. 

Aneurysm  of  the  superior  mesenteric  artery  is  of  rare  occurrence. 
Pain  in  the  epigastric  and  lumbar  regions,  and  chynonstrahle  tumor  near 
to  or  directly  over  the  median  line  of  the  abdomen,  are  the  symptoms  dis- 
played. Detached  fragments  of  the  clot  may  produce  embolism  of  the 
terminal  branches  of  the  mesenteric  arteries.  The  condition  terminates 
usually  in  rupture  into  the  peritoneal  cavity. 

Aneurysm  of  the  inferior  mesenteric  artery  runs  a  course  similar  to 
the  above.      It  is  (juitc  rare  and  possesses  slight  interest. 

Aneurysm  of  the  Renal  Arteries. — Small  multiple  dilatations  are  occa- 
sionally seen,  but  large  ones  are  of  great  rarity.  They  are  prone  to 
rupture  into  the  retroperitoneal  cavity. 

ARTERIO-VENOUS   ANEURYSM. 

Definition. — An  artificial  communication  between  an  artery  and  a 
vein.  A  sac  may  intervene  between  the  two  vessels  {varicose  aneurysm) 
or  there  may  be  a  direct  fistulous  communication  without  an  intervening 
sac  {aneurysmal  varix). 

In  varicose  aneurysm  the  sac  is  developed  from  the  structures  that 
mark  the  boundaries  of  the  communicating  duct.  The  majority  of  cases 
are  caused  by  the  simultaneous  wounding  of  an  artery  and  a  vein  during 
venesection.  Hence  their  most  frequent  seat  is  at  the  bend  of  the  elbow. 
Pepper  and  Griffith  have  analyzed  the  records  of  29  cases  in  which  the 
ascending  portion  of  the  aortic  arch  had  opened  into  the   vena  cava. 

Symptoms. — The  symptoms  are  largely  aneurysmal,  and  in  addi- 
tion there  appear  in  rapid  sequence  great  sicelling  of  the  veins, 
cyanosis,  and  edema  of  the  upper  portion  of  the  body.  A  continuous 
thrill  and  buzzing  murmur,  with  systolic  intensification,  are  the  chief 
signs. 

In  the  treatment  of  thoracic  arterio-venous  aneurysm  the  same  gen- 
eral plan  is  to  be  pursued  as  advised  in  the  purely  arterial  variety. 

CONGENITAL   ANEURYSM. 

This  condition  arises  because  of  a  defective  ante-natal  development  of 
the  elastic  coat.  It  is  often  multiple,  and  the  tumors  are,  as  a  rule, 
small  in  size,  ranging  from  that  of  a  pea  to  a  hazel-nut.  The  most  com- 
mon situations  for  these  growths  are  the  coronary  and  pulmonary  ar- 
teries. To  Eppinger  belongs  the  credit  for  having  pointed  out  the  fact 
that  the  aneurysmal  walls  consist  only  of  the  adventitia  and  intima. 
''•  Peri-arteritis  nodosa,"  a  rare  condition,  which  Eppinger  holds  to  be  a 
form  of  congenital  aneurysm,  presents  the  symptoms  of  general  infection 
rapidly  developed.  "  On  examination  after  death  the  arteries  are  found 
beset  with  nodules  of  active  inflammatory  products,  chiefly  on  the  outer 
coat  "  (Allbutt).  The  condition  may  be  met  with  in  children  and 
rarely  in  adults. 


PART  VI. 

DISEASES    OF   THE    DIGESTIVE   SYSTEM. 


I.   DISEASES  OF  THE  MOUTH. 


STOMATITIS. 


CATARRHAL    STOMATITIS. 
(Stomatitis  Erythematosa.) 

Definition. — A  simple,  acute  inflammation  of  the  huccal  mucous 
membrane.     It  is  more  commonly  met  with  in  children  than  in  adults. 

Ktiology. — As  a  jjrimary  aff"ection  its  causes  are  mainly  mechanical 
and  chemical  irritation,  such  as  the  presence  in  the  mouth  of  hard  and 
sharp  bodies,  dental  caries,  acids,  hot  or  cold  food,  condiments,  tobacco, 
certain  drugs  (as  mercury),  eruption  of  teeth,  and  bad  feeding,  par- 
ticularly in  illy-nourished  children.  It  is  the  result  often  of  a  neglect 
of  the  mouth-toilet,  leading  to  the  decomposition  of  accumulated  bits 
of  food  and  mucus,  and  many  cases  probably  owe  their  origin  to  infec- 
tion. Secondarily,  catarrhal  stomatitis  may  be  associated  Avith  certain 
of  the  eruptive  fevers  (scarlet  fever,  measles,  typhoid),  also  with  gastro- 
enteric derangements,  and  may  folloAv,  by  direct  inflammatory  extension, 
upon  ulcerative  tonsillitis,  pharyngitis,  and  the  like. 

Symptoms. — The  local  symptoms  of  this  affection  are  those  usually 
seen  in  an  inflammation  of  a  mucous  membrane — redness,  heat,  SAvell- 
ing,  and  dryness,  soon  followed  by  increased  secretion  and  soreness. 
The  lips  and  gums  only,  or  the  membrane  of  the  whole  mouth,  may  be 
inflamed,  and  the  swollen  lips,  cheeks,  and  furred  tongue  may  be 
indented  by  teeth-marks.  Enlarged  and  reddened  papillge  on  the  tongue 
and  minute  vesicles  inside  the  cheeks  and  lips  from  projecting  mucous 
follicles  are  sometimes  seen.  These,  later,  may  terminate  in  simple 
small  ulcers.  A  craving  for  cold  drinks  is  nearly  always  noted,  as  well 
as  distress  and  even  pain  on  suckling,  mastication,  or  touching  w'ith  the 
inspecting  finger,  and  there  is  a  disagreeable  taste  due  to  the  perverted 
buccal  secretions.  Chemical  examination  of  the  dribbling  saliva  shoAvs 
an  acid  reaction,  Avith  the  presence,  microscopically,  of  an  excess  of  des- 
quamated pavement  epithelium  that  has  undergone  partial  fatty  degen- 
eration. Leukocytes,  micrococci,  the  leptothrix  buccalis,  and  the  re- 
mains of  food  may  also  be  seen  (Striimpell).  Aside  from  restlessness 
and  the  symptoms  common  to  slight  febrile  disturbances,  the  constitu- 
tional co7idition  is  rarely  disturbed,  except  Avhen  the  stomatitis  is  sec- 

695 


696  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ondary  either  to  inflammations  lower  down  in  the  digestive  tract,  or 
to  the  specific  infectious  fevers. 

The  course  of  the  disease  is  usually  acute,  and  the  duration  about 
one  week. 

The  differential  diagfnosis  of  catarrhal  stomatitis  is  easily  made 
by  inspection  of  the  membrane. 

The  prognosis,  though  favorable,  will  vary  as  to  time  and  severity 
according  to  the  cause. 

Treatment. — After  proper  attention  to  the  hygienic  surroundings 
of  the  patient  and  the  removal  of  all  irritant  influences,  the  treatment  is 
mainly  local.  The  first  indications  are  to  cleanse  the  mouth  and  allay 
the  pain,  and  these  may  be  met  by  the  use  of  cool  solutions  of  boric  acid, 
sodium  bicarbonate,  or  potassium  chlorate,  5  and  10  grains  (0.324  and 
0.648)  respectively  to  the  ounce  (32.0)  of  glycerin  and  rose-water,  as 
mouth-washes,  or  for  swabbing  in  the  case  of  infants.  When  iced  drinks 
are  ungrateful  and  the  inflammation  is  more  intense  and  protracted,  the 
use  of  hot  milk  and  lime-water,  mucilaginous  decoctions,  and  sedative 
and  antiseptic  sprays  of  1  or  2  per  cent,  solutions  of  cocain  or  carbolic 
acid  are  often  beneficial ;  or  mild  astringents  may  be  needed,  as  ^  to  1 
per  cent,  solutions  of  silver  nitrate,  alum  (5  to  10  grains — 0.324  to  0.648 
— to  the  ounce — 32.0 — of  honey),  and  glycerite  of  tannin  (2  drams  to 
the  ounce — 8.0  to  32.0 — of  water),  especially  if  there  is  a  tendency  to 
chronicity  of  the  trouble,  as  in  topers  and  inveterate  smokers.  Tender 
and  spongy  gums  may  be  relieved  by  the  application  of  equal  parts  of 
the  tinctures  of  myrrh  and  rhatany  on  a  camel's-hair  brush  (Strlimpell). 
General  symptoms  as  they  arise  must  be  met  by  the  remedies  rationally 
indicated.  Small  doses  of  aconite  or  potassium  citrate  for  the  pyrexia, 
with  a  minimum  dose  of  bromid  for  irritability  and  sleeplessness,  may 
be  all  that  is  required.  The  internal  use  of  potassium  chlorate  in  chil- 
dren is  not  to  be  recommended  in  this  afl'ection,  both  because  of  its 
deleterious  action  upon  the  kidneys,  and  also  because  it  seems  to  be 
unnecessary  (Forchheimer;  Backader).  Sometimes  an  associated 
gastro-intestinal  catarrh  needs  correction  by  the  use  of  laxatives. 
The  administration  of  bland  foods  and  mild  ferruginous  tonics  should 
be  continued  throughout  convalescence. 

APHTHOUS    STOMATITIS. 
(Follicular  Sto)natitis ;   Stomatitis  Aphthosa.) 

Definition. — A  variety  of  catarrhal  stomatitis  that  is  characterized 
by  the  erujjtion  of  one  or  more  vesicles  upon  the  edges  of  the  tongue,  the 
cheek,  or  the  lips,  rapidly  passing  into  small  round,  or  oval  discrete  spots 
that  are  slightly  raised  and  surrounded  by  yellowish-white  bases  with 
narrow  red  areol:^. 

etiology. — Though  more  common  in  children  between  the  ages  of 
two  and  six  years,  they  are  by  no  means  rare  in  adults.  Predisposing 
influences  may  be  found  in  the  seasons  (spring  and  autumn),  malnutri- 
tion, tuberculosis,  dentition,  persistent  gastro-enteric  disorders,  anemia, 
and  the  acute  exanthemata.  The  exciting  causes  are  supposed  to  be 
certain  deleterious  substances,  bacterial  or  toxic,  though  no  special  par- 
asite has  yet  been  isolated. 


APHTHOUS  STOMATITIS.  697 

Symptoms. — The  herpetic  vesicles  soon  rupture,  leaving  the  aphthous 
ulcers  as  described  above.  They  are  found  singly,  or  at  times  as  many 
as  twenty  in  number,  pin-head  to  split-pea  in  size,  inside  the  lips,  espe- 
cially near  the  frenum,  along  the  tongue-edges,  and  sometimes  inside 
the  cheeks  near  the  edges  of  the  back  teeth.  They  are  exquisitely 
tender,  so  that  almost  any  motion  of  the  affected  parts  causes  sharp 
burning  pain  ;  nourishment  is  therefore  difficult.  Patches  of  catarrhal 
stomatitis,  and  even  of  gingivitis,  are  seen  adjacent  to  the  aphthous  spots. 
There  is  an  increased  flow  of  the  secretions  of  the  mouth,  and  the 
breath  is  heavy,  though  not  offensive.  Greneral  s^mjJtoms,  as  slight 
fever,  anorexia,  and  furred  tongue,  constipation  or  diarrhea,  and  irrita- 
bility, are  usually  present,  with  the  additional  symptoms  of  any  associated 
disease  that  may  coexist.  Gastro-intestinal  affections,  though  often 
associated  with  aphthous  stomatitis,  are  most  probably  due  to  the  common 
cause,  and  are  not  necessarily  the  cause  of  the  stomatitis  in  these  in- 
stances. In  some  of  the  specific  infectious  fevers  many  aphthae  may 
appear  and  tend  to  run  together ;  these  form  large  irregular  ulcers,  and 
give  rise  to  the  conjiuent  form  of  stomatitis  aphthosa.  The  special  fcTi-m 
known  as  Bed^iars  aphthce,  occurring  in  young  marantic  babes,  is  a 
rare  condition  in  America.  Large  white  patches  are  seen  on  both  halves 
of  the  posterior  part  of  the  hard  palate  near  the  alveolar  processes,  and 
these  may  cause  large  ulcers  and  involve  the  bone.  Pressure  of  the 
tongue  upon  the  thin  mucous  membrane  during  nursing,  or  other  forms 
of  traumatic  irritation,  appear  to  act  as  causes. 

Aphtha  Qachectica  (Riga's  disease). — Fede  has  described  a  form 
of  aphtha,  occurring  principally  in  Southern  Italy  (a  raised,  gray  swell- 
ing), situated  on  the  frenum  and  under  surface  of  the  tongue.  It 
affects  children  soon  after  the  eruption  of  the  lower  incisors. .  A  severe 
type  is  sometimes  met,  and  this  may  terminate  fatally. 

The  average  duration  of  the  ordinary  discrete  aphthous  eruption  is 
from  four  to  seven  days ;  in  very  ill-nourished  and  poorly  cared-for  cases 
the  appearance  of  successive  crops  of  aphthge  will  prolong  the  distress. 

Diagnosis. — This  is  based  upon  the  characteristic  appearance  of 
the  ulcers  and  the  degree  of  soreness.  Aphthse  must  be  differentiated 
sometimes  from  thrush,  and  the  distinguishing  features  Avill  be  dwelt  upon 
in  the  description  of  the  latter  affection.  Herpes  of  the  mouth,  so  called, 
and  aphthous  vesicles  are  probably  identical  in  most  cases. 

Prognosis. — The  discrete  form  is  mild,  and  favorable  in  its  course 
toward  recovery ;  confluent  aphthae  is  more  troublesome,  and  folloAvs  a 
prolonged  course  on  account  of  the  general  debility  induced  by  the 
associated  disease  (Starr).  In  certain  cases  the  affection  is  apt  to  recur ; 
relapses  are  also  frequent  in  those  having  weak  digestive  and  imperfect 
assimilative  functions.      Recovery  from  Bednar's  aphthae  is  rare. 

Treatment. — It  is  first  necessary  to  remove  all  irritating  influences, 
and  in  order  to  minimize  the  intense  pain  of  the  aphthous  spots  the 
blandest  liquids  and  the  softest  foods  that  are  consistent  w'ith  the  sus- 
tenance of  the  patient  are  imperative.  Absolute  cleanliness  of  the 
mouth,  the  foods,  and  the  vehicles  of  administration,  especially  in  bottle- 
fed  children,  is  important.  Local  applications  are  of  obvious  value. 
Demulcents,  as  mucilage  of  sumac,  or  of  marshmallow,  with  boric 
acid  (gr.  v  to  5J — 0.324  to  32.0),  sodium  bicarbonate  (gr.  v-x  to  3J — 
0.324—0.648  to  32.0),  carbolic  acid,  or   potassium  permanganate  (gr.  iv 


698  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

to  5J — 0.259  to  32.0),  are  invariably  useful.  Swab-applications  of  wine 
of  opium  (Tn.v  to  5J — 0.333  to  32.0)  or  of  cocain  (4  per  cent,  solution) 
may  be  necessary  when  the  pain  is  intense,  and  prior  to  taking  food. 
To  promote  the  healing  of  the  ulcers  a  very  light  touch  with  the 
silver-nitrate  stick  or  solution  (gr.  x-xxx  to  Ij — 0.648-1.94  to  32.0) 
is  often  beneficial.  Much  favor  is  deservedly  given  also  to  potassium 
chlorate  in  solution  (gr.  x  to  5J — 0.648  to  32.0).  or  applied  in  the  dry 
powdered  form.  In  the  confluent  aphthous  ulcer  the  use  of  sodium 
salicylate  (.5j  to  5J — 4.0  to  32.0)  has  been  recommended,  while  an  ethereal 
solution  of  iodoform  (.^ij  to  sj — 8.0  to  32.0)  has  been  advised  by  J.  LeAvis 
Smith.  For  bleeding  and  spongy  gums  the  mild  astringents  mentioned 
in  the  treatment  of  catarrhal  stomatitis  are  indicated.  Stronger  astrin- 
gents may  answer  for  application  to  .sluggish  ulcers :  thus  copper  sul- 
phate, either  solid  or  in  solution  (gr.  x  to  .5J — 0.648  to  32.0 1.  and  zinc 
sulphate  (gr.  xv  to  3J — 0.972  to  32.0)  are  useful.  Potassium  chlorate 
acts  as  a  specific  in  ulcers  of  the  mouth,  and  is  eliminated  by  the  buccal 
secretions,  which  keep  the  ulcerated  surfaces  constantly  bathed  with  the 
drug,  so  that  its  internal  use  is  to  be  recommended,  though  in  very  small 
doses  in  children,  being  given  well  diluted,  as  in  the  following  formula : 

I^.   Potassii  chlorat.,  gr.  xxiv  (1.55); 

Tinct.  myrrhae,  gtt.  x       (0.666) ; 

Syr.  acacise,  f.lij  (64.0); 

Aqufe  dest.,  q.  s.  ad  f.liij         (96.0). — M. 

Sig.   Teaspoonful  every  three  hours  for  a  child  three  years  of  age. 

Constitutional  symptoms  are  to  be  combated  on  general  principles 
and  require  careful  attention.  Remedies  directed  to  the  correction  of 
digestive  deraucrements  and  to  the  stimulation  of  assimilation  are  also 
often  required.      Good  food  and  ferruginous  tonics  are  necessary. 

MEMBRANOUS    STOMATITIS. 
{Sto>7>a(itis  Crouposa.) 

Definition. — In  this  form  of  stomatitis  the  inflammation  is  more 
intense  and  more  extended  in  area  than  in  the  aphthous  form,  being 
also  attended  with  the  formation  of  a  false  membrane. 

The  pathology  of  these  membranous  patches,  which  are  very  sel- 
dom confined  to  the  mouth  alone,  is  embraced  in  the  article  on  Diph- 
theria. If  in  the  latter  disease  the  typical  false  (diphtheritic)  mem- 
brane is  removed,  it  leaves  a  deeper  ulcer  than  does  the  removal  of  a 
croupous  membrane,  in  which  the  coagulation-necrosis  involves  the  more 
superficial  layers. 

The  etiology  of  membranous  stomatitis  is  usually  specific  (diphther- 
itic, streptococcic).  Membranous  stomatitis  may  also  be  due  to  gonor- 
rhoeal  or  syphilitic  infection  of  the  new-born. 

Symptoms. — Some  of  these  cases  are.  doubtless,  true  diphtheria 
of  the  oral  cavity  (usually  secondary  from  extension),  and  an  account 
of  the  symptoms  presented  may  be  found  in  the  chapter  on  Diphtheria, 
p.  179.  The  writer  has  seen  instances  of  extensive  membranous  stoma- 
titis, in  which  bacteriologic  examination  showed  the  presence  of  strep- 
tococci   (principally),   and    also    staphylococci.       The    symptoms    Avere 


ULCERATIVE   OR  FETID  STOMATITIS.  699 

analogous  to  streptococcic  membranous  pharyngitis  with  this  difiFerence, 
in  my  cases  of  membranous  stomatitis,  that  salivation  was  marked  and 
distressing.     The  general  features  may  be  quite  pronounced. 

ULCERATIVE    OR   FETID    STOMATITIS. 

{Stomatitis  Ulcerosa.) 

Definition. — A  specific  ulcerative  inflammation  of  the  buccal  mu- 
cous membrane  and  gums,  attended  with  marked  fetor  of  the  breath,  and 
having  a  tendency  to  extend  widely  and  deeply. 

Ktiology. — The  predisposing  causes  of  this  malady  are  principally 
as  follows  :  Childhood,  after  the  commencement  of  the  first  dentition, 
and  usually  between  the  ages  of  three  and  eight  years ;  damp  weather, 
especially  during  spring  and  autumn  ;  unhygienic  surroundings,  partic- 
ularly the  lack  of  pure  air,  of  good  and  abundant  food  and  clothing,  and 
the  added  detriments  to  health  for  which  neglect  and  filth,  specific  in- 
fectious diseases,  uncleanliness  of  the  mouth,  caries  and  loosening  of 
the  teeth,  and  congenital  heart-disease  (Duckworth)  are  responsible. 
An  endemic  type  of  this  affection  has  been  observed  among  soldiers  in 
camps  and  barracks,  among  children  in  crowded  eleemosynary  institu- 
tions, and  in  jails.  Its  epidemic  and  contagious  character  likewise 
points  to  a  microbic  origin.  The  specific  exciting  cause,  it  has  been 
held,  corresponds  to  the  hoof-and-mouth  disease  of  cattle,  the  poison 
being  conveyed  in  milk.  Payne  suggests  the  identity  of  the  virus  with 
that  of  impetigo  contagiosa.  The  careless  administration  of  mercury 
may  also  be  followed  by  this  affection.  Scurvy  [scorbutic  stomatitis) 
and  the  persistent  use  of  lead  and  phosphorus  are  also  excitants. 

Clinical  Symptoms. — Locally,  the  disease  starts,  as  a  rule,  at  the 
edges  of  the  gums  opposite  the  lower  incisor  teeth,  gradually  spreading 
backward  and  to  the  adjoining  portions  of  the  lips  and  cheeks.  The 
gingival  mucous  membrane  is  deeply  red  and  swollen  ;  the  gums  soon 
become  spongy,  bleed  easily,  and  break  down  into  thick,  soft,  grayish 
sloughs,  which  leave  deep  and  ragged  ulcers  surrounding  the  necks  of 
the  teeth.  The  latter  even  become  loosened,  and  in  protracted  cases 
the  alveolar  periosteum  may  become  inflamed  and  cause  necrosis  of  the 
bone.  Profuse  salivation,  a  foul  breath  (that  once  earned  for  the  con- 
dition the  term  of  "putrid  sore  mouth  ").  occasional  slight  hemorrhages 
from  the  gums,  and  excessive  discomfort,  or  even  pain,  on  mastication 
are  nearly  always  present.  The  tongue  is  coated,  swollen,  and  tooth- 
marked  ;  aphthae  are  sometimes  seen,  .and  the  submaxillary  glands  are 
generally  swollen.  The  general  symptoms  attending  this  ailment  are 
those  of  a  lowered  state  of  vitality,  produced  by  an  unhygienic  envi- 
ronment, or  cachexia,  or  severe  illness  primary  to  it,  with,  usually,  mod- 
erate fever.  Nausea  and  vomiting  or  an  offensive  diarrhea  may  super- 
vene as  the  result  of  swallowing  the  putrid  discharges. 

Course  and  Duration.— ^Though  acute  in  its  course,  the  highly 
debilitating  character  of  the  disease  may  tend  to  make  it  chronic,  espe- 
cially when  there  is  alveolar  necrosis  and  a  neglect  of  proper  treat- 
ment. Ordinarily,  with  careful  management,  convalescence  may  be 
established  in  from  four  days  to  a  week.  Goodhart  regards  the  occa- 
sional termination  of  the  pyrehia  by  lysis,  with  an  accompanying  im- 


700  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

provement  of  the  local  symptoms  in  such  cases  at  least,  as  suggestive 
of  the  specific  nature  of  ulcerative  stomatitis. 

Neurotic  Ulceration.  —  Under  the  head  of  stomatitis  neurotica 
chronica  Jacobi  describes  an  herpetic  (rarely  pemphigoid)  eruption  in 
neurotic  subjects.  Sibley  has  met  three  cases,  all  of  which  occurred  in 
women  beyond  middle  age.  In  all  cases  the  condition  had  lasted  for  a 
number  of  years  and  produced  great  difficulty  in  talking  and  mastication. 

Diagnosis. — Upon  examining  the  mouth  and  noting  the  character- 
istic ulceration,  the  fetid  breath  and  saliva,  and  the  cachectic  appear- 
ance, the  disease  is  usually  recognized,  and  should  not  be  confounded 
with  the  dark,  extensive,  gangrenous  sloughs  of  noma. 

The  prognosis  is  favorable  in  typical  cases,  though  less  so  in 
marasmic  and  neglected  cases.  When  cancrum  oris  or  necrosis  of  the 
jaw  occur,  chronicity,  deformity,  and  even  death,  may  take  place. 

Treatment. — It  is  well  in  nearly  all  ill-nourished,  uncleanly-kept, 
and  sickly  children,  as  well  as  in  cases  in  which  mercury  is  to  be  admin- 
istered for  any  length  of  time,  to  prescribe  mouth-washes  of  potassium 
chlorate  (gr.  xv  to  .5j — 0.972-32.0),  in  order  to  prevent  the  occurrence 
of  mercurial  or  ulcerative  stomatitis.  The  hygienic  treatment  of  ulcer- 
ative stomatitis  is  important.  On  account  of  the  contagiousness  of  the 
disease  cases  occurring  in  a  fiimily  or  in  institutions  should  be  isolated, 
and  fresh  air,  light  nourishment,  and  cleanliness  are  sine  qud  non  of 
recovery.  The  local  treatment  is  virtually  a  specific  one  in  the  use 
of  ])otassium-chlorate  washes  (gr.  x-xx  to  oj — 0.648-1.296  to  32.0 — 
of  rose-water  or  demulcent),  aided  by  the  internal  administration  of 
the  same  salt  in  small  doses.  For  the  disagreeable  fetid  odor  the  alter- 
nate use  of  antiseptic  washes  is  indicated.  Solutions  of  carbolic  acid 
or  potassium  permanganate,  in  strength  equal  to  or  slightly  over  that 
indicated  in  the  treatment  of  aphth?e,  or  hydrogen  peroxid  (sj-iij  to 
Ij  ;  4.0-12.0  to  32.0),  or  listerin  and  water  (equal  parts),  are  useful. 
Pencilling  the  spongy  gums  Avith  such  astringents  as  tincture  of  rhatany, 
silver  nitrate  (gr.  x  to  .5j — 0.648-32.0),  alum,  and  also  with  tannic-acid 
solutions,  may  be  necessary.  Loosened  teeth  should  not  be  disturbed, 
as  they  may  grow  firm  with  convalescence,  though  surgical  interference 
may  be  required  in  cases  of  necrosis  of  the  alveolar  process.  Kissel's 
method  in  obstinate  cases  is  to  curette  the  ulcers  and  rub  into  them 
powdered  iodoform  once  daily.  Careful  attention  to  the  teeth  is  always 
requisite.  During  the  height  of  the  disease  constitutional  treatment 
may  have  to  be  directed  toward  stimulating  the  languid  and  lowered 
vitality.  For  this  purpose  either  whiskey  or  brandy,  in  half-  or  one- 
teaspoonful  doses  in  milk,  is  extremely  useful ;  the  elixir  of  cinchona, 
with  some  vegetable  salt  of  iron,  as  the  citrate  or  tartrate,  also  forms  a 
useful  combination.  When  there  is  pyrexia  or  a  diminished  urinary 
secretion  the  internal  use  of  potassium  chlorate  must  be  cautiously 
employed.      The  following  prescription  is  almost  specific : 

I^.   Potassii  chloratis,  gr.  xlviij  (3.11); 

Acidi  hvdrochlor.  dil.,  ftj  (4.0); 

Syrupi,^  ftvj  (24.0); 

Aquoe  destillat.,  q.  s.  ad  fsiij  (96.0).— M. 

Sig.   Teaspoonful  diluted,  every  two  hours  for  a  child  three  years 
old  (Starr). 


PARASITIC  STOMATITIS.  701 

The  prolonged  use  of  tonics  and  cod-liver-oil  emulsion  with  lime- 
salts  in  scrofulous,  rachitic,  and  scorbutic  subjects  must  be  carried  on  in 
order  to  prevent  relapses  of  ulcerative  stomatitis. 

PARASITIC    STOMATITIS. 
{Thrush ;  Stomatitis  Mycosa.) 

Definition. — A  specific,  contagious  fungous  disease,  characterized 
by  the  rapid  formation  upon  the  oral  mucous  surfaces  of  small,  whitish, 
soft,  and  lightly  adherent  spots  or  flakes,  tending  to  coalesce  and  spread 
throughout  the  entire  buccal  cavity. 

Ktiology. — Predisposing  causes  are — infancy  with  its  concomitant 
disorders  of  the  gastro-intestinal  tract  (especially  when  unhygienic  sur- 
roundings prevail),  also  congenital  syphilis,  tuberculosis,  and  the  exan- 
themata. The  disease  may  attack  adults  and  complicate  the  typhoid  and 
cachectic  states,  as  in  the  final  stages  of  low  fevers,  carcinoma,  chronic 
tuberculosis,  and  diabetes.  The  growth  of  thrush-patches  is  due,  specific- 
ally, to  the  saccliaromyces  albicans,  though  micrococci  have  also  been 
found.  It  is  a  characteristic  of  this  fungus  to  develop  from  round  or  oval 
spores  in  the  formation  of  long-branching  mycelium  filaments,  from  the 
ends  of  which  a  multiplication  of  ovoid  torulse-cells  takes  place  by  the 
process  of  simple  budding.  These  mycelia  exhibit  a  tendency  to  penetrate 
the  deeper  layers  of  the  mucosa  of  the  mouth  and  also  into  the  mucous 
glands  (Starr).  Since  the  growth  of  this  organism  requires  both  an  altered 
condition  of  the  mucous  membrane  and  an  acid  medium,  the  primary  or 
exciting  cause  of  thrush  is  to  be  found  in  whatever  produces  such  a  favor- 
able nidus.  Most  important  in  this  connection  is  uncleanliness,  particu- 
larly in  the  case  of  poorly-nourished  and  bottle-fed  children.  The 
development  of  catarrhal  stomatitis  and  the  acid  fermentation  of  remnants 
of  food  (especially  of  saccharine  substances),  which  prevent  the  nutrition 
of  the  mucosa  and  acidify  the  normally  alkaline  oral  secretions,  are  com- 
mon causes  of  thrush.  The  further  growth  of  the  fungous  patches  also 
contributes  to  the  acid  state  of  the  already  abnormal  buccal  fluids.  The 
fact  that  the  spores  of  thrush  may  be  transferred  to  other  cases  by 
bottle-tips,  spoons,  and  ill-kept  feeding-bottles  is  well  recognized  as  an 
explanation  for  the  occasional  endemic  character  of  the  malady. 

Syniptoms. — Any  marked  local  symptoms  are  due  rather  to  the 
coexisting  stomatitis  than  to  the  thrush  itself  (Allchin).  There  will  be 
some  sore7iess,  heat,  persistent  dryness,  and  lividity  of  the  mucous  mem- 
brane. Thrush-spots,  slightly  raised  above  the  surface,  begin  to  appear 
on  the  tongue,  and  grow  into  patches  that  may  coalesce  and  spread  to 
the  cheeks,  lips,  and  hard  palate :  they  may  even  invade  the  tonsils, 
pharynx,  and  esophagus,  and,  rarely,  the  true  vocal  cords,  the  stomach, 
and  cecum  (Parrot).  At  first  pearly-white  in  color,  the  curd-like  flakes 
may  become  yellow  and  even  brown,  owing  to  slight  hemorrhages  caused 
by  the  irritation.  Though  early  adherent,  in  a  few  days  they  become 
loose,  and  when  brushed  ofi"  leave  a  smooth  surface  ;  when  complicating 
some  serious  gastro-intestinal  disease  or  dyscrasia,  however,  their  attach- 
ment is  deeper,  and  the  deposit  may  sometimes  appear  in  successive 
crops.     A  microscopic  examination  of  the  thrush-patches  shoAvs  inter- 


702  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lacing,  irregular,  and  branched  mycelial  threads,  spores,  occasional 
bacilli,  and  leptothrix-filaments  imbedded  in  a  mass  of  granular  debris 
and  fetid  particles.  The  buccal  fluids  are  acid  in  reaction.  The  gen- 
eral symptoms  depend  upon  the  associated  disease,  and  are  usually  those 
of  wasting,  artificially-nourished  children  having  digestive  troubles  or  a 
constitutional  taint. 

Diagnosis. — This  may  be  accurately  made  upon  the  discovery  of 
the  fungus  bv  microscopic  examination.  Only  very  rarely  are  portions 
of  the  thrush-organism  found  in  the  false  membrane  of  diphtheritic 
stomatitis.  Milk  curds  may  be  readily  removed,  and  are  not  necessarily 
associated  with  the  stomatitis  accompanying  thrush  or  the  grave  sys- 
temic states.  The  important  point  of  differential  diagnosis  arises  in  the 
case  of  aphthce.     The  following  table  will  express  the  mam  points : 

Parasitic  Stomatitis  (Thrcsh).  Aphthous  Stomatitis. 

Dryness  of  the  mouth.  Salivation. 

"Whitish,  raised  spots  or  patches  with  no  An  ulcer  with  a  yellowish-white,  de- 
red  areola  ;  these  are  easily  removed,  pressed  base,  surrounded  by  a  red  are- 
leaving  no  ulcer  and  causing  no  bleed-  ola.  The  base  is  removed  with  difii- 
ino-.      "  culty  by  forceps,  and  bleeding  results. 

Spots  are  numerous.  Usually  few  in  number  and  discrete. 

Begins  in  the  form  of  minute  spots.  Not  so  :  ulcers  appear,  preceded  by  the 

formation  of  herpetic  vesicles. 

Ulcers  not  painful.     Discomfort  depends  Ulcers  exquisitely  tender, 
on  the  associated  stomatitis. 

The    characteristic  thrush-fungus   is  al-  No  specific  micro-organism  determined, 

ways  present  in  the  deposit,  and  can  be  though  probably  present, 
seen  with  the  microscope. 

Prognosis. — This  is  favorable  as  regards  the  thrush  alone,  but, 
occurring  in  marantic  children  and  cachectic  adults,  its  appearanee  is 
of  grave  significance,  and  may  portend  a  speedy  death. 

Treatment. — Prophylaxis  is  of  great  moment,  since  it  is  much  easier 
to  keep  the  mouth  clean  and  the  secretions  normal,  and  to  attend  to 
proper  food,  and  thus  avoid  creating  a  soil  for  the  growth  of  the  vegetable 
parasite,  than  it  is  to  prevent  absolutely  the  entrance  of  thrush-spores. 
Efforts  directed  toward  preventing  acidity  are  especially  indicated.  This 
is  to  be  done  by  the  use  of  mild  alkaline  mouth-washes,  as  soda- 
water  and  lime-water.  The  dietary  should  be  carefully  looked  after, 
and  should  exclude  sugars  and  all  starchy  food ;  the  addition  of  lime- 
water  to  the  milk  (about  one  part  to  four)  is  a  desirable  precaution 
to  take,  particularly  with  children.  Cleansing  the  feeding-apparatus 
and  the  mouth  after  each  feeding  is  essential,  both  in  the  prevention  of 
the  formation,  and  in  decreasing  the  furtlier  growth,  of  thrush  when  pres- 
ent. The  local  treatment  consists  in  the  use  of  alkaline  and  antiseptic 
applications,  preferably  by  means  of  the  spray.  Solutions  of  boric 
acid  or  sodium  hyposulphite  (3J — 4.0— of  either  to  5J — 32.0 — of  water, 
with  the  addition  of  a  little  glycerin),  potassium  permanganate,  or  hydro- 
gen peroxid,  are  useful.  Syrupy  excipients  are  to  be  excluded.  Potas- 
sium chlorate  may  exert  a  beneficial  effect  in  those  cases  in  which  stom 
atitis  is  associated,  as  may  also  pencilling  with  a  solution  of  silver  nitrate. 
Concetti  ^  urges  the  use  of  a  3  to  5  p^r  cent,  solution  of  silver  nitrate 
instead  of  the  weaker  strengths  usually  employed. 

'  Rev.  mens,  da  Mai.  de  H  Enfance,  July,  1899. 


GANGRENOUS  STOMATITIS.  703 

When  esophageal  obstruction  exists  it  may  be  necessary  to  gently 
force  a  rubber  tube  through  the  mass  of  thrush-cleposit  in  order  to  give 
nourishment  (Forchheimer). 

Medicinal  treatment  embraces  the  administration  of  nourishing;  and 
easily  digestible  food,  occasional  stimulation,  and  the  correction  of 
gastro-intestinal  disorders.  Attention  must  also  be  paid  to  the  pri- 
mary affections  to  which  the  thrush  is  superadded.  Iron,  cod-liver  oil, 
and  acid  and  bitter  tonics  in  palatable  form  are  usually  indicated  in 
debilitated  subjects,  along  with  general  hygienic  measures.  The  inter- 
nal use  of  small  doses,  frequently  repeated,  of  calomel  or  mercuric  chlorid 
may  also  be  tried  for  a  possible  specific  eflFect  in  combating  thrush. 

LA  PERLECHE. 

This  contagious  disease  is  confined  to  the  angles  of  the  mouth.  It 
was  first  described  in  1886  as  prevalent  among  the  children  of  Limousin 
in  France  by  Lemaistre.  It  was  found  that  the  drinking-water  in  that 
locality  contained  cocci  similar  to  the  spherobacteria  that  infested  the 
epithelial  thickenings,  and  that  these  were  probably  conveyed  to  human 
beings  by  drinking-vessels.  Little  elevations  and  fissures,  said  to  resemble 
those  of  congenital  syphilis,  were  seen  around  the  oral  angles.  The  latter 
were  the  seat  of  smarting  pain,  particularly  on  opening  the  mouth  sud- 
denly or  too  far,  and  caused  the  patient  to  lick  [perlicher)  them  con- 
stantly. The  disease  seemed  to  be  entirely  local,  and  lasted  from  two 
to  three  weeks.     Alum  and  copper-sulphate  solutions  were  most  useful. 

GANGRENOUS    STOMATITIS. 
{No7na ;   Cancmm  Oris.) 

Definition. — A  rapidly-spreading  gangrenous  aifection  of  the  cheek 
and  gums,  of  rare  occurrence,  usually  asymmetric,  and  ending  fatally  in 
most  cases. 

Pathology. — In  addition  to  the  necrotic  changes  in  the  cheeks,  the 
process  may  extend  to  the  jaws  and  lips.  The  blood-vessels  contain 
thrombi,  thus  preventing  hemorrhage  from  the  sphacelus.  The  submaxil- 
lary and  cervical  glands  may  be  slightly  enlarged  and  soft.  Blood-changes 
of  an  uncertain  character  have  been  noted.  Hemorrhagic  infarctions, 
aspiration  broncho-pneumonia,  or  gangrene  by  inhalation  of  gangrenous 
particles  or  metastasis,  may  be  met  in  the  lungs.  Wharton  has  described 
an  associated  membranous  form  of  colitis,  and  a  metastatic  infiltration 
of  the  cardiac  muscle  and  purulent  pericarditis  may  also  be  seen  post- 
mortem. Klementorosky  met  with  a  peculiar  and  fatal  form  of  gangrene 
limited  to  the  gums  of  babes  and  occurring  a  few  days  after  birth. 

Ktiology. — Predisposmg  Causes. — This  uncommon  aff"ection  attacks 
girls  more  frequently  than  boys,  usually  betAveen  the  ages  of  two  and 
five  years ;  it  appears  to  be  endemic  in  low,  moist  countries,  as  Holland, 
though  apparently  it  is  not  contagious.  Sickly  and  ill-nourished  chil- 
dren suff"ering  from  the  eifects  of  overcrowding  and  previous  disease 
are  especially  liable  to  noma.  Most  often,  however,  it  is  secondary  to 
measles ;  it  may  also  follovi^  scarlet  fever,  typhoid,  small-pox,  or  less  fre- 


704  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

quently  pertussis.  The  causative  influence  of  mercurialization  and 
ulcerative  stomatitis  has  been  overrated. 

Bacteriology. — Freymuth  holds  that  noma  is  an  infectious  process 
without,  however,  a  specific  microorganism  in  all  cases.  Guzzetti  found 
pseudo-diphtheritic  bacilli  together  with  staphylococci  and  streptococci. 
Noma  is  probably  due  to  a  double  infection  (Foote). 

Symptoms. — The  mucous  membrane  of  one  cheek,  near  the  corner 
of  the  mouth,  is  usually  first  affected,  a  dark,  ragged,  sloughing  ulcer 
appearing  and  spreading  insidiously  for  two  or  three  days  before  the 
substance  of  the  cheek  is  involved.  A  hard  and  sensitive  nodule  may 
then  be  felt  by  grasping  the  cheek  between  the  thumb  and  finger  on 
placing  the  one  within  the  mouth  over  the  ulcer  and  the  other  outside. 
Brawny  induration  of  the  skin  over  this  nodule  soon  becomes  manifest, 
and  then  there  appear  collateral  edema  and  an  unctuous-looking, 
deeply  livid,  gangrenous  spot,  soon  becoming  bullous  and  leaving  a 
black  eschar.  Perforation  of  the  cheek  may  occur  on  the  third  day, 
though  usually  not  until  a  week  has  passed.  There  is  an  ichorous  dis- 
charge of  shreds  of  gangrenous  tissue  from  the  unhealthy  wound.  The 
fetor  of  the  breath  is  almost  intolerable  and  characteristically  gangren- 
ous. The  necrosis  may  extend  over  one-half  the  face  of  the  side  aff'ected, 
and  may  involve  the  gums  and  jaws,  but  seldom  does  it  attack  the 
opposite  side  of  the  face.  The  general  symptoms  of  such  a  grave  mal- 
ady may  be  slight  at  a  very  early  period,  but  with  the  formation  of  the 
eschar  they  become  rapidly  severe  and  typhoid  in  type.  Great  prostra- 
tion, delirium,  pyrexia  (104°  F. — 40°  C.),  diarrhea,  and  edema  of  the 
feet  are  common.      The  course  rarely  extends  beyond  two  weeks. 

Complications. — Septic  lobular  pneumonia  may  occur  from  aspira- 
tion of  gangrenous  particles ;  colitis  and  gangrene  of  the  genitalia  in 
females  {iiioma  pitdetidoi)  are  also  seen.  In  those  very  rare  cases  that 
recover  granulations  form,  the  gangrenous  edges  become  clean,  and 
cicatrization,  with  great  disfigurement  of  the  face  and  even  restricted 
jaw-motion,  is  then  apt  to  follow. 

Diagnosis. — The  disease  Avhen  fully  established  is  easih^  diagnosed 
by  its  characteristic  origin,  the  gangrenous  ulcer-nodule,  the  eschar-for- 
mation, and  perforation,  associated  with  a  previous  history  of  measles  or 
other  acute  infectious  fever  of  childhood.  The  offensive  fetid  odor  and 
severe  constitutional  depression  are  also  of  great  value. 

DiflFerential  Diagnosis. — From  anthrax  it  differs  in  that  the  latter 
affection  is  more  common  in  adults,  with  a  history  of  contagion,  and  in 
the  fact  that  malignant  pustule  starts  on  the  exterior  of  the  cheek,  and 
perhaps  in  a  previous  abrasion  in  the  skin.  The  discovery  of  the 
bacillus  anthracis  in  the  blood  and  discharges  is  conclusive.  tJlcerative 
stomatitis  of  a  severe  and  neglected  type  may  be  confounded  wdth  can- 
crum  oris,  but  in  the  former  the  destruction  of  tissue  is  mainly  of  the 
gums  and  alveoli,  the  cheeks  being  simply  ulcerated  and  no  extensive 
sloughing  taking  place ;  the  breath,  though  fetid,  is  not  gangrenous, 
and  the  oral  discharixc,  thouffh  sometimes  bloody,  is  not  mixed  with 
shreds  of  gangrenous  tissue  (Starr).  Finally,  the  course  of  ulcerative 
stomatitis  is  less  severe,  a  fatal  termination  being  extremely  rare. 

Prognosis. — Noma  is  seldom  recovered  from,  the  mortality  being 
about  80  to  90  per  cent.  (Bogel).     When  recovery  does  take  place  the 


MERCURIAL  STOMATITIS.  705 

development  of  ectropion,  facial  deformity,  and  local  disability,  -with  a 
protracted  convalescence,  render  life  burdensome. 

Treatment. — This  embraces  the  prevention  of  gangrenous  stoma- 
titis by  means  of  a  proper  management  of  the  diseases  that  are  known  to 
cause  it;  careful  hygiene  and  the  avoidance  of  mercurialization  will 
also  be  of  undoubted  use.  The  primary  indication  in  the  local  treat- 
ment is  the  arrest  of  the  gangrenous  process,  thus  causing,  if  possible, 
a  healthy  reaction  on  the  part  of  the  surrounding  tissues.  All  dead 
sloughs  should  be  cut  away  before  using  escharotics,  and  with  this  end 
in  view  some  recommend  the  prompt  application  of  strong  caustics,  as 
fuming  nitric  acid,  the  acid  nitrate  of  mercury,  solid  zinc  chlorid,  silver 
nitrate,  carbolic  acid,  a  concentrated  solution  of  perchlorid  of  iron, 
Vienna  paste,  and  the  actual  cautery.  For  the  protection  of  the  healthy 
parts  and  for  efficiency  the  Paquelin  or  the  galvanic  cautery  is  prob- 
ably best.  Anesthesia  is  requisite  for  such  strong  measures.  Milder 
applications,  however,  seem  to  be  quite  adequate  in  some  cases.  Thus, 
bismuth  subnitrate,  potassium  chlorate,  and  aristol,  or  the  following  for- 
mula by  Dr.  Coates,  may  be  tried : 

i^.   Cupri  sulph.,  ^ij     (8.0); 

Pulv.  cinchon^e,  §ss    (16.0); 

Aquse,  q.  s.  ad  fgiv  (128.0).— M. 

It  is  essential,  for  the  prevention  of  septic  infection  to  ensure  cleanli- 
ness of  the  wound  and  of  the  mouth,  and  to  promote  the  separation  of 
the  sloughs.  To  effect  the  former  we  employ  mild  antiseptic  washes  of 
carbolic  acid,  hydrogen  peroxid,  Labarraque's  solution,  potassium  per- 
manganate, etc. ;  for  the  latter  and  for  the  diminution  of  the  fetor,  anti- 
septic charcoal  poultices  containing  boric  or  salicylic  acid  are  useful. 
Mild  antiseptic  and  astringent  lotions  of  boric  acid,  zinc  sulphate  (gr. 
ij  to  ij — 0.129  to  32.0),  or  balsamic  ointments  with  vaselin,  may  aid  in 
healing  the  granulating  surfaces  in  favorable  cases.  The  internal  treat- 
ment must  be  directed  toward  sustaining  the  strength  of  the  patient  by 
the  administration  of  the  most  nourishing  food,  stimulants,  and  tonics. 
Rectal  feeding  may  be  necessary.  Plastic  operations  may  be  needful 
after  recovery  to  mitigate  oral  disabilities  or  facial  deformities  resulting 
from  cicatricial  contractions.  W.  C.  Cahall  has  successfully  treated  a 
case  of  noma  with  anti-streptococcus  serum. 

MERCURIAL   STOMATITIS. 
{Mercurial  Ptyalism.) 

Definition. — An  inflammation  of  the  mouth  and  salivary  glands, 
caused  by  the  excessive  use  of  mercury ;  it  is  rarely  seen  as  a  result  of 
the  therapeutic  use  of  other  drugs. 

Ktiology. — Predisposing  causes  are  dyscrasia  and  occupation, 
mainly.  The  peculiar  individual  susceptibility  of  these  subjects  to 
dyscrasia  will  not  permit  the  use  of  even  minimum  doses  of  mercury 
without  serious  and  almost  immediate  symptoms  of  ptyalism.  This  is 
also  seen  in  barometer-makers,  mirror-silverers,  chemists,  and  others 
who  handle  mercury  in  their  daily  work.  The  exciting  cause  of  ptya- 
lism is  the  ingestion,  inhalation,  or  cutaneous  absorption  of  mercury. 

45 


706  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symptoms. — A  metallic  taste  in  the  mouth  is  first  noticed  by  the 
patient.  Soon  the  gums  become  "touched" — i.  e.  red,  swollen,  tender 
to  the  touch,  and  sore  during  the  act  of  mastication.  A  marked  secre- 
tion and  flow  of  saliva,  with  a  fetid  breath  and  swollen  tongue,  follow. 
Very  rarely  in  this  disease  the  affection  passes  into  an  ulcerative  stoma- 
titis, and  causes  loosenrng  of  the  teeth  and  necrosis  of  the  maxilla. 
O-eneral  symptoms,  as  constitutional  depression,  anorexia,  diarrhea, 
mental  anxiety,  and  nervousness,  may  supervene. 

The  recognition  of  the  foregoing  causal  factors — predisposing  and 
exciting — renders  the  diagnosis  easy.  The  prognosis  is  favorable,  and, 
although  the  local  symptoms  may  be  harassing,  recovery  is  attainable 
within  a  few  weeks  as  a  rule. 

Treatment. — The  toxic  action  of  mercury  in  the  production  of 
ptyalism  can  be  avoided  by  a  knowledge  of  individual  susceptibility  and 
by  the  local  and  internal  use  of  potassium  chlorate.  Upon  the  first 
appearance  of  the  symptoms  there  must  be  a  prompt  withdrawal  of  the 
mercurial  influence,  and  a  change  of  occupation  if  that  be  the  predis- 
posing cause.  Locally,  soothing,  alkaline,  and  mildly  antiseptic  mouth- 
washes, as  in  the  treatment  of  catarrhal  stomatitis,  may  be  all  that  is 
necessary.  For  the  fetid  breath  solutions  of  boric  acid  or  potassium 
chlorate  may  be  used.  Ulcers  may  be  brushed  with  silver-nitrate  solu- 
tion. The  internal  treatment  should  be  directed  toward  keeping  the 
bowels  soluble;  in  addition,  alkaline  mineral  waters  may  be  used,  and 
in  severe  cases  potassium  chlorate  in  5-  to  10-grain  (0.324-0.6-48)  doses. 
Atropin  (gr.  yfo" — 0.0006)  and  opium  have  been  recommended  to  de- 
crease the  excessive  salivary  secretion  and  to  allay  pain,  and  hot  baths 
will  aid  the  treatment  materially.  In  severe  cases  the  resulting  debility 
and  anemia  should  be  met  by  the  use  of  highly  nourishing  liquid  foods 
and  by  tonics. 

Osier  points  out  that  the  condition  of  the  teeth  known  as  erosion, 
which  sometimes  follows  infantile  stomatitis,  and  especially  the  mercurial 
form,  is  to  be  discriminated  from  the  deformed  teeth  of  congenital  syph- 
ilis. In  the  former  the  first  permanent  molars,  and  then  the  incisors, 
are  observed  to  have  small  pits  or  discolored  and  eroded  spots,  due  to  a 
morbid  deficiency  in  enamel-formation.  The  notched  and  irregular 
teeth  of  hereditary  syphilis  in  children  (Hutchinson)  are  sufficiently 
distinctive. 


II.   DISEASES  OF  THE  TONGUE. 
GLOSSITIS. 

ACUTE    GLOSSITIS. 
(Glossitis  Acuta.) 

Definition. — An  acute  parenchymatous  inflammation  of  the  tongue, 
sometimes  ending  in  abscess. 

Ktiology. — Predisposing  causes  are  supposed  to  be  an  impaired  gen- 
eral health  and  exposure  to  cold,  humid  weather.     The  exciting  causes 


CHRONIC  SUPERFICIAL  GLOSSITIS.  707 

are  most  frequently  the  stings  and  bites  of  insects,  or  burns,  scalds,  and 
the  action  of  corrosives.  I  believe  that  many  cases  follow  slight  in- 
juries to  the  tongue  that  allow  of  the  introduction  of  inflammatory 
poisons  or  microbes.  A.  J.  Hall  describes  a  case  of  membranous  glos- 
sitis complicating  acute  nephritis. 

Symptoms. — These  come  on  rapidly  and  with  more  or  less  local 
severity  and  danger.  The  tongue  becomes  much  swollen,  and  may  even 
protrude  beyond  the  lips.  It  is  very  tender  and  painful,  and  coated 
with  a  thick,  soft  yellowish-white  fur,  and  it  may  also  be  dry,  cracked, 
and  ulcerated.  Catarrhal  stomatitis  is  often  associated,  salivation  is 
usually  profuse,  and  talking,  swallowing,  and  even  breathing  are  ren- 
dered difficult  and  distressing.  Dyspnea,  even  to  suJfFocation,  may  be 
iniminent.  The  cervical  and  sublingual  glands  may  be  swollen,  mode- 
rate/ever is  always  present,  and  the  obstruction  to  breathing  and  admin- 
istration of  nutriment  may  assume  a  dangerous  aspect. 

The  inflammation  reaches  its  height  in  about  three  or  four  days, 
tending  to  subside  almost  entirely  about  the  seventh  day.  Not  rarely 
the  inflammatory  infiltration  passes  into  suppuration  with  the  formation 
of  a  circumscribed  abscess  of  variable  size  in  one-half  of  the  tongue ; 
fluctuation  may  not,  however,  be  obtainable,  spontaneous  rupture  being 
sometimes  the  first  indication  of  abscess.  The  prognosis  is  favorable, 
except  that  serious  obstruction  is  likely  to  remain. 

Treatment. — When  the  case  is  seen  quite  early  and  during  the 
congestive  stage,  the  topical  use  of  ice,  allowed  to  slowly  dissolve  in  the 
mouth,  is  serviceable.  Mucilaginous  mouth-washes,  containing  some 
mild  antiseptic,  as  sodium  borate  with  sodium  bicarbonate  (gr.  v-xx  to 
^j — 0.324—1.296  to  32.0),  should  also  be  employed.  A  brisk  saline 
purge,  given  early,  will  aid  in  reducing  the  inflammation,  and  should 
the  tongue  become  alarmingly  swollen,  deep  scarification  and  the  use  of 
half  a  dozen  leeches  between  the  hyoid  bone  and  the  jaw-angles  may  be 
of  decided  service.  Steam-atomization,  medicated  with  the  compound 
tincture  of  benzoin  or  ammonium  chlorid  (3j  to  5J — 4.0  to  32.0),  favors 
resolution  (Cohen).  Abscesses  must  be  incised  and  washed  out  with 
antiseptic  solutions.  Tracheotomy  is  rarely  called  for  to  relieve  the 
dyspnea.  Rectal  alimentation  with  predigested  foods  may  be  necessary, 
and  during  convalescence  ferruginous  tonics  in  glycerin  and  bland 
foods  should  be  continued  for  some  time,  in  order  to  prevent  chronic  in- 
flammation and  thickening.  Any  local  source  of  irritation,  as  from 
carious  or  sharp  teeth,  should  be  removed. 

CHRONIC    SUPERFICIAL   GLOSSITIS. 

Definition. — A  chronic  inflammation  of  the  mucosa  of  the  tongue. 

Btiologfy. — This  disease  is  often  preceded  by  several  acute  attacks, 
the  habitual  use  of  tobacco,  both  in  smoking  and  chewing,  and  of  strong 
spirituous  liquors  being  mainly  productive  of  the  original  affection. 
The  frequent  use  of  irritating  foods  is  also  a  prominent  factor  in  some 
instances. 

Symptoms. — The  surface  of  the  tongue  is  continually  sensitive  and 
more  or  less  reddened.  Often  there  are  seen  ovoid  patches  of  various 
size,  smooth  and  shiny,  on  account  of  the  loss  of  papillae,  and  separated 


708  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

by  furrows  that  extend  to  the  depth  of  the  mucosa  itself.  The  tongue 
may  also  be  slightly  furrowed  in  intervening  spaces,  especially  at  the 
base.     The  general  health  is  somewhat  deteriorated. 

Diagnosis. — This  rests  upon  the  history  of  the  case  and  upon  the 
results  of  examination  of  the  organ. 

The  prognosis  is  favorable  as  to  alleviation,  but  guarded  as  to  cure. 

Treatment. — The  blandest  dietary  must  be  insisted  on,  as  well  as 
absolute  abstention  from  the  causal  irritants,  exacerbations  being  prone 
to  occur.  The  local  use  of  demulcents  and  of  mildly  alkaline  and  anti- 
septic lotions,  such  as  Seiler's  tablets  in  solution,  and  of  solutions  of 
chromic  acid  or  silver  nitrate  (gr.  v-x  to  sj — 0.324-0.648  to  32.0)  in 
glycerin  or  honey,  applied  once  or  twice  daily  by  gentle  brushing,  is 
to  be  recommended.  General  tonics  and  the  avoidance  of  irritating 
drinks  will  be  indicated. 

GLOSSITIS  DESICCANS. 

A  rare  disease,  chronic  in  nature  and  of  unknown  causation.  It  is 
characterized  by  "  the  gradual  development  upon  the  surface  of  the 
tongue  of  a  nuinber  of  deep  fissures  and  indentations,  giving  the  organ 
an  uneven  and  ragged  look.  The  pain  is  due  to  the  frequent  presence 
of  excoriations  and  ulcers  in  these  fissures  "  (Striimpell).  The  prognosis 
of  the  affection  is  favorable  as  regards  any  danger.  The  treatment  is 
hygienic,  consisting  of  cleanliness  of  the  mouth  and  the  use  of  disinfect- 
ant mouth-lotions,  together  with  the  topical  use  of  alterative  or  astrin- 
gent applications,  as  silver  nitrate  or  chromic  acid,  to  any  ulceration. 

LINGUAL   PSORIASIS    (TYLOSIS   LINGU^). 

In  this  disease  there  are  small  regular  areas  of  hyperplasia  of  the 
glossal  epithelium,  eventually  causing  a  map-like  appearance  of  the  sur- 
face of  the  tongue — '"lingua  geographica."  The  trouble  is  obscure  in 
its  etiology  and  persists  for  years.  Seldom  is  there  any  discomfort  asso- 
ciated, although  mental  anxiety  or  hypochondriasis  may  develop. 

LEUKOPLAKIA   ORIS    (BUCCAL   PSORIASIS). 

In  this  affection  the  mucous  membrane  of  the  mouth  and  tongue  may 
be  involved.  On  the  lateral  borders  of  the  tongue  white  or  bluish-white 
scar-like  spots  or  patches,  often  slightly  notched,  make  their  appearance. 
Some  of  these  pass  away  to  be  replaced  by  others,  and  the  affection  pro- 
gresses despite  all  attempts  to  cure  it.  The  true  cause  is  unknown, 
but  it  has  been  suggested  that  some  irritant,  as  the  use  of  a  pipe, 
may  account  for  the  condition.  The  malady  has,  however,  been  seen 
in  women.  A  syphilitic  taint  is  said  to  especially  predispose  to  the  dis- 
ease (Striimpell).  The  affection  must  be  carefully  diagnosed  from  the 
oral  manifestations  of  syphilis,  if  for  no  other  reason  than  to  relieve 
the  mind  of  a  morbidly  anxious  patient.  Excepting  some  pain  con- 
nected with  possible  ulceration,  there  are  no  annoying  symptoms,  and 
the  treatment  suggested  for  glossitis  desiccans  is  appropriate.  Kyle 
touches  the  white  patches  daily  with  pure  tincture  of  iodin. 

In  children  a  similar  tongue-affection  has  been  named  "  wandering 


DISEASES  OF  THE  SALIVARY  GLANDS.  709 

rash."  The  patches  are  circinate  and  enlarge  peripherally,  forming 
rings  of  epithelial  hyperplasia,  within  which  is  a  red,  glossy  center  "  de- 
void of  filiform  papillae,  though  the  fungiform  remain  "  (Allchin). 

ANGINA   LUDOVICI. 
{Ludwig\<i  Angina) 

Definition. — A  rare  acute  phlegmonous  inflammation  of  the  floor 
of  the  moutb. 

]^tiology. — The  condition  may  be  idiopathic,  but  more  often  it  is 
secondary  to  specific  infectious  diseases  (scarlet  fever,  diphtheria).  Un- 
doubtedly it  is  directly  caused  by  a  streptococcus  and  by  an  extension  of 
the  infection  from  adjacent  glands  (Osier).     It  may  result  from  trauma. 

Symptoms. — These  are  intense  at  the  outset.,  and  begin  Avith  swell- 
ing in  the  region  of  the  submaxillary  gland,  with  a  rapid  involvement 
of  the  cellular  tissue  of  the  floor  of  the  mouth  as  well  as  of  the  anterior 
portion  of  the  neck.  Pain  is  marked,  and  this,  with  the  acute  swelling, 
renders  articulation,  mastication,  and  deglutition  extremely  difiicult. 
Compression  or  edema  of  the  larynx  may  often  cause  dangerous  dyspnea. 
The  constitutional  disturbance  is  usually  febrile,  and  may  either  approach 
the  typhoid  type  or  may  be  septic.  The  condition  generally  terminates 
either  in  abscess  or  extensive  sloughing  {cynanclie  gangroinosd).,  and 
only  rarely  does  resolution  take  place. 

The  diagnosis  is  easily  made  when  complicating  a  specific  fever. 

Th,e  prognosis  is  always  guarded,  since  death  sometimes  occurs. 
Relapses  are  likewise  apt  to  follow  in  weakly  and  strumous  subjects. 

Treatment. — The  most  that  can  be  done  is  to  sustain  the  strength 
of  the  patient  and  secure  prompt  surgical  interference  when  the  process 
has  reached  the  point  of  beginning  suppuration  or  gangrene.  Trache- 
otomy may  be  demanded  if  asphyxia  threatens  life. 


III.  DISEASES   OF  THE  SALIVARY   GLANDS. 
HYPERSECRETION. 

{Ptyalism.) 

Definition. — An  abnormal  increase  in  the  secretion  of  saliva. 

Ktiology. — Salivation  as  an  idiopathic  afl'ection  is  rare,  and  as  such 
is  considered  to  be  a  neurosis.  Thus,  it  has  been  seen  in  emotional 
children  of  from  two  to  eight  years  of  age,  though  apparently  in  perfect 
health.  According  to  Bohn,  the  secretion  in  these  cases  is  mostly  in- 
creased during  active  exercise,  is  reduced  on  lying  down,  and  absent 
during  sleep.  Spontaneous  recovery  takes  place  in  a  few  years.  As 
a  deuteropathic  disease  ptyalism  may  be  the  result  of  oral  disease 
(e.  g.  noma,  ulcerative  stomatitis),  and  also  of  gastro-enteric,  pancreatic, 
uterine  (as  gestation),  centric  (as  diseases  or  tumors  of  the  medulla  or 
of  the  facial  nerve),  toxic,  systemic  (as  small-pox,  the  use  of  mercury, 
iodids,  pilocarpin,  tobacco),  and  hydrophobic  irritation  and  disease. 

Diagnosis. — It  should  be  pointed  out  that  a  failure  in  swallowing 


710  DISEASES  OF  THE  DIGESTIVE  SYSTE3I. 

the  normal  quantity  of  saliva  may  cause  dribbling  from  the  mouth  and 
(Simulate  true  hypersecretion. 

The  prognosis  is  favorable  in  itself,  but  dependent  on  the  cause. 

Treatment. — The  causes  are  to  be  removed  and  the  general  health 
toned  up.  For  stomatitic  salivation  potassium  chlorate  is  first  in  rank 
as  an  internal  and  local  remedy.  Iron  and  arsenic  are  valuable  in  neur- 
otic cases,  and  the  bromids  or  hyoscin  may  be  of  supplemental  use. 
Atropin  (gr.  2^  to  j^ — 0.0003  to  0.0006)  and  belladonna  are  almost 
uniformly  successful  in  idiopathic  as  well  as  in  central  ptyalism. 


XEROSTOMA. 

{Aptyalism ;    "Dry  Mouth.'') 

Definition. — A  morbid  arrest  of  the  salivary  and  buccal  secretions. 

Ktiology. — The  disease  is  probably  due  to  an  affection  of  the  nerve- 
supply  of  all  the  glands  of  the  mouth  (Harris).  It  may  follow  sudden 
mental  phenomena  as  a  temporary  condition.  A.  J.  Hall  collected  39 
cases,  of  which  32  occurred  in  females.  In  most  of  the  cases  the  causes 
were  unknown.  Not  uncommonly  xerostoma  is  an  effect  of  the  febrile 
state,  of  mouth-breathing  (due  to  nasal  obstruction),  and  of  diabetes. 

Symptoms. — Apart  from  the  sensation  of  dryness,  mastication, 
deglutition,  and  articulation  are  difficult.  The  local  appearances  show 
a  glazed,  shiny,  red,  and  sometimes  cracked  condition  of  the  tongue  and 
labial  and  palatine  mucous  membrane.  With  dryness  of  the  mouth  the 
teeth  may  become  diseased  and  crumble. 

The  diagnosis  is  made  on  inspection,  the  prognosis  depending  on 
the  removability  of  the  cause,  and  rightfully  being  guarded  on  account 
of  the  frequent  obstinacy  of  the  trouble. 

Treatment. — Attention  to  the  systemic  condition  is  requisite. 
Small  doses  of  potassium  iodid  and  pilocarpin  (gr.  ^-^^ — 0.003)  in  gelatin 
lamelltfi  or  in  lozenge  form,  allowed  to  dissolve  in  the  mouth  with  the 
aid  of  a  sip  of  water,  have  been  productive  of  relief.  In  cases  of  cen- 
tric origin  the  galvanic  current  should  be  tried. 

Glassblowers*  Mouth. — This  condition  is  found  among  glass- 
blowers  and  also  among  musicians.  It  occurs  in  about  2.5  per  cent,  of  all 
glassblowers.  Scheele,^  who  reports  two  cases,  describes  the  condition 
as  a  hernial-outpocketing  of  the  muscles  of  the  cheeks.  The  epithelium 
of  the  mucous  membranes  shows  the  so-called  plaques  opalines.  It  is 
often  combined  with  a  distention  of  Steno's  duct.  In  addition  to  a 
ballooning  out  of  the  buccal  mucosa,  there  is  likely  to  be  a  disturbance 
of  hearing  and  cranip-likc  contraction  of  the  cheek.  The  parotids  may 
be  emphysematous  and  crepitate  on  palpation. 


SYMPTOMATIC  PAROTITIS. 

{Parotid   Bubo.) 

Definition. — A  secondary  inflammation  of  the  parotid  gland,  gen- 
erally due  to  septic  infection  and  tending  to  suppuration. 

Etiology. — Not  being  a  primary  aff'ection,  the  causes  giving  rise  to 
^  Berlin,  klin.    Wochenschrijt,  Mar.  12,  1900. 


DISEASES  OF  THE   TONSILS.  711 

it  may  be  mentioned  as  follows :  (a)  Acute  infectious  fevers,  as  typhoid, 
typhus,  pneumonitis,  pyemia,  erysipelas ;  (b)  Injury  or  disease  of  the 
abdomen  or  pelvis  (Stephen  Paget),  especially  when  associated  with  the 
genito-urinary  tract,  as  mild  traumatisms  or  derangement  of  the  testes 
or  ovaries,  the  use  of  a  pessary,  or  even  menstruation  or  pregnancy ; 
gastric  ulcer  may  be  accompanied  by  it ;  (c)  Peripheral  neuritis  with 
facial  paralysis  (Gowers). 

Most,  of  the  cases  are  probably  septic  and  indicative  of  an  unfavor- 
able course  in  the  progress  of  the  associated  disease,  and  especially  of 
the  fevers  mentioned.  The  symptoms,  diagnosis,  and  treatment  of  the 
parotitis  itself  fall  more  properly  under  the  scope  of  surgery. 

Chronic  Parotitis. — Mikulicz  first  described  this  condition  and 
reported  a  case  in  which  symmetric  enlargement  of  the  lachrymal,  and 
subsequently  of  the  salivary,  glands  occurred.  Kiimmel  and  Osier 
have  also  recorded  cases.  It  may  be  caused  by  lead  or  mercury  and 
may  be  secondary  to  mumps,  inflammation  of  the  throat,  and  chronic 
Bright's  disease.     The  condition  may  be  painless. 


IV.  DISEASES  OF  THE  TONSILS. 

ACUTE  TONSILLITIS. 

Definition. — An  acute  inflammation  of  the  tonsil  or  tonsils,  affect- 
ing either  the  mucous  membrane,  the  follicles,  or  the  parenchyma,  and 
ending  either  in  resolution,  suppuration,  or  chronic  enlargement. 

Pathology. — In  the  superficial  variety  of  acute  -tonsillitis  the  mu- 
cosa is  simply  red,  swollen,  and  sometimes  covered  with  a  thin,  soft  exu- 
date of  muco-pus.  The  tonsil  itself  may  also  be  swollen.  In  follicular 
tonsillitis  the  lacunse  become  filled  Avith  a  cheesy  exudate  which  often 
protrudes  from  the  tonsillar  crypts ;  epithelial  and  pus-cells,  cellular 
debris,  and  occasional  cholesterin-crystals  are  found  in  these  cheesy 
masses.  In  older,  darker-hued  masses  an  offensive  odor  is  given  off, 
and  numerous  micrococci  and  bacteria  are  found.  In  adults,  calcareous 
infiltration  of  the  cheesy  little  masses  may  be  met  with.  Parenchyma- 
tous tonsillitis  is  shown  by  a  greater  enlargement  of  the  tonsil,  due  to 
a  marked  infiltration  of  all  the  tissues.  Suppuration  in  the  tonsil  is 
frequent,  the  follicles  usually  bursting  and  uniting  in  abscess-forma- 
tion. Pus  may  burrow  into  the  cellular  tissue  surrounding  the  tonsil, 
and  find  its  way  even  down  to  the  clavicle.  The  herpetic  or  ulcero-mem- 
hranous  form  of  tonsillitis  described  by  Rilliet  and  Barthez,  DaCosta,  and 
others,  in  which  an  eruption  of  herpetic  vesicles  on  the  tonsils  is  followed 
by  their  rupture  and  the  formation  of  a  lightly  adherent,  membranous 
covering  is  rarely  met  with.  In  necrotic  tonsillitis  (Striimpell)  a  grayish- 
white  adherent  necrotic  membrane  is  observed,  that  is  limited  by  the 
inflamed  membrane  surrounding  the  mucosa  covering  the  tonsils,  which 
are  moderately  swollen.  A  dirty  ulcer  often  remains  after  the  slough 
separates. 

Ktiology. — Predisposing  causes  are  age,  sex,  temperament,  and 
atmospheric  conditions.  The  disease  is  most  common  in  youth  and  in 
earlv  adult  life.     Boys  and  young  men  appear  to  be  attacked  more  often 


712  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

than  the  opposite  sex.  Tonsillitis  is  most  prevalent  during  the  spring 
season.  An  individual  susceptibility  is  most  distinct  in  lymphatic  and 
strumous  constitutions.  It  is  aggravated  by,  or  tends  to  recur  especi- 
ally in,  the  rheumatic  diathesis.  The  proportion  of  cases  in  which  ton- 
sillitis precedes  rheumatism  is  probably  over  30  per  cent.  It  is  certain 
also  that  one  attack  of  acute  tonsillitis  predisposes  to  subsequent  ones, 
particularly  when  the  first  attack  has  left  some  enlargement  of  the 
tonsils.  Sudden  and  extreme  climatic  changes,  and  the  special  condi- 
tions seen  in  connection  with  outbreaks  of  scarlet  fever,  measles,  and 
diphtheria,  predispose  to  the  disease. 

The  exciting  causes  of  acute  tonsillitis  are  most  commonly  the  follow- 
ing :  {(i)  exposure  to  cold  and  dampness,  or  talking  in  a  cold,  moist  at- 
mosphere ;  {b)  exposure  and  talking  in  an  overheated  atmosphere  viti- 
ated with  smoke  or  other  irritating  vapors  or  gases  ;  (t)  bad  drainage, 
sewer-gases  ;  {d)  specific  infectious  fevers,  as  scarlatina,  measles,  and 
erysipelas;  (g)  irritation  from  hard  and  sharp  foreign  bodies  or  chemical 
irritants:  {  f)  the  presence  of  microbes  (streptococci,  staphylococci). 

Clinical  Symptoms. — Three  principal  varieties  of  acute  tonsillitis 
occur  clinically,  the  symptoms  of  which  will  be  described  separately. 

(a)  Acute  Catarrhal  or  Superficial  Tonsillitis. — This  form  is  often 
associated  Avith  acute  pharyngitis.  The  earliest  local  symptoms  are  pain 
and  difficulty  in  swallowing,  the  former  often  becoming  quite  acute  and 
radiating  to  the  ear  and  lymphatics  at  the  angle  of  the  jaw,  where  ten- 
derness on  pressure  may  also  be  elicited.  In  speaking  a  nasal  twang  is 
often  noticed.  During  the  laborious  act  of  swallowing  the  sensation 
of  a  lump  in  the  throat,  especially  when  the  mouth. is  dry,  is  commonly 
complained  of  Simple  stomatitis  may  be  associated,  and  rarely  there 
is  a  slight  cough  with  the  painful  expectoration  of  a  sticky  mucus  which 
accumulates  in  the  throat  (Browne).  There  may  be  salivation,  with 
fetor  of  the  breath.  Inspection  shows  the  tonsil  to  be  red  and  swollen. 
Though  dry  and  glazed  at  first,  the  surfaces  soon  become  covered  w  ith 
a  thin  exudate  of  muco-pus,  Avhich  is  easily  detached  by  brushing,  gar- 
gling, or  "hawking  "  the  throat.  There  is  usually- some  accompanying 
redness,  and  also  a  tumefaction  of  the  uvula  and  faucial  pillars.  The 
constitutional  symptoms  of  simple  erythematous  tonsillitis  at  the  outset 
are  mildly  febrile.  The  attacks  usually  come  on  rapidly,  and  last  but  a 
few  days,  subsidence  taking  place  rapidly  also.  Otitis  media  may  fol- 
low the  extension  of  the  tonsillar  inflammation,  and  acute  pharyngitis 
is  a  common  complication. 

(b)  Acute  Lacunar  or  Follicular  Tonsillitis. — In  this  form,  which  is 
quite  common  in  children,  not  only  the  mucous  membrane  lining  the 
crypts  is  inflamed,  but  that  covering  the  surface  of  the  tonsils  also,  giv- 
ing rise  to  more  or  less  associated  catarrhal  tonsillitis.  The  local  sub- 
jective symptoms  in  this  disease  are  pain,  tenderness,  and  difficult  deg- 
lutition, the  counterparts  of  those  of  the  preceding  form.  The  tonsils 
are  seen  to  be  covered  with  small,  slightly  prominent,  whitish-yellow 
spots  or  patches  of  a  characteristic  creamy  exudate  corresponding  to  the 
position  of  the  crypts  and  numbering  from  two  to  eight  or  ten  or  more. 
These  little  masses  or  plugs  may  be  pressed  out  of  the  follicles  with  a 
spatula.  A  predominance  of  pus-cocci  and  cells  may  rarely  forerun  the 
further  formation  of  little  follicular  abscesses,  and  even  of  slight  erosions 


ACUTE  TONSILLITIS.  713 

and  ulceration  of  the  mouths  of  the  lacunse.  Unlike  simple  catarrhal 
tonsillitis — at  least  in  so  far  as  simultaneous  involvement  is  concerned 
(Cohen) — both  tonsils  are  usually  aifected  in  this  trouble,  though  one  to 
a  greater  degree  than  the  other.  The  whole  tonsil  is  considerably  swol- 
len, and  in  severe  cases  the  cervical  lymph-glands  also.  The  constitu- 
tional symiJtoms  of  follicular  tonsillitis  may  be  quite  severe.  The  disease 
may  be  ushered  in  with  a  pronounced  chill,  headache,  aching  of  the 
back  and  Mmbs,  marked  anorexia,  a  heavy  deposit  of  urates,  and  in- 
somnia, along  with  a  rapid  rise  in  the  temperature  to  103°  or  104°  F. 
(39.4o_4oo  c.)— in  children  as  high  as  105°  F.  (40.5°  C).  The  gen- 
eral depression  may  be  so  great  as  to  simulate  adynamia.  Though  sud- 
den in  its  onset  and  rapid  and  often  intensely  acute  in  its  progress,  the 
disease  seldom  lasts  more  than  five  or  eight  days.  Follicular  abscesses 
complicate  the  case,  while  chronic  swelling  of  the  tonsils,  desiccation, 
and  bacterial  degeneration  of  the  lacunar  masses  may  be  sequelae. 
Packard  has  reported  five  cases  of  endocarditis  following  acute  angina. 
Pericarditis  and  pleuritis  also  rarely  occur  as  complications.  Albumi- 
nuria with  casts  may  appear  in  the  course  of  tonsillitis.  Skin-lesions, 
particularly  erythema  nodosum,  may  also  accompany  angina.  The 
exudate  may  become  calcified,  and  may  be  expectorated  as  concretions 
or  chalk-plugs. 

(c)  Acute  Parenchymatous  Tonsillitis  [Tonsillar  Abscess  or  Quinsy). 
— In  this  form  of  tonsillitis,  which  occurs  most  often  during  adolescence 
and  early  adult  life,  the  symptoms  reach  the  most  pronounced  and  severe 
types.     The  stroma  is  inflamed  and  the  tendency  is  toward  suppuration. 

Local  Symptoms. — Complaint  is  first  made  of  dryness  of  the  throat, 
with  painful  and  difiicult  deglutition.  The  pain  is  a  prominent  subjec- 
tive sign,  and  may  be  referred  to  one  or  both  ears  according  as  one  or 
both  tonsils  are  inflamed.  The  secretion  of  a  viscid  mucus  soon  takes 
place,  and  as  the  tonsillar  swelling  increases,  the  husky  voice  of  sore- 
throat  and  difiicult  articulation  supervene;  in  cases  of  aggravated 
swelling  dyspnea  may  often  appear  later.  On  examining  the  tonsils 
they  are  found  to  be  greatly  enlarged,  deeply  reddened,  and  edematous. 
The  surrounding  soft  parts,  the  faucial  arches,  pillars,  and  the  uvula, 
also  manifest  a  deep  congestion.  The  swollen  tonsils  may  cause  a 
bulging  forward  of  the  anterior  pillars  of  the  fauces,  and  push  the 
often  elongated  and  edematous  (jelly-like)  uvula  to  one  side;  or  if  both 
tonsils  are  afiected,  they  may  grasp  or  push  it  forward.  In  severe  cases 
the  tonsils  may  meet  in  the  median  line.  They  are  firm  to  the  touch. 
Patches  showing  follicular  tonsillitis  are  not  infrequently  seen  associated 
with  the  trouble.  The  submaxillary  glands  may  be  engorged,  and  open- 
ing the  mouth  is  often  performed  with  difficu^y ;  it  is  usually  only  par- 
tial, on  account  of  the  fixation  of  the  jaw. 

In  a  few  days,  perhaps,  softening  and  fluctuation  may  be  detected  in 
the  tonsils,  and  spontaneous  rupture  and  discharge  of  the  pus  may  occur, 
with  almost  instant  relief  to  the  patient.  Suppuration  and  tonsillar 
abscess  are  not  always  the  termination,  however,  of  parenchymatous 
inflammation,  resolution  sometimes  taking  place  in  the  milder  cases. 
The  abscess  may  open  in  one  or  more  places,  and  rupture  during  sleep 
may  rarely  cause  sufibcation  by  the  entrance  of  pus  into  the  larynx. 
The  tonsil  may  regain  its  original  size  in  a  few  days  after  the  discharge 


714  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  pus,  and  all  the  symptoms  subside.  The  constitutional  phenomena 
of  parench^^matous  tonsillitis  are  usually  severe  from  the  start,  even  in 
children,  and  more  so  than  in  the  follicular  form  (Mackenzie).  The  tem- 
perature rises  to  104°  or  105°  F.  (40°  or  40.5°  C),  and  the  pulse-beats 
may  reach  130  per  minute.  The  usual  symptoms  accompanying  inflam- 
matory fever  are  marked.  There  may  be  delirium,  and  the  symptoms 
generally  increase  until  the  abscess  bursts  or  is  opened,  when  the  con- 
stitutional as  well  as  the  local  disturbance  rapidly  abates. 

Course,  Duration,  and  Terminations. — Though  often  severely  acute 
in  its  course,  quinsy  seldom  goes  on  to  rupture  in  children,  usually  end- 
ing in  resolution  in  from  three  to  five  days.  If  both  tonsils  are  inflamed, 
only  one  suppurates  as  a  rule,  or  but  one  at  a  time.  The  duration  of 
an  attack  ending  in  tonsillar  abscess  is  about  eight  or  ten  days  in  adults. 

Complications  and  Sequehe. — The  tonsillar  suppuration  may  invade 
the  cellular  tissue  between  the  tonsil  and  the  pterygoid  muscles ;  a  peri- 
tonsillar abscess  may  then  result  that  may  open  even  above  the  clavicle. 
Deep  involvement  of  the  tonsil  may  also  cause  ulceration  into  the  in- 
ternal carotid  or  internal  maxillary  arteries,  and  fatal  hemorrhage  occur, 
though  these  accidents  are,  fortunately,  rare.  Edema  of  the  larynx  is 
also  an  infrequent  complication.  French  writers,  as  Guble,  Germain 
Sde,  and  others,  have  reported  cases  of  paralysis  of  the  soft  palate  and 
pharynx  following  inflammatory  throat-diseases.  On  subsidence  of  the 
tonsillar  inflammation  the  trouble  becomes  evident  in  the  diflftcult  swal- 
lowing and  partial  regurgitation  of  li(|uids  and  solids  into  the  nasal 
passages,  and  in  the  nasal  intonation  of  the  voice.  A  frequent  sequel, 
especially  in  those  predisposed  by  heredity,  is  chronic  enlargement  of 
the  tonsils. 

{d)  Necrotic  Tonsillitis. — This  aff'ection  is  considered  by  Strlimpell 
to  be  in  some  instances  entirely  distinct  from  diphtheria  in  its  etiology, 
although  he  admits  that  quite  frequently  it  is  simply  a  mild  form  of  the 
latter  disease,  and  that  often  it  is  impossible  to  distinguish  between  the 
local  appearances  of  the  two  conditions :  these  have  been  referred  to 
under  the  heading  of  Morl)id  Anatomy.  The  constitutional  disturbances 
are  severe,  especially  in  children,  though  they  seldom  last  longer  than  a 
week,  and  are  followed  by  a  rapid  convalescence.  The  cervical  glands 
are  not  swollen  to  the  same  extent  as  in  diphtheria.  The  occurrence 
later  of  palatal  and  pharyngeal  paralysis  in  a  supposed  case  of  necrotic 
tonsillitis  Avould  ])oint  to  its  true  diphtheritic  origin. 

Diagnosis. — The  appearance  of  tlie  several  forms  of  acute  tonsil- 
litis, associated  with  the  clinical  history  of  each  case,  should  enable  a 
ready  diagnosis  to  be  made  in  the  majority  of  cases.  A  difficulty  may, 
however,  arise  in  discrimftiating  follicular  tonsillitis  from  diphtheria, 
and  apparently  transitional  forms  are  not  uncommon.  The  appended 
table  gives  the  important  points  of  diff"erentiation  between  these  diseases  : 

FoLLicrLAR  Tonsillitis.  Diphtheria. 

A   soft,  pultacoous,  yellowish-white   de-  A  tough,  ashy-gray,  continuous,  and  uni- 

posit  occurs  in  spots  or  patches  situated  form  pseudo-membranous  deposit  cov- 

over  the  mouth  of  the  follicles,  with  ers  the  tonsils. 

areas  of  redness  intervening. 

The  exudate  is  easily  removed,  leaving  a  Very  adherent,  and  can  be  torn  oflF  in 

smooth  surface.     ~  strips  only,  leaving  a  bleeding  erosion. 


ACUTE  TONSILLITIS.  715 

Follicular  Tonsillitis.  Diphtheria. 

The  deposit  is  limited  to  the  tonsils  (im-  The  pillars  of  the  fauces  and  uvula  are 

portant).  involved  as  vrell. 

If  the  creamy  deposits  unite  to  form  a  Removal  of  the  membrane  is  followed  by 

continuous  layer,  removal  is  either  not  re-formation  within  twelve  to  .twenty- 
followed  by  re-formation,  or  very  late.  four  hours. 
May  have  high  temperature,  but  lasting  Persistent  elevation  of  the  temperature ; 

only  a  day  or  two.     Albuminuria  ex-  more  or  less  albuminuria  is  common. 

tremely  rare,  if  present  at  all. 

Cervical    lymphatic    glands    seldom    or  Usually  markedly  swollen  glands. 

slightly  swollen. 

Complications  rare  and  mild.  Complications  frequent  and  grave. 

Bacteriologic  test  shows  no  special  or-  Bacteriologic   examination    shows    pres- 

ganism  ;    often,  however,  streptococci  ence  of  Klebs-Loffler  bacillus. 

and  staphylococci. 

Cases  seen  early,  with  severe  constitutional  symptoms  and  red  and 
swollen  tonsils  having  no  deposit,  may  give  rise  to  the  question  whether 
simple  angina  or  scarlet  fever  is  to  follow.  In  such  cases  the  latter  dis- 
ease may  be  excluded  by  a  negative  history  of  exposure  to  contagion, 
by  the  absence  of  a  very  high  pulse-rate,  and  by  the  non-appearance  of 
the  scarlatinal  eruption.  Necrotic  tonsillitis  may  be  discriminated  from 
the  lacunar  variety  in  the  same  manner  as  diphtheria — i.  e.  by  its  local 
manifestations,  a  full  description  of  which  has  already  been  given  under 
the  heading  of  Morbid  Anatomy. 

The  prognosis  is  good  as  regards  life,  and  favorable  as  regards 
complete  recovery.  The  occurrence  of  either  fatal  hemorrhage  or 
asphyxia  in  quinsy  is  extremely  rare.  In  debilitated  and  strumous  in- 
dividuals relapses  are  prone  to  occur,  and  successive  acute  attacks  of 
tonsillitis  tend  to  cause  permanent  hypertrophy  of  the  tonsils.  In  cases 
of  necrotic  tonsillitis,  especially  during  the  earlier  periods,  the  prog- 
nosis should  always  be  guarded. 

Treatment. — Particularly  in  the  lacunar  and  necrotic  forms  of  ton- 
sillitis the  patient  should  be  kept  apart  from  others  as  much  as  possible, 
since  both  types  appear  to  be  contagious  to  a  certain  degree  ;  or,  if 
other  persons  in  the  house  are  subject  to  a  common  source  of  infection 
— not  human — their  frequent  nearness  to  a  given  case  only  serves  to 
augment  their  own  liability  to  similar  attacks.  Individual  susceptibility 
to  frequent  attacks  of  sore  throat  may  be  lessened  by  systematic  cold 
bathing  of  the  neck.  Constitutional  and  local  rest  is  a  first  and  con- 
stant requisite.  Efibrts  at  swallowing  and  talking  should  be  reduced 
to  a  minimum,  and  in  marked  cases  of  follicular  or  suppurative  tonsil- 
litis rest  in  bed  is  often  sought  without  direction.  Bland  nourishing 
liquids,  as  milk,  broths,  and  the  like,  should  constitute  the  only  nutri- 
ment during  the  stadium  of  the  tonsillar  inflammation.  Early  in  the 
case  a  free  evacuation  of  the  bowels  should  be  obtained,  and  small  doses 
of  calomel  (gr.  \  —  \ — 0.008.-0.010,  repeated  hourly  until  about  gr.  1 
— 0.0648 — has  been  taken),  followed  by  a  Seidlitz  powder  or  Rochelle 
salts  in  hot  water,  will  be  eifective  in  most  cases.  In  severe  cases  of 
quinsy  relief  from  the  pain  is  urgently  called  for,  and  either  a  Dover's 
powder  or  a  hypodermic  injection  of  morphin  (gr.  \—\ — 0.010-0.016) 
and  atropin  (gr.  ^00" — 0.0006)  will  probably  suffice  for  their  relief  A 
high  temperature  must  be  combated  by  small  doses  of  aconite,  fre- 
quently repeated :  this  drug  has  been  much  used  in  the  follicular  ton- 


716  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sillitis  of  children.      Quinin,  in  solution  ^vith  dilute  sulphuric  acid,  is 
also  often  given. 

The  administration  of  sodium  salicylate  or  benzoate,  of  salol,  or  of 
the  ammoniated  tincture  of  guaiac  in  1-dram  (4.0)  doses  (Sajous),  seems 
to  lessen  the  duration  and  severity  of  tonsillitis,  and  even  to  cure  some 
cases  of  the  lacunar  form  within  forty-eight  hours  tod  without  local 
applications.  The  tincture  of  the  chlorid  of  iron  in  glycerin  (4  or  5 
drops  to  the  dram — 4.0 — given  every  two  hours)  is  regarded  by  Bos- 
worth  as  almost  specific  at  the  commencement  of  an  attack  of  acute 
follicular  tonsillitis.  During  convalescence  semi-liquid  and  soft,  light 
foods  may  be  allowed  gradually ;  and  bitter  tonics  and  iron  are  to  be 
administered  if  there  are  depression  and  anemia.  The  following  is  a 
favorite  prescription  : 

I^.   Strychninge  sulph.,  gr.  ss  (0.032); 

Syr.  acaciae,  .Iss      (16.0); 

Liq.  ferri  et  ammon.  acetat.,      q.  s.  ad  5iij       (96.0). — M. 
Sig.  3j  (4.0)  t.  i.  d.,  in  water,  after  meals. 

If  the  case  is  seen  quite  early  during  congestion,  the  use  of  cold  is 
of  great  value  in  giving  local  relief  and  in  shortening  the  attack.  Ice 
may  be  sucked,  and  flannel  dipped  in  ice-water  and  Avrung  out  may  be 
applied  around  the  neck,  or  an  ice-bag  used.  Lozenges  of  guaiac  (gr. 
ij — 0.129)  or  the  ammoniated  tincture  in  1-dram  (4.0)  doses  in  milk, 
and  used  as  a  gargle,  are  indicated  early,  and,  according  to  Sajous,  seldom 
fail  to  control  or  arrest  the  inflammation.  Equal  parts  of  the  tincture 
of  the  chlorid  of  iron,  glycerin,  and  Avater,  applied  gently  with  a  camel's- 
hair  brush,  have  long  been  used  locally  on  the  surfaces  of  the  tonsils, 
and  with  marked  benefit.  Alkaline  and  mild  antiseptic  solutions,  used 
as  gargles  or  sprays  (preferably  the  latter),  are  generally  useful.  Thus, 
Dobell's  solution,  or  Seiler's  tablets  dissolved  in  water,  or  borax  and 
thymol,  or  carbolic  acid,  or  potassium  permanganate  in  Aveak  solution, 
may  be  serviceable.  Mild  counter-irritation  at  the  angle  of  the  jaw 
by  means  of  iodin  or  slightly  irritating  embrocations  is  helpful. 

Early  scarification  of  the  tonsils  as  a  depletory  measure,  and  painting 
with  cocain  (10  per  cent.),  I  have  found  useful  to  bring  about  resolution. 

Astringent  sprays  containing  alum  or  silver  nitrate  are  often  effica- 
cious after  a  day  or  two.  When  the  case  is  first  seen  and  fully  devel- 
oped, the  atomization  of  a  warm  solution  of  cocain  (4  to  8  per  cent.)  or 
lime-water,  with  the  external  application  of  heat  by  means  of  poultices, 
is  indicated.  Should  gargling  be  possible,  nothing  is  better  than  hot 
water  or  milk.  If,  in  parenchymatous  tonsillitis,  fluctuation  be  detected 
or  suppuration  be  even  suspected  of  commencing,  the  prompt  use  of  the 
bistoury  (the  blade  being  guarded  by  wrapping  Avith  cotton  or  adhesive 
plaster),  with  the  production  of  free  bleeding  or  the  discharge  of  pus, 
will  give  great  satisfaction  and  relief.  The  patient's  head,  especially  if 
it  be  a  child,  should  be  tilted  forward  during  the  operation,  so  as  to  allow 
most  of  the  blood  and  pus  to  pass  into  the  mouth.  When  incision  of 
the  tonsil  fiiils  to  bring  pus,  it  has  been  advised  to  puncture  through  the 
anterior  pillar,  where  pus  may  be  formed  in  the  cellular  tissue  in  front 
of  or  behind  the  tonsil. 

When  the  tonsillar  enlargement  threatens  life  through  suffocation. 


CHRONIC  TONSILLITIS.  717 

excision  of  the  tonsils,  laryngotomj,  tracheotomy,   or  intubation  may 
have  to  be  performed. 


CHRONIC  TONSILLITIS. 

{Hypertropiiied  Tonsils;  Adenoid  Tegetations.) 

Definition. — Enlargement  of  the  tonsils  (faucial  and  pharyngeal), 
due  to  chronic  inflammation  or  hypertrophy,  and  usually  associated  with 
or  causing  a  perverted  local  and  systemic  condition. 

Pathology. — The  faucial  tonsils  show  a  true  chronic  hypertrophy 
of  the  lymphoid  and  fibrous  elements.  According  to  the  hyperplasia 
of  the  latter  the  organs  will  be  smaller  and  more  indurated.  They  may 
be  rough  on  the  surface  from  "  distended  lacunae  or  ruptured  follicles  " 
(Berkley  Robinson),  the  latter  being  in  a  state  of  chronic  inflammatory 
thickening,  and  showing  caseous  degeneration  of  their  contents.  The 
growths  in  the  vault  of  the  pharynx  are  adenomatous  papillomata  ;  they 
are  either  sessile  or  pedunculated,  and  are  fleshy  in  appearance  and  con- 
sistence and  very  vascular.  They  range  in  size  from  a  grain  of  wheat 
to  an  almond-kernel  (Allen),  and  project  from  the  pharyngeal  vault, 
lying  in  the  depression  posterior  to  and  on  a  line  with  the  fossa  of  the 
Eustachian  tube  (Rosenmliller's  fossa).  '••  Hypertrophy  of  the  pharyn- 
geal adenoid  tissue  may  also  be  present  without  great  enlargement  of 
the  tonsils  proper  "  (Osier).  A  congestive  type  of  nasal  catarrh  in 
adults  often  accompanies,  or  is  the  result  of.  neglected  adenoid  growths 
and  hypertrophied  tonsils  that  date  from  childhood.  Chronic  pharyn- 
gitis is  also  not  infrequently  associated. 

etiology. — The  irredisposing  causes  of  chronic  hypertrophy  of  the 
tonsils  are — {a)  heredity,  especially  in  the  scrofulous  and  syphilitic  diath- 
eses ;  (6)  age,  most  frequently  betAveen  five  and  fifteen  years ;  [e)  sex, 
boys  appear  to  be  affected  more  frequently ;  (d)  hygienic  surroundings. 

The  exciting  causes  are  usually  previous  attacks  of  acute  tonsillitis, 
either  simple  or  that  which  is  symptomatic  of  diphtheria  or  scarlatina. 
According  to  Harrison  Allen,  adenoid  growths  from  the  normal  lymph- 
oid tissue  of  the  vault  of  the  pharynx  (pharyngeal  tonsils)  may  be  con- 
genital, and  are  ''in  some  way  associated  with  the  canal  which  is  found 
in  early  fetal  life  penetrating  the  brain-case  and  uniting  the  anterior 
part  of  the  pituitary  body  to  the  lining  membrane  of  the  pharynx." 

Symptoms. — Local. — With  slight  or  even  moderate  tonsillar  en- 
largement there  may  be  few  or  no  symptoms  attributable  to  it.  There 
may  be  simply  an  increased  secretion  of  mucus,  and  a  susceptibility  to 
fresh  anginal  attacks  or  to  severe  tonsillar  manifestations  in  diphtheritic 
or  scarlatinal  attacks. 

The  first  symptom  to  attract  the  attention  is  the  direct  effect  of  naso- 
pharyngeal obstruction — i.  e.  oral  respiration.  This  mouth-breathing 
is  visibly  labored  and  abnormally  audible,  and  is  especially  marked  at 
night,  the  child's  respiration  being  noisy,  snorting,  and  irregular.  Sleep 
is  disturbed  by  paroxysms  of  dyspnea,  sometimes  due.  perhaps,  to  reflex 
spasm  of  the  glottis.     Xightmare  folloAvs  as  a  result  of  imperfect  aera- 


718  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tion  of  the  blood  which  supplies  the  brain  on  account  of  the  obstruction 
to  perfect  respiration.  The  act  of  swallowing  is  rendered  difficult  by 
the  faucial  obstruction,  and  is  often  painful,  owing  to  the  superadded 
acute  tonsillar  trouble  that  is  so  liable  to  occur  in  the  hypertrophied 
glands.  Indirect  results  of  chronic  tonsillar  enlargement  are  a  laryngeal 
stridor  and  a  croupy  cough.  Sometimes  asthmatic  attacks  coexist,  and 
seem  also  to  be  due  to  the  hypertrophy.  An  excessive  secretion  of 
mucus  in  the  pharynx  is  a  common  symptom,  and  causes  hawking  in 
subjects  past  young  childhood.  The  hearing  is  often  impaired,  and 
tinnitus  aurium  is  complained  of,  being  the  result  of  pressure  of  the 
growths  against  the  orifice  of  the  Eustachian  tube  or  of  clogging  of  the 
tube  wMth  mucus,  due  to  the  extension  of  inflammation  from  the  naso- 
pharynx. Absolute  deafness  may  result,  and  the  senses  of  taste  and  smell 
are  likewise  diminished  or  perverted.  Inspection  of  the  fauces  will  show 
the  tonsils  bulging  as  two  lumps  covered  with  thick  mucus,  or  the  latter 
may  ooze  around  the  uvula  from  the  pharynx.  In  mouth-breathers  of 
long  standing  the  superior  dental  arch  is  narrowed  and  the  hard  palate 
is  highly  arched.  The  breath  is  fetid,  owing  to  the  cheesy,  inspissated 
exudate'  in  the  tonsillar  crypts.  In  very  old  cases  a  tonsillar  calculus 
may  be  felt,  and  is  the  result  of  calcification  of  the  secretion. 

The  facial  expression,  is  characteristically  stupid  and  pathetic ;  the 
disposition  is  dull,  irritable,  and  stubborn ;  the  lips  are  thick,  and  a 
vacant  stare  is  in  the  eyes.  Speech  is  slow,  phonation  nasal  in  quality, 
and  articulation  of  the  nasal  consonants  n  and  m,  I  and  o,  is  changed  or 
muffled.  Stammering  is  not  rarely  associated  with  tonsillar  hypertrophy. 
The  anterior  nares  may  be  dilated  and  present  a  pinched  appearance 
above  their  openings. 

The  prolonged  interference  with  normal  respiration  gives  rise  to  a 
peculiar  chest-conformation,  simulating  that  of  rickets  (chicken-breast). 
The  ribs  are  prominent  anteriorly,  and  there  is  a  marked  forward  angle 
at  the  manubrio-gladiolar  junction,  as  well  as  a  grooved  depression  at 
the  ensiform  cartilage.  Depressions  between  the  widely-separated  ribs 
exist  anteriorly  also.  Posteriorly,  and  at  tlie  base  of  the  chest  in  par- 
ticular, the  intercostal  spaces  are  practically  absent  on  account  of  the 
closeness  of  the  ribs.  The  upper  part  of  the  chest  is  very  narrow  and 
the  shoulder-bones  quite  prominent  On  percussion  the  hepatic  area  of 
dnlness  is  diminished  on  the  chest-wall,  but  increased  downward  and  to 
the  left.  The  first  cardiac  sound  is  weak.  On  inspiration  there  is  a 
retraction  of  the  intercostal  spaces  in  the  lower  and  lateral  thoracic 
regions. 

The  resulting  thoracic  deformity  may  express  itself  principally  as  an 
excavation  of  the  lower  sternal  area  (triichter  brust).  When  chronic 
tonsillar  enlargement  leads  to  oft-recurring  asthmatic  attacks,  the  chest 
may  become  barrel-shaped,  as  in  emphysema,  at  an  early  period  of  life. 

The  general  symptoms  of  tonsillar  hypertrophy  are  more  marked 
when  the  growths  exist  in  the  pharyngeal  vault  alone.  Developmental 
processes  in  children,  such  as  dentition,  and  at  puberty,  particularly 
when  the  v'oice-changes  are  looked  for,  are  often  retarded  or  perverted. 
Anemia,  headache,  especially  during  study,  cardiac  palpitation,  enuresis, 
and  habit-chorea  of  the  facial  muscles,  may  be  associated  with  general 


CHRONIC  TONSILLITIS.  719 

capriciousness,  mental  dulness,  indisposition  to  intellectual  exertion, 
dro^Asiness,  and  sullen  irritability.  The  term  aprosexia  has  been  given 
to  the  loss  of  power  to  concentrate  the  mind  for  any  length  of  time  that 
is  so  characteristic  of  these  cases. 

Diagnosis* — Inspection  of  the  fauces  will  reveal  enlarged  tonsils. 
It  should  be  borne  in  mind,  however,  that  the  act  of  gagging  often 
causes  the  tonsils  to  rotate  forward  and  inward,  making  them  appear 
larger  really  than  is  the  case.  Adenoid  growths  of  the  pharyngeal 
vault  may  exist  without  tonsillar  enlargement,  and  can  be  detected  by 
posterior  rhinoscopy  or  by  the  insertion  of  the  finger  into  the  naso- 
pharynx ;  the  vegetations  may  thus  be  felt  blocking  the  vault. 

Differential  Diagnosis. — It  is  important  not  to  attribute  the  obstruc- 
tive symptoms  to  nasal  hypertrophies  or  atresia  or  to  malignant  growths 
in  the  naso-pharyngeal  space.  The  latter  are  infrequent  at  the  ages  at 
T^hich  chronic  tonsillar  enlargement  of  the  fauces  and  pharynx  is  most 
apt  to  occur — i.  e.  early  in  life.  Again,  palpation  of  sarcomatous  or 
carcinomatous  growths  gives  marked  differences  in  consistence,  and 
there  are  usually  spontaneous  hemorrhages  and  local  pain  in  attendance 
upon  these  neoplasms.  "  Thumb-suckers  "  diifer  from  mouth-breathers 
in  that  in  the  former  the  incisors  are  inclined  forward  and  cause  slight 
protrusion  beneath  the  upper  lip ;  the  dental  arch  is  flat.  In  mouth- 
breathers,  however,  the  incisors  are  vertical  or  nearly  so,  or  incline  so 
as  to  overlap  each  other ;  the  dental  arch  is  high  and  curved  (H.  Allen). 
Retropharyngeal  abscess  may  be  confounded  with  tonsillar  enlargement, 
especially  in  children.  But  in  this  disease  the  attacks  of  dyspnea,  the 
dysphagia,  and  the  local  distress  are  more  marked.  Again,  in  the 
pharyngeal  disease  the  swelling  is  in  the  median  line,  pushing  the  soft 
palate  forward  perhaps,  and  on  palpation  it  may  give  a  sense  of  elas- 
ticity or  fluctuation  to  the  finger.      Slight  fever  may  also  be  present. 

Prognosis. — Tonsillar  hypertrophy  is  not  a  severe  disease  as  re- 
gards life.  Thei-e  is,  however,  an  increased  liability  to  contract  colds, 
recurrences  of  follicular  tonsillitis,  attacks  of  diphtheria,  and  severe 
scarlatinal  angina.  The  prognosis  in  acute  respiratory  affections  asso- 
ciated with  chronic  tojisillar  enlargement  is  always  more  or  less  grave. 
Adenoid  growths,  even  when  neglected,  tend  to  lessen  in  size  after 
puberty,  with  a  subsidence  of  local  and  reflex  symptoms.  After  removal 
the  growths,  as  a  rule,  do  not  return. 

Treatment. — The  old-fashioned  use  of  astringent  applications  is 
probably  useless  when  there  is  any  marked  chronic  enlargement  of  the 
tonsils,  and  active  surgical  treatment  alone  is  to  be  recommended  for 
the  condition.  The  use  of  absorbents  and  caustics,  either  externally  or 
by  parenchymatous  injection,  is,  I  think,  objectionable  on  account  of 
the  necessarily  protracted  and  painful  course  of  treatment. 

There  are  no  more  satisfactory  means  of  doing  radical  good  in  cases 
of  this  kind  than  the  galvano-cautery,  scarification,  and  the  removal  of 
the  tonsils  with  the  tonsillotome,  snare,  or  bistoury.  In  offensive  fol- 
licular disease  applications  of  chromic  acid  may  give  good  results.  Ade- 
noid growths  may  be  removed  by  means  of  the  finger,  curet,  or  forceps. 

Constitutional  treatment  is  often  necessary  in  improving  the  nutrition 
of  the  patient.      Good  food,  a  change  of  air,  systematic  bathing,  prudent 


720  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

habits,  careful  dress,  and  medicinal  tonics  and  alteratives,  as  cod-liver 
oil,  iodid  of  iron,  and  the  hypophosphites,  are  usually  indicated. 


V.  DISEASES  OF  THE   PHARYNX. 
PHARYNGITIS. 

ACUTE   PHARYNGITIS. 
[Pharyngitis  Acuta  Simplex.) 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  pharynx. 

Pathology. — The  mucous  membrane  is  congested  diff"usely  or  in 
patches,  and  there  may  be  an  inflammatory  exudate  in,  and  a  consequent 
swelling  of,  the  submucosa  and  the  contained  glandular  structures.  The 
surface  of  the  membrane  is  more  or  less  coated  with  a  viscid  muco-pus. 

Htiology. — Predisposing  causes  are — age,  it  being  more  frequent 
in  adolescence  and  young  adult  life  ;  a  depraved  constitution  ;  digestive 
disorders,  and  a  rheumatic,  gouty,  or  scrofulous  diathesis.  The  usual 
exciting  cause  is  exposure,  particularly  of  certain  portions  of  the  body, 
as  the  neck  and  chest,  to  cold  or  to  sudden  changes  of  temperature  and 
to  irritating  vapors.  An  acute  naso-pharyngeal  catarrh,  by  bathing  the 
pharyngeal  mucosa  with  its  irritating  secretions,  may  set  up  the  trouble. 
"  Epidemic  pharyngitis  "  is  probably  a  manifestation  of  influenza.  Acute 
simple  pharyngitis  may  be  a  comj)lication  of  scarlatina,  measles,  and 
small-pox  {eTanthematoiis  pharyngitis).  Micrococci  are  present,  the 
streptococci  often  predominating. 

Symptoms. — Locally.,  the  aff'ection  is  ushered  in  with  a  feeling  of 
dryness  and  soreness,  especially  on  swallowing.  With  the  production 
of  the  muco-purulent  secretion  a  tickling  sensation  provokes  hawking  or 
a  slight  "  throat  cough  "  and  efforts  at  exspuition.  The  catarrhal  pro- 
cess may  extend  to  the  larynx  (ind  cause  some  hoarseness,  or  to  the 
Eustachian  tube,  causing  dulness  of  hearing.  Movements  of  the  neck 
SbYe  painful  and  stiff,  particularly  if  there  is,  as  is  often  the  case,  slight 
involvement  of  the  lymph-glands.  Inspection  of  the  throat  shows  the 
pharynx,  often  the  posterior  pillars,  of  the  fauces  and  the  soft  palate, 
and  even  the  anterior  pillars  and  tonsillar  surfaces,  to  be  deeply  red- 
dened and  tumefied ;  the  coursing  veins  are  enlarged,  and  particles  of  a 
yellowish-white  secretion  appear  here  and  there.  Sometimes  the  phar- 
yngeal follicles  become  subject  to  acute  inflammation,  and  appear  as 
elevated,  discrete,  shiny  spots  (^herpetic  pharyngitis — Mackenzie). 

At  the  onset  of  this  affection  there  may  be  chilliness,  followed  by 
slight  fever,  headache,  an  accelerated  pulse,  a  dry  skin,  and  anorexia. 
The  pharyngeal  symptoms  seldom  last  more  than  from  three  to  five 
days,  when  resolution  takes  place,  some  tenderness  of  the  pharynx, 
however,  remaining  for  a  time. 

Diagnosis. — On  examination  of  the  throat  there  should  neither  be 
any  difficulty  in  diagnosing  the  aff'ection  nor  any  likelihood  of  confound- 
ing the  aff'ection  with  simple  tonsillitis. 


MEMBRANOUS  PHARYNGITIS.  721 

The  prognosis  is  always  favorable.  In  weakly  patients,  however, 
there  is  a  liability  to  subsequent  attacks. 

Treatment. — In  the  early  stages  sucking  of  small  pieces  of  ice 
does  much  to  allfty  the  congestion  and  irritability.  A  spray  of  cocain 
or  menthol  in  albolene  (2  per  cent.)  may  also  be  used,  followed  by  a  4 
per  cent,  solution  of  antipyrin.  Eucain  may  be  substituted  for  cocain 
(2  per  cent,  solution),  and  is  preferred  by  Gibb  and  others.  Dobell's 
solution  is  always  to  be  recommended  for  its  alkaline,  sedative,  and  anti- 
septic action.  Swabbing  the  pharynx  with  a  silver-nitrate  solution  (gr. 
xl  to  the  ounce — 2.59  to  32.0)  is,  according  to  Sajous,  of  great  benefit. 

In  well-established  cases  relief  is  often  obtainable  by  medicated 
steam  inhalation,  as  with  the  compound  tincture  of  benzoin.  In  rheu- 
matic cases  lozenges  of  guaiac  (gr.  iij — 0.194)  are  useful.  The  sipping 
of  hot  milk  in  which  sodium  bicarbonate  has  been  dissolved  is  grateful. 

The  general  treatment  embraces  measures  directed  at  the  fever  and 
the  diathetic  condition.  A  hot  foot-bath  and  a  calomel  purge,  Avith 
belladonna,  acetanilid,  or  aconite  for  the  fever  and  pain,  and  sodium 
salicylate  (gr.  Ix-lxxx — 4.0-5.1 — in  the  twenty-four  hours),  may  be  re- 
quired.    The  diet,  of  course,  should  either  be  liquid  or  semi-solid. 

Persons  susceptible  to  repeated  attacks  must  exercise  caution  in 
regard  to  exposure  to  severe  cold  and  weather-changes,  irritating  vapors, 
and  the  like.  Daily  cold  sponge-baths  may  be  used  to  harden  the  skin. 
Tonic,  nutrient  treatment  is  also  frequently  called  for. 

MEMBRANOUS   PHARYNGITIS. 
(Pharyngitis  Crouposa.) 

Definition. — An  acute  superficial  inflammation  of  the  pharyngeal 
mucosa,  characterized  by  the  formation  of  a  whitish  false  membrane, 
due  usually  to  the  streptococcus. 

Ktiology. — The  principal  causes  of  this  form  of  pharyngitis  are 
exposure  of  persons  in  debilitated  health  to  cold  or  an  impure  or 
a  septic  atmosphere,  particularly  during  epidemics  of  such  diseases  as 
scarlatina. 

Symptoms. — The  local  and  general  symptoms  are  those  of  ordinary 
sore  throat,  though  of  a  more  severe  type. 

Diagnosis. — The  pseudo-membrane  is  thin,  of  a  yellowish-white 
color,  and  appears  in  small  patches  over  the  pharynx  ;  it  is  easily  de- 
tached, and  is  thus  distinguished  from  diphtheria,  with  which  alone  it 
might  be  confounded.  The  presence  of  small  vesicles  or  ulcers  and  the 
absence  of  grave  constitutional  disturbances  are  also  features  in  this 
affection  that  serve  to  differentiate  it  from  diphtheritic  pharyngitis. 

The  prognosis  is  favorable. 

Treatment. — Local  applications  of  solutions  of  hydrogen  peroxid 
or  potassium  permanganate  (gr.  x  to  the  ounce — 0.648  to  32.0)  are  very 
satisfactory.  For  the  painful  dysphagia  the  sedative  and  soothing  rem- 
edies suggested  for  simple  acute  pharyngitis  may  be  used.  Internally, 
sodium  benzoate  (gr.  v-xv — 0.324-0.972)  in  glycerin,  elixir  of  calisaya, 
and  salol  have  each  been  recommended.  Tonic  treatment  is  nearly 
always  needed. 

4fi 


722  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHRONIC  PHARYNGITIS. 

Definition. — A  chronic  inflammation  of  the  mucous  membrane  of 
the  pharynx.  It  may  consist  of  either  a  hypertrophic  or  an  atrophic 
involvement  of  the  follicles,  or  both  processes  may  coexist. 

Varieties, — {a)  Chronic  naso-pharyngeal  catarrh ;  (6)  chronic  hyper- 
trophic pharyngitis  or  naso-pharyngitis  (p/(!a?-_j/>?^iY/s  sicca);  (c) follicular 
or  granular  pharyngitis.  The  last  named  is  probably  the  result  of,  and 
nearly  always  is  associated  with,  chronic  simple  (or  hypertrophic)  pha- 
ryngeal (or  naso-pharyngeal)  catarrh. 

Pathology. — The  mucous  membrane  in  simple  chronic  pharyngitis 
is  either  reddened,  thickened,  and  viscid  (hypertrophic  form),  or  pale, 
thin,  and  dry  (atrophic  form) ;  in  both  instances  dilated  and  tortuous 
veins  are  prominently  shown.  In  the  follicular  variety  the  pharyngeal 
mucous  glands  are  swollen  into  little  red,  glistening  nodules  studding 
the  congested  membrane.  The  enlarged  follicles  are  due  to  a  hyperplasia 
of  lymphoid  cells  and  an  accumulation  of  retained  dried-up  secretions. 

Htiology. — A  protracted  impairment  of  the  general  health,  espe- 
cially in  those  who  over-exert  mentally  and  are  of  sedentary  habits,  is 
a  common  predisposing  cause  of  chronic  pharyngitis.  Repeated  acute 
attacks  mav  precede  the  affection.  It  is  most  common  in  adolescent 
and  middle  life. 

The  exciting  causes  are  frequent  and  prolonged  over-use  and  strain 
of  the  voice  in  clergymen,  singers,  teachers,  army-oflBcers,  and  street- 
venders  ;  irritation  from  tobacco-smoke,  chemical  vapors,  and  continued 
exposure  to  cold  air.  Among  prevailing  causes  may  be  mentioned  post- 
nasal adenoids,  deviations  of  the  septum,  and  neoplasms.  It  may  arise 
from  gastric  disorders. 

Symptoms. — In  all  varieties  of  chronic  pharyngitis  the  local  dis- 
comfort is  often  very  slight,  and  more  annoying  than  painful,  except 
when  an  exacerbation  takes  place.  It  is  a  particularly  uncomfortable 
condition  in  those  whose  occupation  requires  more  or  less  constant  use 
of  the  voice.  There  is  a  sensation  of  dryness  and  ticlding  or  burning 
in  the  throat  and  the  desire  to  clear  the  throat  of  sticky  mucus  by 
hawking  or  a  shoi^t  cough.  These  symptoms  are  usually  worse  on  rising 
in  the  morning,  especially  if  some  unfavorable  influence  has  been  ex- 
erted during  the  night  previous,  the  throat  being  dry  and  a  viscid  secre- 
tion having  collected.      Swallowing  is  seldom  interfered  with. 

If  the  larynx  is  somewhat  aft'ected  by  extension  of  the  pharyngeal 
inflammation,  hoarseness  and  a  drg,  hacking  cough  are  produced.  After 
using  the  voice  there  is  a  sense  of  fatigue,  with  huskiness  and  irritability. 

The  local  appearances  of  chronic  pharyngitis  vary  according  to  the 
form  of  the  affection  present  in  the  case.  In  chronic  catarrh  of  the 
pharynx  a  considerable  collection  of  muco-pus  is  seen  adhering  to  the 
mucosa  and  extending  downward  from  the  posterior  nares.  The  senses 
of  hearing  and  taste  may  be  impaired.  The  uvula  is  frequently  elong- 
ated, and  its  tip  may  rest  on  the  base  of  the  tongue.  A  nasal  intona- 
tion of  the  voice  is  sometimes  provoked.  The  posterior  nares  as  seen 
by  the  rhinal  mirror  are  often  stopped  up  by  foul  secretions  or  by 
hypertrophy  of  the  nasal  mucous  membrane.  Headache  and  attacks 
of  vertigo  may  occur. 


ACUTE  INFECTIOUS  PHLEGMON  OF  THE  THROAT.  723 

* 

Chronic  hyjjertropMc  pharyngitis  and  follicular  pharyngitis  ("  clergy- 
man s  sore  throat  ")  are  commonly  associated.  The  thickened,  reddened, 
pimply,  vein-coursed  appearance  of  the  mucosa  is  characteristic.  The 
follicles  may  be  seen  sometimes  as  polypoid  elevations,  and  the  pharyn- 
geal tonsil  may  be  found  by  the  finger  to  be  enlarged  (Kolliker). 

In  the  dry,  atrophic  pharyngitis  that  occurs  more  often  in  later  life, 
and  as  a  sequel  of  the  simple  chronic  or  follicular  variety,  a  pale,  smooth, 
relaxed,  lustrous,  and  often  quite  painful  membrane  is  observed. 

The  general  symptoms  are  usually  those  of  a  weak,  debilitated,  nerv- 
ous constitution,  though  in  mild  cases  the  general  health  may  be  unim- 
paired.    In  atrophic  pharyngitis  considerable  cachexia  may  be  present. 

Diagnosis. — Care  should  be  exercised  in  discriminating  the  variety 
of  chronic  pharyngitis  present  in  any  given  case,  so  that  the  treatment 
may  be  planned  accordingly.  Careful  and  repeated  inspection  of  the 
throat  must  render  the  diagnosis  easy  unless  ulceration  has  taken  place : 
in  such  cases  a  tuberculous  or  syphilitic  sore  throat  must  be  eliminated 
by  the  superficial  character  of  the  ulcers,  by  their  ready  response  to 
proper  treatment,  by  the  history  of  the  case  as  to  specificity,  and  by  the 
absence  of  marked  pain  or  symptoms  pointing  to  tuberculosis.  When 
due  to  gastric  disturbance  the  lower  throat  will  be  deeply  congested  and 
the  tongue  will  be  irritable,  with  red  papillse  standing  over  its  base 
(Price-BroAvn). 

Prognosis. — This  should  be  guarded  as  to  cure,  on  account  of  the 
stubborn  resistance  to  treatment  and  the  difficulty  in  removing  unfavor- 
able influences.  Acute  exacerbations  are  liable  to  recur  unless  rigid 
caution  is  practised  at  all  times  in  avoiding  the  cause  of  the  trouble. 

Treatineiit. — The  local  use  of  astringent  and  alkaline  antiseptic 
sprays  or  of  the  nasal  douche  is  usually  recommended,  but  has  only  a 
palliative  effect.  Silver-nitrate  cauterization  may  be  tried.  The  only 
effectual  means,  however,  of  curing  the  follicular  or  hypertrophic  variety 
is  that  used  by  most  throat-specialists — namely,  the  wire  galvano-  or 
actual  cautery.  Applications  of  silver  nitrate  (gr.  x  to  the  ounce — 0.648 
to  32.0)  and  the  internal  use  of  the  oleoresin  of  cubebs  have  been  recom- 
mended for  the  atrophic  pharyngitis.  Insufflation  of  powdered  tannin 
or  alum  is  also  of  service. 

Systemic  disturhances  need  attention  according  as  they  present  them- 
selves. Mineral  baths  are  sometimes  of  great  benefit,  and  tonics  are 
usually  indicated.  All  irritating  causal  factors  must  be  removed  or 
avoided  before  any  favorable  results  can  be  hoped  for  from  local  applica- 
tions. Tobacco-smokers  and  topers  must  deny  themselves  their  habitual 
luxuries.  Krause  and  Heryng  recommend  with  favor  curetting  and  the 
application  of  lactic  acid  to  superficial  tuberculous  ulcers. 

ACUTE  INFECTIOUS  PHLEGMON  OF  THE  THROAT. 

Definition. — An  inflammation  of  the  pharyngeal  mucosa  that  passes 
rapidly  into  a  suppurative  process.     It  is  exceedingly  rare. 

Its  etiology  is  not  definiteh"  known.  I  have  met  with  no  cases 
except  in  my  hospital  Avards,  though  they  doubtless  occur  in  general 
medical  practice.     The  clinical  features  have  been  described  by  Senator. 

The  symptoms  are  sudden  in  their  onset  and  quite  intense.      They 


724  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

are  severe  soreness  of  the  throat,  dysphagia,  and  hoarseness,  as  a  rule ; 
in  advanced  cases  there  has  been  diflScult  respiration.  Inspection  shows 
the  pharynx  to  be  deeply  injected  and  the  seat  of  marked  inflammatory 
edema,  the  neck  appearing  greatly  swollen  as  well.  The  general  dis- 
turbance is   correspondingly   severe. 

The  treatment  is  w  holly  symptomatic. 


RETROPHARYNGEAL  ABSCESS. 

Definition  and  Pathology. — A  suppurative  inflammation  (rare) 
of  the  connective  tissue  lying  anterior  to  the  cervical  spinal  column. 

;^tiology. — The  disease  is  relatively  most  common  before  two  years 
of  age.  It  is  usually  a  primary  aff"ection,  occurring  without  assignable 
cause,  but  a  certain  proportion  of  instances  are  doubtless  caused  by 
caries  of  the  cervical  vertebra?.  It  may  rarely  be  secondary  to  any  of 
the  specific  fevers.     Traumatism  causes  occasional  instances. 

The  syniptoms  are  pain  in  swallowing,  impeded  respiration,  soon 
becoming  stertorous  in  character,  the  dyspnea  meanwhile  constantly  in- 
creasing. There  may  be  couyh,  and  the  voice  may  present  abnormal 
characteristics.  The  signs  of  stenosis  finally  declare  themselves  with 
considerable  violence,  and  an  examination  of  the  pharynx  usually  serves  to 
make  the  diagnosis  positive ;  the  projecting  tumor  is  visible,  and  the  pal- 
pating finger  readily  detects  fluctuation.  In  children  the  general  features 
(slight  fever,  anorexia,  languor)  overshadow  for  days  the  local,  while 
in  adults  the  condition  develops  acutely  with  severe  faucial  symptoms. 

The  course  of  the  disease  may  be  acute,  lasting  one  or  two  weeks ; 
more  frecjuently,  however,  it  is  subacute  (rarely  chronic),  as,  for  exam- 
ple, when  it  is  due  to  caries  of  the  vertebne. 

The  prognosis  is  favorable  in  all  cases  that  are  early  diagnosticated. 
If  unrecognized  until  the  later  stages  have  been  run,  suff'ocation  may 
ensue,  or  rupture  into  the  larynx  may  cause  death  by  asphyxia. 

Treatment. — As  soon  as  fluctuation  is  detected  the  abscess  should 
be  freely  opened,  and  preferably,  as  a  rule,  through  the  mouth  by  means 
of  a  guarded  bistoury.  The  throat,  after  the  abscess  is  thoroughly 
evacuated,  should  be  washed  out  with  some  mild  antiseptic  solution 
(salicylic  acid  2  per  cent,  or  boracic  acid  2  per  cent.).  When  pointing 
occurs  at  the  side  of  the  neck,  as  sometimes  happens,  the  incision  should 
be  made  through  the  skin  in  that  locality.  Constitutional  indications 
are  to  be  fulfilled  in  accordance  Avith  general  principles,  and  the  strength 
of  the  patient  is  to  be  maintained  by  a  highly  nutritious  dietary. 


VI.    DISEASES  OF  THE  ESOPHAGUS. 
ESOPHAGITIS. 

ACUTE   ESOPHAGITIS. 

Definition. — An  acute  inflammation   affecting   either  the    mucous 
meml)r;ine  or  submucous  tissues  of  the  esophagus,  or  both. 

Pathology. — The  ordinary  morbid  changes  of  an  acute  esophagitis 


DISEASES  OF  THE  ESOPHAGUS.  725 

are  those  of  a  simple  catari'hal  inflammation  of  the  mucosa.  It  is  rather 
characteristic  of  the  condition  that  there  is  no  increased  secretion,  a 
spoDginess  and  rapid  desquamation  of  the  epithelium  taking  place  in- 
stead, and  causing  a  granular  appearance  of  the  membrane.  Occasion- 
ally the  mucous  glands  are  swollen,  and  may  break  doAvn,  with  the  for- 
mation of  small  follicular  ulcers.  Catarrhal  erosions  may  also  be  seen 
here  and  there.  A  croupous  or  diphtheritic  exudate  is  seldom  found 
in  the  lower  portion  of  the  esophagus,  and  small-pox  pustules  are 
rarely,  if  eyer,  seen.  A  diffuse  or  circumscribed  pui'ulent  inflammation 
of  the  submucosa  may  dissect  up  the  mucous  membrane  so  as  to  consid- 
erably diminish  the  esophageal  caliber ;  pus  is  usually  discharged  into 
the  tube.  In  severe  cases  of  poisoning  (corrosive  esophagitis)  sloughing 
may  extend  into  the  muscular  layer,  and  may  produce  a  foul,  dark,  hem- 
orrhagic mass.  A  fibrinous  cast  of  the  gullet  has  been  vomited  up  by  an 
hysteric  woman  (Birch-Hirschfeld). 

Htiology. — The  causes  of  acute  esophagitis,  other  than  traumatic, 
are  rare.  Under  the  latter  are  included  the  mechanical,  thermal,  and 
chemical  irritants,  such  as  the  presence  of  foreign  bodies  and  the  swal- 
lowing of  hot  liquids,  corrosive  poisons,  ''concentrated  lye,"  mineral 
acids,  and  arsenic.  The  condition  may  also  be  the  result  of  the  follow- 
ing :  (a)  an  extension  of  catarrhal  inflammation  of  the  pharynx ;  (5) 
specific  infectious  fevers,  as  typhoid,  typhus,  and  pneumonitis ;  (c)  diph- 
theria ( pseudo-membra7ioics  esophagitis)  by  the  extension  of  pharyngeal 
diphtheria ;  (c/)  small-pox,  giving  rise  to  a  pustular  inflammation  of  the 
gullet ;  (e)  local  disease,  as  carcinoma  of  the  esophagus,  glandular  or 
vertebral  abscess,  or  laryngeal  perichondritis  (Strlimpell). 

Symptoms. — Pain  during  deglutition  may  be  referred  to  the  region 
of  the  esophagus,  and  a  steady,  dull  pain  may  exist  beneath  the  sternum. 
Dysphagia  and  regurgitation  of  food  may  be  caused  by  spasm  in  severe 
cases.  Mucus,  blood,  and  pus  may  be  discharged  later.  The  absence 
or  mildness  of  pain  is  not  a  true  indication  of  the  gravity  and  extent  of 
esophageal  inflammation. 

Sequelce. — Simple  catarrhal  or  follicular  ulcers  may  appear,  and  the 
necrotic  form  of  the  disease  may  be  followed  by  suppurating  ulcers, 
Avhich.  if  healing  takes  place,  may  cause  cicatricial  stenosis. 

Diagnosis. — This  may  be  based  upon  the  localization  of  pain, 
especially  during  deglutition ;  upon  the  pain  occasioned  by  the  passage 
of  the  esophageal  sound ;  and  upon  the  mucus,  blood,  or  pus  adherent 
to  its  bulb  on  withdrawal,  provided  carcinoma  at  the  cardiac  orifice  of 
the  stomach  can  be  excluded.  The  expulsion  of  a  pseudo-membrane 
(diphtheritic)  from  the  gullet  should  be  differentiated  from  esophago- 
mycosis  (thrush),  especially  in  children.  The  diagnosis  of  the  particu- 
lar form  of  esophagitis  will  depend  upon  the  facts  elicited  relating  to 
the  etiology. 

The  prognosis  is  good  in  mild  cases,  and  should  be  guarded  in 
those  associated  with  grave  disease.  Death  may  occur  in  either  the 
purulent  or  necrotic  form. 

Treatment. — This  is  entirely  symptomatic,  and  in  severe  cases  is 
of  little  value.  A  soft,  bland  diet,  preferably  of  milk,  may  be  borne  in 
ordinary  instances ;  if  not,  rectal  alimentation  should  be  resorted  to. 
For  the  mild  cases  swallowing  of  bits  of  ice,  and  later  of  warm  demul- 


726  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cent  drinks,  should  be  recommended.  In  cases  of  marked  pain  and 
esophageal  spasm  relief  may  be  aiforded  by  a  hypodermic  injection  of 
morphin  and  atropin. 

CHRONIC   ESOPHAGITIS. 

Chronic  catarrh  of  the  gullet  may  result  from  continued  irritation 
by  the  causes  of  the  acute  form,  and  also  from  passive  congestion  due  to 
hepatic  cirrhosis,  chronic  cardiac  or  renal  disease.  The  last-named  con- 
ditions may  also  cause  varicose  esophageal  veins,  and  fatal  hemorrhage 
may  result  therefrom.  The  increased  mucous  secretion  may  cause  eruc- 
tations and  nausea. 

Postmortem  evidence  of  esophagitis,  either  acute  or  chronic,  is  found 
with  extreme  rarity. 


ULCER  OF  THE  ESOPHAGUS. 

This  is  a  conseijuence  of  a  simple  or  follicular  catarrh  of  the  gullet 
or  of  gangrene.  "  Catarrhal  erosions  "  and  follicular  ulcers  may  occur, 
and  also  necrotic  ulcers,  in  bedridden  persons  opposite  the  cricoid  carti- 
lage. The  extensive  purulent  ulceration  folloAving  the  separation  of 
necrotic  sloughs  may  heal  and  cause  stenosis  of  the  tube,  or  it  may  rup- 
ture into  the  trachea,  the  posterior  mediastinum,  or  the  aorta.  Ulcers 
simulating  those  occurring  in  the  stomach  {idceres  ex  cligestione)  may 
sometimes  be  found  at  the  lower  end  of  the  esophagus.  Postmortem 
digestion,  however,  must  not  be  mistaken  for  peptic  ulceration.  There 
may  be  localized  points  of  pain  on  the  passage  of  the  esophageal  bougie, 
with  some  pus  and  blood  on  the  bulb  after  its  withdrawal.  Rest  from 
swallowing  should  be  secured  as  far  as  possible.  The  sipping  of  hot 
milk  may  be  soothing,  and  the  slow  swallowing  of  mild  boric-acid  and 
sodium-bicarbonate  solutions  may  be  tried  with  benefit. 


CARCINOMA  OF  THE  ESOPHAGUS. 

This  is  the  most  frequent  affection  of  the  tube,  and,  as  it  is  the  com- 
monest cause  of  stenosis,  it  is  important  from  a  diagnostic  standpoint. 

Pathology. — Carcinoma  of  the  esophagus  is  primary  and  of  an  epi- 
thelioniatous  nature,  the  mucous  membrane  here  being  composed  of  pave- 
ment-cells. The  new  growth  affects  the  mucosa  first,  and  then,  increas- 
ing in  size  and  causing  ulceration,  it  involves  the  entire  circumference 
of  the  tube  like  a  ring-like  mass.  This  may  either  be  hard  and  fibrous, 
or  soft  and  jelly-like.  The  esophageal  lumen  is  markedly  diminished, 
though  disintegratinj;  ulceration  or  "flat"  carcinoma  mav  encroach 
upon  the  caliber  but  little.  There  may  be  a  diff"use  dilatation  of  the 
esophagus  above  the  growth,  as  well  as  an  hypertrophy  of  the  circular 
muscular  fibers.  The  cancerous  tumor  is  found  most  commonly  in  the 
lower  third  of  the  esophagus  (generally  at  the  point  where  the  left 
bronchus  crosses  the  tube). 


CARCINOMA    OF  THE  ESOPHAGUS.  727 

l^tiology. — The  predisposing  causes  of  esophageal  carcinoma  are  age 
and  sex,  males  past  forty  years  of  age  being  the  usual  subjects  of  this 
neoplasm.  The  exciting  causes  are  of  uncertain  origin.  It  has  been 
alleged  that  various  forms  of  protracted  irritation  of  the  mucous  mem- 
brane may  cause  the  development  of  carcinoma ;  and  especially  has  this 
point  been  maintained  in  connection  with  the  frequent  occurrence  of 
carcinoma  of  the  gullet  in  topers.  It  is  also  believed  by  some  that  as 
gastric  carcinoma  may  develop  from  the  scars  of  old  ulcers,  a  like  con- 
dition in  the  esophagus  may  act  as  a  nucleus  for  a  carcinomatous  growth. 

Symptoins. — Dysphagia  is  the  earliest  symptom  of  esophageal  car- 
cinoma with  beginning  stenosis  of  the  tube.  This  gradually  and  steadily 
increases,  so  that  liquids  alone  can  be  swallowed,  and  later  regurgitation 
even  of  liquid  foods  takes  place.  There  may  be  considerable  pain.  I 
recently  saw  an  instance  with  Dr.  W.  Frank  Haehnlen  in  which  enormous 
quantities  of  mucus  were  regurgitated  and  in  Avhich  the  symptoms  of 
bronchiectasis  developed  near  the  close. 

The  ejecta  may  contain  cancerous  fragments,  blood,  and  mucus.  The 
dysphagic  symptoms  may  subside  spontaneously,  owing  to  the  disinte- 
gration and  ulceration  of  the  growth,  or  the  dysphagia  may  be  so  slight 
as  to  be  masked  by  the  prominent  symptoms  of  hepatic  or  pulmonary 
carcinoma  and  gangrene  secondary  to  a  very  flat  esophageal  carcinoma. 
Or,  without  secondary  manifestations  of  such  a  groAvth,  the  esophageal 
symptoms  may  rarely  be  latent.     The  cervical  glands  may  be  enlarged. 

The  most  important  general  symptom  of  esophageal  carcinoma,  as  of 
this  malignant  growth  elsewhere,  is  the  progressive  emaciation,  which 
increases  with  the  stenosis  and  obstruction  to  the  entrance  of  nourish- 
ment into  the  stomach.  Though  seemingly  anemic,  the  patient's  blood 
may  contain  an  excessive  number  of  corpuscles  in  a  given  bulk.  This  is 
due  to  inspissation  from  failure  to  absorb  water  and  food  into  the  body. 

Course,  Duration,  and  Termination. — The  disease  is  chronic, 
becoming  progressively  worse,  and  is  often  beset  with  grave  complica- 
tions (vide  infra).  It  seldom  lasts  longer  than  one  and  a  half  years, 
and  the  duration  of  medullary  carcinoma  of  the  gullet  is  usually  much 
shorter.  A  fatal  ending  is  inevitable,  by  inanition  and  exhaustion,  or 
as  the  result  of  metastasis  and  secondary  complications. 

Complications. — These  follow  extension  of  the  cancerous  growth 
to  neighboring  parts.  Thus,  involvement  of  the  larynx,  trachea,  and 
bronchi  has  been  noted.  The  cancerous  ulcer  may  also  perforate  the 
pleura,  the  pericardium,  or  the  aorta  or  its  branches,  and  cause  fatal 
hemorrhage.  The  vertebrae  have  been  eroded,  and  compression  of  the 
cord,  with  resulting  paraplegia,  may  take  place. 

Paralysis  of  the  vocal  cords  may  be  the  effect  of  pressure  by  the 
growth  upon  the  recurrent  laryngeal  nerve ;  most  frequently  pulmonary 
gangrene  is  due  to  perforation  of  the  lung  or  to  the  inspiration  of  can- 
cerous and  decomposing  particles  that  have  been  regurgitated. 

Diagnosis. — As  the  dysphagia  is  a  symptom  of  paramount  im- 
portance in  the  diagnosis  of  esophageal  carcinoma,  all  other  causes  of 
the  symptoms  must  be  excluded.  The  enlarged  tonsils,  pharyngeal 
tumors,  pressure  from  without  by  cervical  intrathoracic  tumors,  as  aneur- 
ysm, or  by  displacement  of  the  sternal  end  of  the  clavicle,  and  the 
presence  of  foreign  bodies  or  cicatricial  strictures  of  the  gullet — all  fig- 
ure in  the  production  of  difficult  deglutition.     The  history  of  the  case, 


728  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

the  age  of  the  patient,  the  progressive  emaciation  (cancerous  cachexia), 
and  the  obstinately  increasing  dysphagia  will  enable  us  to  exclude  the 
other  affections  named.  In  using  the  esophageal  bougie  for  diagnostic 
purposes  great  care  should  be  exercised,  as  an  aneurysm  may  thus  be 
ruptured  or  a  deeply  ulcerated  carcinoma  perforated.  The  withdrawal 
of  cancerous  tissue  upon  the  bulb  will  decide  the  case.  The  esophago- 
scope  may  be  useful  in  certain  cases,  but  requires  great  care  and  special 
skill.     The  exceptional  occurrence  of  latent  cases  must  be  remembered. 

The  prognosis  is  hopeless,  and  the  supervention  of  grave  compli- 
cations or  jjulmonary  gangrene  renders  the  chances  of  an  early  demise 
very  probable. 

Treatment. — This  is  essentially  symptomatic  and  sustentative.  If 
feeding  bv  the  mouth  is  difficult  on  account  of  the  extreme  stenosis, 
although  permitting  the  passage  of  an  esophageal  tube,  the  latter  may 
be  used  for  the  passage  of  liquid  nourishment.  Rectal  feeding  may 
later  become  imperative.  The  mechanical  treatment  of  the  cancerous 
stricture  by  the  passage  of  the  graduated  esophageal  bougie  is  seldom 
of  any  avail,  although  temporary  improvement  may  perhaps  be  obtained. 
Soft,  disintegrating,  and  ulcerating  carcinoma  should  thus  be  treated, 
though  with  the  absence  of  any  force  Avhatsoever.  lest  perforation  take 
place.  The  performance  of  gastrostomy  may  prolong  life  in  some  cases 
in  which  there  is  formidable  difficulty  in  passing  a  tube  into  the  stomach. 


RUPTURE  OF  THE  ESOPHAGUS. 

The  first  recorded  case  of  this  rare  condition  occurred  under  the  ob- 
servation of  Boerhaave  in  1724  in  the  person  of  the  Baron  Wassemar. 

Pathology. — Softening,  together  with  a  great  friability,  of  the 
esophageal  walls  may  be  found,  this  probably  being  the  effect  produced 
by  the  solvent  action  of  the  gastric  juice  upon  the  mucous  membrane  at 
a"^  time  when  the  local  circulation  is  disturbed  and  the  vitality  of  the 
tissues  thus  lessened. 

The  postmortem  evidence  of  this  accident  consists  of  a  longitudinal 
(as  a  rule)  tear  about  5  cm.  (2  inches)  in  length,  and  situated  in  the 
lower  half  of  the  esophagus.  Food  and  air  may  be  found  to  have  es- 
caped into  the  left  pleural  cavity,  and  unless  death  occur  at  an  early 
date  signs  of  secondary  purulent  inflammation  will  probably  be  noticed. 
Postmortem  digestion  of  the  esophagus  is  more  common  (Osier).  The 
perforation  is  often  (juite  large,  and  is  located  in  the  posterior  wall  of 
the  tube. 

Btiology. — Softening  of  the  walls  of  the  gullet  [esophago-malacia) 
is  suggested  by  Zenker  as  a  condition  that  always  precedes  spontane- 
ous rupture,  so  called.  The  exciting  cause  is  believed  to  be  violent  and 
persistent  vomiting  after  a  particularly  heavy  meal  or  during  acute 
alcoholism. 

Symptoms. — These  come  on  suddenly  or  soon  after  a  full  meal, 
and  commence  with  nausea  and  very  severe  vomiting,  accompanied  by 
great  pain  and  rapid  and  extreme  collapse  of  the  whole  body,  due  to 
the  shock.  A  cutaneous  emphysema  of  the  neck  and  chest  is  mani- 
fested soon  after  the  rupture. 


NEUROSES  OF  THE  ESOPHAGUS.  729 

The  diagnosis,  if  made  at  all,  must  rest  upon  the  clinical  history. 
Death  usually  takes  place  in  a  few  hours,  or  days  at  the  most,  and  the 
prognosis  is  necessarily  hopeless. 

The  treatment  is  equally  so  in  the  present  status  of  surgery.  Pain, 
if  excruciating,  should  be  dulled  by  the  hypodermic  administration  of 
morphin. 


NEUROSES  OF  THE  ESOPHAGUS. 

MUSCULAR    SPASM. 
( Esophagismus.) 

Definition, — A  spasmodic  contraction  of  the  muscular  layer  of  the 
esophagus. 

Ktiology. — It  is  almost  always  a  secondary  affection,  met  Avith  not 
infrequently  in  hysteria,  hydrophobia,  and  rarely  in  chorea  and  epilepsy. 
I  have  seen  one  instance  of  the  idiopathic  form  of  the  disease  in  a  female 
possessing  a  highly  neurotic  constitution.  In  this  case  the  esophageal 
bougie  could  be  passed  only  with  a  great  deal  of  difficulty  during  the 
spasm.  It  has  usually  been  observed  in  aged  males,  and  especially  in 
those  suffering  from  hypochondriasis.  It  may  be  due  to  reflex  causes, 
originating,  for  example,  in  the  uterus ;  thus,  in  some  cases,  it  occurs 
only  during  the  pregnant  state.  Rosenheim  contends  that  cardiospasm 
may  follow  primary  atony  and  ectasia  of  the  esophagus. 

Symptoms. — The  chief  subjective  characteristic  is  dysphagia.  Al- 
though liquids  can  be  SAvallowed,  solids,  as  a  rule,  cannot.  Post-sternal 
2)ain  is  sometimes  noticed,  and  choking  signs  are  quite  common.  In  the 
hysteric  variety  emotional  disturbances  are  found  among  the  prodromata, 
and  most  probably  bear  a  causal  relation. 

Diagnosis. — The  etiologic  factors  must  be  carefully  Aveighed  in 
connection  Avith  the  symptoms  and  the  valuable  testimony  gained  by 
the  use  of  the  sound.  The  bougie  on  reaching  the  constriction  is  rather 
tightly  gripped,  though  gentle  pressure  soon  causes  it  to  relax.  After 
the  subjective  symptoms  and  spasm  are  over  the  sound  passes  without 
the  slightest  difficulty,  providing  a  point  of  the  greatest  diagnostic 
import.  The  elderly  hypochondriac  is,  as  before  stated,  liable  to 
develop  a  similar  condition,  which  must  not  be  confounded  with  true 
cancerous  stricture.     The  prognosis  is  good. 

The  treatment  is  directed  to  the  disease  on  which  the  condition  is 
found  to  depend,  and  this  must  receive  careful  attention.  The  sound 
should  be  used  as  previously  indicated  under  the  discussion  of  Esopha- 
geal Stricture.  Its  passage  has  often  been  followed  by  speedy  and  per- 
manent cures.  A  special  electrode  with  which  to  apply  electricity  to 
overcome  the  spasm  of  the  cardia  has  been  employed. 

PARALYSIS  OP  THE  ESOPHAGUS.^ 

In  extensive  bulbar  paralysis,  Avhen  adjacent  parts  are  inA^olved,  we 
may  infer  the  existence  of  esophageal  implication,  though  there  be  no 

^  For  remarks  on  the  treatment  of  this  complaint  the  reader  is  referred  to  section  on 
I^ervous  Diseases. 


730  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

objective  evidence  to  adduce  in  confirmation.  Doubtless  tbe  esophagus 
rarely  shares  in  post-diphtheritic  paralysis  also.  Dysphagia  is  the  lead- 
ing symptom.  An  invaluable  peculiarity  belonging  to  diphtheritic 
paralysis  is  the  fact  that  solids  are  more  readily  swallowed  than  liquids. 


DILATATION  OF  THE  ESOPHAGUS. 

Pathology  and  Etiology. — Diffuse  dilatation  of  the  esophagus  is 
usually  secondary  to  stricture  at  or  near  the  cardiac  oi'ifice.  In  accord- 
ance with  the  common  law  of  compensation,  the  first  effect  of  the  stenosis 
is  to  engender  hypertrophy  of  the  muscular  layer  above  it  with  a  view 
of  overcoming  the  resistance  caused  by  the  obstruction.  The  wall  of  the 
esophagus  becomes  thickened,  and  the  tube  is  generally  somewhat  nar- 
rowed, above  the  seat  of  the  stenosis ;  but  finally,  as  a  result  of  degen- 
erative changes,  the  muscular  coat  weakens,  the  esophagus  dilates,  and 
food  accumulates  above  the  stricture — a  condition  that,  once  begun, 
progresses.     Dilatation  may  rarely  follow  hysteric  spasm  of  the  cardia. 

Congenital  dilatation,  in  which  the  whole  extent  of  the  tube  partici- 
pates, has  also  been  met  with,  though  such  a  condition  is  rare  indeed. 
It  sometimes  results  from  fatty  degeneration  of  the  muscular  wall,  and 
a  predisposition  to  the  complaint  may  be  acquired  as  the  result  of  injury 
or  prior  inflammation. 

Symptoms. — The  essential  symptom  is  chronic  dysphagia.  When 
dilatation  follows  stenosis  the  patient  often  locates  the  point  at  which 
the  food  lodges  in  the  esophagus.  Most  of  the  ingesta  are  regurgitated 
several  hours  after  eating,  and  this  process  is  often  attended  by  more  or 
less  severe  strangling.  The  esophageal  sound  comes  upon  the  stricture, 
'and  is  either  gripped  firmly  or  totally  resisted;  in  the  latter  event  the 
bulb  can  be  moved  about  above  this  point  with  abnormal  freedom.  In  the 
rare  cases  of  spindle-shaped  dilatation  without  stenosis  the  sound  usually 
detects  no  obstacle  on  its  Avay  into  the  stomach.  A  sac  is  occasionally 
formed,  however,  as  the  result  of  localized  bulging  of  the  paralyzed  wall, 
in  which  food  mav  collect  or  the  exploring  sound  mav  catch,  thus  lead- 
ing  to  erroneous  inferences.  Dysphagia  is  present,  though  it  pre- 
sents peculiarities,  in  that  the  food  may  either  pass  down  very  slowly 
until  it  reaches  the  stomach,  or  it  may  find  its  way  down  for  some  dis- 
tance and  then  lodge  in  the  shallow  pouch,  as  above  described.  In  the 
latter  event  the  food  may  be  gulped  up  from  time  to  time.  If  the  sound 
can  be  easily  introduced  into  the  stomach,  we  may  safely  eliminate 
stricture  as  the  cause  of  the  dilatation. 

The  prognosis  is  good  as  long  as  sufficient  food  can  be  gotten  into 
the  stomaeh  for  the  support  of  life. 

Treatment. — The  chief  object  in  the  treatment  of  this  condition  is 
to  keep  the  patient  well  nourished.  If  sufficient  food  cannot  be  swal- 
lowed, a  Symond's  tube  should  be  inserted  and  nourishment  given 
through  it ;  and  w  hen  this  mode  of  feeding  is  no  longer  feasible,  the 
physician  has  to  choose  between  gastrostomy  and  rectal  feeding.  There 
can  be  no  doubt  that  by  means  of  nutrient  enemata  nutrition  may  be 


ESOPHAGEAL  DIVERTICULUM.  731 

fairly  well  maintained  for  a  considerable  period  of  time,  but  not  indef- 
initely, as  these  cases  would  seem  to  demand.  In  the  hands  of  a  com- 
petent surgeon,  on  the  other  hand,  gastrostomy  is  often  fruitful  of 
brilliant  results.  Galvanism  has  been  recommended  on  high  authority, 
but  I  cannot  speak  from  personal  experience  in  its  use.  Local  lesions, 
when  present,  must  be  dealt  with  in  accordance  with  the  rules  govern- 
ing the  treatment  of  the  several  causal  conditions. 


ESOPHAGEAL  DIVERTICULUM. 

{Pharyngocele.) 

Definition. — A  circumscribed  sac  in  the  wall  of  the  esophagus. 

Pathology  and  Ktiology. — Two  varieties  are  met  with,  which 
Zenker  has  termed  pressure  and  traction  diverticula ;  the  latter  are  rare. 
Diverticula  that  occur  at  or  near  the  inferior  constrictor,  and  more  par- 
ticularly the  larger  ones,  are  congenital  in  origin.  When  acquired  they 
are  the  result  of  a  localized  lesion  in  the  muscular  coat,  through  which 
the  mucous  membrane  bulges  like  a  hernia.  This  is  owing  to  repeated 
slight  pressure  occasioned  by  the  passage  of  food.  When  once  such  a 
process  is  started,  various  factors  tend  to  continually  enlarge  the  pouch. 
Chief  among  these  are  the  morsels  of  food  that  find  lodgement  and 
naturally  tend  to  augment  the  size  of  the  diverticulum  by  dragging  it 
downward.  The  sac  may  finally  attain  a  diameter  of  not  less  than  4 
inches  (10  cm.).  Its  situation  is  nearly  always  on  the  posterior  wall  at 
the  pharyngo-esophageal  junction,  and  its  form  is  usually  saccular  or 
pear-shaped.  Most  instances  have  been  met  with  in  males  after  middle 
life.  The  cause  of  the  Aveakened  area  at  which  the  diverticulum  occurs 
is  to  be  found  sometimes  in  injury,  but  more  frequently  in  an  antecedent 
inflammation.  Histologic  changes  are  observed  only  in  the  mucous  and 
submucous  layers,  these  anatomic  elements  together  forming  the  pouch. 
Traction  diverticula  are  produced  by  the  fringe  of  tissues  that  often 
becomes  adherent  to  the  upper  aspect  of  the  esophagus,  and  from  their 
mode  of  occurrence  they  will  obviously  be  more  or  less  funnel-shaped. 
Their  dimensions  are  small.  They  are  more  common  in  children  than 
in  adults,  for  the  reason  that  in  the  former,  more  frequently  than  in  the 
latter,  do  the  bronchial  glands  suppurate,  with  subsequent  cicatrization. 
This  circumstance  affords  an  explanation  of  the  fact  that  traction  diver- 
ticula are  usually  seated  on  the  anterior  wall  of  the  esophagus,  near  the 
bifurcation  of  the  trachea. 

Clinical  History. —  Traction  diverticula  do  not,  as  a  rule,  give  rise 
to  clinical  symptoms.  Exceptionally,  however^  as  the  result  of  the 
mechanical  irritation  caused  by  bits  of  food  that  are  retained  in  these 
funnels,  ulceration  may  occur  and  be  followed  by  perforation  of  their 
apices.  In  this  manner  the  main  bronchi  are  often  perforated  (causing 
pneumonia  and  pulmonary  gangrene),  also  the  pleura  (causing  empyema), 
and,  more  rarely,  the  pericardium  (causing  suppurative  pericarditis). 
Pressure  diverticula  when  small  cannot  be  recognized,  owing  to  the 


732  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

absence  of  signs  and  symptoms.  When  they  attain  considerable  size, 
however,  they  are  often  attended  Avith  severe  symptoms.  The  earliest 
clinical  manifestation  is  difficulty  in  swallowing:  some  of  the  food  enters 
the  sac,  and,  if  allowed  to  remain,  undergoes  putrefactive  decomposition, 
csLMsmg  fetor  of  the  breath.  From  time  to  time,  and  especially  on  at- 
tempting to  swallow,  the  partly  or  wholly  filled  condition  of  the  pouch 
excites  nausea  and  vomiting.,  associated  with  prolonged  strangling ;  this 
results  in  the  ejection  of  a  portion  of  the  accumulated  contents.  After 
such  an  attack  the  patient  is  unable,  temporarily,  to  swallow  food,  and 
in  consequence  of  the  limited  amount  of  food  taken  signs  of  inanition 
soon  appear;  this  may  finally  become  extreme,  and  is  sometimes  the 
immediate  cause  of  death.  The  appearance  of  a  pear-shaped  swelling 
in  the  side  of  the  neck  has  been  observed.  As  the  tumor  enlarges  it 
displaces  the  larynx  and  presses  upon  the  enlarged  vessels — more  rarely 
upon  the  superior  laryngeal  nerve,  giving  rise  to  dyspnea  and  distressing 
fits  of  coughing. 

Diagnosis. — A  point  in  the  differentiation  of  this  affection  is  the 
enlargement  of  the  sac  after  meals  (not  all  the  food  passing  into  the 
stomach),  and  its  disappearance  after  being  emptied.  Another  discrim- 
inating sign  is  the  effect  of  compression  by  the  hand  in  causing  the 
contents  ('•  air  and  sodden  food  ')  to  flow  back  into  the  mouth.  In 
those  instances  in  which  the  tumor  is  absent  we  may  demonstrate  its 
existence  by  the  use  of  the  esophageal  sound.  If  the  sound  passes  into 
the  sac,  the  descent  will  soon  be  arrested.  If,  however,  the  instrument 
fails  to  enter  the  mouth  of  the  pouch,  it  readily  glides  into  the  stomach. 
An  elbowed  sound,  bent  at  an  obtuse  angle  near  the  tip,  is  especially 
useful  in  such  cases.  It  may  be  inserted  in  different  directions,  so  as 
.to  avoid  entrance  into  the  sac.  Schwalbe  and  Rosenfeld  have  been  able 
to  recognize  the  condition  by  the  aid  of  radiography. 

Prognosis. — The  outlook  is  unfavorable  in  the  absence  of  operative 
treatment,  though  modern  surgery  gives  promise  of  curing  a  certain 
proportion  of  cases.  Wheeler  has  operated  successfully  in  one  instance 
at  least.  The  physicinn  may  prolong  life  by  directing  attention  to  the 
nutrition  of  the  patient,  but  he  cannot  hope  to  promote  a  cure.  If  the 
patient  cannot  swallow  an  adequate  amount  of  nourishment,  he  may  be 
successfully  fed  for  an  indefinite  period  through  a  tube,  which  he  him- 
self should  be  allowed  to  pass.  When  sufficient  food  cannot  be  intro- 
duced by  this  method  to  maintain  the  powers  of  the  patient,  rectal  feed- 
ing should  be  instituted.  If  excision  of  the  diverticulum  be  deemed 
impracticable  by  the  surgeon,  then  the  establishment  of  a  gastric  fistula 
is  worthy  of  extended  trial  in  cases  in  which  the  above-mentioned  modes 
of  feedincr  have  failed. 


STRICTURE  OF  THE  ESOPHAGUS. 

!]^tiology. — A  stricture  of  the  esophagus  may  be  due  either  to  {a) 
Congenital  narrowing  (exceedingly  rare);  {b)  Scjuaraous  epithelioma, 
usually  producing  an  annular  constriction ;  (c)  Rarely  to  polypi  pro- 
truding from  the  mucosa,  which  almost  occlude  the  lumen  of  the  tube: 


STRICTURE  OF  THE  ESOPHAGUS.  733 

{cT)  Rarely  to  specific  inflammation,  as  syphilis  and  tuberculosis ;  {e) 
Simple  stricture  generally  results  from  the  ingestion  of  corrosive  fluids, 
which  cause  extensive  sloughing  of  the  mucosa,  followed  by  cicatricial 
contraction  ;    (/)  Rarely  as  a  sequel  of  typhoid  and  peptic  ulceration. 

Clinical  History. — The  symptoms  vary  wuth  the  special  cause  and 
with  the  degree  of  stenosis.  The  first  and  most  prominent  indication  of 
narrowing  of  the  gullet  is  a  very  sloAvly  increasing  dysjjliagia.  The 
patient  for  a  long  time  complains  of  a  sense  of  j^ressure  at  a  certain  sub- 
sternal point  on  swalloAving  solid  food,  or,  more  rarely,  an  apparently 
healthy  person  will  suddenly  experience  painful  pressure  in  attempting 
to  swallow  a  larger  quantity  of  food  than  usual.  By  and  by  even  fluids 
cause  dysphagia,  and  the  patient  observes  that  the  time  required  for  the 
food  to  reach  the  stomach  is  lengthened.  The  impediment  to  the  act  of 
swallowing  is  not  due  alone  to  mechanical  stenosis,  but  partly  to  the 
weakness  of  the  muscular  coat,  sometimes  owing  to  its  partial  destruc- 
tion, and  in  exceptional  cases  partly  to  spasmodic  contraction.  When 
due  to  carcinoma,  diflicult  deglutition  is,  as  a  rule,  the  only  symptom 
complained  of  When  occasioned  by  corrosive  fluids  or  traumatism,  pain 
is  prominent  from  the  onset. 

Above  the  seat  of  stricture  the  esophagus  is  often  dilated  and  con- 
tains accumulations  of  the  ingesta.  The  latter,  together  with  consider- 
able mucus,  are  regurgitated  three  or  four  hours  after  meals,  and  we  may 
be  certain  that  the  materials  thus  ejected  do  not  come  from  the  stomach 
if  they  are  alkaline  in  reaction.  The  leading  clinical  features  are  the 
gradually  increasing  dehility  and  emaciation,  finally  reaching  an  extreme 
degree. 

Diagnosis. — However  characteristic  the  symptoms  may  be,  the 
bougie  should  invariably  be  passed  before  pronouncing  a  positive  diag- 
nosis. By  this  means  Ave  ascertain  the  degree  and  the  seat  of  the  stric- 
ture. To  begin  with,  a  medium-sized  gum-elastic  bouo-ie  (No.  16  Engr- 
lish  scale)  should  be  employed,  after  warming  it  and  lubricating  with 
glycerin.  Its  use  should  be  preceded  by  a  cocain-spray  to  prevent 
spasm.  The  patient  should  occupy  a  low  seat,  with  his  head  supported 
by  an  assistant  from  in  front  of  the  operator.  The  head  should  be  only 
slightly  thrown  backward.  The  forefinger  of  the  left  hand  should  then 
be  passed  back  over  the  tongue  until  it  touches  the  epiglottis,  and  the 
bougie  inserted  along  it  with  the  right  hand,  thus  avoiding  the  error 
of  passing  it  into  the  naso-pharynx  or  the  larynx.  When  the  bougie 
reaches  the  cricoid  cartilage  it  is  sometimes  gripped  pretty  firmly  even 
in  a  healthy  person — a  fact  that  is  always  to  be  remembered.  No  force 
should  be  applied.  The  instrument  may  pass  the  constriction  w-ith  a 
jerk,  or  it  may  not  only  be  gripped,  but  distinctly  arrested,  when  a 
smaller  bougie  should  be  tried.  By  moving  the  instrument  upward 
gently  Ave  may  detect  sometimes  several  strictures  lying  one  above  an- 
other. To  locate  the  obstacle,  the  distance  from  the  teeth  to  the  point 
of  stricture  is  measured  on  the  instrument,  and  the  results  compared 
with  the  normal  measurements,  Avhich  are  as  follows:  from  the  teeth  to 
the  cricoid  cartilage,  7  inches  (17.7  cm.) ;  to  the  left  bronchus.  11  inches, 
(27.8  cm.) ;  and  to  the  opening  into  the  diaphragm.  15  inches  (37.9  cm,). 

Auscultation  of  the  esophagus  has  been  practised,  but  the  clinical 
indications  afi'orded  are  of  little  practical  value.      The  stethoscope  is 


734  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

placed  to  the  left  of  the  spine,  and  the  patient  takes  a  mouthful  of  -water, 
when,  if  a  stricture  be  present,  a  splashinfj.  cooing  sound  will  be  heard 
at  the  seat  of  the  stricture  instead  of  the  normal  esophageal  bruit. 

Differential  Diagnosis. — It  is  important  to  determine  not  only  the  ex- 
istence of  a  stricture,  but  also  the  diseased  underlying  process,  since 
without  this  knowledge  rational  methods  of  treatment  cannot  be  in- 
stituted. First  and  foremost,  we  must  exclude  those  affections  that 
simulate  simple  and  malignant  stricture,  in  certain  of  which  the  in- 
troduction of  the  sound  would  be  attended  with  grave  dangers.  C0771- 
pressio7i  of  the  esojyhagus  by  enlarged  or  accessory  thyroids,  aortic 
aneurysms,  vertebral  abscess,  enlarged  lymphatic  glands,  and  occasion- 
ally pericardial  effusions,  may  produce  dysphagia,  and  on  passing  the 
bougie  resistance  is  offered  at  the  seat  of  the  external  pressure.  As  a 
rule,  the  extent  of  the  stenosis  is  moderate.  If  the  narrowing  be  due 
to  aneurysm — "(a)  rhythmic  movement  is  sometimes  communicated  to 
the  free  end  of  the  sound  introduced  as  far  as  the  stenosis."  Careful 
physical  examination  will  often  reveal  the  presence  of  an  aneurysm  or 
other  pressing  tumor,  and  should  never  be  neglected.  A  passage  of 
the  sound  in  cases  of  aneurysm  has  even  caused  rupture  of  the  sac  and 
death,  (h)  Spasm  of  the  esophagus  or  paralysis  (the  latter  rarely)  may 
closely  resemble  true  stenosis.  These  neurotic  forms  are  almost  exclu- 
sively met  Avith  in  hysteric  females ;  on  the  other  hand,  malignant  stric- 
tures are  found  generally  in  males  over  forty  years ;  while  in  simple 
stricture  there  is  usuall}^  a  definite  history  and  certain  etiologic  factors. 

To  discriminate  between  simple  and  malignant  stricture  is  not  diffi- 
cult, as  a  rule.  When  a  clear  history'  of  gumma,  of  tuberculous  disease, 
or  of  injury  (from  corrosive  liquids)  is  obtainable,  the  presence  of  a 
simple  stricture  may  be  safely  inferred  after  eliminating  the  affections 
previously  mentioned.  In  the  absence  of  etiologic  data  pointing  to  the 
simple  form,  cases  occurring  in  the  male  after  forty  years  of  age  may  be 
looked  upon  as  malignant. 

Prognosis. — In  forming  a  prognostic  opinion  the  chief  factor  to  be 
considered  is  the  nature  of  the  stricture.  Practicallv,  so  long  as  the 
stenosis  is  dilatable,  the  prognosis  is  not  unfavorable  provided  sufficient 
nourishment  can  be  taken  ;  moreover,  not  a  few  cases  of  simple  stricture 
are  curable.    The  majority,  however,  come  to  a  fatal  termination  finally. 

Treatment. — The  chief  object  of  the  treatment  is  to  gradually 
and  methodically  dilate  the  stricture  in  a  mechanical  manner.  The 
flexible  English  bougie  above  mentioned  is  the  best  for  the  purpose, 
commencing  with  one  of  good  size;  conical  ivory  bougies,  having  a 
flexible  Avhalebone  handle,  may  also  be  used,  though,  being  quite  hard, 
they  are  apt  to  inflict  injuries  unless  used  cautiously.  It  is  sometimes 
necessary,  on  account  of  the  tightness  of  the  stricture,  to  begin  with  a 
catgut  sound.  The  method  of  introducing  these  instruments  has  already 
been  given.  They  should  be  used  once  daily,  and  often  can  be  passed 
successfully  by  the  patient  himself.  At  intervals  of  three  or  four  days 
trials  of  bougies  of  larger  size  should  be  made.  I  have  seen  truly 
remarkable  results  from  this  treatment  when  carried  forward  systemati- 
cally in  cases  due  to  cicatricial  contraction,  the  patients  increasing  in 
bodily  weight  and  strength.  In  annular  constrictions  of  a  malignant 
type,  however,  it  is  productive  of  temporary  benefit  only. 


DISEASES  OF  THE  STOMACH.  735 

The  diet  deserves  most  careful  attention.  When  the  stenosis  is  so 
pronounced  as  to  prohibit  sufficient  food  being  swallowed,  a  Symonds 
tube  should  be  passed  into  the  stomach,  and  through  it  liquid  food  is 
introduced.  Concentrated  forms  of  nourishment,  as  raw  eggs,  bovinin, 
and  the  various  infants'  foods,  may  be  administered  with  milk. 

When  the  passage  of  the  bougie  is  no  longer  possible  relief  may  be 
secured  in  one  of  two  ways:  (1)  rectal  feeding;  (2)  gastrostomy,  if  the 
seat  of  the  stricture  be  near  the  stomach,  and  esophagostomy  if  at  the 
upper  portion  of  the  gullet.  I  have  recently  witnessed  favorable  re- 
sults from  gastrostomy  in  a  case  of  simple  stricture  operated  upon  by 
Laplace.  It  is  important  that  the  patient  should  thoroughly  masticate 
the  food  before  introducing  it  into  the  stomach.  Before  resorting  to 
operative  procedures,  however,  careful  trial  should  be  made  of  rectal  feed- 
ing. Various  forms  of  nutritious  enemata  and  other  points  regarding 
rectal  alimentation  will  be  found  in  the  Treatment  of  Gastric  Ulcer. 


VII.   DISEASES  OF  THE   STOMACH. 
METHODS  OF  DIAGNOSIS. 

EXAMINATION   OF   THE    GASTRIC   FUNCTIONS. 

Secretory  Function. — When  food  enters  the  stomach  the  glands  im- 
mediately begin  to  secrete  their  various  juices,  and  continue  to  do  so 
until  the  food  has  passed  into  the  duodenum.  During  the  later  stages 
of  gastric  digestion  the  activity  of  the  secretory  function  of  the  stomach  . 
diminishes,  and  to  obtain  accurate  knowledge  of  any  pathologic  condition 
of  the  organ,  examinations  of  the  gastric  contents  must  be  made  under 
conditions  as  nearly  like  the  physiologic  as  possible.  Reliable  results 
cannot,  therefore,  be  obtained  from  an  examination  of  ordinary  vomita, 
but  the  contents  of  the  stomach  must  be  procured  at  a  definite  period 
after  a  so-called  test-meal  {vide  infra). 

Numerous  test-meals  have  been  offered  to  the  profession,  but  those 
that  I  have  found  most  satisfactory  are  "  the  test-breakfast  of  EAvald 
and  Boas"  and  "the  test-dinner  of  Leube-Riegel."  The  former  being 
simpler  and  easier  of  preparation  than  the  latter,  it  is  the  oftenest  used. 

The  Ewald-Boas  test-breakfast  consists  of  one  or  two  rolls  (50-70  gm.) 
and  one  cup  of  tea  or  water  (300-400  c.c).  I  constantly  advise  the 
use  of  one  roll  and  a  glass  of  water.  About  an  hour  after  this  meal 
has  been  taken  the  contents  of  the  stomach  are  to  be  withdrawn,  and 
at  such  a  time  HCl  should  be  the  only  acid  present. 

The  Leube-Riegel  test-dinner  consists  of  a  large  plate  of  soup  (300- 
400  c.c),  a  large  piece  of  beefsteak  (150-200  gm.),  and  some  potatoes 
(about  50  gm.)  or  a  roll— practically,  a  large  plate  of  soup,  a  piece  of 
meat  (preferably  beefsteak),  and  a  roll  of  bread.  The  examination  is  to 
be  made  about  three  and  a  half  to  four  hours  after  the  meal. 

To  obtain  the  contents  of  the  stomach  we  should  use  a  soft,  flexible- 
rubber  tube  with  an  end-opening,  or,  better  still,  Avith  several  additional 
openings  on  the  sides,  and  it  should  be  marked  at  a  point  23.5  to  25.5 


736  DISEASES  OF  THE  DIGESTIVE  SYSTE3I 

inches  (58-64  cm.)  from  the  end  introduced,  this  helping  the  examiner 
to  determine  whether  it  has  entered  the  fundus.  The  tube  is  moistened 
Avith  water  and  the  end.  carried  back  to  the  pharynx ;  the  patient  is  now 
asked  to  swallow,  and  the  tube  is  gently  pushed  down  the  esophagus, 
these  acts  being  repeated  until  the  tube  reaches  the  stomach.  An  ordi- 
nary Politzer  bag  is  now  attached  to  the  tube  (Ewald),  or  a  Boas  aspi- 
rator (which  consists  of  a  rubber  bulb  having  a  soft-rubber  tube  at  one 
extremity  with  clamps).  If  the  Politzer  bag  be  employed,  it  is  com- 
pressed and  allowed  to  re-expand,  the  contents  being  thus  withdrawn 
into  the  bag.  There  are  cases  in  which  it  is  safer  to  empty  the  stomach 
by  siphonage.  This  is  readily  accomplished  by  using  a  long  tube  and 
exerting  gentle  pressure  on  the  abdomen  to  start  the  current. 

The  method  I  have  most  frequently  used  is  that  of  "expression,"  as 
follows :  The  patient  is  asked  to  take  a  deep  inspiration,  and  then  to 
contract  his  aljdominal  muscles  as  in  the  act  of  having  a  stool :  in  this 
way  the  contents  are  quickly  expelled  through  the  stomach-tube  above 
described.  These  should  be  first  examined  microscopically  to  detect  any 
residue  from  previous  meals,  such  as  meat  and  the  like,  and  the  quantity 
obtained  should  be  20  to  40  c.c.  After  filtering  the  gastric  contents 
thus  obtained  they  are  variously  tested. 

Among  qualitative  tests  the  following  are  important : 

To  determine  the  reaction,  ordinary  litmus-paper  is  used;  if  acid,  the 
blue  turns  red. 

The  presence  of  free  acids  is  determined — {a)  By  Congo-red,  a  solu- 
tion of  which  is  turned  blue  by  the  addition  of  liquids  containing  free 
acids.  The  use  of  Congo-paper  (prepared  by  dipping  ordinary  filter- 
paper  in   Congo-red  solution)  is  the  easiest  method. 

(b)  Tropeolin  0.  0. — Alcoholic  solutions  of  tropeolin  are  turned  by 
the  addition  of  liquids  containing  free  acids  to  a  brownish-red,  deep 
red,  or  deep  mahogany-brown,  according  to  the  amount  of  acids  present. 
Tropeolin-paper  (filter-paper  immersed  for  some  time  in  an  alcoholic  so- 
lution) may  be  used,  but  must  not  be  kept  too  long. 

Free  HCl. —  G-'dnzhurcfs  test — phloroglucin  gr.  xxx  (2.0),  vanillin 
gr.  XV  (1.0),  absolute  alcohol  5J  (30  c.c).  To  two  or  three  drops  of 
this  reagent  add  an  equal  number  of  the  gastric  filtrate  in  a  porcelain 
dish,  and  slowly  evaporate  to  dryness  over  a  fiame ;  and  if  free  HCl  is 
present,  a  rose-red  tint  appears  along  the  edges.  Blowing  at  the  edge 
will  hasten  the  reaction.  The  great  delicacy  of  this  test  is  conclusively 
shown  by  its  availability  when  HCl  is  present  in  the  proportion  of  1  to 
20,000.      There  are  no  recognized  interfering  conditions. 

Boas'  Resorcin  Test. — Resublimed  resorcin  5  parts,  white  sugar  3 
parts,  and  diluted  alcohol  100  parts.  The  method  of  procedure  is  the 
same  as  in  Giinzburg's  test,  and  a  purple-red  color  appears.  More 
caution  is  required  in  evaporating,  but  this  method  will  also  detect  the 
presence  of  free  HCl  in  the  proportion  of  about  1  :  20,000. 

Topfer'S  Test. — To  a  few  c.c.  of  filtered  (or  untiltered)  stomach- 
contents,  1  to  4  drops  of  the  reagent  (dimethylaniidoazobenzol  in  a  0.5 
per  cent,  alcoholic  solution)  are  added;  in  the  presence  of  free  HCl  a 
rose-  or  cherry-red  color  is  produced.  Combined  HCl  gives  a  negative 
result.  The  presence  of  acid  salts,  peptones,  mucin,  and  starch  (in  the 
usual  percentage)  do  not  interfere  with  this  reaction. 


EXAMINATION  OF  THE  STOMACH.  737 

Lactic  Acid. —  Uffelmanns  Test. — The  reagent  should  always  be 
freshly  made,  as  follows  :  To  10  to  15  c.c.  of  a  2  per  cent,  aqueous 
solution  of  carbolic  acid  add  1  or  2  drops  of  neutral  ferric  chlorid,  when 
an  amethyst-blue  color  will  appear.  To  1  or  2  c.c.  of  the  mixture 
add  a  few  drops  of  the  filtrate,  and  if  lactic  acid  is  present  it  changes 
to  a  canary-yellow  color.  Sources  of  error  may  be  overcome  by  shak- 
ing 5  or  10  c.c.  of  the  filtrate  with  double  the  quantity  of  ether,  and, 
after  allowing  the  ether  to  separate  and  pouring  it  off,  more  is  added, 
the  whole  shaken,  and  the  washing  is  repeated.  The  ether  is  then  de- 
canted and  evaporated  almost  to  dryness  in  a  water-bath.  To  the  res- 
idue about  1  c.c.  of  water  is  added,  and  to  this  an  equal  quantity  of 
the  UfFelmann  reagent  from  a  pipette ;  and  if  a  canary-yellow  now  ap- 
pears, positive  proof  of  the  presence  of  lactic  acid  is  aiforded.  Boas 
and  others  hold  that  the  presence  of  lactic  acid  in  the  gastric  contents 
during  the  first  stage  of  digestion  has  pathologic  significance.  He 
also  found  that  ordinary  bread  contains  lactic  acid,  and  hence  he  has 
adopted  a  thin  gruel  made  by  adding  to  a  quart  of  water  flavored  with 
salt  half  an  ounce  of  oatmeal-flour.  Boas  states  that  no  lactic  acid  is 
present  in  the  filtrate  several  hours  after  this  test-meal,  except  in  cases 
of  carcinoma  of  the  stomach.  The  use  of  this  test-meal  for  usual  clin- 
ical purposes  is  now  generally  held  to  be  superfluous.  Lactic  acid 
in  the  stomach-contents  occurs  with  fermentation-stagnation  from  either 
obstruction  or  deficient  motility, 

A  more  reliable  test  for  lactic  acid  than  the  foregoing  is  that  of 
Boas,  as  follows :  Digest  the  filtrate  several  times  with  ether  to  remove 
the  fatty  acids  ;  add  a  few  drops  of  phosphoric  acid  and  boil.  Transfer 
the  mixture  to  a  distillate  flask ;  add  HgSO^  and  MgOg;  heat,  and  lactic 
acid  will  be  distilled  over.  This  can  be  conducted  into  a  strongly  alka- 
line solution  of  iodin  and  potassium  iodid.  The  presence  of  lactic  acid 
is  then  shown  by  the  production  of  iodoform,  which  can  be  recognized 
by  its  odor  and  by  the  precipitate  that  is  formed. 

Fatty  or  Volatile  Acids. — Heat  to  boiling  a  few  c.c.  of  the  filtrate  in 
a  test-tube,  over  the  mouth  of  which  place  a  strip  of  moistened  blue 
litmus-paper ;  the  presence  of  fatty  acids  wall  change  the  paper  to  red. 

Acetic  Acid. — In  large  quantities  this  acid  is  detected  by  its  odor, 
and  in  smaller  quantities  its  presence  is  determined  by  neutralizing 
with  sodium  carbonate  the  watery  residue  of  the  ethereal  extract,  and 
adding  neutral  ferric  chlorid,  when  a  blood-red  color  will  be  struck. 
Quantitative  estimation  of  certain  constituents  is  desirable. 

Total  Acidity. — To  10  c.c.  of  the  filtrate  add  1  or  2  drops  of  a  1  per 
cent,  alcoholic  solution  of  phenophthalein,  and  as  many  cubic  centimeters 
of  a  decinormal  solution  of  sodium  hydrate  are  added  slowly  from  a  buret 
until  the  reddish  color  that  appears  fails  to  disappear  on  shaking.  The 
number  of  cubic  centimeters  of  the  decinormal  solution  normally  required 
ranges  from  4  to  6  ;  hence,  if  these  be  multiplied  by  10,  we  have  40  to  60 
as  the  percentage  of  acidity.  Under  pathologic  conditions  these  num- 
bers may  be  either  higher  or  lower.  This  total  represents  both  free  and 
combined  acids.  If  no  organic  acids  be  present,  the  above  figures  will 
represent  the  percentage  of  HCl.  The  latter  is  also  reckoned  thus :  If 
it  required  5  c.c.  of  the  decinormal  solution  of  sodium  hydrate  to  be 
added  to  10  c.c.  of  the  filtrate  to  get  the  red  color  (alkalinity)  with  the 

47 


738  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

phenophthalein,  we  say  the  acidity  is  50,  and  multiplied  by  0-003,646  = 
0.1823  per  cent,  of  hydrochloric  acid.  It  should  be  stated  that  the 
normal  range  of  percentage  is  from  0.1-4  to  0.24. 

Estimation  of  Free  HCl. — 3Iintz's  method:  To  10  c.c.  of  the  filtrate 
add  a  decinormal  solution  of  sodium  hydrate  from  a  buret  until  no  re- 
action is  given  with  GUnzburg's  reagent.  The  number  of  c.c.  of  the 
decinormal  solution  used,  multiplied  by  10  and  then  by  0.003,646,  gives 
the  percentage  of  free  hydrochloric  acid. 

Topfer's  Method. — To  10  c.c.  of  filtered  gastric  juice  1  or  2  drops 
of  Topfer's  reagent  are  added,  and  then  also  a  decinormal  solution  of 
soda,  drop  by  drop,  until  the  last  trace  of  red  has  changed  to  yellow. 
To  estimate  the  percentage  of  HCl,  the  number  of  c.c.  of  soda  solution 
required  to  neutralize  the  free  HCl  in  100  c.c.  of  stomach-contents  is 
multiplied  by  0.00365.  E.xample :  To  remove  the  red  color  4  c.c.  of 
soda  solution  are  required;  hence,  0.00365  X  40  =  0.14,  the  percent- 
age of  free  HCl. 

Estimation  of  Lactic  Acid. — If  the  volatile  acids  are  present,  they 
should  be  removed  by  boiling.  Take  the  total  acidity  of  10  c.c.  of  the 
filtrate;  then  to  a  second  10  c.c.  add  25  to  30  c.c.  of  ether;  sh^ke 
Avell,  allow  the  ether  and  filtrate  to  separate,  remove  the  ether,  and 
again  add  25  to  30  c.c.  of  ether  ;  shake,  and  repeat  the  process.  Next 
obtain  the  acidity  of  the  watery  solution,  and  the  difference  between 
this  and  the  total  acidity,  multiplied  by  10  X  0.09,  will  give  approxi- 
mately the  amount  of  lactic  acid. 

In  the  gastric  digestion  of  the  albuminoids  (proteolysis)  the  proteids 
are  converted  into  peptone.  Although  commenced  in  the  stomach,  this 
function  is  dependent  in  greater  part  upon  the  action  of  the  pancreatic 
ferment  in  the  small  intestines.  Among  the  substances  earliest  engen- 
dered by  this  process  are  the  albumoses  (propeptone),  whose  separation 
may  be  thus  eff"ected :  Add  a  small  ((uantity  of  a  saturated  solution  of 
sodium  chlorid  to  an  equal  amount  of  gastric  filtrate,  and  if  it  becomes 
cloudy  propeptone  is  present,  the  degree  of  the  cloudiness  indicating 
the  amount  present.  If  the  mixture  does  not  become  turbid,  add  a  few- 
drops  of  acetic  acid,  when  it  will  become  so  in  the  presence  of  this  sub- 
stance, however  slight  the  quantity.  If  heated,  the  solution  becomes 
clear,  and  if  allowed  to  cool,  the  propeptone  precipitates  and  may  be 
obtained  by  filtration. 

In  a  later  stage  of  the  process  of  albumin-digestion  peptone  is  pro- 
duced and  its  detection  is  easy.  To  a  small  quantity  of  the  filtrate  (the 
propeptone  having  been  removed)  add  enough  sodium  or  potassium  hy- 
drate to  render  the  solution  alkaline ;  then  add  a  few  drops  of  a  1  per 
cent,  solution  of  cupric  sulphate,  and,  if  peptone  be  present,  a  purplish 
color  is  presented. 

The  Test  for  Pepsin. — In  a  test-tube  containing  15  c.  c.  of  filtrate 
add  a  small  piece  of  egg-albumin,  and  keep  at  a  temperature  of  about 
100°  F. ;  if  present,  the  albumin  disappears  in  from  two  to  six  hours. 
If  hydrochloric  acid  is  absent  from  the  filtrate,  it  is  necessary  to 
add  a  few  drops  of  the  dilute  acid.  It  should  be  pointed  out  that 
laboratory  attempts  to  estimate  the  rate  of  albumin-digestion  are 
unreliable. 

Rennet  Ferment. — To  5  or  10  c.c.  of  raw  milk  add  a  few  drops  of  the 
gastric  filtrate,  and  keep  it  at  a  temperature  of  about  100°  F. ;  if  rennet 


EXAMINATION  OF  THE  STOMACH.  739 

is  present,  coagulation  into  a  single  cake  occurs  in  from  a  few  minutes 
to  an  hour  or  more. 

Rennet  Zymogen  (which  is  converted  into  rennet  ferment  in  the  pres- 
ence of  an  acid). — To  5  c.c.  of  gastric  filtrate  add  enough  sodium  car- 
bonate or  sodium  hydrate  to  make  it  slightly  alkaline  ;  then  add  calcium 
chlorid  (1—2  c.c.  of  a  2  per  cent,  solution) ;  then  mix  with  an  equal  quan- 
tity of  milk,  and,  if  zymogen  is  present,  coagulation  occurs  as  in  the 
case  of  rennet  ferment.  Both  rennet  ferment  and  rennet  zymogen  may 
be  assumed  to  be  present  when  HCl  has  previously  been  found. 

Starchy  Derivatives. — To  a  small  quantity  of  gastric  filtrate  add  1 
or  2  drops  of  Lugol's  solution ;  the  presence  of  dextrin  gives  a  blue 
reaction — erythrodextrin  purple,  achroodextrin,  grape-sugar,  and  malt- 
ose (intermediate  substances) — showing  a  yellowish  color.  If  there  is  a 
mixture  of  these  starchy  derivatives,  as  when  the  digestion  of  starches 
proceeds  naturally,  the  first  few  drops  of  Lugol's  solution  may  produce 
no  color-reaction,  or  it  may  be  taken  up  by  the  dextrose  or  maltose,  while 
the  addition  of  more  of  Lugol's  solution  will  give  a  purple  (if  erythro- 
dextrin be  present)  or  a  blue  color,  due  to  starch. 

Indeed,  if  a  minute  quantity  of  the  solution  strikes  a  blue  or  purple 
tinge,  conversion  of  starch  into  maltose  has  been  abnormally  tardy.  I 
believe  this  is  oftenest  due  to  hyperacidity,  though  it  may  also  more 
rarely  be  due  to  a  defective  ptyaline-supply.^ 

The  Tests  for  the  Motor  Function. — More  important  than  the  secret- 
ory is  the  motor  function  of  the  stomach.  There  are  three  recognized 
tests : 

The  oldest  method  is  that  of  Leuhe.  It  consists  in  washing  out  the 
stomach  from  six  to  seven  hours  after  a  large  meal,  preferably  consisting 
of  beef-soup  (13  oz.),  beefsteak  (6|-  oz.),  bread  (IJ  oz.),  and  water  (6J 
oz.),  or  from  two  to  two  and  a  half  hours  after  Ewald's  test-breakfast. 
Normally,  the  stomach  should  be  empty  within  these  periods  of  time,  so 
that  if  a  residue  remains  it  denotes  a  lack  in  the  motor  force. 

Salol  Test  of  Ewald  and  Sievers. — Salol  being  composed  of  phenol 
and  salicylic  acid,  it  is  not  acted  upon  in  an  acid  medium  ;•  therefore, 
when  introduced  into  the  stomach  it  remains  a  stable  compound,  and  is 
only  broken  up  in  the  intestine  by  the  action  of  the  pancreatic  juice. 
The  salicylic  acid  is  absorbed  into  the  blood  and  eliminated  through  the 
urine,  in  which  it  can  be  detected  by  adding  a  few  drops  of  neutral 
ferric  chlorid,  a  violet  color  appearing.  The  patient  is  given  15 
grains  (1  gm.)  of  salol  in  two  thin  gelatin  capsules ;  the  bladder  is  emp- 
tied, and  the  patient  told  to  urinate  every  half  hour  for  two  hours. 
Normally,  it  requires  from  three-fourths  to  an  hour  for  the  salicyluric 
acid  to  appear  in  the  urine,  but  when  the  motor  function  of  the  stomach 
is  much  impaired  it  may  require  two  or  more  hours.  In  order  to  detect 
the  earliest  traces  of  the  eliminated  salicyluric  acid,  Ewald  and  Einhorn 
have  suggested  moistening  a  piece  of  filter-paper  with  the  urine,  and 
then  allowing  a  drop  of  neutral  ferric  chlorid  solution  to  come  in  con- 
tact with  it,  the  edges  of  the  drop  showing  a  violet  color  in  the  presence 
of  the  slightest  traces.     The  varying  reaction  of  the  intestinal  contents 

^  The  tests  for  the  estimation  of  the  combined  acids,  of  some  of  the  fatty  acids,  and  of 
many  of  the  products  of  proteolysis  are  complicated  and  unnecessary  in  an  ordinary  clini- 
cal examination. 


740  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

renders  the  salol  test  very  unreliable.  Sometimes  in  healthy  individuals 
the  decomposition  of  the  salol  is  retarded,  and  to  overcome  this  objection 
Huber  has  suggested  the  determination  of  the  precise  time  when  the 
salicyluric  acid  no  longer  appears  in  the  urine.  He  found  that  normally 
it  required  from  twenty-four  to  thirty  hours.  If,  then,  the  reaction  out- 
lasts this  period,  it  shows  peristalsis  or  the  motor  function  to  be  unduly 
tardy.     Leube's  test  is  much  more  reliable. 

Klemperer  s  Oil-test. — The  stomach  is  thoroughly  washed,  and  3^ 
ounces  (100  c.c.)  of  olive  oil  are  poured  into  it  through  the  tube.  Two 
hours  later  the  remaining  oil  is  withdrawn  by  aspiration.  As  the  stom- 
ach-wall does  not  absorb  oil,  the  difference  between  the  original  amount 
and  that  withdrawn  shows  the  condition  of  the  motility.  Klemperer 
states  that  at  this  time  the  residue  should  not  exceed  20  to  40  c.c.  This 
test  is  also  unreliable. 

To  Test  the  Absorptive  Power. — The  method  described  by  Penzoldt 
has  been  almost  universally  adopted :  A  capsule  containing  grains  1^ 
(0.1),  of  potassium  iodid  is  given  to  the  patient,  care  being  taken  that 
the  capsule  is  first  carefully  wiped.  The  iodid  is  absorbed  from  the 
stomach  and  appears  in  the  saliva,  which  is  to  be  examined  for  the  pres- 
ence of  iodin.  For  this  purpose  strips  of  starch-paper  (filter-paper 
moistened  in  a  solution  of  starch  and  dried)  are  used ;  they  are  moist- 
ened with  the  saliva  of  the  patient,  and  the  moistened  areas  treated 
with  a  drop  of  fuming  nitriq  acid.  As  soon  as  the  iodin  enters  the  saliva, 
the  characteristic  reaction  for  starch  is  struck — a  blue  color.  Normally, 
this  reaction  occurs  in  from  ten  to  fifteen  minutes  ;  under  abnormal  con- 
ditions it  may  be  delayed  for  half  an  hour  or  more.  Rarely  it  fails  to 
occur.     This  test  cannot  be  strongly  depended  upon. 

PHYSICAL   OR   EXTERNAL   EXAMINATION. 

This  implies  the  well-known  physical  signs — inspection,  palpation, 
percussion,  succussion  or  splashing,  and  auscultation. 

Inspection, — (a)  General. — This  may  give  an  idea  of  the  nature  of 
the  illness  as  Avell  as  its  severity  by  noting  whether  the  patient  appears 
to  belong  to  a  neurotic  group,  the  general  health  often  being  good,  or 
whether  the  patient  is  emaciated,  or  has  with  the  latter  the  cachexia  of 
a  malignant  growth.  In  diseases  of  the  stomach  attention  should  be  di- 
rected to  the  mouth,  and  especially  to  the  teeth,  because  the  latter  are 
often  of  causal  importance  in  many  gastric  ailments.  Dental  affections 
often  prevent  the  possibility  of  curing  the  various  chronic  diseases  of 
the  stomach. 

(b)  Local  Inspection. — In  patients  with  thin  and  relaxed  abdominal 
Avails  the  contour  of  the  stomach  can  be  plainly  noted ;  especially  is  this 
the  case  in  very  large,  dilated  stomachs  or  in  those  that  have  been  dis- 
placed. The  examiner  is  greatly  aided  by  inflating  the  stomach  with 
air  or  gas.  The  former  is  to  be  preferred,  for  the  reason  that  the  supply 
is  easily  regulated ;  he  is  enabled  to  watch  the  different  steps  of  the  dis- 
tention, and  after  the  examination  is  completed  the  air  is  allowed  to 
escape  through  the  tube.  For  this  purpose  an  ordinary  stomach-tube  is 
most  convenient,  and  its  passage  is  to  be  effected  in  the  same  way  as  in 
removing  the  gastric  contents.     A  double  bulb-attachment  is  connected 


EXAMINATION  OF  THE  STOMACH.  741 

with  the  external  end  of  the  tube,  by  means  of  which  air  is  readily 
forced  into  the  stomach  (Runeherg' s  method). 

FrericTis'  method  is  sometimes  used.  It  consists  in  administering 
3j  (4.0)  of  tartaric  acid,  dissolved  in  half  a  glassful  of  water,  and  im- 
mediately afterward  3j  (4.0)  of  sodium  bicarbonate,  dissolved  in  the  same 
amount  of  water.  Effervescence  now  occurs,  with  a  progressive  visible 
distention  of  the  organ.  The  chief  objection  to  this  method  is  the  fact 
that  either  too  much  or  too  little  distention  is  obtained. 

The  inflated  stomach  presents  a  circumscribed  protuberance,  usually 
in  the  epigastric,  and  also  in  the  umbilical  region  if  the  organ  is  dis- 
located or  dilated.  The  air  may  find  its  way  into  the  intestine,  produ- 
cing a  visible  change  in  the  contour  of  the  abdomen.  Tumors  and 
other  abdominal  enlargements  may  also  be  recognized,  and  an  idea 
obtained  as  to  which  organ  is  involved,  after  making  due  allowances  for 
displacement,  as  in  gastroptosis  and  pyloric  carcinoma.  Exaggerated 
peristaltic  waves  may  also  be  noticeable  in  the  upper  portion  of  the 
abdomen,  usually  when  associated  with  the  stomach,  and  in  the  lower 
portion  if  it  is  in  the  small  intestine.  Peristalsis  is  increased  from 
various  causes — inflation  of  the  stomach,  external  tapping,  neuroses, 
pyloric  obstruction,  and  the  like. 

The  value  of  the  gastroscope  in  inspecting  the  interior  of  the  stom- 
ach is,  I  think,  doubtful.  Gastro-diaphany  (illumination  of  the  stomach) 
is  sometimes  useful  in  showing  the  fundus  extending  to  a  lower  level  (at 
the  navel)  than  is  indicated  by  percussion,  and  in  indicating  the  pres- 
ence of  tumors  in  the  anterior  wall  of  this  organ.  The  Rontgen  rays 
show  the  outline  of  the  stomach,  though  indistinctly,  after  the  admin- 
istration repeatedly  of  20  grains  of  bismuth  subnitrate. 

Palpation. — This  elicits  at  times  more  trustworthy  information  than 
inspection.  The  patient  should  be  in  the  recumbent  position,  the  lower 
limbs  partially  flexed  on  the  abdomen  and  the  head  low.  The  examiner 
should  stand  at  the  right  side  of  the  patient  and  use  the  right  hand, 
which  should  be  warm.  With  the  palmar  surface  down  gentle  pressure 
should  be  made  with  the  fingers  and  the  ulnar  side  of  the  hand.  If 
the  abdominal  wall  is  tense,  it  is  best  to  distract  the  attention  of  the 
patient  from  the  examination  by  talking  to  him.  In  this  manner  we 
can  corroborate  the  inspection  as  to  the  size,  shape,  and  position  of  the 
stomach,  and  can  detect  morbid  growths  and  determine  their  consistency 
and  movability. 

Deep  palpation,  by  increasing  pressure  with  a  slightly  rotatory  move- 
ment, elicits  the  degree  of  sensitiveness,  tenderness,  or  pain,  whether 
circumscribed  as  in  ulcer  or  diffuse  as  in  generalized  inflammatory  states 
(enterocolitis,  peritonitis).  In  deep-seated  tumors  palpation  should  also 
be  made  in  the  knee-elbow  position,  and  if  movable  they  may  drop  to 
the  abdominal  wall.  Gurgling  and  succussion-sounds  of  some  diag- 
nostic value  may  be  elicited.  In  some  instances  relief  from  pain  may 
be  noted  on  pressure  with  the  broad  hand  in  neuroses.  Variations  in 
the  degree  of  tension  and  of  resistance  are  found  and  prove  helpful. 

With  Boas'  algesimeter  we  are  enabled  to  detect  the  amount  of 
pressure  necessary  to  be  exerted  over  a  given  area  to  cause  pain  by 
reading  the  number  of  kilograms  from  a  scale.  In  some  instances  this 
is  a  serviceable  instrument,  but  in  ulcer,  when  palpation  must  be  done 


742  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

with  the  greatest  gentleness,  it  would  not  be  a  very  safe  procedure  as 
compared  with  the  soft  hand — nature's  own  instrument. 

Percussion. — The  patient  is  placed  in  the  recumbent  position ;  the 
examiner  uses  his  fingers  and  endeavors  to  discriminate  the  slightest 
differences  in  the  note,  and  percusses  lightly.  If  the  stomach  is  empty 
or  partially  filled  with  gas,  it  gives  a  lower  tympanitic  sound  than  the 
colon.  To  ascertain  the  size  and  position  of  the  stomach  by  percussion 
the  process  should  begin  at  the  symphysis  pubis  and  follow  the  median 
line  upward.  The  upper  border  of  the  stomach  is  at  the  ensiform  car- 
tilage, the  lower  about  two  fingers'  breadth  (3  cm.)  above  the  umbilicus. 
If  the  upper  margin  is  some  distance  below  the  ensiform,  displacement 
of  the  organ  is  indicated  ;  this  depression  may  be  occasioned  by  various 
diseases  of  the  thorax.  The  stomach  may  be  elevated  by  great  dis- 
tention of  the  gut  or  peritoneal  sac. 

It  is  well  to  trace  the  limits  of  resonance  of  the  stomach  and  of  any 
areas  of  dulness  met  with,  so  that  their  size  and  position  may  be  graph- 
ically represented.  The  differences  in  the  percussion-note  over  the 
stomach  and  colon  may  be  greatly  exaggerated  by  inflating  the  former. 
Runeberg's  method  is  to  be  preferred.  By  employing  light  percussion 
the  limits  of  the  stomach  can  now  be  easily  and  accurately  defined, 
unless  the  transverse  colon  be  at  the  same  time  greatly  distended 
with  gas.  In  such  instances  Dehio's  modification  of  Piorry's  method  is 
to  be  resorted  to.  It  consists  in  giving  about  1  liter  (1  quart)  of  water 
in  fractional  doses  while  the  patient  is  standing  ;  one-quarter  of  the 
liter  is  swallowed  and  percussion  practised,  when  a  dull  note  will  be 
obtained  over  the  most  dependent  portion  of  the  stomach.  A  second 
quantity  of  equal  amount  is  given  and  a  re-examination  made,  and  so 
on,  the  object  being  to  ascertain  to  what  point  the  lower  border  sinks  on 
the  addition  of  more  fluid.  Boas  holds  that  this  method  tests  effectively 
the  tone  of  the  stomach,  and  that  a  marked  descent  of  the  lower  border 
after  each  addition  of  water  is  indubitable  evidence  that  there  exists 
weakness  or  atony  of  its  walls.  If  a  neoplasm  originates  posterior  to 
the  stomach  or  colon,  inflation  of  the  latter  may  cause  the  previous 
circumscribed  dulness  to  disappear. 

By  striking  the  abdomen  in  the  epigastric  region  splashing-sounds 
may  be  produced.  This  sign  is  of  diagnostic  value  in  dilatation  of  the 
stomach,  though  its  absence  does  not  contradict  the  presence  of  the 
dilatation.  Again,  if  the  splashing-sound  is  obtained  in  a  fasting  stom- 
ach, it  may  give  a  clue  to  some  abnormal  condition.  The  stomach  may 
contain  large  quantities  of  fluid  and  no  splashing-sound  be  obtained. 
Caution  should  be  exercised  lest  the  splashing-sound  sometimes  pro- 
duced in  the  transverse  colon  be  mistaken  for  that  originating  in  the 
stomach ;  in  the  former  the  sound  is  usually  associated  with  diarrhea, 
while  in  the  latter  constipation  usually  obtains.  The  outlines  of  the 
stomach  can  be  most  satisfactorily  determined  by  auscultatory  percussion. 

Auscultation. — Various  sounds  are  heard,  none  of  which  are  pathog- 
nomonic of  any  diseased  condition. 

Succussion-sounds  are  produced  by  shaking  the  patient,  and,  if  the 
stomach  is  dilated  and  contains  fluid,  the  sounds  may  be  audible  some 
distance  from  the  patient.  If  these  sounds  are  heard  after  digestion 
should  be  completed  they  indicate  some  abnormal  condition — defective 


MALPOSITION  OF  THE  STOMACH.  743 

motility,  in  particular.  If  heard  below  the  umbilical  line,  it  usually 
indicates  dilatation.  In  motor  insufficiency  (atony)  of  the  stomach- 
walls  splashing-sounds  are  audible  after  swallowing  a  few  ounces  of  water. 
Partial  obstruction  of  the  cardiac  orifice  causes  a  delay  of  the  "  deglu- 
tition murmur  "  (a  hissing  sound  followed  in  six  or  seven  seconds  by 
either  gurgling,  clucking,  sprinkling,  or  splashing),  as  heard  over  the 
esophagus  with  the  stethoscope  while  the  patient  is  swalloM'ing  a  liquid, 
"while  in  complete  or  almost  complete  closure  of  the  cardia,  this  mur- 
mur is  absent  "  (Ewald). 


MALPOSITION  OF  THE  STOMACH. 

The  stomach  may  occupy  a  truly  vertical  position  in  consequence  of 
the  persistence  of  the  normal  infantile  condition  or  of  improper  cloth- 
ing— e.  g.  long-continued  pressure  from  corsets.  Unless  an  angular 
condition  of  the  duodenum,  causing  obstruction  to  the  outflow  of  the 
gastric  contents,  followed  by  dilatation  of  the  stomach,  be  engendered, 
the  malposition  is  of  little  or  no  clinical  significance.  Transposition  of 
the  stomach,  with  the  organs  occupying  the  right  hydochondrium,  is 
rarely  met  in  association  with  transposition  of  other  viscera. 

GASTROPTOSIS. 

Definition. — DoAvnward  displacement  of  the  stomach.  The  lesser 
curvature  of  the  organ  lies  about  midway  between  the  ensiform  cartilage 
and  the  umbilicus,  and  the  greater  curvature  near  the  symphysis  pubis. 

Htiology. — So  far  as  our  present  knowledge  extends,  the  conditions 
and  circumstances  contributing  mostly  to  the  origin  and  development 
of  gastroptosis  are — [a)  Age  and  sex.  Meinert  of  Dresden  found 
among  girls  of  fourteen  years  gastroptosis  in  80  per  cent.,  and  among 
the  women  who  presented  themselves  at  his  private  clinic  in  90  per  cent. 
According  to  my  observation,  gastroptosis  is  not  as  frequent  among 
American  girls  and  women  as  among  the  Germans.  "  Dislocation 
occurs  in  about  5  per  cent,  of  the  male  population  of  Dresden."  (6) 
Improper  clothing,  particularly  tight  lacing,  (c)  Dislocation  of  the 
right  kidney.  This  operates  potently,  and  prolapse  of  other  abdominal 
organs,  as  the  liver  and  intestines,  is  often  associated,  and  may 
constitute  the  chief  point  of  departure,  {d)  Repeated  pregnancies,  in- 
ducing a  relaxed  state  of  the  abdominal  wall,  (e)  Muscular  strain  and 
local  injury,  by  diminishing  the  tonicity  of  the  gastrohepatic  omentum. 
(/)  Abnormalities  of  the  chest-formation  (kyphosis);  great  meteorism, 
and  enlargement  of  the  abdominal  organs,  especially  of  the  spleen  and 
liver.   Certain  chronic  diseases  may  be  active — e.  g.  chlorosis,  tuberculosis. 

Symptoms. — Malposition  of  the  stomach  may  exist  without  symp- 
toms, but  in  most  instances  it  produces  functional  disturbances  of  clin- 
ical importance.  The  latter  are  due,  first,  to  the  difficulty  that  the 
stomach  experiences  in  emptying  its  contents.  Soon  functional  dis- 
orders arise  in  consequence  of  gastric  atony,  and  later  there  is  apt  to 
be  a  greatly  diminished  gastric  secretion,  associated  with  a  nervous  dys- 
peptic condition.  Especially  to  be  emphasized  is  the  fact  that  the  stom- 
ach may  be  of  natural  or  of  diminished  size  (as  the  primary  result  of 
the  compression  of  the  corsets — Fleiner),  or  it  may  be  dilated — a  not 


744  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

uncommon  event  that  often  colors  the  clinical  picture  in  a  peculiar  man- 
ner. Constipation  due  to  defective  peristalsis,  and  colicky  pains  due  to 
spasm  of  the  intestinal  muscles,  are  important  features. 

Physical  examination  of  the  inflated  stomach '  permits  the  accurate 
demonstration  of  gastroptosis.  The  epigastrium  is  hollowed,  while  the 
lower  quadrants  of  the  abdomen  are  prominent.  The  percussion-note 
now  indicates  the  position  of  the  organ.  It  is  to  be  borne  in  mind  that 
the  cardiac  end  remains  fixed  at  the  twelfth  dorsal  vertebra,  while  the 
pylorus  moves  downward  and  to  the  left:  this  will  explain  why  the 
epigastrium  is  free  of  gastric  tympany.  Succussion  splashing-sounds 
may  be  heard  if  atony,  with  retained  gastric  contents,  obtains.  The 
differentiation  of  gastroptosis  from  dilatation  of  the  stomach  is  also  ac- 
complished by  the  method  of  inflation,  since  this  makes  plain  the  course 
and  position  of  the  lesser  curvature  and  of  the  pylorus. 

The  prognosis  is  not  bad ;  it  is  modified  in  some  cases  by  the  pres- 
ence of  special  causal  agencies,  and  in  others  by  the  occurrence  of  cer- 
tain complications,  as  dilatation  of  the  stomach. 

The  treatment  has  relation  to  the  removal  of  all  causes  that  favor 
the  condition.  Nervines  and  nutrients  are  especially  to  be  employed. 
Gastropexy  and  gastrorrhaphy  have  given  promising  results. 


DILATATION  OF  THE  STOMACH. 

The  condition  is  to  be  subdivided,  clinically,  into  acute  and  chronic 
forms.  The  normal  capacity  of  the  stomach  varies  within  rather  wide 
limits,  though  the  maximum  normal  capacity,  according  to  Ewald,  does 
not  exceed  1600  c.c.  (1.5  quarts) ;  enlargements  above  this  capacity 
may   then   be  said   to   fall  under  the  heading  of  dilatation. 

Pathology  and  Btiology. — The  chief  factor  in  the  production  of 
chronic  dilatation  is  pyloric  stenosis.  This  is  usually  due  (a)  to  such 
diseases  of  the  stomach  as  carcinoma,  cicatrix  of  an  ulcer,  fibroid  over- 
growth and  contraction  of  the  pylorus,  or  the  contraction  consequent 
on  the  action  of  corrosive  poisons ;  (b)  to  the  external  compression  aris- 
ing from  carcinoma  of  the  liver,  pancreas,  or  gall-bladder,  from  the 
omental  lymph-glands,  and  not  infrequently  from  a  displaced  right 
kidney,  or  from  large  gall-stones ;  (r)  congenital  pyloric  stenosis  and 
adhesions  about  the  pylorus  may  also  act  as  causes  of  dilatation. 

Obviously,  in  all  such  instances  increased  force  is  necessary  to  pro- 
pel the  food  from  the  stomach  into  the  duodenum,  thus  leading  gradually 
to  a  hypertrophy  of  the  muscular  fibers ;  this  is  noted  in  an  especial 
degree  in  the  immediate  vicinity  of  the  pylorus.  So  long  as  this  hyper- 
trophied  state  of  the  muscular  layer  compensates  for  the  obstructive 
lesion  no  pathologic  dilatation  can  occur.  Just  as  soon,  however,  as 
the  muscles  prove  to  be  inadequate  on  account  of  secondary  degenera- 
tive changes,  accumulation  of  the  undigested  food  in  the  stomach  en- 
sues.    This  tendency  for  the  contents  of  the  stomach  to  accumulate  is 

'  Inflation  may  be  accomplished  by  the  use  of  eflervescent  mixtures  or  by  the  intro- 
duction of  atmospheric  air  {vide  ante). 


DILATATION  OF  THE  STOMACH.  745 

very  much  augmented  by  the  increasing  weakness  of  the  muscle  on  the 
one  hand  and  the  increasing  degree  of  stenosis  on  the  other.  A  further 
step  in  the  anatomic  alteration  is  the  development  of  a  chronic  gastric 
catarrh  in  consequence  of  the  chemical  and  mechanical  eifect  of  the  un- 
digested food,  the  latter  inevitably  undergoing  fermentative  aud  putre- 
factive changes  from  prolonged  retention.  The  degree  of  dilatation  is, 
to  some  extent,  augmented  by  the  generation  of  excessive  amounts  of 
gases  under  these  abnormal  conditions,  as  well  as  by  the  great  weight  of 
the  accumulated  gastric  contents.  When  produced  in  this  manner  the 
stomach  attains  enormous  dimensions,  and  one  instance  has  been  re- 
corded in  which  it  was  capable  of  containing  90  pounds  of  fluid  (Loomis). 
Dilatation  is  usually  general,  though  there  may  be  mere  diverticula  cor- 
responding to  the  seats  of  ulcers  or  to  erosions  of  the  walls. 

Dilatation  may  also  occur  independently  of  pyloric  stenosis,  though 
this  class  of  cases  is  not  so  large  as  the  preceding,  nor  does  the  condi- 
tion attain  so  pronounced  a  degree.  In  this  variety  of  dilatation  there 
is  atony  of  the  muscular  coats,  due  to  various  and  dissimilar  causes  : 
(a)  repeated  over-strain  of  the  muscular  layer,  due  to  over-filling  of  the 
organ  with  food  and  drink,  is  a  comparatively  frequent  cause,  and  one 
met  with  in  diabetics  and  in  those  who  habitually  drink  large  quantities 
of  beer  ;  (h)  chronic  gastric  catarrh  frequently  weakens  the  muscle,  and 
more  especially  when  associated  with  an  over-indulgence  in  food  and 
drink  ;  {c)  fatty  and  other  forms  of  degeneration  or  nutritional  disturb- 
ances associated  with  certain  constitutional  diseases  (particularly  carci- 
noma, anemia,  and  tuberculosis) ;  {d)  congenital  weakness  of  the  mus- 
cular coat ;  (e)  impaired  innervation,  leading  to  imperfect  peristalsis  and 
consequent  dilatation  ;  (/)  omental  hernias  (Bamberger)  that  drag  down 
the  stomach  ;  {g)  fibrous  bands,  by  binding  the  stomach  to  other  organs, 
will  occasionally  cause  slight  dilatation. 

Acute  dilatation  has  for  its  chief  causes — (a)  specific  fevers,  pro- 
ducing parenchymatous  degeneration  of  the  muscular  coats  ;  {b)  the 
acute  paralytic  distention  of  Fagge,  who  ascribed  the  condition  prima- 
rily to  chronic  catarrhal  inflammation  ;  (c)  the  drinking  of  large  quan- 
tities of  effervescing  liquids ;  {d)  following  shock  (Boas,  Rosenheim) ; 
(e)  sudden  obstruction  of  the  pylorus  and  of  the  duodenum  (Bettmann). 

Clinical  History. — Since  the  diseases  causing  dilatation  are  numer- 
ous and  diverse,  the  clinical  history  presents  great  variations.  Associated 
with  the  symptoms  of  dilatation  are  usually  those  of  the  causal  afiections, 
and  the  latter  sometimes  overshadow  the  former.  Among  the  earlier 
symptoms,  increased  hunger  and  thirst  are  frequently  observed,  partly 
due  most  probably  to  the  general  condition  of  inanition.  The  thirst  is 
also  due,  according  to  Von  Weinig,  to  the  fact  that  the  stomach  does 
not  readily  absorb  water,  and  the  pyloric  obstruction  prevents  the  passage 
of  water  into  the  intestines.  Vomiting  occurs  at  intervals  of  several  days, 
the  matter  ejected  amounting  to  from  1  to  3  gallons  (4-12  liters).  The 
clinical  characters  of  the  vomitus  are  strikingly  peculiar.  Occasionally 
the  vomiting  occurs  more  or  less  regularly  some  hours  after  feeding.  The 
ejecta  often  contain  remnants  of  previous  meals,  are,  as  a  rule,  excess- 
ively acid,  emitting  a  sour  odor,  and  on  microscopic  examination  they 
show  bacteria,  sarcinse,  and  torulse  in  great  numbers.  The  vomitus  un- 
dergoes fermentative  changes  very  rapidly,  is  ill-smelling,  the  odors 
being  mainly'due  to  sulphuretted  and  phosphuretted  hydrogen.     It  con- 


746  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sists  of  acetic,  butyric,  and  lactic  acids  and  partially  decomposed  food 
(HCl  being  usually  absent),  and  on  standing  separates  into  three  layers 
— an  upper  layer  of  brownish  froth,  a  middle  one  of  grayish-brown 
fluid,  and  a  lower  one  composed  of  remnants  of  food.  The  acid 
contents  of  the  stomach  are  not  infre(iuently  regurgitated,  causing 
pyrosis.  Eructations  of  foul  gases  are  also  common,  and  certain  general 
symptoms  almost  invariably  ensue.  Progressive  emaciation  naturally 
follows,  sometimes  becoming  extreme.  A  characteristic  symptom  is  mus- 
cular cramp)  affecting  the  calves  of  the  legs  and  sometimes  spreading  to 
the  flexors  of  the  arras  and  the  abdominal  muscles.  Owing  to  the  fact 
that  but  a  small  amount  of  liquid  reaches  the  intestines,  and  also  to  the 
impaired  absorption  from  the  stomach,  there  are  coyistipation  and  scanty 
urine,  the  latter  usually  being  alkaline  in  reaction.  The  nervous 
phenomena  of  chronic  gastritis  are  in  evidence  and  insomnia  is  often 
pronounced.  Loss  of  consciousness  has  been  met  with.  Tetany,  partic- 
ularly after  lavage,  has  also  been  observed.  Cardiac  palpation  and 
arrythmia  are  often  present  and  are  induced  principally  by  the 
effects  of  the  dilatation.  Nocturnal  dyspnea  (asthma  ?)  may  develop. 
A  striking  instance  is  reported  by  J.  T.  Whitcomb  in  which  nearly  all 
the  muscles  of  the  body,  including  those  of  the  esophagus,  appeared  to 
be  in  a  tetanic  condition.  Dreschfield  calls  attention  to  dilatation  of  the 
epigastric  veins  in  both  inguinal  regions  as  an  evidence  of  dilatation  of 
the  stomach ;  he  has  observed  it  in  more  than  60  cases,  and  refers  to 
compression  of  tributaries  of  the  portal  vein  by  the  dilated  and  displaced 
stomach  as  the  supposed  cause  of  the  condition. 

Physical  Signs. — Inspection  reveals  a  rounded  prominence  just  above 
the  umbilicus  in  the  supine  and  just  below  the  umbilicus  in  the  standing 
posture.  In  the  epigastric  region  there  is  sometimes  a  noticeable  de- 
pression. Obviously,  then,  the  abdomen  is  asymmetric  in  appearance. 
The  outlines  of  the  stomach  may  be  made  distinct  by  the  patient  taking 
an  effervescing  draught,  and  may  sometimes  be  readily  seen,  particularly 
the  greater  curvature,  "  passing  obliquely  from  the  tip  of  the  tenth  rib 
on  the  left  side  toward  the  pubes,  and  then  curving  upward  to  the  right 
costal  margin "  (Osier).  Sometimes  peristalsis  is  visible  through  the 
abdominal  walls,  and  rarely  the  peristaltic  waves  are  seen  passing  from 
right  to  left.  These  movements  may  be  excited  mechanically  by  various 
manipulations.  Palpation. — The  increased  resistance  of  the  walls  of  the 
stomach  and  their  peculiar  elasticity  aid  us  in  mapping  out  the  contour 
of  the  stomach  with  more  precision  by  palpation  than  by  inspection 
alone.  The  movements  of  the  organ  can  be  plainly  felt,  frequently  lead- 
ing up  to  a  pyloric  mass.  A  sign  of  considerable  diagnostic  importance  is 
the  loud  splashing  sound  obtained  by  tapping  the  region  of  the  stomach 
with  the  finger-tips  of  both  hands  alternately,  or  by  shaking  the  body 
while  the  hand  is  placed  over  the  epigastrium,  though  this  should  not  be 
mistaken  for  a  similar  sound  that  may  be  obtained  when  the  colon 
contains  fluid.  The  patient  may  produce  and  maintain  similar  splash- 
ing-sounds  by  voluntary  efforts.  A  tumor  of  the  pylorus,  which  is  often 
displaced,  may  be  palpable.  Percussion  furnishes  subsidiary  evidence 
as  compared  with  palpation.  The  examiner  should  first  percuss  the 
empty,  and  then  the  filled  stomach,  if  he  would  obtain  reliable  aid  from 
this  sign.  When  empty,  an  increased  area  of  tympanitic  resonance  will 
be  obtained,  extending  from  above  downward  to  a  point  several  inches 


DILATATION  OF  THE  STOMACH.  747 

below  the  umbilicus.  If  now  water  amounting  to  1  quart  (1  liter)  be  in- 
troduced into  the  organ,  and,  in  consequence,  a  li-ne  of  dulness  at  or  below 
the  navel  be  noted  where  tympanitic  resonance  had  been  found,  we  have 
good  evidence  of  the  existence  of  dilatation.  The  posture  of  the  patient 
should  next  be  changed,  when  it  will  be  found  that  the  line  of  dulness 
has  also  altered,  The  stomach  may  be  expanded  by  gas  or  air  {vide 
Physical  Examination)  and  its  limits  mapped  out  by  auscultatory  percus- 
sion. Auscultation  reveals  little  that  is  of  diagnostic  value.  The  transmit- 
ted sounds  heard  over  the  stomach  have  a  metallic  ring.  I  have  confirmed 
the  observation  by  Franck  and  others,  who  claimed  to  have  heard  pecu- 
liar gurgling  sounds  produced  by  the  heart's  action  and  systolic  in 
rhythm.  Fluids  swallowed  by  the  patient  may  be  heard  dropping  into 
the  dilated  stomach,  and  succussion-sounds  may  be  elicited  by  shaking 
his  body.  Measurements  made  by  introducing  a  probang  into  the  stom- 
ach until  it  reaches  the  greater  curvature  are  valuable  only  when  the 
degree  of  dilatation  is  considerable,  on  account  of  the  obvious  chances  of  - 
error.  In  health  the  instrument  passes  about  60  cm.  (24  inches),  reach- 
ing a  point  more  or  less  nearly  on  a  level  with  the  umbilicus,  while 
under  conditions  of  extreme  dilatation  it  may  be  introduced  70  cm.  (28 
inches). 

Diagnosis. — The  diagnosis  embraces,  first  and  foremost,  the  recog- 
nition of  the  special  causes.  The  unmistakable  clinical  manifestations 
are  the  characters  of  the  vomitus  and  the  peculiar  manner  of  recurrence 
of  the  vomiting.  These,  together  with  the  physical  signs  and  a  know- 
ledge of  the  causal  condition  in  the  individual  case,  are  adequate  for  a 
positive  diagnosis. 

Differential  Diagnosis. — The  condition  is  most  apt  to  be  confounded 
with  ascites  or  over-distentio7i  of  the  bowel,  and  in  the  female  with 
ovariafi  cyst.  In  dilatation  of  the  intestines  the  gastric  symptoms  of 
dilatation  of  the  stomach  are  wanting ;  moreover,  the  physical  signs  are 
dissimilar.  The  splashing  sounds  on  manipulation,  the  line  of  dulness 
below  the  umbilicus  after  filling  the  stomach,  and  other  signs  so  signifi- 
cant of  gastric  dilatation  are  absent  in  over-distention  of  the  intestines. 
In  addition,  we  should  make  trial  of  the  salol  test,  though  this  is  now 
considered  of  little  value  (vide  Chemical  Examination).  In  dilatation 
of  the  stomach  salicyluric  acid  appears  in  the  urine  two  or  three  hours 
after  salol  has  been  taken,  while  in  health  as  early  as  from  one-half  to 
one  hour.  From  dilatation  of  the  stomach  we  may  discriminate  ascites 
by  the  history  and  by  the  characteristic  gastric  symptoms  belonging  to 
the  former  affection.  In  dilatation  the  abdomen  is  asymmetric,  the  pro- 
jecting prominence  being  in  the  vicinity  of  or  just  below  the  umbilicus. 
In  ascites  the  lower  portion  of  the  abdomen  is  chiefly  distended,  and 
on  assuming  the  recumbent  posture  the  abdominal  area  becomes  broad- 
ened and  flattened.  On  palpation  fluctuation  may  be  elicited  in  the 
hypogastric  and  iliac  regions.  Megcdogastria,  or  simple  "  big  stomach," 
is  distinguished  by  its  absence  of  symptoms,  and  especially  by  the  fact 
that  the  food  is  passed  into  the  intestines  as  quickly  as  in  health. 
Gastroptosis  is  easily  distinguished  from  gastric  dilatation  {vide  article 
on  Gastroptosis).     The  distinction  is  aided  by  the  use  of  the  r-rays. 

Acute   Gastric  Dilatation. — Acute  dilatation  of  the  stomach  has  a 
sudden  onset,  and  gives  rise  to  all  of  the  above-mentioned  physical  signs. 


748  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

In  this  type  of  the  disease,  however,  vomiting  is  more  frequent  and 
severe  than  in  the  chronic  form.  Cyanosis  is  a  common  symptom,  and 
pain  often  a  prominent  one.  The  patient  frequently  passes  into  a  condi- 
tion of  collapse  that  may  prove  speedily  fatal.  Acute  dilatation  may 
arise  in  the  course  of  chronic  gastrectasis.  Some  of  these  cases  prob- 
ably represent  a  mere  episode  in  the  course  of  the  chronic  disease  (Veeder, 
Todd). 

Prognosis. — The  prognosis  in  the  acute  form  is  uncertain,  though 
the  majority  of  cases  recover ;  the  condition  may,  however,  tend  to 
merge  into  the  chronic  form. 

Chronic  dilatation  offers  a  bad  prognosis,  most  instances  being  utterly 
incurable.  Obviously,  it  depends  greatly  upon  the  causal  conditions.  A 
resort  to  surgical  interference  sometimes  gives  promise  of  a  more  favor- 
able subsequent  course  in  cases  of  cicatricial  stenosis.  Cases  of  dilata- 
tion that  are  not  secondary  to  pyloric  obstruction,  however,  give  a  more 
favorable  prognosis  on  the  whole. 

Treatment. — One  of  the  chief  aims  of  the  physician  should  be  to 
lessen  the  labor  of  the  muscular  coat  and  to  prevent  the  continual  neces- 
sity of  passing  the  contents  of  the  stomach  into  the  intestines.  This  is 
to  be  accomplished  by  careful  attention  to  the  character  and  amount  of 
food  taken  and  by  frequent  cleansing  of  the  stomach.  It  is  neces- 
sary to  thoroughly  empty  the  organ  by  lavage,  this  being  repeated 
daily.  A  thorough  and  safe  manner  of  washing  out  the  stomach  is 
by  means  of  the  soft  Nelaton  catheter,  its  introduction  being  unat- 
tended by  injurious  local  effects.  Perhaps  the  best  way  in  which 
to  thoroughly  empty  the  stomach  is  by  the  use  of  the  stomach- 
tube,  as  will  be  detailed  under  Chronic  Gastritis.  Recently  this  has 
been  replaced  by  the  siphon  apparatus  as  a  simpler  and  more  con- 
venient mechanism  than  the  former,  and  one  not  so  likely  to  be  at- 
tended with  harmful  effects,  though  perhaps  less  efficacious.  The  long 
course  of  these  conditions  renders  it  desirable  that  the  patient  should, 
whenever  possible,  be  taught  to  wash  out  his  own  stomach.  On  account 
of  the  fermentative  and  putrefactive  changes  going  on  in  the  ingesta 
it  is  necessary  to  use  weak  antiseptic  solutions  for  this  purpose,  suita- 
ble ones  being  a  3  per  cent,  solution  of  boracic  acid  or  a  1  per  cent, 
solution  of  salicylic  acid.  Subsequently  warm  water  alone  may  be  em- 
ployed. The  diet  should  be  composed  chiefly  of  fluids,  given  in  small 
quantities  and  at  stated  intervals.  If  the  pyloric  obstruction  be  not  too 
far  advanced,  tender  meats,  eggs,  and  other  easily  digested  albuminous 
articles  of  food  may  be  allowed  in  moderate  quantities.  Since  gastric 
digestion  and  absorption  are  very  often  markedly  impaired,  it  is  well  also 
to  include  those  substances  that  are  readily  digested  and  assimilated  after 
leaving  the  stomach,  though  the  latter  must  be  given  in  a  fluid  state.  In 
no  other  manner  can  we  bring  such  marked  relief  from  disagreeable 
gastric  symptoms  as  by  a  suitable  dietary,  and  in  no  other  manner 
can  the  general  nutrition  of  the  patient  be  so  markedly  improved.  The 
weakened  condition  of  the  muscle-walls  is  due'  to  over-strain  and  to 
degenerative  processes  ;  hence,  after  having  removed  as  much  of  the 
labor  thrown  upon  it  as  possible,  we  should  attempt  to  overcome  its 
paretic  state  by  the  employment  of  such  agents  as  strychnin  and  elec- 
tricity. Stockton,  and  later.  Reed  and  others,  have  obtained  good 
results  from  direct  electrization  of  the  stomach  by  the  use  of  special 


ACUTE  CATARRHAL   GASTRITIS.  749 

electrodes  ;  it  -  improves  motility  and  lessens  the  size  of  the  organ. 
Exercises  to  develop  the  muscles  and  abdominal  massage  are  useful. 
For  the  associated  catarrhal  state  the  remedies  recommended  under 
Chronic  Gastric  Catarrh  may  be  employed. 

Since  some  of  the  more  annoying  symptoms  and  remote  evil  conse- 
quences are  directly  attributable  to  the  fact  that  too  small  a  proportion 
of  the  stomach-contents  finds  its  way  into  the  intestines,  we  should  com- 
pensate for  this  deficiency  of  intestinal  fluid  by  rectal  injections  of  a  weak 
solution  (gr.  v  to  §j — 0.324  to  32.0)  of  sodium  chlorid,  not  less  than  one 
pint  of  this  solution  being  injected  twice  daily.  In  addition,  nutrient 
enemata  should  be  employed  when,  despite  proper  regulation  of  the 
dietary,  loss  of  flesh  and  strength  continue.  For  the  anemia  and 
debility  tonics  are  indicated,  particularly  iron,  which  may  be  adminis- 
tered hypodermically  in  the  form  of  the  albuminate.  Finally,  surgical 
intervention  may  become  necessary. 


INFLAMMATORY  DISEASES  OP  THE  STOMACH. 

ACUTE    CATARRHAL   GASTRITIS. 
{Acute  Gastric  Catari^h.) 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  stomach,  attended  with  more  or  less  severe  local  and  con- 
stitutional symptoms. 

Pathology. — The  postmortem  evidences  of  an  acute  inflammation 
of  the  gastric  mucosa  are  distinctive  only  of  the  graver  forms,  since  the 
latter  alone  usually  terminate  fatally.  Observations  upon  cases  of  gas- 
tric fistula,  however,  have  shown  that  in  the  milder  grades  of  acute  gas- 
tric catarrh  the  morbid  appearances  are  similar  to  those  characteristic 
of  acute  catarrhal  inflammations  of  the  portions  of  mucous  membrane 
normally  exposed  to  view.  Thus,  at  first  there  are  small  irregular 
patches  of  redness,  slight  swelling,  dryness,  and  ecchymosis.  Later, 
serum  efi"used  from  the  congested  vessels,  and  mixed  with  an  increased 
quantity  of  mucus,  escaped  leukocytes,  and  desquamated  epithelium,  is 
present.  Hemorrhagic  erosions  may  be  seen ;  the  mucous  membrane 
is  now  thickly  swollen,  softened,  and  covered  with  a  tenacious  muco- 
pus,  which,  from  an  increase  in  the  number  of  leukocytes  in  a  more 
intense  inflammation,  may  pass  into  a  purulent  exudate.  Infiltration 
and  swelling  of  the  solitary  lymph-follicles  are  frequent ;  these  some- 
times form  minute  abscesses  that  burst  and  result  in  follicular  ulcers. 
The  gastric  tubules  may  be  filled  with  a  granular  debris  of  epithelial 
cells  that  have  undergone  cloudy  swelling  and  fatty  degeneration.  The 
above  changes  are  more  commonly  seen  near  the  pylorus. 

Ktiology. — The  predisposing  causes  of  acute  gastric  catarrh  em- 
brace those  various  impairments  of  the  system  in  which  the  normal  func- 
tional activity  of  the  stomach  is  altered  or  diminished.  These  are  seen 
as  the  result  of  {a)  improper  hygienic  surroundings ;  (5)  malnutrition ; 
(c)  the  various  anemias;  [d]  in  gouty  and  rheumatic  subjects;  (e)  in  the 
tuberculous,  cancerous,  and  malai-ial  dyscrasise ;  (/)  associated  with 
chronic   passive   hyperemia  of  the  stomach   due   to  emphysema  of  the 


750  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lungs,  cirrhosis  of  the  liver,  and  renal  and  cardiac  diseases  ;  (^)  in  sickly 
and  delicate  children,  in  convalescents  from  acute  diseases,  and  in  ener- 
vated chronic  invalids,  [h)  Persons  having  chronic  gastric  catarrh  are 
predisposed  to  superadded  attacks  of  the  acute  disorder. 

The  excitants  are  mainly  (1)  dietetic.  These  include  the  ingestion 
of  much  indigestible  food ;  food  or  drink  that  is  too  hot  or  too  cold 
(thermal)  ;  sour  and  highly-seasoned  articles  ;  the  too  free  use  of  condi- 
ments ;  and  especially  the  eating  of  decomposed  canned  goods  and 
tainted  meats.  In  cases  due  to  the  latter  the  fermentative  and  putre- 
factive agents  (acetic,  lactic,  and  butyric  acids,  and  the  ptomains)  are 
the  immediate  causes  of  the  catarrhal  inflammation  and  tend  to  produce 
the  constitutional  disturbances,  sometimes  typhoid  or  septic  in  nature, 
that  give  rise  to  the  so-called  "gastric  fever."  The  term  ^'■crapulous 
gastritis  "  has  been  applied  to  those  cases  due  to  gluttonous  meals.  (2) 
Toxic  gastritis.  Excessive  indulgence  in  spirituous  liquors  is  a  common 
cause.  Certain  drugs,  as  the  salicylates,  iodids,  bromids,  arsenic,  and 
mercury.  (For  the  intense  form  of  toxic  gastritis,  vide  p.  752.)  (3) 
Acute  infectious  fevers,  as  measles,  typhus  fever,  and  scarlatina,  pro- 
voke the  disorder  {^^  infectious  gastritis"),  as  do  also  remittent  and 
intermittent  fevers,  especially  when  of  the  pernicious  variety.  (4)  The  in- 
fluence of  cold  as  an  excitant  of  this  disease  has  very  probably  been  over- 
estimated. (5)  Since  the  publication  of  the  observations  by  Klebs.  Friinkel, 
and  others,  the  mycotic  origin  of  the  condition  cannot  any  longer  be 
doubted.  Among  the  microorganisms  incriminated  are  the  anthrax  ba- 
cillus, the  favus  fungus,  the  Oidium  albicans,  and  the  yeast  fungus. 

Clinical  History. — The  symptoms  of  the  ordinary  or  milder  vari- 
ety of  acute  gastric  catarrh  are  embraced  in  the  description  of  the  "  sub- 
acute gastritis  "  or  "  acute  dyspepsia  "  of  some  writers.  Soon  after  eat- 
ing there  are  uneasiness,  fulness,  pressure,  distress,  and,  perhaps,  a  dull 
pain  referred  to  the  epigastrium.  Thirst  is  common,  also  nausea,  eruc- 
tations of  gas  or  liquid,  and,  less  often,  vomiting.  The  vomitus  con- 
sists of  undigested  food,  considerable  mucus,  and  fluid  constituents  that 
are  sometimes  bile-stained.  The  percentage  of  HCl  in  the  stomach- 
contents  is  variable,  although  either  absent  or  greatly  diminished  as  a 
rule.  The  tongue  is  coated.  The  general  condition  of  the  patient 
remains  unimpaired,  and  the  average  duration  is  less  than  twenty-four 
hours.  In  severer  cases  the  symptoms  before  stated  are  intensified,  and 
particularly  the  nausea  and  vomiting.  Physical  exploration  discloses 
slight  prominence  of  the  epigastric  area,  with  more  or  less  tenderness 
on  palpation.  The  tongue  is  dry  and  heavily  coated,  the  breath  unpleas- 
ant as  a  rule,  the  patient  complaining  of  a  flat  or  bitter  taste  in  the 
mouth.  Constitutional  symptoms  appear  early,  and  the  onset  is  often 
marked  by  rigor  and  a  febrile  reaction,  the  temperature  rising  to  102° 
or  even  103°  F.  (38.8°-39.4°  C).  Herpes  may  appear  on  the  lips  and 
skin — a  fact  that  points  to  the  infectious  nature  of  tliis  complaint.  The 
pulse  is  usually  accelerated,  and  there  are  indisposition  to  exertion, 
headache,  dulness,  and  other  nervous  symptoms.  An  erythematous 
cutaneous  eruption  is  often  present,  and  particularly  in  febrile  cases  in 
children.  The  marked  general  disturbance  is  due  to  the  toxic  effects  of 
the  products  of  fermentation  and  decomposition. 

Complications. — Constipation  is  a  comparatively  frequent  compli- 


ACUTE  CATARRHAL    GASTRITIS.  751 

cation,  and  diarrhea  a  comparatively  infrequent  one.  Either  coinci- 
dently  or  by  direct  extension  the  duodenum  is  similarly  affected,  and 
in  some  instances  jaundice  becomes  an  accompanying  feature.  The 
duration  of  this  variety  of  the  disease  rarely  exceeds  four  or  five  days. 

Diagnosis. — The  diagnosis  of  the  lighter,  afebrile  forms  of  the  dis- 
order is  not  attended  Avith  the  slightest  difficulty.  A  logical  diagnosis 
in  cases  in  Avhich  well-marked  local  and  general  symptoms  appear  is  not 
easy.  The  definite  etiology,  the  vomiting  (affording  temporary  relief), 
the  pain  or  tenderness,  the  sudden  rise  of  temperature,  and  the  equally 
sudden  fall  at  the  end  of  a  few  days,  however,  are  almost  unequivocal. 

Differential  Diagnosis. — The  absence  of  prodromata,  of  rose  spots,  of 
the  peculiar  temperature-range,  and  of  enlargmeiit  of  the  spleen  serve 
to  distinguish  this  complaint  from  typlioid  fever.  The  instances  of  in- 
determinate etiology  may  present  a  clinical  picture  not  to  be  differen- 
tiated from  certain  infectious  diseases.  Here  a  careful  analysis  of  the 
local  symptoms  and  signs  Avill  usually  lead  to  a  correct  conclusion,  despite 
the  apparently  complete  identity  of  the  general  disturbances.  Close  ob- 
servation of  the  behavior  of  any  given  obscure  case  for  a  couple  of  days 
will  usually  enable  the  physician  to  arrive  at  a  correct  diagnosis.  In 
children  headache  and  vomiting  are  symptoms  often  so  well  marked  as 
to  create  a  striking  resemblance  to  tubercular  meningitis,  but  the  latter 
can  be  discriminated  by  the  history  and  longer  duration.  In  children 
acute  gastritis  with  an  erythematous  rash  is  often  mistaken  for  scarlet 
fever.  The  final  elimination  of  the  latter  disease  is  usually  easy,  how- 
ever, in  consequence  of  the  absence  of  angina,  of  the  typical  tongue,  the 
hard  and  very  rapid  pulse,  and  the  peculiar  desquamation  affecting  the 
hair  and  the  nails. 

Prognosis. — Quite  generally  the  prognosis  is  good.  When,  as 
sometimes  happens,  however,  the  disease  is  purely  secondary,  the  prog- 
nosis must  depend  largely  upon  the  primary  affection.  I  have  found 
that  many  persons  suffer  from  repeated  attacks  of  gastric  catarrh,  each 
increasing  the  liability  to  subsequent  attacks. 

Treatment. — Our  chief  aim  should  be  to  remove  the  cause  and  then 
to  give  the  stomach  complete  rest.  Hence,  Avhenever  the  disease  is  dis- 
tinctly traceable  to  errors  of  diet,  emetics  of  the  blandest  sort  should  be 
employed ;  large  draughts  of  warm  water  usually  suffice,  but  lavage  is 
to  be  preferred  in  some  cases.  This  should  be  followed  by  a  purge  made 
up  as  folloAvs : 

I^.  Hydrarg.  chlorid.  mit.,  gr.  j         (0.0648); 

Sodii  bicarb.,  gr.  xviij  (1.16) ; 

Sacchari  lactis,  gr.  xij      (0.777). 

M.  et  ft.  chart.  No.  vj. 
Sig.  One,  dry  on  the  tongue,  every  hour ;  the  last  to  be  folloAved 
in  tAvo  hours  by  a  Avineglassful  of  Hunyadi  Janos  or  other 
^  saline  laxative. 

The  stomach  must  now  have  absolute  rest  for  about  twenty-four 
hours,  Avhen  pancreatized  milk  or  milk  boiled  with  lime-water  may  be 
given  at  stated  intervals.  If  nausea  and  continued  vomiting  prohibit 
the  use  of  milk  by  the  mouth,  I  resort  to  rectal  alimentation  early,  and 
particularly  in  children.      Certain  symptoms,  as  yiausea,  pain,  and  rest- 


752  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Ie88ness,  demand  as  early  relief  as  possible,  and  can  be  most  success- 
fully met  by  the  use  of  morphin  in  small  doses  hypodermically  at  inter- 
vals of  twelve  hours.  When  constant  nausea  is  the  symptom  chiefly 
complained  of,  I  have  found  creasote  combined  with  bismuth  or  cocain 
in  small  doses  to  be  highly  serviceable.  Convalescence  is  usually  unin- 
terrupted, and  is  soon  complete.  When  protracted  it  is  often  on  account 
of  the  too  early  return  to  solid  articles  of  diet  or  the  too  early  use  of 
bitter  tonics.  The  mineral  acids  should  first  be  administered,  well  di- 
luted, after  the  local  symptoms  have  in  a  great  measure  subsided,  and  to 
these  the  bitter  vegetable  tonics  are  later  to  be  gradually  added.  Locally, 
I  employ  sinapisms  at  the  beginning  of  severe  types  of  the  affection, 
and  follow  these  with  warm  linseed  poultices  lightly  applied  to  the  entire 
epigastric  and  hypochondriac  regions. 

TOXIC    GASTRITIS. 

Pathology  and  Btiology. — This  is  an  intense  form  of  acute  gas- 
tritis, produced  by  the  ingestion  of  irritant  and  corrosive  poisons,  among 
the  former  being  such  agents  as  phosphorus,  antimony,  and  arsenic,  and 
among  the  latter  concentrated  mineral  acids  and  strong  alkalies.  When 
caused  by  the  non-corrosive  poisons  intense  hyperemia  and  tumefaction, 
leading  to  desquamative  changes  in  the  glandular  structure,  ensue. 
When  excited  by  corrosive  substances  necrosis  of  the  mucous  membrane 
may  occur,  leading  even  to  an  involvement  of  all  the  coats,  and  termi- 
nating in  perforative  peritonitis.  The  lesions  may  be  of  various  grades 
of  severity,  and  are  either  localized  or  general. 

Symptoms. — The  symptoms  vary  somewhat  with  the  nature  of  the 
special  poison,  though  they  are  usually  quite  violent.  Incessant  vomit- 
ing, great  pain  in  the  epigastric  region,  and,  later,  diarrhea,  and  exces- 
sive thirst,  together  with  such  symptoms  as  intense  hnrning  pains  in  the 
mouth  and  throat  and  dysphagia,  are  the  most  characteristic  signs. 
The  vomitus  contains  mucus,  sometimes  blood,  and  rarely  shreds  of 
mucous  membrane.  The  phi/sical  examination  reveals  a  marked  disten- 
tion of  the  abdomen,  which  is  also,  as  a  rule,  very  painful  on  pressure 
over  the  epigastric  region.  The  general  condition  of  the  patient  soon 
becomes  one  of  profound  prostration ;  the  skin-surface  is  cold  and 
clammy,  and  the  pulse  and  respiration  are  greatly  hurried,  terminating 
at  times  in  fatal  collapse  within  a  few  hours.  Sometimes  there  is  a 
marked  febrile  movement ;  the  temperature  may  reach  104°  F.  (40°  C.) ; 
the  pulse  ranges  from  100  to  130 ;  and  if  life  be  spared  long  enough 
toxic  nephritis,  with  or  without  hematuria,  develops.  The  nervous  symp- 
toms (convulsions,  stupor,  sometimes  ending  in  coma)  may  be  due  in  part 
to  the  renal  lesions,  though  mainly  to  the  diminished  alkalinity  of  the 
blood.  Symptoms  of  gastric  ulcer  or  of  esophageal  stricture  may  be 
sequelse. 

Diagnosis. — The  diagnosis  rests  upon  the  history  of  the  ingestion 
of  some  poison,  upon  the  character  of  the  symptoms  (referable  not  only 
to  the  stomach,  but  also  to  the  mouth  and  the  pharynx),  and  upon  the 
results  of  an  inspection  of  the  mouth,  pharynx,  and  the  vomitus.  A 
chemical  examination  of  the  stomach-contents  and  urine  may  be  necessary. 

Prognosis. — This  depends  upon  the  nature  of  the  poison  and  its 
dose.     When  free  emesis  occurs  early  the  prognosis  is  thereby  rendered 


ACUTE  SUPPURATIVE  GASTRITIS.  753 

more  favorable,  since  under  these  circumstances  both  the  local  and  con- 
stitutional eifects  are  mitigated.  Among  unfavorable  symptoms  may  be 
mentioned  the  development  of  signs  of  collapse  or  of  peritonitis. 

Treatment. — To  ascertain,  in  the  first  place,  the  special  cause  of 
the  gastritis,  and  when  this  is  found  to  administer  the. proper  antidote 
to  that  poison,  are  measures  of  prime  importance.  The  stomach  should 
be  washed  out  Avith  warm  water  containing  some  demulcent  substance 
and  a  small  proportion  of  the  appropriate  antidote.  While  lavage  may 
be  resorted  to,  it  must  be  cautiously  undertaken.  Subsequently  meas- 
ures should  be  employed  to  combat  the  active  local  inflammation.  Ex- 
ternally, leeches,  folloAved  by  the  ice-bag,  have  proved  to  be  the  best 
agents  in  my  own  hands  ;  internally,  opium,  bismuth,  and  demulcents, 
with  bits  of  ice,  are  most  useful.  Rectal  alimentation  should  form  the 
sole  method  of  feeding  so  long  as  the  signs  of  severe  inflammation  along 
the  upper  alimentary  tract  are  present.  The  indications  presented  by 
the  general  conditions  will  vary  Avith  the  general  effects  of  the  peculiar 
poison  in  each  case. 

DIPHTHERITIC    GASTRITIS. 

This  form  of  gastritis  is  ahvays  a  secondary  condition,  though  it  is  not, 
as  Ijas  often  been  stated  by  others,  always  caused  by  a  direct  extension  of 
the  diphtheritic  process  from  the  pharynx  down  through  the  esopha- 
gus to  the  stomach.  It  arises  more  frequently  in  the  course  of  some 
other  acute  infectious  malady,  as  pneumonia,  scarlet  fever,  or  small-pox. 
Though  it  is  regarded  as  a  rare  disease,  the  fact  that  it  is  unrecognizable 
during  life  renders  it  certain  that  the  affection  is  sometimes  overlooked. 
I  have  seen  two  instances  associated  with  croupous  inflammation  of  the 
intestines,  both  occurring  in  greatly  debilitated  children.  Osier  saw  a 
case  which  occurred  as  a  secondary  process  in  pneumonia. 

ACUTE    SUPPURATIVE    GASTRITIS. 
{Phlegmonous  Gastritis.) 

Definition. — An  acute  suppurative  inflammation  of  the  submucosa. 

Pathology  and  Ktiology. — Phlegmonous  gastritis  is  confessedly 
a  rare,  and  almost  invariably  a  secondary,  disease.  I  have  observed 
pathologic  evidences  of  its  presence,  however,  in  two  cases  that  came 
to  autopsy,  both  patients  having  died  of  sepsis.  It  is  excited  by  an 
invasion  of  pyogenic  cocci.  It  may  very  rarely  originate  sponta- 
neously or  follow  an  injury,  though  more  commonly  it  is  merely  a 
symptom  of  a  general  septic  process  or  a  complication  of  an  acute  infec- 
tious malady.  Two  forms  are  described — namely,  a  diffuse  purulent 
infiltration  and  a  circumscribed  form  (stomach-abscess).  The  morbid  pro- 
cess begins  in  the  submucous  layer,  and  then  spreads  in  various  direc- 
tions, involving  soon  the  muscular  and  serous  coats  on  the  exterior  and 
the  mucous  coat  on  the  interior.  The  limited  variety  results  in  the 
formation  of  true  abscesses  that  may  attain  considerable  size  and  rupture 
either  into  the  peritoneal  cavity  or  into  the  stomach. 

Symptoms. — There  may  or  may  not  be  an  initial  rigor.  Whether 
the  case  is  ushered  in  by  a  chill  or  not,  however,  the  te?nperature  soon 

48 


754  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rises  to  103°  or  104°  F.  (40°  C),  and  subsequently  pursues  an  irreg- 
ular course.  The  symptoms  of  the  typhoid  state  supervene,  and  are 
usually  associated  with  the  symptoms  of  the  primary  affection.  Hence 
the  clinical  picture  is  greatly  diversified.  For  a  variable  period  prior  to 
the  fatal  issue  the  patient  passes  into  coma.  The  local  symptoms  and 
physical  signs  are  rarely  diagnostic.  There  is  a  constantly  increasing 
epigastric  pain ;  emesis  also  ajjpears,  the  vomita  often  containing  a 
notable  quantity  of  pus-cells. 

The  physical  signs  reveal  but  little  in  most  instances,  and  vary  with 
the  form  of  the  complaint.  Inspection  shows  in  the  diffuse  form  a  con- 
siderably distended  abdomen.  On  pressure  the  stomach  is  found  to  be 
quite  tender.  In  the  limited  variety  the  gastric  abscess  sometimes 
gives  rise  to  the  physical  signs  of  a  tumor,  and  a  localized  prominence 
may  be  seen  over  the  seat  of  the  abscess ;  the  tenderness  to  the  pressing 
finger  may  be  confined  to  the  same  area.  Palpation  has  served  to  elicit 
fluctuation  and  to  define  the  limits  of  the  tumor,  the  latter  sometimes 
attaining  the  size  of  a  cocoanut ;  on  percussion  either  dulness  or  a  muffled 
tympanitic  resonance  is  elicited,  according  to  the  size  of  the  mass. 

Diagnosis. — The  diffuse  variety  cannot,  as  a  rule,  be  positively 
distino:uished  from  certain  other  gastric  affections.  The  detection  of 
pus-cells  is,  however,  of  the  utmost  diagnostic  value.  Gastric  abscess, 
on  the  other  hand,  is  often  recognizable,  since  the  physician  has  not 
only  the  history  to  aid  him,  but  also  the  physical  signs,  which  may 
demonstrate  the  presence  of  a  fluctuating  tumor. 

Course  and  Prognosis. — The  majority  of  cases  reach  a  fatal  ter- 
mination within  one  week,  and  those  that  do  not  terminate  in  death  thus 
early  pursue  a  subacute  or  even  chronic  course.  They  present  such 
symptoms  as  local  pain,  chills,  and  fever,  and  death  results,  sooner  or 
later,  either  from  exhaustion  or  such  complications  as  peritonitis  and 
metastatic  abscess  with  jaundice. 

Treatment. — The  treatment  in  the  diffuse  form  is,  at  best,  only 
palliative.  In  the  circumscribed  variety  the  aid  of  the  surgeon  should 
be  invoked  as  soon  as  a  probable  diagnosis  has  been  made. 

CHRONIC   CATARRHAL   GASTRITIS. 
{Chronic  Catarrh  of  the  Stomach;   Chronic  Catarrhal  Dyspepsia.) 

Definition. — A  chronic  catarrhal  inflammation  of  the  gastric  mu- 
cous membrane,  presenting  various  degrees  of  intensity  and  embracing 
the  symptoms  that  are  more  or  less  characteristic  of  widely  different 
clinical  forms  of  gastric  derangement. 

Pathology. — The  anatomic  changes  are  most  marked  near  the  py- 
lorus, where  the  mucous  membrane  often  presents  a  distinctly  wrinkled, 
mammillated  appearance.  The  mucous  membrane  looks  either  red  or 
gray  (the  latter  hue  being  due  to  pigmentation),  and  is  pretty  generally 
covered  by  tenacious  mucus,  mingled  with  detached  epithelium.  Ewald 
describes  the  histologic  changes  thus:  "  The  minute  anatomy  shows  the 
picture  of  a  parenchymatous  and  an  interstitial  inflammation.  The 
gland-cells  are  in  part  eroded  or  show  cloudy,  granular  swelling  or  atro- 
phy. The  distinction  between  the  '  haupt '  and  '  beleg  '  cells  cannot  be 
recognized,  and  in  many  places,  particularly  in  the  pyloric  region,  the 


CHRONIC  CATARRHAL   GASTRITIS.  755 

tubes  have  lost  their  regular  form  and  show  in  many  places  an  atypical 
branching  like  the  fingers  of  a  glove.  Individual  glands  are  cut  off  to- 
ward the  fundus,  but  appear  at  the  border  of  the  submucosa  as  cysts, 
partly  empty,  with  a  smooth  membrane,  partly  filled  with  remnants  of 
hyaline  and  refractile  epithelium.  An  abundant  small-celled  infiltration 
presses  apart  the  tubules,  and  is  particularly  marked  toward  the  surface 
of  the  mucosa,  and  from  the  submucosa  extensions  of  the  connective  tissue 
may  be  seen  passing  between  the  glands.  The  mucoid  transformation  of 
the  cells  of  the  tubules  is  a  striking  feature  in  the  process  and  may  ex- 
tend to  the  very  fundus  of  the  glands."  Hemorrhagic  abrasions  may  be 
found  in  cases  due  to  cardiac  disease  or  to  portal  engorgement.  Super- 
ficial ulcers  may  form,  usually  in  the  pyloric  region  or  along  the  lesser 
curvature,  varying  in  size  from  a  few  lines  to  an  inch  or  more  in  diameter, 
and  nearly  circular  in  shape.  Long-standing  cases  also  present  sclerotic 
changes  of  the  mucous  membrane.  Of  these,  two  forms  are  distinguished. 
In  the  one  variety  the  mucous  membrane  is  perfectly  smooth  and  atro- 
phied ;  the  glands  are  displaced,  narrowed,  and  shortened,  while  the 
gap  thus  formed  is  more  or  less  filled  with  connective  tissue.  There  is 
a  thinning  of  the  stomach-wall,  with  enlargement  of  its  cavity.  The 
other  form  presents  a  hyperplasia  of  the  mucous  membrane,  the  gland- 
ular structure,  and  the  submucous  layer,  sometimes  resulting  in  enormous 
thickening  of  the  stomach-walls,  with  great  diminution  in  the  size  of  its 
cavity  (gastrophthisis).  The  contraction  of  the  new-formed  connective 
tissue  may  cause  polypoid  projections.  I  have  seen  one  instance  in 
which  the  stomach  held  less  than  a  half  pint. 

etiology. — It  is  evident  that  the  factors  which  produce  acute  gastric 
catarrh  wdll,  if  long  continued,  produce  a  chronic  condition.  The  causes 
of  chronic  gastritis  act  either  as  mechanical,  chemical,  thermic,  or  bio- 
logic irritants,  and  fall  naturally  into  the  folloAving  classes :  (a)  Errors 
of  diet  (referring  more  particularly  to  important  articles  of  food),  its 
variety,  and  preparation  ;  excessive  alimentation  ;  the  habit  of  eating 
at  irregular  intervals  or  with  undue  haste,  and  thus  not  allowing  time 
for  perfect  mastication  of  the  food.  The  too  free  use  of  ice-water,  tea, 
and  coffee  during  meals  plays  an  important  role  in  the  causation  of 
dyspepsia  in  America,  (b)  The  immoderate  use  of  alcohol  stands  second 
in  order  of  importance.  Those  persons  who  habitually  indulge  in  alco- 
holic beverages  to  excess  are  prone  to  an  irregular  mode  of  life,  which 
leads  to  digestive  disturbances.  Such  patients  are  apt  to  suffer  from 
the  more  active  forms  of  the  complaint,  and,  at  intervals  of  time,  from 
genuine  acute  gastritis.  In  the  same  category  should  be  mentioned 
certain  toxic  irritants,  as  the  over-use  of  tobacco  and  the  prolonged  use 
of  tonics  and  purgatives,  (c)  Functional  derangements  of  the  stomach 
sometimes  merge  into  the  disease  under  consideration.  This  is  true  of 
that  form  in  which  there  is  a  deficiency  in  the  gastric  juice.  Under 
these  circumstances  fermentative  and  putrefactive  changes  set  in. 
Stockton  holds  that  the  majority  of  cases  of  chronic  dyspepsia  are  of 
nervous  origin.  (d)  Local  mechanical  influences  (portal  congestion) 
may  offer  resistance  or  obstruction  to  the  olitflow  of  venous  blood  from 
the  stomach  to  the  right  heart.  In  this  way  chronic  gastric  catarrh 
is   a   secondary  process  in   chronic  affections   of  the  liver,   heart,   and 


756  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

lungs,  (e)  Such  constitutional  conditions  as  gout,  chronic  rheumatism, 
chronic  tuberculosis,  Bright's  disease,  diabetes,  anemia,  chlorosis, 
chronic  malaria,  syphilis,  and  chronic  forms  of  skin-disease.  The  ex- 
planation of  the  peculiar  liability  of  these  conditions  to  catarrh  of  the 
stomach  lies  in  the  obstruction  ofiered  to  the  passage  of  blood  through 
the  hepatic  and  cardio-pulmonary  circulation.  This  is  true  in  an  especial 
degree  in  chlorosis,  anemia,  chronic  tuberculosis,  and  malaria;  in  gout, 
chronic  Bright's  disease,  and  syphilis  it  is  probably  due  largely  to  the 
action  of  chemico-vital  irritants  in  the  circulating  medium. 

Clinical  History. — The  local  st/mptoms  bear  a  striking  resemblance 
to  those  of  other  forms  of  gastric  disturbance.  They  vary  greatly  in 
severity,  though  never  entirely  absent,  as  in  the  case  of  purely  functional 
disorders.  Deficient  secretion  of  the  gastric  juice,  due  to  the  anatomic 
changes  in  the  gastric  tubules,  is  a  potent  factor  in  the  production  of 
the  symptoms  directly  referable  to  the  stomach.  It  is  the  function  of 
hydrochloric  acid,  normally  present  in  the  gastric  secretions,  to  destroy 
the  ferment-producing  spores;  hence  when,  owing  to  lack  of  free  HCl, 
the  latter  are  not  destroyed,  deleterious  products  of  fermentation  are 
the  result,  these  in  turn  aggravating  and  prolonging  the  course  of  the 
affection.  Recent  investigations  go  to  show  that  deficient  motor  power 
is  more  important  than  a  deficiency  in  the  secretions  in  bringing  about 
the  clinical  phenomena  of  the  disease.  The  presence  of  an  inordinate 
amount  of  mucus  which  is  alkaline  in  reaction  neutralizes  in  part  the 
HCl ;  it  may  also  more  or  less  completely  cover  the  ingesta,  thus  pre- 
venting the  gastric  secretions  from  reaching  them,  and  lengthening,  at 
the  same  time,  the  period  of  digestion. 

Among  the  earlier  symptoms  directly  attributable  to  the  gastric 
lesions  are  anorexia  (though  at  times  the  appetite  may  be  moderately 
good  or  even  keen) ;  fulness  and  distress ;  burning  sensations  and  dull 
pain  in  the  epigastric  region  ;  eructations  of  gas,  Avhich  may  be  either 
offensive  or  odorless,  during  and  immediately  after  meals;  regurgitation 
of  fluid,  either  acid  (heartburn),  due  to  the  presence  of  organic  or  hydro- 
chloric acid,  or  a  bitter  form  of  peptones.  These  symptoms  are  usually 
increased  in  intensity  after  meals.  The  tongue  frequently  appears  broad 
and  flabby,  and  almost  constantly  the  edges  and  tip  are  somewhat  red- 
dened, whilst  the  papillte  are  enlarged.  Occasionally  it  is  small,  with 
enlarged  and  red  papilla?,  or  it  may  look  healthy.  A  bad  or,  at  times, 
a  persistently  bitter,  taste  in  the  mouth  and  great  thirst  may  be  com- 
plained of.  There  is  often  a  profuse  secretion  of  saliva,  but  the  mouth 
may  be  dry.  Nausea  is  common,  and  is  most  marked  in  the  morning 
hours ;  it  is  frequent  before  or  after  meals,  and  often  vomitiny  oc- 
curs either  immediately  after  meals  or  a  couple  of  hours  later.  The 
vomitus  will  vary  somewhat  with  the  time  of  the  occurrence  of  emesis. 
Usually  it  consists  of  food  in  the  first  stages  of  digestion,  mixed  with 
large  quantities  of  mucus.  In  alcoholic  catarrh  morning  vomiting  occurs 
quite  commonly,  and  consists  of  a  watery  fluid  composed  of  saliva  and 
mucus.  This  class  of  sufferers  from  chronic  gastritis  not  infrequently 
exhibits  well-marked  evidences  of  salivation.  I  have  repeatedly  found 
the  material  vomited  in  chronic  gastric  catarrli  to  be  acid  in  reaction, 
unless,  as  occasionally  happens,  the  vomiting  takes  place  several  hours 


CHRONIC  CATARRHAL   GASTRITIS.  757 

after  eating,  when  it  is  sometimes  faintly  alkaline  or  neutral.  The 
acidity  of  the  vomitus  is  not  due  to  the  presence  of  free  HCl,  but 
possibly  in  small  measure  to  combined  HCl,  and  partly  and  sometimes 
largely  to  acid  salts  or  the  weaker  acids  (lactic,  butyric)  resulting  from 
the  abnormal  processes  of  fermentation. 

3Iicroscopie  examination  sometimes  reveals  the  presence  of  sarcinse 
ventriculi,  yeast  fungi,  and  numerous  bacterial  organisms.  The  relations 
of  these  low  forms  of  life  to  the  pathologic  processes  going  on  in  the 
stomach  are  not  well  understood,  except  in  the  case  of  the  yeast  fungus, 
which  is  concerned  with  the  process  of  fermentation.  The  sarcinse 
ventriculi  may,  however,  exercise  a  causative  influence,  since  certain 
cases  yield  readily  to  the  antiseptic  method  of  treatment. 

A  chemical  examination  of  the  contents  of  the  stomach  for  purposes  of 
diagnosis  according  to  the  methods  laid  down  in  the  preliminary  section 
{vide  p.  735)  should  not  be  neglected.  In  simple  chronic  gastric  catarrh 
the  hydrochloric  acid  is  found  to  be  diminished,  and  rarely  lactic,  buty- 
ric, and  acetic  acids  are  present.  In  many  cases  of  chronic  catarrhal 
gastritis  there  is  an  abundance  of  mucus  {gastritis  mucipara — Boas) ; 
and  in  other  cases  there  is  present  a  normal  amount  of  acid  or  even 
hyperacidity — the  gastritis  acida  of  Boas.  In  protracted  forms  free 
HCl  is  sometimes  greatly  diminished  or  entirely  absent — gastritis 
anacida.  According  to  Boas  the  difi"erence  between  this  and  the 
atrophic  form  is  but  one  of  degree,  all  secretion  being  lost  in  the  lat- 
ter. On  the  other  hand,  in  atrophic  gastritis  there  is  little  or  no  mucus 
in  the  gastric  contents,  while  there  is  in  established  cases  an  absence 
of  HCl  and  of  the  gastric  ferm.ents  {gastritis  atroj^hicans).  Ewald  has 
subdivided  all  cases  into  three  varieties :  {a)  Simjjle  gastritis,  in  which 
the  fasting  stomach  contains  only  a  small  quantity  of  slimy  fluid,  while 
after  the  test-breakfast  the  HCl  is  diminished  in  quantity,  and  lactic 
acids  and  the  fatty  acids  are  usually  present,  {b)  Mucous  gastritis, 
in  which  class  the  acidity  is  always  slight  and  the  condition  is  distin- 
guished from  simple  gastritis  by  the  large  amount  of  mucus  present, 
(c)  Atrophy.  Here  the  fasting  stomach  is  always  empty,  while  after 
the  test-breakfast  HCl,  pepsin,  and  the  curdling  ferments  are  wholly 
wanting. 

The  absorbent  and  motile  powers  of  the  stomach  are  both  more  or 
less  diminished. 

Physical  Signs. — Sometimes  there  may  be  observed  an  undue  disten- 
tion of  the  stomach,  the  prominence  being  more  marked  toward  the  left. 
On  making  firm  pressure  over  the  epigastric  region  tenderness  is  often 
elicited.  This  is  not  present  in  the  early  stages,  nor  constantly  later, 
since  the  degree  of  inflammatory  action  is  subject  to  great  oscillation. 
Difi'use  tenderness  in  the  absence  of  a  new  growth  is  of  great  diagnostic 
value.  It  is  to  be  recollected,  however,  that  resistance  may  be  felt  when 
the  stomach  is  thickened  in  chronic  interstitial  gastritis.  Dilatation 
of  the  organ  may  be  indicated  by  splashing-sounds,  and  these  may  be 
present  in  the  absence  of  gastrectasis  at  a  time  when  the  stomach  should 
contain  no  food. 

On  percussion  we  may  note  alterations  in  the  size  of  the  organ. 

Among  the  general  or  indirect  symptoms  manifested  the  nervous  phe- 
nomena are  of  first  importance.      So  prominent  are  they  in  the  clinical 


758  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

picture  ofttimes  as  to  lead  the  incautious  physician  to  the  conclusion  that 
his  patient  is  suffering  from  some  primary  disease  of  the  brain  or  nerves. 
The  nervous  derangements  have  been  attributed  solely  to  morbid  sympa- 
thetic disturbances ;  it  is  quite  probable,  however,  that  we  should  ascribe 
a  share  of  the  morbid  influence  to  the  absorption  of  toxic  materials  from 
the  stomach  and  intestines.  Headache  is  frequently  complained  of;  it  is 
generally  frontal,  though  also  occipital,  and  tends  to  appear  before  meals. 
The  so-called  sick  headache  more  rarely  occurs.  Indisposition  to  mental 
or  physical  exertion,  vertigo,  depression  of  spirits,  and  well-marked  hypo- 
chondriasis are  common  concomitants.  Patients  complain  of  wakeful- 
ness and  disturbed  dreams,  though  drowsy  after  meal-time.  There  is  a 
sympathetic  disturbance  of  the  cardiac  rhythm,  and  sometimes  dyspnea, 
owing  to  the  same  cause.  The  urine  is  often  highly  colored,  scanty,  and 
deposits  an  abundant  uratic  sediment ;  occasionally,  however,  it  is  of  low 
specific  gravity,  rather  copious  in  amount  and  pale  in  color,  owing  to  the 
influence  of  phosphates.  This  condition  is  found  in  cases  in  which  the 
nervous  element  is  notably  prominent. 

Complications. — The  intestines  often  become  involved,  and  usually 
by  direct  extension.  Implication  of  the  duodenum  may  lead  to  jaundice 
and  to  obstinate  constipation,  though  only  moderate  constipation  is  the 
rule  in  catarrh  of  the  stomach.  When  the  process  extends  to  the  large 
intestines  diarrliea  develops.  Alternating  constipation  and  diarrhea  are 
often  observed.  The  nutritive  system  is,  in  confirmed  cases,  seriously 
implicated,  as  shown  by  the  anemia,  emaciation,  and  general  debility 
present.  It  is  particularly  in  examples  of  combined  intestinal  and 
gastric  catarrh  that  we  observe  the  most  notable  impairment  of  the  gen- 
eral health,  and  the  reason  of  this  will  be  clear  when  it  is  recollected 
that  under  these  circumstances  all  the  digestive  fluids  are  lessened  in 
amount.  The  gases  generated  in  the  stomach  often  find  their  way  into  the 
intestinal  canal,  giving  rise  to  distention,  and  sometimes  to  colicky  pain. 
Perhaps  many  reflex  sympathetic  disturbances  are  of  intestinal  origin. 
The  gastric  catarrh  may  extend  upward  to  the  oral  cavity.  Under  such 
circumstances  the  tongue  is  large  and  heavily  coated,  with  impressions  of 
the  teeth  upon  its  edges.  Since  the  mucous  membranes  are  unhealthy, 
there  is  produced  an  abnormal  condition  of  the  secretions  that  renders 
the  breath  foul  and  causes  thirst.  Certain  skin-eruptions,  as  eczema, 
lichen,  and  urticaria,  are  common  concomitants  of  this  disease.  By 
some  authors  these  disorders  of  the  skin  are  supposed  to  be  caused  by 
the  catarrh  of  the  stomach.  I  have  frequently  observed,  however,  that 
when  present  their  improvement  has  been  followed  by  an  aggravation  of 
the  gastric  symptoms,  and  vice  versd.  A  sequel  of  the  disease  is  dilata- 
tion of  the  stomach,  but  I  believe  this  to  be  less  frequent  than  was  for- 
merly supposed.  The  course  of  chronic  gastric  catarrh  is  long,  the  average 
duration  being  considerably  more  than  one  year.  Its  duration  may  be 
much  abridged  by  early  recognition  and  proper  treatment  of  the  condi- 
tion.   The  symptoms  at  first  intermit  and  are  mild,  but  later  are  persistent. 

Diagnosis. — A  positive  diagnosis  may  be  based  on  a  clear  etiology, 
the  presence  of  persistent  symptoms  and  signs  of  chronic  disturbance  of 
digestion,  a  diminished  [usually),  normal,  or  even  increased,  amount 
of  HCl  (the  atrophic  form  apart,  vide  supra),  an  abundance  of  mucus 
in  the  gastric  contents,  and  deficient  absorptive  and  motor  power. 
The  points  of   difference  between  the  more    serious    aff'ections    of  the 


CHRONIC  CATARRHAL   GASTRITIS.  759 

stomach  (carcinoma,  ulcer,  and  dilatation)  and  chronic  gastric  catarrh 
■will  be  detailed  when  the  former  diseases  are  considered.  As  I  have  said, 
Ewald  makes  three  leading  forms  of  the  complaint,  based  on  the  results 
obtained  from  an  analysis  of  the  stomach-contents,  but  transitional  or 
atypical  types  are  constantly  met  with  in  practice. 

Prognosis. — Chronic  catarrh  of  the  stomach  may  be  said  not  to 
manifest  an  innate  lethal  tendency.  It,  ho"svever,  predisposes  to,  as  well 
as  aggravates,  the  symptoms  of  existing  forms  of  acute  and  serious  forms 
of  chronic  diseases,  especially  other  organic  affections  of  the  stomach. 
The  prognosis  depends  considerably  upon  the  stage  that  has  been 
reached  Avhen  first  met  with,  since  the  condition  is  amenable  to  treatment 
only  when  not  too  far  advanced.  The  prognosis  is  rendered  somewhat 
more  grave  by  the  presence  of  certain  complications,  particularly  the 
presence  or  absence  of  intestinal  involvement.  I  have  seen  one  case 
that  proved  fatal  in  consequence  of  stricture  of  the  pylorus. 

Treatment. — It  must  never  be  forgotten  as  far  as  possible  to  search 
for  and  remove  the  causal  affections  in  every  case.  When  associated  with 
grave  forms  of  cardiac,  hepatic,  or  renal  disease  these  must  receive  care- 
ful attention  primarily. 

The  masticating  apparatus  must  be  looked  after  by  the  physician,  who 
must  also  instruct  his  patient  in  the  art  of  eating  slowly,  so  that  insaliva- 
tion  of  the  food  is  thoroughly  effected.  Too  often  the  quantity  of  ali- 
ment consumed  is  beyond  the  need  of  the  bodily  functions,  and  the 
method  of  preparing  the  same  faulty.  All  food  eaten  should  be  fresh 
and  pure.  Such  patients  should  eat  oftener  than  in  health,  taking  four 
or  five  meals  in  the  twenty-four  hours.  The  physician  must  with  untir- 
ing diligence  attend  to  every  dietetic,  sanitary,  and  therapeutic  detail. 
The  major  portion  of  the  treatment  has  relation  to — 

(1)  The  Diet. — In  the  matter  of  arranging  the  dietary  in  separate 
cases  the  general  condition  and  peculiarities  of  the  individual  must  be 
taken  into  account.  The  wise  physican  will  be  guided  to  some  extent  by 
the  dictates  of  his  patient's  experience,  and  wall  not  fail  to  avail  himself 
of  any  information  obtainable  upon  this  head.  In  severe  cases  an  exclu- 
sive milk  diet  for  a  period  of  two  to  four  weeks  often  gives  the  best  re- 
sults. The  daily  amount  requisite  to  meet  the  demands  of  the  vital  functions 
is  4  to  8  pints.  Of  this,  5  to  8  ounces  are  to  be  taken  slowly  every  two 
hours  during  the  day.  The  beginning  amount,  however,  must  occasion- 
ally be  smaller — 2  to  3  ounces — to  be  gradually  increased.  A  pinch  of 
salt  or  from  |-  to  1  ounce  of  lime-water  may  be  added  to  each  feeding,  or 
the  milk  may  be  diluted  with  Vichy.  The  milk  should  not  be  taken  iced, 
but  warmed  or  at  the  temperature  of  the  room.  Boiled  milk  is  objection- 
able. The  stools  are  to  be  watched  for  curds,  and  when  the  digestive 
capacity  is  exceeded  the  amount  of  the  nutrient  should  be  lessened  and 
other  articles  cautiously  added. 

When  ivhole  milk  cannot  be  digested  on  account  of  an  actual  loathinsr 
for  it,  skimmed  or  partly  skimmed  milk  or  buttermilk  should  be  substi- 
tuted. If  the  latter  cannot  be  utilized  in  proper  amount,  animal  broths, 
together  with  some  of  the  artificial  foods  (panopeptone,  liquid  peptonoids), 
may  be  added.  As  tolerance  for  a  liberal  amount  of  milk  becomes  estab- 
lished the  appetite  is  no  longer  satisfied,  and  then  I  begin  to  add  the 
light  solids  in  a  gradual  manner  ;  for  example,  white  meat  of  chicken  or 


760  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

game  (except  tame  ducks  and  turkey),  stale  or  twice-baked  bread,  milk 
or  dry-toast  or  zweiback,  soft-boiled  eggs,  oysters,  fish,  and,  later,  Ham- 
burg steaks,  stewed  sweetbread,  and  the  like.  For  dessert,  junket  or  cus- 
tards, sweetened  with  saccharin,  are  well  borne  as  a  rule.  Subsequently, 
farinaceous  articles,  if  thoroughly  cooked  (except  oatmeal),  and  certain 
plain  vegetables,  may  be  allowed,  but  their  effects  must  be  minutely  ob- 
served. The  former  are  to  be  eschewed  in  cases  in  which  acid-fermenta- 
tion or  flatulency  is  a  prominent  feature.  Among  the  latter,  rice,  spin- 
ach, lettuce,  and  macaroni  (stewed  in  milk)  are  to  be  selected.  Peas  and 
beans,  if  green  and  succulent,  may  be  tried,  but  if  ripe  are  to  be  dis- 
carded. The  only  form  of  fat  permissible  is  good  butter.  Stewed 
fruits,  Graham  bread,  and  soft,  green  vegetables  are  often  well  borne 
and  tend  to  overcome  constipation.  Pig  s-  and  calf's-foot  jelly  may  be 
allowed. 

In  light  cases  and  in  those  of  moderate  severity,  particularly  if  the 
cause  of  the  complaint  is  removable,  the  dietary  need  not  be  rigid  at  the 
start.  Indeed,  to  minimize  the  saccharine  articles  and  starches  and  to 
avoid  the  coarser  vegetables,  hot  bread,  pastries,  and  the  like,  is  all  that 
is  required.  In  the  case  of  confirmed  dyspeptics  the  following  articles 
are  to  be  scrupulously  avoided :  very  fiit  meats,  fat  fish-foods,  condiments, 
certain  fruits  (strawberries,  bananas),  hot  bread,  saccharine  articles  of 
diet  and  farinacea,  potatoes,  particularly  sweet  potatoes,  and  other  coarser 
vegetables. 

Of  drinks,  the  best  during  meal-time  is  simple  hot  water,  to  which  a 
little  milk  may  be  added,  or  a  single  coffee-cup  of  weak  tea.  Occasion- 
ally cocoa  is  allowable,  but  ordinary  chocolate,  coffee,  and  strong  tea  are 
harmful.  Too  much  liquid  should  not  be  taken  during  a  meal,  since  it 
dilutes  the  gastric  secretion  to  a  deleterious  extent,  and  cold  drinks  are 
to  be  interdicted  during  the  same  period.  Alcohol,  and  particularly  con- 
centrated spirituous  liquors,  exert  an  irritating  effect,  and  hence  should 
be  forbidden.  In  cases  in  which  there  is  no  gastric  fermentation  certain 
wines  may  be  allowed  (Oporto.  Malaga,  imported  Hungarian  Tokay). 

(2)  Hygienic  measures  are  of  signal  value  in  this  disease.  Of  these 
the  most  important  are  forms  of  fresh-air  exercise,  as  bicycling,  walking, 
boating,  and  horseback-riding.  Suitable  indoor  apparatus  for  physical 
exercise  is  now  easily  obtainable  at  little  cost,  and  therefore  open-air 
exercise  may  be  supplemented  by  the  latter.  Physical  exercise  must  be 
carefully  supervised,  so  as  to  avoid  the  deleterious  effects  of  over-exertion. 
I  am  convinced  of  the  superior  advantage  of  travel,  including  a  sea- 
voyage,  and  an  appropriate  change  of  air — for  example,  to  the  seaside 
or  mountains — particularly  for  the  large  class  of  self-centered  and  low- 
spirited  dyspeptic  patients.  A  cold  sponge-bath,  followed  by  brisk  fric- 
tion of  the  skin,  is  to  be  advised.  An  abdominal  bandase,  made  of  wool- 
len  or  silk  material  and  constantly  worn,  tends  to  increase  the  patients 
comfort. 

(3)  Medicinal  Treatment. — Saline  laxatives,  as  sodium  phosphate, 
Rochelle  salts  or  Carlsbad  salts,  taken  fasting  in  hot  water,  are  advan- 
tageous, since  they  serve  to  regulate  the  bowels,  to  deplete  the  engorged 
gastro-intestinal  vessels,  as  well  as  to  rinse  the  stomach.  Hunyadi  Janos 
or  Carlsbad  mineral  waters  may  be  substituted.     Their  efficacy  is  much 


CHRONIC  CATARRHAL   GASTRITIS.  761 

enhanced  when  the  alkaline  carbonates  are  administered  simultaneously. 
Further  than  this,  little  is  needed  in  the  majority  of  instances.  The 
use  internally  of  antiseptics,  combined  with  alteratives  and  mild  astrin- 
gents, is  often  beneficial.  I  can  speak  most  positively  in  favor  of  the 
following  pill : 

^i.  Argenti  nitratis,  gr.  iv     (0.259)  ; 

Ext.  hyoscyami,  gr,  viij  (0.518), 

M.  et  ft,  pil.  No.  xvj. 
Sig.   One  about  one  hour  before  each  meal,  the  stomach  being 
first  prepared  by  rinsing  with  a  2  per  cent,  solution  of 
borax  in  water. 

Hemmeter  recommends  silver  nitrate,  in  the  form  of  lavage  (1  :  2000), 
or  in  the  form  of  solution  0.3  to  120  of  peppermint-water  ;  of  this  one 
tablespoonful  three  times  daily  on  an  empty  stomach. 

In  the  fermeritative  form  of  chronic  gastric  catarrh  the  hyperacidity  is, 
in  reality,  often  dependent  upon  the  lack  of  free  HCl ;  hence  this  agent 
should  be  supplied.  It  is  best  administered  immediately  after  meals,  the 
dose  being  not  less  than  10  minims  (0.666),  well  diluted,  and  this  may  be 
repeated  in  the  course  of  ten  or  fifteen  minutes  in  obstinate  cases ;  it  may 
be  combined  advantageously  with  pepsin  (gr.  v-x — 0.324-0.648)  or  pan- 
creatin  (gr.  x — 0.648).  Pancreatin  is  better  associated  with  sodium  bi- 
carbonate in  the  form  of  a  tablet  containing  each  gr.  ij  (0.129).  Of 
these  two  or  three  may  be  administered  fifteen  to  thirty  minutes  after 
meal-time.  Care  is  to  be  taken  to  use  only  the  best  articles  of  pepsin 
and  pancreatin.  When  hyperacidity  exists,  diastas6  and  ptyalin  may  be 
exhibited,  but  I  have  failed  to  obtain  encouraging  results  from  their 
employ.  This  class  of  cases  represents  an  aggravated  or  advanced  form 
of  the  disease  (atrophic  stage),  and  demands  prolonged  and  varied  treat- 
ment. At  the  end  of  the  digestive  process  it  is  well  to  thoroughly  irri- 
gate the  stomach  (lavage),  and  more  particularly  if  evidences  of  dilatation 
be  present.  The  stomach  may  also  be  cleansed  and  prepared  for  the  re- 
ception of  the  next  meal  in  a  very  agreeable  manner  by  having  the 
patient  sip  a  2  per  cent,  solution  of  borax  in  warm  water  or  a  2  per  cent, 
solution  of  sodium  chlorid  half  an  hour  before  meals ;  indeed,  the  con- 
tinued use  of  simple  hot  water  for  the  same  purpose  has,  in  my  hands, 
often  given  excellent  results.  With  it  must,  of  course,  be  combined  the 
saline  laxatives  and  the  restricted  diet.  Not  less  than  1  pint  of  water, 
hot  as  it  can  be  taken  by  the  patient,  should  be  sipped  at  each  sitting. 

To  assist  the  appetites  of  these  patients  and  to  stimulate  the  secretory 
function  a  few  drops  (not  more  than  5)  of  the  tincture  of  nux  vomica  may 
be  given  fifteen  minutes  before  meals,  with  gr,  ij-iij  (0.129-0.194)  of  so- 
dium bicarbonate.  These  indications  are  also  fulfilled  by  lavage  once  daily 
or  bi-daily  (if  the  patient  be  feeble).  If  hyperacidity,  due  to  the  organic 
acids,  persists  despite  the  measures  already  recommended,  we  may  combine 
bismuth  subnitrate  with  magnesia  and  a  few  grains  of  charcoal,  this  being 
administered  when  the  stomach  is  empty.  We  may  also  check  fermenta- 
tion by  the  exhibition  of  salicylic  acid  (gr.  v — 0.324)  thrice  daily  or  cre- 
asote  (gr.  |- — 0.0324)  thrice  daily.  Germain  See  has  recently  found  stron- 
tium bromid  (^ss  to  3j  ;  2.0—4.0)  to  be  of  great  value  in  cases  in  which 
gaseous  fermentation  with  hyperacidity  is  combined  with  permanent  ten- 


762  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

derness.  Happy  results  often  follow  a  course  at  some  spa  if  the  patient 
be  under  the  charge  of  a  competent  physician  during  his  sojourn.  The 
robust  or  plethoric  should  go  to  Carlsbad,  Ems,  and  Kissingen  abroad, 
and  to  Saratoga  in  this  country,  using  more  especially  the  Hawthorne 
water.  The  anemic  should  go  to  Franzenbad  or  the  spa  near  Brussels, 
and  in  this  country  to  the  iron  springs  at  Bedford,  Pennsylvania.  A 
course  of  the  alkaline  mineral  waters  may  be  successfully  taken  at  home 
in  many  instances,  though  patients  are  much  more  apt  to  obey  the  phy- 
sician's injunctions  as  to  diet,  exercise,  and  the  like  when  at  a  spa  than 
when  at  home.  These  waters  do  not  simply  act  as  purgatives,  but  also 
as  antacids.  It  has  been  experimentally  shown  that  sodium  chlorid,  so- 
dium carbonate,  as  well  as  carbon  dioxid,  promote  the  secretion  of  the 
gastric  juice.  In  the  more  chronic  cases  belonging  to  this  class  or  those 
that  have  resisted  other  forms  of  treatment  intestinal  complications  are 
usually  found.  Here  the  alkaline  waters  are  to  be  alternated  with  calomel 
in  small  doses,  prescribed  thus : 

I^.   Hydrarg.  chloridi  mitis,  gr.  ij  (0.129); 

Sodii  bicarb.,  3J        (-1.0) ; 

Sacchari  lactis,  3ss      (2.0). 

M.  et  ft.  chart.  No.  xij. 
Sig.   One,  dry  on  the  tongue,  four  times  daily. 

I  have  been  in  the  habit  of  continuing  the  use  of  these  powders  for 
several  days  to  one  week,  then  returning  to  the  alkaline  waters  for  two 
weeks,  and  so  on. 

In  the  mucous  variety  of  gastric  catarrh  additional  indications  for 
treatment  are  presented.  The  chief  aim  should  be  to  limit,  as  far  as 
possible,  the  production  of  mucus  and  to  cleanse  thoroughly  the  stomach 
prior  to  each  meal,  thus  preparing  the  organ  for  the  reception  and  better 
digestion  of  food.  Here,  again,  at  least  one  pint  of  hot  water,  contain- 
ing the  substances  before  mentioned,  should  be  sipped  half  an  hour  before 
each  meal.  This  mode  of  cleansing  the  stomach  is  usually  successful ;  if 
unsuccessful,  however,  it  should  be  supplemented  by  lavage  once  daily, 
using  the  same  solutions  as  above  indicated,  though  in  larger  quantities. 
The  siphon  is  also  highly  useful  in  cases  of  this  sort  in  which  stricture  of 
the  pylorus  is  suspected  and  when  the  food  is  retained  in  the  stomach 
much  longer  than  the  normal  period  of  digestion.  This  frequently 
happens,  for  the  reason  that  the  mucous  covering  which  the  food  receives 
not  only  prevents  it  from  being  acted  upon  by  the  gastric  juice,  but  also 
renders  absorption  tardy.  The  therapy  of  this  form  of  chronic  gastritis 
requires,  in  addition  to  what  has  before  been  given,  the  more  potent 
astringents  for  the  purpose  of  arresting  hypersecretion  of  mucus.  The 
best  way  to  use  these  agents  is  topically.  The  stomach  may  be  washed 
out  (at  bed-time  or  early  in  the  morning)  with  a  2  per  cent,  solution  of 
alum  or  a  1  per  cent,  solution  of  tannic  acid ;  antiseptic  solutions  are 
employed  in  like  manner,  a  2  per  cent,  solution  of  salicylic  acid  being 
especially  efficacious.  If  lavage  cannot  be  practised,  such  astringents  as 
catechu,  cerium  oxalate,  and  silver  nitrate,  with  small  doses  of  opium 
[vide  supra),  should  be  tried.  For  use  internally  one  of  the  very  best 
remedies  is  atropin  sulphate. 

Certain  symptoms  belonging  to  all  varieties  of  the  affection  may  demand 


GASTRIC   ULCER.  763 

relief.  These  must  be  met  in  accordance  with  general  principles.  Vom- 
iting, which  is  at  times  a  distressing  symptom,  is  best  allayed  by  small 
doses  of  resorcin  or  creasote  in  combination  with  cerium  oxalate. 

As  soon  as  the  morbid  irritability  of  the  stomach  has  been  reduced 
mild  forms  of  bitter  tonics,  with  a  view  to  imparting  vigor  to  the  digestive 
organs,  may  be  cautiously  employed.  Their  too  early  use  is  very  apt  to 
aggravate  existing  symptoms,  or  even  to  reproduce  such  as  have  already 
disappeared.     Iron  is  often  indicated  during  convalescence. 


GASTRIC  ULCER. 

{Simple  or  Round  Ulcer  of  the  Stomach.) 

Definition. — An  ulcer  presenting  sharp  borders,  with  a  tendency  to 
extend  in  depth,  generally  without  collateral  inflammation,  giving  rise, 
usually,  to  one  or  more  characteristic  symptoms,  as  pain,  vomiting,  and 
hematemesis.     Peptic  ulcers  may  be  single,  but  are  oftener  multiple. 

Pathology. — The  gross  anatomic  characteristics  and  peculiarities 
may  be  briefly  considered  seriatim,  (a)  In  shape  it  is  usually  round  or 
oval.  It  often  happens  that  there  are  several  ulcers,  and  these  may 
form  larger  ones  having  irregular  borders.  They  are  at  first  superficial, 
though  their  floor  (when  seen  at  autopsy)  is  below  the  mucous  membrane, 
owing  to  a  tendency  to  extend  in  depth.  This  characteristic  has  given 
rise  to  the  term  "perforating  ulcer."  Thus,  the  ulcer  has  for  its  base, 
very  frequently,  the  muscular  or  serous  coats,  but  sometimes,  and  not 
rarely,  the  ulcerative  process  extends  through  the  walls  of  the  stomach, 
in  which  case  adhesions  form  between  the  stomach  and  the  adjacent  vis- 
cera, one  or  other  of  the  latter  organs  occupying  the  base  of  the  ulcer. 
Almost  always  the  walls  slope  inward,  giving  rise  to  the  characteristic 
funnel-shape.  The  edges  may,  however,  be  sharp  and  abrupt.  The  floor 
of  the  ulcer  is  quite  generally  clean,  and  rarely  may  present  a  hemor- 
rhagic aspect.  A  recent  ulcer  presents  clean-cut  edges,  that  are  not  the 
seat  of  collateral  inflammatory  edema,  though  an  old  ulcer  often  presents 
somewhat  thickened  margins,  {h)  In  size  it  is  quite  variable.  The 
majority  of  the  ulcers  are  not  larger  than  a  dime;  others  may  measure 
as  much  as  10  cm.  (4  inches)  in  their  greatest  diameter.  The  edges  are 
almost  invariably  formed  from  the  coalescence  of  two  or  more  smaller 
ones,  (c)  The  positio7i  is  most  frequently  near  the  pylorus  on  the  poste- 
rior wall,  and  particularly  in  the  vicinity  of  the  lesser  curvature.^  For- 
tunately, they  occupy  the  anterior  surface  but  rarely,  this  being  a  danger- 
ous situation,  as  will  presently  be  explained. 

The  ulcer  often  heals  by  cicatrization.  The  resulting  scar  is  pale  and 
stellate,  and  there  is  puckering  of  the  surrounding  mucous  membrane. 
If  the  ulcer  has  not  extended  deeper  than  the  mucous  membrane,  granu- 
lation-tissue develops  from  the  edges  and  base ;  this  tissue  slowly  con- 

^  Of  793  cases  collected  by  Welch  from  hospital  statistics,  288  were  on  the  lesser 
curvature,  235  on  the  posterior  wall,  95  at  the  pylorus,  69  on  the  anterior  wall,  50  at  the 
cardia,  29  at  the  fundus,  27  on  the  greater  curvature.  The  duodenal  ulcer  is  usually  sit- 
uated just  outside  the  ring  in  the  first  portion  of  the  gut  (Osier,  page  369). 


764  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tracts,  uniting  the  margins  and  leaving  a  comparatively  smooth  scar. 
On  the  other  hand,  if  the  ulcer  be  large  and  involve  the  muscular  and 
serous  coats,  stricture  of  the  pylorus,  followed  by  dilatation,  may  re- 
sult. The  stomach  may  present  an  hour-glass  shape,  due  to  the  con- 
traction of  a  girdle  ulcer  in  the  central  part  of  the  organ.  .  Nearly  all 
gastric  ulcers  would  perforate  the  coats  were  it  not  for  the  development 
of  a  localized  peritonitis  with  the  establishment  of  protective  adhesions. 
The  ulcers  being  usually  situated  on  the  posterior  wall,  the  surface  of 
the  pancreas  forms  the  point  of  attachment  most  frequently,  though  the 
stomach  may  also  become  adherent  to  the  left  lobe  of  the  liver,  the 
spleen,  omentum,  diaphragm,  or  the  transverse  colon.  The  organs  with 
which  the  stomach  becomes  agglutinated  may  be  penetrated  by  the 
ulcerative  process,  resulting  in  suppurative  inflammation  (abscess);  or. 
guided  by  the  limiting  adhesions,  fistulous  connections  of  the  stomach 
with  the  transverse  colon,  the  pleura,  the  pericardium,  lungs,  gall- 
bladder, and  the  duodenum  may  be  established.  Of  these,  gastrocolic 
fistulie  are  the  most  common.  Osier  states  that  there  are  two  instances 
on  record  in  which  the  ulcer  perforated  the  left  ventricle.  Penetration 
of  the  ulcer  through  the  posterior  gastric  wall  opens  the  lesser  perito- 
neal cavity,  in  which  case  the  base  remains  limited,  producing  a  condi- 
tion known  as  subphrenic  pyo-pneumothorax.  When  the  anterior  surface 
of  the  stomach,  which  has  no  anatomic  relations  Avith  other  organs  favor- 
able for  the  establishment  of  protective  adhesions,  is  perforated,  general 
infectious  peritonitis  rapidly  supervenes  if  a  fatal  end  be  not  reached  im- 
mediately. Intense  hyperemia  or  the  erosion  of  small  vessels  gives  rise 
to  small  or  moderate  hemorrhages.  If  the  ulcer  penetrate  one  of  the 
larger  vessels,  as  happens  not  rarely,  then  profuse  and  even  fatal  hema- 
temesis  is  the  result.  This  accident  is  doubtless  frequently  prevented 
by  the  development  of  a  "  protective  thrombosis."  In  several  instances 
small  aneurysms  have  been  found  at  the  bases  of  the  ulcers  (Doucrlas, 
Powell.  Welch). 

Htiology. — Since  gastric  ulcer  was  first  accurately  described  by  Cru- 
veilhier  many  and  widely  various  theories  as  to  its  mode  of  origin  have 
been  promulgated.  Whilst  there  is  to-day  no  universally  accepted  view 
of  its  pathogenesis,  yet  there  are  two  points  that  may  be  regarded  as 
definitely  settled :  (a)  that  the  ulcer  is  due  to  a  self-digestion  of  a  cir- 
cumscribed portion  of  the  stomach  ;  (b)  that  the  alkalinity  of  the  part 
digested  has  been  previously  reduced.  Among  the  conditions  lessening 
the  supply  of  alkaline  arterial  blood,  which,  as  is  well  known,  prevents 
the  stomach  from  being  digested  in  health,  the  chief  are  embolism  and 
thrombosis  of  the  nutrient  artery  of  the  part,  the  infarct  thus  produced 
being  annihilated  by  the  gastric  secretions  (Virchow).  This  view  receives 
confirmation  from  the  experiments  of  Claude  with  rabbits  that  Lad  died 
of  inanition.  On  postmortem  examination  there  was  found  hemorrhage 
into  the  muscular  coat  of  the  stomach  ;  this  was  caused  by  thrombosis 
of  the  arterioles  followed  by  rupture,  which  Avould  have  given  rise  to 
ulceration.  Opposed  to  this  view  are  the  experiments  by  Panum  and 
Cohnheim,  which  show  that  ulcers  produced  artificially  tend  to  heal 
rapidly.  Stockton  holds  that  the  disease  is  a  neurosis.  Traumatic 
injuries  of  the  mucosa  and  external  traumatism  have  been  suggested. 
Predisposing  Causes. — Most  influential  stands,  doubtless,  hyperacidity 


GASTRIC  ULCER,  765 

of  the  gastric  juice-^a  condition  almost  universally  present  in  this  dis- 
ease; although  the  ulcers  may  not  result  primarily- from  the  presence 
of  an  excess  of  acid,  it  is  quite  probably  that  further  extension  of  the 
ulcerative  process  may  be  due  to  this  factor.  Peter  assumes  the  cause 
of  simple  ulcer  to  be  gastritis,  and  it  is  often  met  "with  in  connection 
with  the  latter  disease.  The  aifection  is  often  secondary  in  chlorosis, 
anemia,  and  oftener  still  in  amenorrhea.  The  fact  that  in  all  the  dif- 
ferent forms  of  anemia  there  is  a  diminished  alkalinity  of  the  blood  is 
of  great  interest  in  this  connection.  Obviously,  then,  ulcer  occurs  more 
frequently  in  females  than  in  males.  It  is  most  common  between  seven- 
teen and  thirty-five  years ;  it  is  rare  in  young  children,  though  Gorgarf 
saw  an  instance  in  a  child  thirty  hours  after  birth,  and  less  rare  in  those 
past  middle  life.  It  is  more  frequent  in  the  poor  than  in  the  rich  ;  occu- 
pation has  also  a  noticeable  influence,  and  I  have  personally  seen  a 
number  of  instances  in  weavers.  It  is  also  prone  to  attack  servants, 
cooks,  and  needlewomen  among  females,  and  shoemakers  and  tailors 
among  males. 

Clinical  History. — In  typical  cases  of  gastric  ulcer  the  clinical 
symptoms  are  almost  positively  diagnostic.  The  earliest  manifestations 
commonly  point  to  chronic  or  subacute  gastric  catarrh,  these  being  fol- 
lowed, soon  or  late,  by  those  that  are  characteristic,  as  pain,  vomiting, 
and  hematemesis.  Of  these,  pain  is  most  constantly  present,  and  pre- 
sents certain  peculiarities  that  demand  rather  elaborate  mention.  It  is 
commonly  dull,  at  times  burning,  and  is  associated  usually  with  great 
oppression.  These  symptoms  are  doubtless  often  due  to  coexisting 
catarrhal  gastritis.  The  character  of  pain  that  is  most  diagnostic  is 
an  intense  gnawing,  burning  or  boring  in  the  epigastrium,  more  or 
less  periodic  and  strictly  localized  in  a  circumscribed  area.  These  par- 
oxysms usually  come  on  almost  immediately  after  eating,  occasionally  one 
or  two  hours  later,  and  disappear  quite  promptly  when  the  stomach  is 
emptied  either  by  vomiting  or  by  its  contents  passing  into  the  duodenum. 
From  the  time  of  its  occurrence,  the  quality,  and  strict  localization  of 
the  pain,  it  may  safely  be  assumed  that  it  is  due  to  direct  irritation,  set 
up  by  the  food,  of  the  sensory  fibers  occupying  the  base  of  the  ulcer.  In 
addition,  there  are  paroxysms  of  diffuse  pain  {gastralgia)  that  are  often 
strictly  intermittent,  though  not  necessarily  excited  by  the  partaking  of 
food.  This  pain  is  due  to  a  sympathetic  nervous  disturbance  or  reflected 
irritation.  Finally,  sharp,  intense,  lancinating  pains,  that  are  caused 
by  local  or  general  peritonitis,  may  appear  suddenly,  ceasing  only  with 
the  death  of  the  patient.  We  often  meet  with  the  four  kinds  of  pain 
described  above  in  a  single  case,  though  they  vary  in  relative  intensity 
in  difi"erent  cases.  The  pain  in  round  gastric  ulcer  is  greatly  modified 
by  numerous  conditions,  all  of  which  are  largely  under  human  control. 
The  effect  of  taking  food  has  been  already  referred  to,  though  it  should 
be  added  that,  obviously,  undigestible,  imperfectly  masticated,  highly- 
spiced  food,  sweet  and  hot  substances,  cause  the  paroxysms  to  be  more 
intense  than  less  irritating  articles  of  diet.  Rest  diminishes  the  severity 
of  the  pain  in  that  it  prevents  traction  on  the  ulcer.  Certain  postures 
may  aggravate  it,  and,  though  not  a  trustworthy  guide,  we  may  often  de- 
termine the  situation  of  the  ulcer  by  the  effect  of  posture  after  taking 
solid  food.     The  severity  of  the  pain  is  often  increased  by  bodily  fatigue 


766  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

or  even  moderate  exercise,  and,  to  a  greater  degree,  by  special  emotional 
influences.  The  situation  of  the  pain  when  strictly  localized  is  of  the 
utmost  importance  in  diagnosis.  I  have  found  it  almost  invariably 
from  one  to  two  inches  below  the  ensiform  cartilage,  though  it  has  been 
rarely  observed  in  the  umbilical  and  hypochondriac  regions.  It  is 
absent  in  one-half  of  all  cases.  Here  may  be  mentioned  a  pain-point 
in  the  dorsal  region  (often  at  a  level  with  the  tenth  to  the  twelfth  thoracic 
vertebra)  on  the  left  side. 

Vomitiyif/,  next  to  pain,  is  the  most  frequent  symptom,  but  unless  the 
vomitus  contains  blood,  which  is  present  in  less  than  50  per  cent,  of  all 
the  cases,  it  has  little  diagnostic  importance.  Nausea  and  eructations 
of  acid  or  food  often  precede  or  accompany  the  emesis.  Vomiting 
usually  occurs  about  two  hours  after  eating,  and  is  often  coincident  with 
the  height  of  the  paroxysm  of  pain,  which  the  vomiting  relieves  as  a 
rule.  The  vomitus,  as  first  shown  by  Riegel,  usually  contains  an  in- 
creased proportion  of  HCl  (superacidity). 

Hematemesis  is  a  symptom  of  unequalled  clinical  significance.  On  it 
alone  frequently  rests  a  positive  diagnosis.  When  the  hemorrhage  is  con- 
siderable, pure  blood,  more  or  less  clotted,  may  be  ejected,  this  being 
highly  characteristic  of  gastric  ulcer.  Frequently,  however,  the  blood 
oozes  gradually  into  the  stomach  and  mingles  with  the  gastric  juice,  and 
in  consequence  the  oxyhemoglobin  of  the  blood  is  converted  into  hematin, 
the  vomitus  presenting  the  appearance  of  coffee-grounds.  On  microscopic 
examination  under  these  circumstances  only  larger  or  smaller  pigment- 
masses  can  be  seen,  and  no  blood-corpuscles.^  Vomiting  of  blood  may 
recur  at  intervals  of  a  few  hours  or  on  each  successive  day.  The  amount 
also  varies  within  the  widest  limits  according  to  the  size  of  the  vessel 
eroded.  Some  of  the  effused  blood  passes  through  the  pylorus,  escaping 
with  the  feces  and  giving  to  the  latter  a  tarry,  black  appearance.  A 
few  cases  have  been  reported  in  which  all  the  blood  was  evacuated  with 
the  stools  except  that  which  was  absorbed  from  the  alimentary  tract. 
Either  as  the  result  of  a  single  copious  hemorrhage  or  of  repeated  smaller 
bleedings  a  pronounced  anemia  is  produced,  the  objective  signs  and  the 
cerebral  and  cardiac  manifestations  of  the  latter  disease  at  once  becom- 
ing evident.  As  a  rule,  however,  the  evidences  of  anemia  are  only 
moderately  well  marked,  and  to  assume  that  the  anemia  is  due  solely  to 
the  hemorrhages  would  probably  be  an  error.  A  slight  rise  of  temper- 
ature is  often  observed  under  these  circumstances  ;  this  is  to  be  regarded 
as  the  so-called  anemic  fever.  The  pain  and  the  most  unpleasant  local 
symptoms  have  been  frequently  observed  to  disappear  after  its  cessation 
— a  circumstance  that,  as  Striimpell  observes,  may  be  owing  in  part  to 
the  extreme  caution  of  the  patient  thereafter.  Not  infrequently  conva- 
lescence sets  in  almost  immediately. 

Physical  signs  are  few  and  slight.  On  palpation  tenderness  is  found, 
though  not  in  all  cases.  The  spot  of  localized  agonizing  pain  before 
alluded  to  is  often  excessively  tender  on  pressure — a  valuable  sign.  The 
true  gastralgic  attacks,  so  common  in  gastric  ulcer,  are  at  times  relieved 
by  making  firm  pressure  with  the  broad  hand  over  the  epigastrium.  Near 
the  pyloric  end  of  the  stomach  palpable  tumors  may  be  felt,  due  to  the 

*  The  blood,  however,  can  be  identified  by  chemical  tests  and  the  spectroscopic  appear- 
ance of  the  hematin. 


GASTRIC  ULCER.  767 

thickened  floor  of  the  ulcer.  When  these  indurated  masses  become  ad- 
herent to  adjacent  organs — the  pancreas,  for  example — epigastric  tumors 
of  considerable  size  may  be  felt,  suggesting  the  presence  of  carcinoma. 
Greneral  symptoms  often  do  "not  appear  until  late  in  the  disease,  the 
patient  continuing  to  look  as  well  as  usual.  Anemia  is  usually  noted 
first,  to  be  followed  by  debility  and  emaciation  ;  the  degree  of  the  general 
disturbances  is  in  direct  proportion  to  the  severity  and  duration  of  the 
causes  producing  them — namely,  the  coexisting  catarrh,  hemorrhages, 
pain,  and  vomiting.  In  some  instances  the  cachexia  is  pronounced,  and 
the  face,  on  account  of  the  prolonged  sufi"ering,  assumes  a  drawn,  hag- 
gard appearance. 

Other  Clinical  Forms. — These  have  been  subdivided  into  numerous 
types,  some  of  which  merge  into  one  another  and  cannot  be  separated 
clinically.  The  following  atypical  forms  should  be  distinguished :  (a) 
Latent  ulcers,  whose  existence  is  not  suspected  during  life,  but  which  are 
revealed,  should  they  come  to  autopsy,  as  open  ulcers  or  cicatrices,  (b) 
An  explosive  form,  in  which  the  ulcer  may  or  may  not  give  rise  to  gastric 
disturbances  prior  to  the  occurrence  of  perforative  peritonitis,  (c)  A  re- 
current form,  described  by  Welch  thus  :  "  In  this  the  symptoms  of  gastric 
ulcer  disappear,  and  then  follow  intervals,  often  of  considerable  duration, 
in  which  there  is  apparent  cure,  but  the  symptoms  return,  especially 
after  some  indiscretion  in  the  mode  of  living.  This  intermittent  course 
may  continue  for  many  years.  In  these  cases  it  is  probable  either  that 
fresh  ulcers  form  or  that  the  cicatrix  of  an  old  ulcer  becomes  ulcerated." 

Complications. — Perforation  of  the  ulcer  (most  common  when  it 
is  situated  in  the  anterior  wall)  leads  to  peritonitis,  which  almost  always 
ends  fatally.  Rarely  a  localized  peritonitis  is  the  result,  owing  to  rapidly 
formed  limiting  adhesions  or  perforation  into  the  lesser  peritoneal  cavity. 
The  symptoms  of  this  complication  will  be  given  in  their  proper  place 
(see  also  Pain,  p.  765).  Hemorrhage  may  prove  a  serious  complicating 
accident,  being  in  not  rare  instances  an  immediate  cause  of  death.  I 
recently  saw  a  case  in  which  hemorrhage  caused  rapid  dissolution. 

General  Course. — This  presents  wide  variations  in  diff'erent  cases. 
It  may  be,  though  seldom,  limited  to  a  few  hours,  as  in  the  explosive 
form.  Innately,  the  disease  is  an  exceedingly  chronic  one,  often  lasting 
several,  and  sometimes  ten  or  fifteen,  years.  Its  duration  in  curable 
cases  may  be  lessened  by  proper  treatment.  Recovery  may  be  incom- 
plete, and  the  scar  resulting  from  the  healing  process  may  give  rise  to 
true  attacks  of  gastralgia.  Again,  if  the  cicatrices  be  situated  at  the 
pyloric  orifice,  dilatation  will  almost  invariably  develop. 

Diagnosis. — The  typical  cases  in  which  the  characteristic  symp- 
toms above  mentioned  are  conspicuous  are  easy  of  diagnosis.  Hemor- 
rhages occurring  with  gastralgic  attacks  are  almost  pathognomonic.  A 
considerable  proportion,  however,  off"er  formidable  difficulties.  Without 
the  presence  of  hematemesis,  for  example,  a  positive  diagnosis  should 
not  be  made,  and  yet  this  symptom  does  not  appear  in  50  per  cent,  of 
all  cases.  In  the  absence  of  hemorrhage  we  may,  however,  infer  the 
altogether  probable  existence  of  ulcer  if  there  be  a  history  of  the  more 
important  etiologic  factors ;  if  there  be  gastralgia,  hyperacidity,  local 
pain  and  tenderness,  a  dorsal  pain-point ;  and,  particularly,  if  the  latter 
symptoms  be  excited  or  greatly  aggravated  by  the  taking  of  food.      The 


768  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

long  course  and  liability  to  remission,  to  be  followed  by  exacerbations 
of  the  symptoms,  are  strongly  confirmatory. 

DiflFerential  Diagnosis. — This  disease  may  be  mistaken  for  gastralgia, 
chronic  gastritis,  the  passage  of  gall-stones,  cirrhosis  of  the  liver,  and 
carcinoma  of  the  stomach.  The  differentiation  of  the  latter  complaint 
will  be  given  later,  (a)  In  certain  cases  of  cirrhosis  of  the  liver  hema- 
temesis  is  met  with,  but  here  there  is  absence  of  all  the  other  character- 
istic symptoms  of  ulcer,  and  the  presence  of  a  group  of  symptoms  and 
physical  signs  pointing  to  disease  of  tlie  liver,  (b)  Hepatic  colic  simu- 
lates ulcer  of  the  stomach  without  hemorrhage.  The  sudden  onset,  the 
longer  duration  of  the  attack  of  pain,  its  sudden  complete  cessation,  the 
presence  of  jaundice  and  certain  physical  signs  presented  by  the  liver, 
suffice  to  distinguish  this  affection  from  gastric  ulcer,  (f)  Chronic  gas- 
tric catarrh  with  hematemesis  resembles  ulcer  of  the  stomach  in  many 
particulars.  The  great  diminution  in  the  proportionate  amount  of 
hydrochloric  acid  found  in  chronic  gastric  catarrh  and  the  increased 
amount  in  gastric  ulcer  are  facts  that  will  help  materially  in  discrimina- 
ting these  two  diseases.  When  they  are  associated  with  one  another  my 
observation  teaches  that  there  is  an  excess  of  HCl  present ;  hence  a 
proportionately  diminished  amount  of  HCl  probably  argues  against  the 
presence  of  ulcer.  The  vomiting  in  ulcer  is  combined  with  severe  par- 
oxysms of  pain ;  not  so  in  chronic  gastritis,  and  the  vomit  in  the  former 
contains  larger  quantities  of  blood  than  in  the  latter  disease,  (d)  Doubt- 
less ulcer  of  the  stomach  has  often  been  mistaken  for  neurotic  gastralgia, 
and  the  discrimination  cannot  always  be  accomplished  to  a  certainty. 
Their  chief  differential  points  may  be  conveniently  arranged  thus : 

Gastric  Ulcer.  Gastralgia. 

History  of  certain  occupations,  anemia,  History  of  neurasthenia,  neuralgia,  and 

chlorosis,     amenorrhea,     tuberculosis,  hysteria  common, 
and  diseases  of  the  heart  common. 

Most  frequent  from  fifteen  to  thirty-five  Most  frequent  before  or  near  the  meno- 

years  of  age.  pause  (in  the  female). 

The  paroxysms  of  pain  usually  come  on  Paroxysms  more  frequent  when  the  stom- 

at  a  definite  [)eriod  after  eating.  ach  is  empty  than  soon  after  meals. 

Eating  rarely  relieves  pain.  Eating  usually  brings  relief. 

Tenderness  on  pressure  over  a  certain  Tender  spot  absent.     General    hyperes- 

limited  area  in  the  epigastrium.  thesia  of  the  skin  often  present. 

Pressure   usually   aggravates,  and   only  Pressure  almost  always  relieves  the  pain, 
occasionally    relieves    patient    during 
paroxysm  of  pain — not  during  the  in- 
tervals between  seizures. 

In  the  intervals  between  the  attacks  gas-  In  the  intervals  between  attacks  no  gas- 
tric disturbances,  more  or  less  severe,  trie  disturbances  present,  as  a  rule, 
are   present ;     also    tender   point    fre- 
quently. 

Hematemesis  present  in  nearly  one-half  Hematemesis  absent, 
of  the  cases. 

General  health  often  much  impaired,  par-  General  health  less  affected  than  in  ulcer, 
ticularly  late  in  the  affection. 

Physical  signs  of  a  mass  may  be  present.  Signs  of  tumor  always  absent. 

Dilatation  may  coexist  in  the  late  stage.  Dilatation  never  present. 

Hyperacidity  of    gastric    juice    usually  Hyperacidity    present    only    in    certain 

present.  forms  {sup7-a). 

Improvement  follows  rest  and  regulation  Regulation  of  diet  has  no  effect, 
of  diet. 


GASTRIC  ULCER.  769 

The  prognosis  is  obviously  uncertain.  The  average  mortality  is 
about  20  per  cent.  Such  grave  complications  as  free  bleedings  and  peri- 
tonitis have  been  discussed  sufficiently  in  the  Clinical  History.  Among 
thoracic  complications,  pneumonia,  tuberculosis,  and  left-sided  perfor- 
ative empyema  are  those  most  frequently  encountered.  They  all  render 
recovery  almost  positively  hopeless.  The  possibility  that  the  resulting 
scar  may  cause  persistent  gastralgia,  and  the  probability  that  a  cicatrix 
surrounding  the  whole  or  any  part  of  the  pylorus  may  cause  obstruction 
at  this  orifice,  followed  by  dilatation,  must  be  kept  in  remembrance. 
Carcinoma  may  develop  in  the  floor  of  an  old  ulcer  in  subjects  who,  on 
account  of  a  predisposition,  furnish  a  suitable  soil. 

Treatment. — The  treatment  of  gastric  ulcer  embraces  three  lead- 
ing objects :  (1)  Of  paramount  importance  is  absolute  rest  for  the  stom- 
ach. This  is  to  be  accomplished  by  maintaining  the  recumbent  posture 
in  bed,  on  the  one  hand,  and  by  rectal  feeding,  wholly  or  partly,  on  the 
other.  This  mode  of  alimentation  will  be  discussed  presently.  Perfect 
rest  constitutes  the  best-known  safeguard  against  those  serious  accidents 
that  intervene  suddenly  in  the  course  of  this  aflFection.  It  also  ensures 
more  rapid  cicatrization  than  any  other  single  agent.  The  process  of 
repair  is  very  slow  under  the  most  favorable  circumstances ;  hence  the 
patient  should  be  informed  at  the  outset  that  from  four  to  six  months, 
at  least,  must  be  spent  in  bed.  (2)  The  careful  regulation  of  the  diet. 
It  is  not  possible  for  the  stomach,  when  the  seat  of  ulcer,  to  digest  the 
normal  amount  of  nitrogenous  food  without  being  injuriously  affected 
thereby.  Those  articles  of  diet  should  be  employed  that  are  digested 
and  assimilated  chiefly  in  the  intestinal  tract.  But,  though  the  patient 
is  fed  by  the  mouth,  this  should  be  supplemented  by  rectal  feeding 
almost  from  the  beginning.  By  pursuing  this  combined  method  and 
giving  per  rectum  but  a  limited  amount  of  albuminous  food  the  vital 
forces  can  more  effectually  be  supported.  Failure  to  cure  cases  of  gas- 
tric ulcer  is  often  due  to  the  fact  that  but  little  nourishment  is  supplied 
to  the  system,  the  patient's  general  strength  being  allowed  to  become 
exhausted  quite  early.  Frequently  the  stomach  is  so  irritable  as  to 
render  it  exceedingly  difficult  to  introduce  into  it  even  a  fractional  part 
of  the  amount  of  food  necessary  to  support  life  properly ;  and  in  all 
cases  that  I  have  seen  the  amount  of  food  that  could  be  taken  by  the 
mouth  was  really  inadequate,  considering  the  dietetic  requirements  of 
the  disease.  Should  nutrient  enemata  not  be  well  borne,  they  may  be 
discontinued  until  the  unpleasant  symptoms  have  subsided,  and  then 
resumed  immediately.  By  giving  only  a  portion  of  the  food  in  this 
manner  rectal  feeding  may  be  continued  for  a  long  period  without  dis- 
agreeable intestinal  symptoms.  The  following  dietary  will  be  found  use- 
ful: At  7  A.  M.  give  100  c.cm.  (oiij)  of  Leube's  beef-solution  ;  at  11  a.  m., 
200  c.cm.  (Ivj)  of  pancreatized  milk-gruel;^  at  3  p.  M.,  200  c.cm.  (svj) 
of  peptonized  milk  or  skimmed  milk  or  buttermilk  ;  and  at  7  P.  M.,  200 
c.cm.  (Svj)  of  pancreatized  milk-gruel ;  in  addition,  the  following  by  rectal 
injection  :  at  8  a.  m.,  6  ounces  of  pancreatized  milk-gruel,  with  \  ounce  of 
bovinin  and  10  drops  of  tincture  of  opium,  this  to  be  repeated  at  2  P.  M. 
and  8  P.  m.     If  the  nutrient  enemata  must  be  discontinued  for  a  time,  the 

^  The  milk-gruel  is  prepared  with  wheaten  flour  or  arrowroot,  mixed  with  an  equal 
quantity  of  milk. 
49 


770  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

reofular  diet  must  be  increased  proportionately.  If,  on  the  other  hand, 
the  stomach  rejects  the  above-mentioned  food,  then  the  feeding  must  be, 
for  a  time,  exclusively  rectal ;  this  is  quite  practicable  if  the  proper 
choice  be  made  of  nutrient  preparations.  In  addition  to  the  substances 
before  mentioned  we  may  employ  from  4  to  6  ounces  (150-200  com.)  of 
Leube's  beef-solution,  or  the  same  amount  of  defibrinated  blood  or  pan- 
creatized  milk  with  brandy.  DaCosta  reported  recently  a  number  of 
instances  that  Avere  cured  by  a  diet  of  ice-cream.  It  has  been  recom- 
mended to  employ  lavage  Avhen  the  stomach  is  exceedingly  irritable, 
but  the  use  of  the  stomach-tube  is  liable  to  damage  the  ulcer  even  in 
the  most  careful  hands.  The  good  effects  from  washing  out  the  stom- 
ach for  uncontrollable  vomiting  and  pain  have,  however,  been  frequently 
witnessed.  It  may  often  be  satisfactorily  accomplished  by  the  use,  in- 
ternally, of  1  pint  (I  liter)  of  warm  water  containing  a  few  grains  of 
sodium  bicarbonate,  sipped  slowly  when  the  stomach  is  empty.  If  at 
the  expiration  of  two  months  the  condition  of  the  patient  indicates 
that  the  reparative  process  is  far  advanced,  then  well-boiled  rice,  stale 
bread,  and  potatoes  may  be  alloAved ;  and  later  eggs,  oysters,  fish,  and 
sago,  the  patient  not  being  allowed  to  resume  an  ordinary  solid  diet  for 
at  least  six  months.  (3)  The  medicinal  treatment,  which  is  altogether 
subsidiary  to  the  dietetic,  has  reference  to  two  ends :  (a)  Promotion  of 
the  healing  process.  We  cannot  be  certain  that  any  remedial  agents  at 
our  command  can  accomplish  this  object,  and  yet  it  is  our  duty  to 
attempt  it.  Of  the  efficacy  of  alkaline  remedies  in  this  disease  Ave  are 
thoroughly  convinced ;  in  neutralizing  the  hyperacidity  of  the  gastric 
secretions  they  fulfil  an  important  indication,  since  the  excess  of  HCI 
must  have  an  unfavorable  effect  upon  the  ulcer.  Of  these,  sodium  bi- 
carbonate (in  full  doses)  or  the  alkaline  purgative  mineral  waters,  as 
Carlsbad,  Kissingen,  Hunyadi  Janos,  are  most  useful.  The  Carls- 
bad salts  are  also  highly  beneficial.  They  may  be  prepared  artificially 
as  foUoAvs :  sodium  sulphate,  50  parts  ;  sodium  bicarbonate.  6  parts ; 
sodium  chlorid,  3  parts — of  Avhich  a  teaspoonful  may  be  taken  in  hot 
water,  fasting,  in  the  morning.  The  preparations  of  bismuth  may  be 
given  in  combination  Avith  antiseptics,  Avhich  latter  are  especially  to 
be  recommended.  Fleiner's  method  of  giving  10  gm.  of  bismuth 
in  200  gm.  of  Avarm  Avater  on  an  empty  stomach,  and  then  allowing 
the  patient  to  drink  several  sAvalloAvs  of  Avater,  and  afterAvard  placing 
him  in  the  horizontal  position  Avith  the  hips  elevated  for  about  an  hour, 
has  yielded  gratifying  results.  About  200  gm.  of  bismuth  administered 
in  the  above  manner  usually  suffice  to  effect  a  cure  (Savelieff).  Sil- 
ver nitrate  has  long  enjoyed  an  enviable  reputation  in  this  disease. 
For  the  chronic  gastric  catarrh  Avhich  is  very  generally  associated  with 
ulcer,  silver  nitrate,  as  before  stated,  is  most  efficient,  and  may  be  com- 
bined Avith  small  doses  of  opium  or  hyoscyamus.  The  previous  general 
condition  of  the  patient  is  frequently  unfavorable  to  the  successful  heal- 
ing of  the  ulcers,  and  to  combat  the  anemia  and  chlorosis  that  are  often 
present  Ave  may  employ  iron  and  arsenic.  The  albuminate  of  iron  has 
been  Avarmly  recommended,  and  small  doses  of  FoAvler's  solution  of 
arsenic  are  generally  well  borne  by  the  stomach  ;  the  former  may  also 
be  given  hypodermically.  When  organic  cardiac  diseases  are  concom- 
itants they  should  receive  careful  attention,  and  the  recognition  and 
treatment  of  all  associated  diseases  must  not  be  overlooked. 


CARCINOMA    OF  THE  STOMACH.  771 

(b)  The  relief  of  urgent  symptoms.  The  preceding  measures  relat- 
incr  to  the  diet  and  treatment,  and  particularly  small  doses  of  the  extract 
of  opium  combined  with  silver  nitrate,  often  relieve  the  pain.  Mild 
counter-irritation  is  also  of  service,  but  warm  poultices  should  not  be 
employed.  The  application  of  cold  to  the  epigastrium  (ice-bag)  some- 
times alleviates  the  pain,  though  quite  as  often  it  fails  to  benefit.  For 
the  severe  gastralgic  attacks  morphin  should  be  administered  hypo- 
dermically. 

Vomiting,  when  not  excessive,  will  be  allayed  by  the  use  of  the  agents 
already  mentioned,  and  bismuth,  creasote.  silver  nitrate,  and  opium  are 
especially  useful ;  chipped  ice,  with  a  small  amount  of  brandy  thrown 
over  it,  is  also  of  value.  When  obstinate  the  following  remedies,  in 
small  doses,  may  be  tried  separately :  cerium  oxalate,  potassium  bromid, 
tincture  of  iodin,  cocain,  chloral,  and  hydrocyanic  acid. 

For  the  hematemesis,  rest,  the  application  of  a  broad,  flat  ice-bag, 
together  with  the  use  of  ergot  hypodermically,  will  usually  suflBce.  For 
exhaustive  hemorrhages  infusion  into  the  veins  or  into  the  subcutaneous 
tissue  (hypodermoclysis)  of  normal  salt  solution  is  an  important  measure. 
In  recurring  hematemesis  W.  L.  Rodman  advises  operation  between 
attacks — always  after  the  third  bleeding. 

Perforation  of  the  gastric  ulcer  calls  for  surgical  intervention  as  soon 
as  the  diagnosis  is  established  with  any  degree  of  certainty.  Nothing 
more  should  be  given  by  the  mouth.  In  the  cases  of  perforation  which 
have  been  operated  upon  within  the  first  twelve  hours  during  the  past 
three  years,  83.78  per  cent,  have  been  saved  (Tinker).  Most  of  the 
cases  not  cured  bv  medical  treatment  are  also  savable  by  operation. 


CARCINOMA  OF  THE  STOMACH. 

Pathology. — Xext  to  the  uterus,  the  stomach  is  the  most  favored 
seat  of  carcinoma.  In  a  total  of  over  30,000  cases  studied  by  Welch, 
21.4  per  cent,  were  found  to  show  involvement  of  this  organ.  With  refer- 
ence to  the  parts  of  the  organ  most  frequently  attacked,  Welch  analyzed 
1300  cases  with  the  following  results :  pyloric  region,  791;  lesser  curva- 
t;ure,  148 ;  cardia,  104  ;  posterior  wall,  68  ;  greater  curvature,  34  ;  ante- 
rior wall,  30  :  fundus.  19.  The  forms  of  gastric  carcinoma  noted  are 
columnar  epithelial  (including  colloid)  and  the  glandular  carcinomata 
(embracing  encephaloid  and  scirrhous).  The  epitheliomata  grow  from 
the  lining  epithelium  whilst  the  encephaloid  and  scirrhous  are  new 
growths  from  the  glandular  epithelium  proper.  The  last  two  forms 
are  therefore  similar  in  structure,  the  differences  possibly  being  due  to 
variations  in  their  growth  (rapid  in  the  encephaloid  and  slow  in  the  scir- 
rhous variety),  and  to  the  consequent  varying  proportion  between  fibrous 
tissue  and  cells :  the  encephaloid  cancers  are  thus  soft,  and  readily  break 
down  on  their  surface,  forming  large  ulcers  that  have  a  clean  floor,  while 
the  scirrhous  cancers  are  hard  and  firm.  Columnar  epitheliomata  are 
frequent,  and  are  situated  at  the  pyloric  end  of  the  stomach,  where  the 
glands  are  formed  of  a  single  layer  of  columnar  cells  on  a  basement  mem- 


772  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

brane.  They  are  often  the  seat  of  colloid  degeneration.  Squamous  epi- 
theliomata  occur  only  at  the  cardiac  end.  All  the  varieties  mentioned 
are  prone  to  produce  secondary  new  growths  in  adjacent  organs,  the  scir- 
rhous, however,  manifestintj  a  less  marked  tendency  to  metastasis  than 
the  others.  They  occur  either  as  circumscribed  tumors  or  as  a  diffuse  in- 
filtration, and  in  the  immediate  vicinity  of  the  gastric  carcinoma  there  is 
a  marked  thickening  of  the  muscularis.  Perforation  of  the  stomach-walls 
occurs  in  3.3  per  cent.  (Brinton).  Welch  collected  37  cases  of  secondary 
carcinoma  of  the  stomach ;  17  were  secondary  to  carcinoma  of  the  breast. 

Ktiology. — The  factors  bearing  upon  the  etiology  of  gastric  carcino- 
ma may  all  be  regarded  as  predisposing  causes.  Of  these  age  is  the  most 
potent.  Of  2038  cases  examined  by  Welch  with  reference  to  this  point, 
75  percent,  occurred  between  the  fortieth  and  seventieth  years,  24.5  per 
cent,  between  forty  and  fifty  years,  and  30.4  per  cent,  between  fifty  and 
sixtv  years.  According  to  Lebert  the  maximum  liability  lies  between 
the  forty-first  and  sixtieth  years.  It  is  comparatively  rare  under  thirty 
years  of  age,  and  almost  never  occurs  during  the  first  decade.  Heredity 
stands  next  to  age  as  a  causal  factor,  thouujh  it  is  far  less  influential. 
Welch  analyzed  1744  cases,  and  found  that  a  family  history  of  carcinoma 
was  present  in  about  14  per  cent.  Sex  has  little  if  any  influence.  The 
extent  to  which  gastric  carcinoma  is  dependent  upon  previous  disease 
of  the  stomach  is  not  definitely  determined,  but  in  persons  that  are  pre- 
disposed, by  reason  of  age  or  heredity,  the  cicatrix  of  an  old  ulcer  or  a 
pre-existing  chronic  catarrh  of  the  stomach  may  become  additional 
causative  factors.  Strlimpell  has  called  renewed  attention  to  the  proba- 
ble relation  between  gastric  ulcer  and  gastric  carcinoma.  Schmidt  also 
has  recently  found  the  same  cell-degenerations  around  both  cancerous 
and  ulcerous  growths. 

Clinical  History. — Prior  to  the  development  of  gastric  carcinoma 
the  symptoms  of  catarrhal  dyspepsia  may  be  present  for  a  variable  period 
of  time.  The  onset,  however,  is  often  comparatively  abrupt.  Again, 
it  may  be  insidious,  and  be  marked  more  by  the  evidences  of  failing 
general  health  and  strength  than  by  distinct  local  subjective  symptoms. 
Osier  and  McCrae '  have  reported  cases  of  latent  carcinoma  of  the  stomach. 
Anorexia  is  commonly  present,  though  occasionally  the  appetite  re- 
mains unimpaired.  A  sense  of  oppression,  rarely  amounting  to  true 
cardialgia,  and  frequent  eructations,  come  on  soon  after  eating.  In 
many  cases  but  little  pain  is  complained  of,  whilst  in  a  lesser  number 
pain  is  a  prominent  symptom  throughout  the  entire  course  of  the  affec- 
tion. Its  character  is  very  often  described  as  lancinating,  less  often  as 
burning  or  gnawing ;  the  latter  form  of  pain  is  due,  most  probably,  to 
associated  and  secondary  ulcers.  The  pain  is  often  referred  to  the 
shoulders  and  the  back  or  loins.  Vomiting  is  infrequent,  excepting 
in  the  more  advanced  stages  of  the  disease,  when  it  is  almost  con- 
stantly present  to  a  greater  or  less  degree.  During  the  early  stages  it 
is  due  to  the  catarrhal  irritation,  later  to  obstruction.  When  the  latter 
is  at  the  cardiac  orifice,  the  pain  occurs  at  once  after  eating;  when  at  the 
pylorus,  it  appears  several  hours  after  meals.  Vomiting  may  also  be 
caused  by  the  occurrence  of  fermentation  in  large  accumulations  in  the 
stomach.  The  vomitus  has  few,  if  any,  of  the  physical  characteristics 
'  Philadelphia  Medical  Journal,  February  3,  1900. 


CARCINOMA    OF  THE  STOMACH.  773 

noted  in  simple  ulcer  of  the  stomach.  Free  hematemesis  is  very  rare  ; 
when,  however,  the  surface  of  the  new  growth  ulcerates,  there  is  almost 
invariably  an  occasional  slow  oozing  of  blood  into  the  stomach.  It  is 
here  acted  upon  by  the  altered  gastric  juice,  and  the  black  hematin  re- 
sulting from  the  transformation  of  the  red  hemoglobin  gives  rise  to  the 
well-known  "  coffee-ground  "  vomit  of  carcinoma  of  the  stomach.^  It  is 
to  be  recollected  that  the  chocolate-colored  appearance  of  the  vomitus  is 
not  found  alone  in  carcinoma  of  the  stomach,  but  may  also  occur  under 
other  abnormal  conditions  of  the  stomach-contents. 

The  chemical  examination  of  the  gastric  secretions  is  of  prime 
diagnostic  importance,  showing  as  it  does  the  almost  constant  absence 
of  free  HCl  after  the  test-meal  (see  p.  735).  Riegel  has  recently  given 
emphasis  to  the  fact  that  the  presence  of  free  HCl,  supposing  the  ex- 
aminations to  be  properly  made  (by  the  use  of  the  color  test)  and  suffi- 
ciently often  repeated,  speaks  almost  positively  against  carcinoma.  In 
not  one  of  154  artificial  digestive  experiments  was  albumin  digested  in 
this  disease.  Rare  cases  do,  however,  occur  in  which  free  HCl  is  pres- 
ent, as  when  carcinoma  of  the  stomach  is  secondary  to  an  ulcer,  the 
free  acid  in  the  latter  being  usually  increased.  '  More  important  than 
the  foregoing  are  those  instances  in  which  free  HCl  is  absent,  as  in  carci- 
noma of  the  esophagus,  extensive  amyloid  disease,  advanced  cases  of 
renal  disease,  and  the  febrile  state.  Riegel  also  noted  the  absence  of 
free  HCl  in  carcinoma  of  the  duodenum. 

Two  leading  views  are  held  concernino;  the  cause  of  the  failure  to 
find  HCl :  (1)  That  it  is  due  to  inflammatory  degeneration  of  the  mucous 
membrane,  commencing  as  a  catarrhal  inflammation  and  advancing  to 
interstitial  change  and  atrophy  {RosenJiehn  s  view) ;  (2)  that  the  absence 
of  the  acid  is  due  not  so  much  to  non-secretion  as  to  its  combination 
with  some  substance  arising  from  the  carcinoma  {^RiegeVs  view).  Lac- 
tic acid  in  excess  occurs  in  the  stomach  in  carcinoma.  Hemmeter 
has  found  lactic  acid  in  82  per  cent,  of  his  cases  and  Oppler-Boas 
bacilli  in  94  per  cent.  The  microscopic  appearances  of  the  vomitus 
and  wash-water  are  in  some  ways  identical  with  those  observed  in 
gastric  ulcer,  and  if  they  be  examined  speedily,  red  blood-corpuscles 
may  rarely  be  seen.  The  microscope  also,  very  occasionallv,  reveals 
pieces  and  bits  of  cancer-tissue,  and  Kaufmann,  Hammerschlag,  and 
others  emphasize  the  frequency  of  long  bacilli.  It  has  been  claimed 
that  sarcinse  are  present,  but  Riegel  states  that  they  are  infrequent. 
Chronic  interstitial  gastritis  and  atrophy  of  the  mucosa  may,  among 
other  conditions,  show  symptoms  in  addition  to  the  absence  of  HCl. 

Physical  examination  often  discloses  the  presence  of  a  tumor.  In- 
spection may  reveal  an  irregular  tumor,  particularly  if  the  patient  be 
much  emaciated.  When  dilatation  exists  the  outlines  of  the  organ  may 
be  seen.  On  palpation  the  new  growth,  in  a  majority  of  cases,  may  be 
felt  through  the  abdominal  walls,  though  often  not  clearly,  as  a  hard, 
nodular,  and  sometimes  movable  mass.  Though  this  generally  appears 
in  the  epigastrium,  it  must  be  recollected  that  it  depends  upon  the  part 

^  Teichnann's  test  for  hematin  crystals  may  be  employed  as  follows:  Place  a  drop 
of  the  "coffee-ground"  material  upon  the  slide  and  add  a  few  ciystals  of  sodium  chlorid. 
Then  introduce  a  few  drops  of  acetic  acid  beneath  the  cover-glass,  and  on  warming  hema- 
tin crystals  will  form. 


774  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

involved ;  also  that  a  tumor  united  with  the  wall  of  the  stomach,  par^ 
ticularly  if  situated  at  the  pylorus,  sags  downward  more  and  more,  even 
to  a  point  below  the  umbilicus.  Less  frequently,  on  account  of  its 
mobility,  it  is  discovered  in  such  unlooked-for  situations  as  the  right  or 
left  hypochondi-iac  region.  The  varying  degree  of  fulness  of  the  stomach 
will  obviously  alter  the  position  of  the  tumor.  When  situated  at  the 
cardia  it  is  beyond  reach  of  palpation  ;  when  attached  to  the  lesser 
curvature  of  the  stomach  or  the  posterior  wall,  it  is  rarely  to  be  felt 
unless  it  be  of  large  size.  The  new  growth  cannot  be  definitely  made 
out  when  it  assumes  the  form  of  a  diffuse  infiltration,  though  it  oifers 
increased  resistance  to  the  palpating  fingers  and  exhibits  more  or  less 
tenderness  on  pressure.  Usually  the  patient  lies  in  the  dorsal  position 
during  the  examination,  with  the  limbs  drawn  up,  breathing  regularly 
while  the  mouth  is  kept  open.  The  detection  of  a  tumor  Avhen  in  an 
unfavorable  situation  may  be  facilitated  by  shifting  the  patient's  position 
from  the  dorsal  to  the  lateral,  the  standing,  or  the  knee-elbow  position 
respectively ;  at  the  same  time  one  or  two  tumblers  of  some  carbonated 
water  should  be  given  with  a  view  to  distending  the  stomach  and  carry- 
ing the  tumor  downward.  Pulsations  are  frecjuently  communicated  from 
the  aorta  to  the  palpating  hand  through  the  tumor.  If  the  growth  is 
situated  at  the  lesser  curvature,  a  deep  inspiration  will  often  cause  the 
tumor  to  fall  lower,  and  thus  become  accessible  to  palpation.  Percussion 
over  the  seat  of  the  new  growth  causes  a  muffled  t^-mpanitic  resonance; 
superficial  percussion,  however,  frequently  gives  absolute  dulness. 

The  presence  of  metastatic  netv  growths  in  the  liver  and  enlargements 
of  the  supraclavicular  or  inguinal  lymph-glands  are  of  value  in  the  diag- 
nosis. In  one  instance  that  I  saw  in  the  Philadelpliia  Hospital  a  nodule 
the  size  of  a  walnut  protruded  from  the  umbilicus,  leading  to  the  suspi- 
cion that  gastric  carcinoma  might  be  present,  though  the  general  symp- 
toms pointed  strongly  to  chronic  gastric  catarrh  at  the  time.  Subse- 
quently, however,  a  round  and  somewhat  nodulated  pyloric  neoplasm 
could  be  readily  held  in  the  grasp.  In  several  instances  in  which  the 
lymph-glands  in  the  groins  and  in  the  supraclavicular  spaces  were  the 
seat  of  enlargement  a  probable  diagnosis  of  abdominal  carcinoma  was 
made  in  the  absence  of  positive  symptoms  and  physical  signs,  and  the 
diagnosis  was  borne  out  at  the  autopsies. 

Creneral  Symptoms. — Quite  early  in  the  disease  such  evidences  of  gen- 
eral nutritional  disturbance  as  loss  of  flesh  and  anemia  may  be  observed, 
and,  obviouslv,  cases  attended  with  constant  anorexia  and  vomiting  will 
earliest  manifest  the  wasting  process.  Almost  from  the  beginning  the 
face  gradually  assumes  the  cachectic  appearance  which,  in  the  advanced 
stages,  becomes  so  characteristic  of  gastric  carcinoma.  Anemia  soon 
becomes  a  prominent  feature.  There  is  a  waxy  pallor  of  countenance, 
and  the  cerebral  symptoms  as  well  as  the  peculiar  cardiac  murmurs  of 
anemia  appear.  The  blood  frequently  presents  peculiarities  that  bear  a 
resemblance  to  those  seen  in  pernicious  anemia,  and  sometimes  there  is 
a  marked  leukocytosis,  particularly  near  the  close  of  life.  Osier  and 
IVJcCrae  have  shown  that  the  number  and  kind  of  leukocytes  present  are 
of  no  value  in  the  diagnosis  of  this  condition,  and  also  that  the  presence 
or  absence  of  digestive  leukocytosis  is  too  uncertain  to  be  of  diagnostic 
importance.     The  blood-count  rarely  shows  the  marked  oligocythemia 


CARCINOMA    OF  THE  STOMACH.  775 

seen  in  progressive  pernicious  anemia  {vide  Pernicious  Anemia).  "  When 
any  degree  of  anemia  is  presented  nucleated  red  corpuscles  may  be  found 
in  dry  and  stained  specimens,  and  this  method  of  examination  may  be  of 
much  service  when  an  actual  blood-count  is  impossible.  The  condition 
is,  however,  an  anemia  with  wasting,  and  the  layer  of  panniculus  is  not 
retained  as  in  the  ordinary  forms  of  pernicious  anemia"  (Osier).  The 
causes  of  the  profound  anemia  met  with  in  this  affection  are  not  quite 
plain,  since  frequently  it  becomes  pronounced  before  the  nutritional  dis- 
turbances (shown  by  a  loss  of  flesh)  have  become  marked.  The  fact  that 
metastatic  carcinoma  has  been  found  to  be  abundant  in  the  marrow  of 
the  bones  is  significant  in  this  connection,  as  pointing  to  the  probable 
interference,  in  some  instances,  with  the  blood-producing  function  of  the 
bone-marrow.  In  advanced  cases  moderate  edema  of  the  ankles  and  of 
the  backs  of  the  hands  is  frequently  observed,  and  is  probably  dependent 
upon  excessive  anemia.  The  temperature  at  first  shows  no  abnormali- 
ties, as  a  rule,  though  after  the  cachexia  has  become  decided  it  is  often 
subnormal.  Sudden  elevations  of  temperature  (103°  to  104°  F. — 40°  C), 
preceded  by  rigors  and  followed  by  profuse  sweating,  are  rarely  observed. 
The  explanation  of  their  occurrence  is  to  be  found  in  the  fact  that  sup- 
puration sometimes  takes  place  in  the  bases  of  the  cancerous  ulcers. 
The  mind  almost  invariably  remains  clear  to  the  last,  though  delirium 
may  be  a  late-appearing  symptom. 

Complications. — Intestiyial  symptoms  are  frequently  observed,  and 
constipation  in  particular  is  quite  common.  It  is  apt  to  alternate  with 
diarrhea  toward  the  close  of  the  disease,  or  diarrhea  may  in  the  later 
stages  become  a  persistent  and  obstinate  symptom.  Some  of  the  com- 
plicating conditions  have  reference  to  the  secondary  new  growths. 
When,  as  frequently  happens,  the  liver  is  implicated,  jaundice  is  not 
uncommon,  being  associated  with  signs  of  hepatic  enlargement.  In- 
deed, so  prominent  may  be  the  symptoms  and  physical  signs  referable 
to  secondary  carcinoma  of  the  liver  as  entirely  to  mask  the  more  or  less 
hidden  forms  of  carcinoma  of  the  stomach.  The  mesenteric  and  retro- 
peritoneal lymph-glands  or  the  lungs  may  be  the  seat  of  secondary  car- 
cinoma, though  in  these  situations  it  rarely  gives  rise  to  characteristic 
symptoms.  Occasionally  the  new  growths  spread  to  the  peritoneum  and 
sometimes  give  rise  to  ascites.  As  has  been  stated  under  Pathology,  per- 
foration may  rarely  occur,  and  we  then  have  the  pronounced  and  rapidly 
supervening  symptoms  of  diffuse  peritonitis.  Fistulous  communications 
between  the  stomach  and  the  transverse  colon  or  the  small  intestine — 
the  latter  rarely — may  also  occur.  Nervous  symptoms  may  be  regarded 
as  complicating  conditions,  and  sometimes  hasten  the  fatal  termination  ; 
the  patient  becomes  somnolent  or,  rarely,  even  comatose ;  the  breathing 
is  difficult  and  the  respiration  deep  and  labored.  This  mode  of  termina- 
tion I  noted  in  one  of  my  own  cases.  Traces  of  albumin.,  and  in  the 
later  stages  tube-casts,  may  be  present  in  the  urine.  An  increased 
quantity  of  indican  has  frequently  been  noted ;  acetone  and  diacetic 
acid  are  present  in  rare  instances. 

Atypical  Porms. — The  disease  rarely  is  entirely  latent,  and  most 
often  in  persons  previously  much  enfeebled  and  in  the  aged.  In  other 
instances  the  pain  is  wanting  ;  hence  it  frequently  happens  that  the  pres- 
ence of  cancerous  tumors  in  the  stomach  is  not  suspected  until  accident- 


776  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ally  discovered,  the  symptoms  being  attributed  to  less  grave  conditions. 
In  still  other  instances  the  development  of  a  ])ronounced  anemia  and  of 
the  progressive  cachexia  alone  furnish  ground  for  suspicion. 

General  Course  and  Duration. — The  course  of  gastric  carcinoma 
is  invariably  toward  a  fatal  issue,  death  usually  taking  place  before  the 
expiration  of  two  years.  The  average  duration  of  the  disease  is  about 
one  year.  According  to  my  own  observation,  when  it  occurs  in  emaci- 
ated persons  it  pursues  a  slower  course  than  when  occurring  in  fleshy 
individuals.  .  Carcinoma  of  the  stomach  below  thirty  years  of  age  usually 
runs  a  rapid  course  (Mathieu). 

Diagnosis. — A  positive  diagnosis  of  gastric  carcinoma  is  easily 
made  when  a  tumor  is  demonstrable.  It  is,  however,  possible  to  diag- 
nosticate the  disease  in  the  absence  of  a  }>alpable  new  growth.  The 
history,  the  presence  of  such  characteristic  symptoms  as  pain,  coffee- 
ground  vomit,  the  existence  of  dilatation  of  the  stomach,  the  constant 
absence  of  free  hydrochloric  acid,  the  almost  constant  presence  of  lactic 
acid  after  the  Boas  test-meal — all  occurring  in  an  elderly  person,  to- 
gether with  the  existence  of  progressive  cachexia,  are  sufficient  to  war- 
rant a  diagnosis.  It  is  needful,  however,  to  exclude  the  diseases  other 
than  gastric  carcinoma  in  which  the  absence  of  free  hydrochloric  acid 
has  been  noted.  Hemmeter  states  that  the  early  diagnosis  of  carcinoma 
of  the  stomach  is  possible  in  a  certain  number  of  cases  from  histologic 
examination  of  small  fragments  of  gastric  mucosa,  either  detached  ac- 
cidentally or  removed  intentionally.  Exploratory  laporotomy  may  be 
safely  advised  at  the  present  day  if  improvement  does  not  follow  medical 
treatment  in  strongly  suspicious  cases  within  a  reasonable  period. 

Differential  Diagnosis. — A  gastric  carcinoma  presenting  a  discernible 
mass  is  liable  to  be  mistaken  for  a  cicatrized  ulcer,  for  carcinoma  of  the 
pancreas,  of  the  transverse  colon,  duodenum,  omentum,  and  the  left  lobe 
of  the  liver,  as  well  as  for  aneurysm  of  the  abdominal  aorta.  The  aneur- 
ysmal tumor,  hoAvever,  is  smooth,  and  is  not  nodular  like  the  cancer- 
ous growth  ;  moreover,  it  gives  rise  to  an  expansile  impulse.  In  aneur- 
ysm the  characteristic  gastric  symptoms  and  the  cachexia  are  wanting. 
In  pancreatic  carcinoma  the  tumor  is  always  fixed ;  there  is  an  absence 
of  the  coffee-ground  appearance  of  the  vomit  and  of  dilatation,  and  free 
HCl  is  present  in  the  gastric  contents.  Further  than  this,  fat  may  be 
present  in  the  stools  and  sugar  and  fat  in  the  urine.  Carcinoma  of  the 
transverse  colon  and  omentum  will  be  excluded  by  the  presence  of  such 
significant  symptoms  as  gastric  hemorrhage  and  the  consequent  hemate- 
mesis,  by  a  chocolate-colored  appearance  of  the  vomitus,  the  permanent 
absence  of  HCl,  and  persistent  presence  of  lactic  acid. 

Simple  round  ulcer  of  the  stomach  may  in  cicatrizing  give  rise  to  a 
small  tumor,  followed  by  pyloric  stenosis  and  secondary  dilatation — an 
exact  counterpart  of  the  course  of  gastric  carcinoma.  Great  reliance 
should  be  placed  on  the  age  of  the  patient,  the  presei»ce  of  HCl  in  the 
gastric  secretions,  the  grave  gastric  disturbances,  particularly  the  ])oints 
of  pain  (dorsal  and  epigastric),  and  localized  tenderness  with  hematenie- 
sis,  coupled  with  the  longer  duration  of  ulcer  (more  than  two  or  three 
years).  Ulcer  with  tumor-like  thickening  may  show  an  excess  of  lactic 
acid,  due  to  associated  motor  insufficiency,  rendering  a  differential  diag- 
nosis exceedingly  difficult.  Finally,  carcinoma  may  originate  in  ulcer. 
Hypertrophic  stenosis  of  the  pylorus  is  also  closelv  simulated. 


CARCINOMA   OF  THE  STOMACH. 


777 


Simple  gastric  ulcer  and  chronic  gastritis  are  often  confounded  with 
carcinoma  of  the  stomach.  The  facts  of  greatest  value  in  the  discrimi- 
nation of  these  three  aifections  are  so  well  presented  by  DaCosta  that 
they  are,  in  the  main,  here  subjoined  : 

Chronic  Gastritis. 
Not  confined  to  any  age. 
More  common  in  middle- 
aged  or  elderly  people. 


Pain  at  the  epigastrium 
somewhat  augmented  by 
food ;  soreness  is  also 
present.  Both  are  con- 
stant, although  compar- 
atively slight. 


Symptoms  of  indigestion 
marked. 

Sometimes  vomiting. 

No  hemorrhage,  or  but  tri- 
fling hemorrhage ;  at 
most  blood-streaks  in 
vomited  matter. 

Bovrels  constipated. 

No  fever. 


Not  much  emaciation ;  no 
cachectic  appearance. 


Disease  may  be  relieved  or 
cured ;  is  often  of  very 
long  duration. 


No  tumor. 

Contents  of  stomach  al- 
most always  contain  free 
hydrochloric  acid. 

No  lactic  or  fatty  acids  after 
the  rigid  Boas  test-meal. 

No  dropsy. 


Gastric  Ulcer. 

May  occur  in  middle-aged 
persons,  but  is  most  fre- 
quent in  young  adults, 
especially  women. 

Pain  at  the  epigastrium 
much  augmented  by 
food  ;  subsides  when  this 
is  digested  :  paroxysms 
of  pain,  not  lancinating  ; 
strictly  localized  soreness 
to  touch  in  epigastrium  ; 
sometimes  a  painful  spot 
over  lower  dorsal  verte- 
brge.  Intermissions  in 
the  pain  of  considerable 
length  are  frequent. 

Symptoms  of  indigestion 
sometimes  very  slight. 

Vomiting  may  be  present 
or  absent. 

Abundant  hemorrhage 
from  the  stomach  com- 
mon. Stools  may  con- 
tain blood  (tarry). 

Bowels  may  or  may  not  be 
constipated ;  usually  are. 

No  fever. 


Frequently  extreme  pallor 
and  debility,  especially 
if  preceded  by  anemia. 


Duration  uncertain ;  may 
get  well,  may  I'un  on 
rapidly  to  perforation  ; 
on  the  other  hand,  may 
last  for  years. 

Rarely  a  tumor. 

Hydrochloric  acid  in  excess 
in  contents  of  stomach. 

No  lactic  or  fatty  acids  after 
the  rigid  Boas  test-meal. 
No  dropsy. 


Gastric  Carcinoma. 

Most  common  in  elderly 
people  ;  rarely  occurs  in 
persons  under  thirty 
years  of  age. 

Pain  frequently  of  a  radi- 
ating kind,  often  parox- 
ysmal, not  infrequently 
severe  and  lancinating, 
but  not  of  necessity  asso- 
ciated with  soreness.  Lit- 
tle or  not  at  all  alfected 
by  food.  Pain  rarely 
remits ;  never  intermits 
for  any  considerable 
time. 

Symptoms  of  indigestion 
marked.  Anorexia ;  ex- 
treme acidity  of  stomach. 

Vomiting  a  very  frequent 
symptom. 

Hemorrhage  not  very  abun- 
dant, but  frequently  oc- 
casioning coffee-ground- 
looking  vomit. 

Bowels  obstinately  consti- 
pated. 

Intercurrent  attacks  of 
slight  fever  may  occur ; 
but  temperature  often 
subnormal. 

Gradual  and  progressive 
loss  of  flesh,  and  debility  ; 
and  at  times,  with  the 
cachexia,  hypertrophy  of 
the  peripheral  lymphatic 
glands,  especially  above 
the  clavicles. 

Average  duration  one  year ; 
may  be  shorter,  but  sel- 
dom longer. 


Generally  a  tumor. 
No   hydrochloric    acid    in 
contents  of  stomach. 

Lactic   acid    present    after 

Boas's  test-meal. 
Edema  of  ankles  often  met 

with. 


Treatment. — The  diet  should  receive  careful  attention,  and  it  will 
be  necessary  to  adapt  it  to  the  peculiarities  of  the  individual  case.  In 
general  terms,  articles  of  food  that  are  digested  and  assimilated  in  the 
intestines  should  be  employed.      After  well-marked  evidences  of  pyloric 


778  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

obstruction  appear  we  may  add  greatly  to  the  comfort  of  the  patient  by 
limiting  the  dietary  to  liquids,  and  by  predigesting  them  if  they  are  not 
otherwise  well  borne.  Should  the  stomach  reject  all  food,  rectal  alimen- 
tation should  be  promptly  instituted.  The  medicinal  treatment  of  gas- 
tric carcinoma  is  altogether  symptomatic,  no  remedy  with  any  power 
over  the  lesion  having  been  found.  The  more  troublesome  symptoms 
— namely,  pain,  vomiting,  and  constipation — are  to  be  met  on  general 
principles.  Should  free  hematemesis  occur,  it  should  be  treated  as  pre- 
viously indicated  under  Gastric  Ulcer.  The  claims  that  have  been  ad- 
vanced in  favor  of  arsenic  and  other  preparations  as  possessing  power  to 
control  the  progress  of  gastric  carcinoma  have  not  been  confirmed  by 
any  extended  experience.  If  dilatation  coexists,  it  is  to  be  managed  in 
accordance  Avith  the  recommendations  found  under  Dilatation  of  the 
Stomach  (p.  748 1.  Surgical  treatment  may  also  be  called  into  service. 
Hypertrophic  Stenosis  of  the  Pylorus. — By  this  term  is 
meant  pyloric  obstruction  due  to  hypertrophy,  principally  of  the  cir- 
cular layer  of  the  muscularis  with  hyperplasia  leading  to  secondary 
dilatation  of  the  stomach.  This  may  be  (a)  congenital;  (6)  acquired. 
The  etiology  is  unknown,  although  spasm  of  the  pylorus  has  been  sug- 
gested. The  syinptoms  are  those  of  dilatation  of  the  stomach  and  a 
pyloric  tumor  is  sometimes  palpable.  The  resemblance  to  ulcer  with 
tumor-like  thickening  and  to  ulcus  carcinomatusum  may  be  striking 
{vide  also  p.  777).  Congenital  atresia  proves  rapidly  fatal,  while  the 
adult  form  may  run  a  long  course.  Exceptionally  other  forms  of 
gastric  tumor  occur — lipomata,  sarcomata,  fibromata,  and  cysts. 


HEMATEMESIS. 


He.matemesis  is  a  symptom.  Inasmuch  as  it  is  due  to  various 
causes  and  diseases  other  than  those  of  the  stomach,  it  is  hardly  to  be 
properly  classed  among  gastric  affections,  and,  at  all  events,  is  not 
entitleil  to  more  than  a  brief  separate  description. 

Htiology. — Among  the  causes  of  hematemesis  are — 1.  Traumatic 
injury  to  the  stomach  ;  2.  Diseases  of  its  coats  (carcinoma,  ulcer,  miliary 
aneurysm  of  the  arteries);  3.  A  mechanical  impediment  to  the  portal 
circulation  ;  4.  Vicarious  menstruation  ;  5.  Alterations  in  the  blood ;  6. 
A  disease  of  some  neighboring  organ,  such  as  carcinoma  of  the  pancreas, 
may  perforate  the  gastric  coats  and  open  its  vessels. 

Symptoms  and  Diagnosis. — If  the  fact  that  it  is  always  a  symp- 
tom, and  not  the  disease  itself,  be  recollected,  the  importance  of  recogniz- 
ing its  special  causal  condition  in  each  instance  will  be  obvious.  The 
manner  of  its  occurrence  and  the  characteristics  presented  by  the  blood 
often  give  a  clue  to  its  nature  and  origin.  Thus,  we  have  seen  that  the 
clinical  signs  in  hematemesis  due  to  carcinoma  and  ulcer  of  the  stomach 
vary  greatly,  being  almost  peculiar  to  each.  This  fact  must,  however, 
be  weighed  with  the  history  and  SN'mptoms  of  the  case  in  which  it  may 
occur ;  in  this  manner,  and  in  this  manner  only,  can  errors  be  avoided. 
A  process  of  exclusion  is  the  best  way  to  reach  a  decision.  If  a  careful 
inquiry  determines  the  absence  of  morbid  lesions  of  the  stomach,  such  as 


NEUROSES  OF  THE.  STOMACH.  779 

carcinoma,  ulcer,  or  chronic  gastritis,  then  the  other  organs  of  the  abdo- 
men, and  more  particularly  the  liver,  must  be  examined.  If  this  and  the 
heart  be  found  to  be  healthy,  attention  should  then  be  turned  toward  the 
state  of  the  blood,  since  the  presence  of  any  specific  fever  may  readily 
account  for  the  hematemesis.  Should  the  blood  present  nothing  abnor- 
mal, it  may  be  found  that  the  menstrual  or  other  habitual  discharge  has 
become  suppressed. 

Differential  Diagnosis. — It  is  to  be  recollected  that  the  source  of  the 
blood  may  be  other  than  the  stomach.  Rarely,  an  abdominal  aneurysm 
bursts  into  the  stomach  ;  occasionally,  too,  a  thoracic  aneurysm  opens  into 
the  esophagus,  whence  the  blood  speedily  finds  its  way  into  the  stomach. 
A  careful  consideration  of  the  history  and  of  the  attending  symptoms, 
together  with  a  thorough  physical  examination,  will,  after  excluding  the 
various  conditions  causing  true  gastric  hemorrhage,  lead  to  a  correct  inter- 
pretation of  the  phenomena.  Blood  coming  from  the  throat,  tonsils, 
mouth,  or  the  respiratory  organs,  including  the  nose,  is  sometimes  swal- 
lowed, and  afterward  ejected  by  vomiting.  To  discriminate  from  this 
condition  it  is  only  necessary  to  make  an  examination  of  the  lungs  and 
elicit  most  carefully  the  history.  It  must  also  be  recollected  that  hys- 
teric females  and  malingerers  have  been  known  to  swallow  the  blood  of 
animals  and  other  dark  fluids,  and  vomit  them  subsequently.  The  vom- 
itus  may  resemble  dark  blood  in  appearance  when  stained  by  bile  or  iron 
or  after  a  free  indulgence  in  wine.  The  points  of  contrast  between 
hematemesis  and  hemoptysis  have  been  placed  side  by  side  in  the 
following  table : 

Hematemesis.  Hemoptysis. 

The  history  points  to  gastric,  splenic,  he-  History  of  cough  and  other   symptoms 

patic,  or  cardiac  disease.  points  to  pulmonary  or  cardiac  disease. 

A  feeling  of  uneasiness,  and  sometimes  A  feeling  of  weight   and  uneasiness  in 

of  nausea   or   faintness,  precedes   the  the  chest,  a  saline  taste,  and  a  tickling 

hemorrhage.  in  the  throat  precede  the  hemorrhage. 

The  blood  is  ejected  by  vomiting ;  violent  The  blood  is  raised  by  coughing,  though, 

vomiting  may  excite  cough.  if  it  be  swallowed,  vomiting  may  follow. 

The  blood  is  either  clotted  or  fluid  and  The  blood  is  bright-red,  frothy,  in  small 

dark ;   it  may  be   mingled  with    rem-  coagula,  sometimes  mixed  with  muco- 

nants  of  food,  and  is  acid  in  reaction.  pus,  and  alkaline  in  reaction. 

Prognosis. — Hematemesis,  except  it  be  due  to  rupture  of  an  aneur- 
ysm, rarely  presents  a  hopeless  prognosis.  In  cases  of  splenic  enlarge- 
ment, hepatic  cirrhosis,  or  gastric  ulcer,  it  may  prove  fatal. 

The  treatment  has  been  detailed  in  the  discussion  of  Gastric 
Ulcer. 


NEUROSES  OF  THE  STOMACH. 

NERVOUS    DYSPEPSIA. 
{Neurasthenia   Gastrica.) 

Definition. — A  functional  disorder  of  the  stomach,  usually  charac- 
terized by  regularly  (and  sometimes  irregularly)  recurring  attacks  of 
gastric  disturbance,  followed  by  almost  complete  freedom  from  symptoms. 
Under  the  term  nervous  dyspepsia  I  shall  embrace  a  general  considera- 


780  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tion  of  all  the  forms  of  gastric  neuroses  to  be  hereafter  described. 
There  are  no  local  lesions  detectable. 

Ktiology. — The  vast  majority  of  cases  occur  in  highly  emotional 
and  hysteric  persons,  under  such  exciting  conditions  as  great  anxiety, 
violent  passion,  dissipation,  social  excesses,  mental  over-exertion  in  busi- 
ness life,  grievances,  and  any  startling  news  or  sudden  excitement.  The 
condition  is  most  commonly  met  -nith  in  healthy-looking,  ruddy-cheeked 
adults,  though  it  may  also  occur  in  the  weak  and  pale-faced.  It  is  more 
common  in  females  than  males.  Persons  living  amid  luxurious  surround- 
ings suffer  most.  It  is  probable  that  a  nervous  temperament  operates  as 
an  underlying  cause  for  an  exacerbation  of  nervous  dyspepsia.  Gastric 
neuroses  may  be  of  reflex  origin  in  various  organic  affections,  partic- 
ularly of  the  nervous  system  and  in  irritation  of  the  genito-urinary 
organs  of  both  sexes. 

Symptoms. — The  symptoms  follow  immediately  upon  the  action  of 
the  exciting  cause  and  are  largely  under  the  influence  of  the  emotions. 
In  the  ordinary  form  the  gastric  secretions  are  often  normal,  and  the 
stomach  is  found  empty  after  a  test-meal  within  the  physiologic  time- 
limit.  There  is  anorexia,  which  occasionally  alternates  with  a  voracious 
appetite.  After  meals  the  patient  complains  of  distress  and  oppression 
in  the  epigastrium  ;  eructations,  and  an  occasional  regurgitation  of  the 
acid  liquid  or  solid  contents  of  the  .'^tomach,  with  heartburn,  will  also  be 
noted.  Vomiting  is  not  rare,  and  occurs  independently  both  of  the  time 
of  eating  and  of  the  character  of  the  food.  Gastric  peristalsis  is  some- 
times so  well  marked  as  to  be  readily  felt  and  even  visible  through  the 
stomach-wall.  Kussmaul  has  called  special  attention  to  this  symptom, 
which,  I  believe,  belongs  largely  to  nervous  dyspepsia  (vide  peristaltic 
unrest,  p.  784).  The  increased  peristaltic  waves,  especially  under 
emotion,  excite  cooing,  gurglinor  sounds  that  are  a  source  of  great 
annoyance  to  the  patient. 

The  physical  examijiation  sometimes  reveals  abdominal  distention  and 
hyperesthesia  of  the  surface,  but  no  localized  tenderness,  pressure  with 
the  broad  hand  usually  affording  relief  from  pain.  Nervous  phenomena 
always  exist,  and  their  correct  interpretation  is  of  the  utmost  importance 
in  the  diagnosis.  Neurasthenic  and  hysteric  manifestations  are  com- 
monly associated.  The  mental  condition  is  unstable  and  illy  regulated, 
and  this  fact  furnishes  a  satisfactory  explanation  of  the  operation  of 
the  etiologic  factors.  The  general  health  is  in  many  instances  not 
noticeably  impaired;  in  others,  particularly  in  those  subject  to  frequent 
vomiting  and  complete  anorexia,  the  general  nutrition  suffers  con'feider- 
ably. 

Complications. — The  bowels  are  often  constipated,  are  apt  to  be 
distended  with  gas,  and  may  be  the  seat  of  an  abnormal  peristalsis. 
The  course  of  nervous  dyspepsia,  in  all  of  its  clinical  varieties,  is  chronic, 
and  it  may  terminate  in  catarrh  of  the  stomach. 

Nervous  dyspepsia  with  hypochondriasis  forms  a  group  of  cases  in 
which  the  hypochondriasis  may  sustain  a  causal  relation  ;  it  may.  how- 
ever, be  secondary  to  the  gastric  disturbances.  In  either  event  it  is  apt 
to  become  pronounced  after  the  gastric  symptoms  have  lasted  a  long 
time.  The  symptoms  other  than  the  nervous  phenomena  are  quite 
similar  to  those  previously  described. 


NEUBOSES  OF  THE  STOMACH.  781 

Diagnosis. — The  diagnosis  is  based  on  the  following  points:  (a)  The 
etiologic  factors.  Here  it  is  important  to  ascertain  the  particular  caus- 
ative influence  that  produces  the  gastric  symptoms,  taking  also  into 
consideration  any  well-recognized  predisposing  causes,  (b)  The  course 
of  the  complaint  and  the  absence  of  some  of  the  physical  signs  and 
symptoms  that  Avould  point  positively  to  anatomic  lesions  of  the  stomach. 
When  there  is  a  catarrhal  process,  the  symptoms  become  more  pro- 
nounced immediately  after  taking  food  than  in  neurasthenia  gastrica.  The 
influence  of  the  ingestion  of  indigestible  substances  upon  sympathetic 
dyspepsia  is  often  to  relieve,  or  is  of  neutral  eff"ect,  whereas  in  catarrhal 
indigestion  it  decidely  aggravates  the  condition.  The  dull  pain  after 
eating  and  the  tenderness  on  pressure  are  usually  more  marked  in  the 
catarrhal  variety,  and  the  stomach  contains  large  amounts  of  mucus. 
The  symptoms  of  the  latter  do  not  intermit  from  time  to  time,  as  in 
nervous  dyspepsia,  but  are  more  constantly  present.  The  analysis  of 
the  stomach-contents  obtained  after  a  test-breakfast  will  also  assist  in 
the  diagnosis.  The  gastric  contents  in  cases  of  nervous  dyspepsia  are 
often  found  about  normal,  though  any  abnormality  (even  to  complete 
achlorhydria)  may  be  present  {vide  Special  Forms  of  Gastric  Neuroses, 
p..  782). 

Prognosis. — If  there  be  an  absence  of  an  inherited  predisposition, 
and  if  the  cause  is  removable,  complete  recovery  may  be  prognosticated. 
In  a  neurotic  constitution,  however,  the  tendency  to  recurrence,  even 
after  a  decided  improvement  has  taken  place,  is  very  strong.  The  most 
unpromising  cases  are  those  in  which  the  cause  is  irremovable,  though 
as  to  life  the  prognosis  is  not  unfavorable.  The  patient  himself  is 
always  of  the  opinion  that  he  is  sufi"ering  from  a  serious  and  incurable 
afi'ection. 

Treatment. — Every  causal  factor  must  be  recognized  and  mitigated 
or  removed.  If  we  fail  to  accomplish  this  end,  our  efforts  at  cure  will  be 
unsuccessful.  The  dietary  should  be  generous  and  composed  of  highly 
nutritious  articles  of  food,  and  to  convince  the  patient  that  his  stomach  is 
capable  of  digesting  a  full  meal  is  the  first  duty  of  the  physician,  though 
the  task  is  confessedly  difficult.  So  soon  as  the  patient  realizes  the  truth 
in  reference  to  his  digestive  capacity  his  sufferings  are  largely  at  an  end. 
It  is  the  nervous  system  that  demands  especial  attention,  and  the  internal 
treatment  of  the  stomach  is  merelv  placeboic.  Nerve-tonics  combined 
with  nerve-stimulants  are  often  serviceable. 

A  change  of  air  from  the  city  to  the  country,  the  mountains,  or 
the  sea-coast  is  usually  followed  by  improvement.  In  some  manner 
the  patient  must  be  extricated  from  the  old  surroundings  under  the 
influence  of  which  the  disease  was  started  and  has  continued.  Sea 
air  has  seemed  to  me  to  be  more  serviceable  than  mountain  air  in  these 
cases,  though  I  believe  it  to  be  an  axiom  in  climatic  therapeutics  that  the 
latter  confers  more  lasting  benefits  than  the  former.  These  patients  are 
often  averse  to  taking  exercise,  but  so  great  is  the  value  of  this  sanitary 
measure  that  it  should  never  be  overlooked.  Cold  sponging  of  the  sur- 
face, followed  by  friction  to  the  skin,  should  be  practised  daily  for  its 
effect  upon  the  skin-circulation  and  the  nervous  system.  Occasional 
lavage,  hot  and  cold  douches,  electricity  (intra-  and  extra-gastric),  and 


782  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

gastric  massage,  may  all  be  tried,  and  may  prove  of  distinct  advantage. 
In  highly  neurotic  and  hysteric  females  the  S.  Weir  Mitchell  treatment 
is  often  attended  ^vith  good  results.  The  hypochondriac  form  is  often 
intractable.  Strychnin,  however,  if  perseveringly  used,  and  if  coupled 
with  a  change  of  air,  often  proves  beneficial.  One  of  the  most  obstinate 
examples  of  this  nature  that  I  have  ever  seen  occurred  in  a  retired  mer- 
chant living  in  Philadelphia.  This  man  was  finally  cured  in  consequence 
of  his  own  suggestion,  resulting  in  his  removal  to  the  country  and 
engaging  in  farming. 


SPECIAL  FORMS  OF  GASTRIC  NEUROSES.  CHARAC- 
TERIZED BY  MARKED  AND  PECULIAR  ANOMALIES 
OF  SENSATION,  MOTILITY,  AND  SECRETION. 

NEUROSES   OP   SECRETION. 

HYPERCHLORHYDRIA. 

( Hyperacidiiy . ) 

Definition. — An  augmentation  of  the  secretory  function  of  the 
stomach  during  the  digestive  period,  resulting  in  the  presence  of  an  ex- 
cessive amount  of  hydrochloric  acid. 

Ktiology. — Hyperacidity  is  common  during  digestion,  and  in  most 
instances  is  due  to  some  one  of  the  causative  influences  mentioned 
under  Nervous  Dyspepsia  (grief,  great  anxiety,  mental  over-taxation). 
The  disease  is  common  among  the  professional  classes,  and  it  affects 
men  oftener  than  women.  Highly-sea-soned  foods  and  alcoholic  intoxi- 
cants may  occasion  the  condition. 

Symptoms. — Hyperchlorhydria  may  be  continuous,  though  more 
often  it  is  Jiscontinuous  and  lasts  from  a  few  hours  to  several  days.  After 
the  periodic  form  has  lasted  a  long  time  it  may  gradually  become  a 
permanent  condition.  The  patient  at  first  complains  of  uneasiness  in  the 
epigastrium  one  or  two  hours  after  meals.  Later,  this  amounts  to  jjain 
of  moderate  intensity,  and  soon  follows  every  meal  after  a  like  interval. 
The  duration  of  the  pain  is  from  one  to  three  hours.  Acid  eructations 
are  frequently  noted.  The  increase  of  hydrochloric  acid  interferes  Avith 
the  digestion  of  starches,  and  thus  tends  to  increase  the  pain.  On  the 
other  hand,  hoAvever,  a  diet  composed  of  albuminoids  often  affords  relief, 
and  the  salts  of  the  alkalies  also  ease  the  pain.  Associated  nervous 
symptoms  (headache,  dizziness)  are  often  observed,  though  the  bodily 
nutrition  is  usually  well  maintained.  Palpation  of  the  epigastrium  may 
show  a  diffused  tenderness.  Evidences  of  moderate  dilatation  of  the 
stomach  sometimes  appear,  and  splashing  sounds  may  be  detectable. 

Diagnosis. — Though  the  diagnosis  of  hyperacidity  is  made  probable 
by  the  above-mentioned  symptoms,  it  is  rendered  certain  only  by  a  re- 
peated analysis  of  the  gastric  contents.  The  findings,  according  to  Ein- 
horn,  are — (1)  On  examination  of  the  stomach  in  the  fasting  condition, 
the  organ  either  is  found  empty  or  contains  only  a  few  cubic  centimeters 
of  juice  ;  (2)  one  hour  after  Ewalds  test-breakfast  the  hyperacidity  is 
greatly  increased,  owing  to  the  great  amount  of  free  HCl. 


NEUROSES  OF  SECRETION.  783 

Gastric  ulcer  must  be  eliminated.  In  this  disease  the  pain  is  aggra- 
vated immediately  after  eating,  and  is  not  relieved  by  albuminous  food, 
nor  by  large  doses  of  alkalies  as  in  hyperchlorhydria.  In  ulcer,  more- 
over, the  pain  often  leads  to  vomiting,  and  severe,  painful  attacks  fre- 
quently occur  at  night. 

Gastro-succorrhoea  {Reichmann) ;  Gastroxynsis  (Rossbach). — In  this 
aifection  there  is  an  increase  of  hydrochloric  acid,  either  constantly  or 
intermittently,  -when  no  food  is  present.  An  epigast7-ic  gnawing  pain 
and  nausea  appear  in  the  full  bloom  of  health.  The  nausea  soon 
results  in  the  vomiting  of  enormous  quantities  of  gastric  contents.  The 
appetite  is  lost,  but  the  thirst  is  excessive,  and  the  amount  of  drink 
taken  and  of  liquid  vomited  are  proportional.  During  the  night  or 
in  the  early  morning  hours  the  patient  commonly  vomits  large  amounts 
of  a  clear  or  bile-tinted  liquid  containing  hydrochloric  acid  and  the 
gastric  ferments  in  excess.  This  may  be  followed  by  persistent  vom- 
iting, attended  with  much  retching.  After  a  lapse  of  a  few  hours  the 
ejection  of  a  large  quantity  of  highly  acid  liquid  may  be  repeated.  The 
pain  often  becomes  intense,  headache  is  common,  and  a  tendency  to  col- 
lapse is  usually  marked.  The  attacks  last,  as  a  rule,  about  two  or  three 
days,  when  they  quite  abruptly  give  place  to  apparent  good  health. 
Recurrence  at  the  end  of  periods  ranging  from  a  few  months  to  a  year 
or  more  are  common.     A  physiologic  form  has  been  advanced. 

The  diagnosis  is  made  upon  the  presence  of  the  clinical  symptoms 
and  course,  as  well  as  upon  the  results  of  oft-repeated  analyses  of  the 
vomitus.  Gastric  ulcer  and  certain  organic  spinal  and  cerebi^al  nervous 
affections,  in  which  there  is  excessive  gastric  secretion,  must  be  excluded 
before  an  absolute  diagnosis  can  be  made. 

Gastro-succorrhoea  Continua  Chronica. — Reichmann  first  described  a 
condition  characterized  by  a  constant  secretion  of  gastric  juice  either 
in  the  absence  or  presence  of  food.  The  symptoms  are  much  the 
same  as  those  in  hyperacidity,  but  tend  to  become  continuous,  so  that 
the  vomiting  finally  becomes  a  daily  occurrence.  In  the  fasting  state 
a  highly  acid  secretion  that  contains  no  food-particles  flows  through  the 
tube  from  the  stomach.  Albuminoids  are  rapidly  and  starches  slowly 
digested  by  these  patients,  as  is  shown  by  an  examination  of  the  gas- 
tric contents  three  or  four  hours  after  the  Leube-Riegel's  test-meal  (one 
plate  of  soup — 400  c.c. — a  large  portion  of  meat,  some  potatoes,  and  a 
roll).  The  disease  is  quite  rare,  and  must  not  be  confounded  with  the 
organic  diseases  to  which  continuous  gastric  succorrhea  may  be  second- 
ary and  upon  which  it  is  dependent.  Schreiber,  Boas,  and  others 
believe  that  this  is  almost  always  a  symptom  of  gastric  atony  or  gastric 
ulcer.     The  occurrence  of  hematemesis  or  melena  would  favor  ulcer. 

Leube  has  described  a  neurosis  in  which  there  is  a  constant  sub- 
acidity  of  the  secretion. 

Achylia  Gastrica  (JEinliorn). — The  suspension  of  the  gastric  secre- 
tions may  result  either  from  atrophy  of  the  stomach  glandules  or  from 
a  nervous  derangement  of  secretion.  The  condition  has  been  mistaken 
for  malignant  disease  of  the  stomach.  Lactic  acid,  however,  is  not  pres- 
ent in  excess.  Achylia  gastrica  may  cause  chronic  lienteric  diarrhea 
(A.  A.  Jones). 


784  DISEASES  OF  TEE  DIGESTIVE  SYSTEM. 

The  prognosis  in  the  foregoing  affections  is  not  bad  as  to  life,  and 
not  infrenuently  a  cure,  even,  can  be  effected. 

Treatment. — The  dietary  of  the  neuroses  of  secretion  embraces 
principally  nitrogenous  articles  of  food.  Einhorn  advises  three  large  and 
two  small  meals  daily.  The  two  smaller  meals  should  consist  of  a  glass 
of  milk  with  bread  and  butter,  or  like  fare.  Acids  and  spirits — substances 
that  excite  the  glands  of  the  stomach — must  be  excluded.  The  medic- 
inal treatment  should,  in  addition  to  meeting  the  general  neurotic  con- 
dition, consist  of  full  doses  of  sodium  bicarbonate.  In  some  cases  more 
active  alkalies  than  sodium  bicarbonate  may  be  needful — e.g.  magnesium 
and  sodium  salicylate,  either  separately  or  in  combination.  Lavage 
daily,  before  the  chief  meal,  is  also  sometimes  beneficial.  Lemoine 
advises  hydrotherapy  and  rest  to  strengthen  the  nervous  .system. 

NEUROSES   OF    MOTILITY. 
INCREASED   PERISTALSIS    OF   THE    STOMACH. 

Gastric  peristalsis  is  increased  in  various  conditions,  which  will  be 
considered  seriatim,  though  briefly. 

{a)  BelcMng  and  Eructations. — These  may  be  of  nervous  origin  and 
are  met  with  generally  in  hysteric  subjects,  and  less  frequently  in 
neurasthenics.  The  air  is  swallowed,  and  then  expelled  Avith  more  or 
less  noise,  owing  to  an  increased  contractility  of  the  stomach.  The  gas  is 
odorless.^  and  differs  in  this  point  from  the  gases  of  fermentative  dys- 
pepsia. Epigastric  distress  and  distention  often  arise,  and  certain  nervous 
phenomena,  as  anxiety  or  palpitation,  may  coexist.  It  must  not  be 
forgotten,  moreover,  that  in  hysteric  subjects  the  belching  may  be  from 
the  esophagus  alone. 

(h)  Pyrosis  means  regurgitation  of  the  acid  contents  of  the  stomach. 

(c-)  Rumination  (Meri/cism). — A  rare  affection  in  which  the  food  is  re- 
gurgitated into  the  mouth,  the  cud  chewed,  and  again  swallowed  after  the 
fashion  of  ruminants. 

(d)  Nervous  Vomiting. — This  is  a  reflex  neurosis  that  may  affect 
persons  of  any  age,  though  most  frequently  it  is  seen  in  adult  females 
with  an  hysteric  tendency.  Without  previous  nausea,  and  independ- 
ently of  the  character  of  the  food  taken,  the  contents  of  the  stomach 
are  readily  expelled  or,  more  correctly  speaking,  regurgitated  into  the 
mouth,  and  then  expectorated.  Though  this  usually  takes  place  after 
meals,  it  may  occur  without  reference  to  meal-time — a  feature  that  indi- 
cates its  nervous  origin.  The  attacks  of  vomiting  are  separated  by 
longer  or  .shorter  intervals  of  excellent  health.  Periodic  vomiting  mav 
also  occur  independently  of  hysteria  or  other  nervous  affections,  as  pointed 
out   by  Leu  be.     The  course  is  rarely  unfavorable. 

{e)  Peristaltic  unrest  (Kussmaul).  or  spasm  of  the  stomacli,  has  been 
referred  to  under  Nervous  Dyspepsia.  It  has  also  been  observed  in 
compensatory  hypertrophy  of  the  stomach-wall  following  pyloric  strict- 
ure. In  a  case  of  gastric  carcinoma  in  my  own  care  the  supermotility 
of  the  stomach  caused  an  almost  immediate  expulsion  of  the  gastric 
contents,  and  even  of  the  rigid  test-meal  at  certain  times. 

( f )  Cardiospasm. — By  this  term  is  meant  a  painful  cramp  of  the 
cardia.     Two  forms  are  distinguished :  (a)  acute  cramp  (of  brief  dura- 


NEUBOSES  OF  MOTILITY.  785 

tion)  ;  (b)  chronic  cramp  (exceedingly  rare).  Among  causes  are  neuras- 
thenia, hysteria,  and  local  irritation  (thermal,  mechanical).  Chronic 
spasm  may  lead  to  complete  atresia  of  the  cardia,  and  is  a  distressing 
affection.     In  acute  cardiospasm  the  attacks  often  tend  to  recur. 

(^)  Pylorospasm. — Cramp  of  the  ring-musculature  of  the  pyloris 
may  be  primary  or  secondary.  The  latter  is  due  to  intense  local  irrita- 
tion (superacidity,  hypersecretion,  excess  of  organic  acids).  The  pain- 
ful spasm  in  the  pyloric  region  induces  stagnation  of  the  ingesta,  fol- 
lowed by  atony  of  the  stomach  and  consequent  dilation. 

Treatment. — To  the  regimenal  management,  including  a  hygienic 
mode  of  living,  the  attention  of  the  physician  should  be  primarily  di- 
rected. The  medicinal  treatment  is  to  be  aimed  at  the  causal  or  primary 
nervous  affection.  The  valerianates  and  the  bromids  often  do  good 
service.  For  the  cramp  of  the  cardia  and  pylorus  belladonnse  or  codeine 
are  efficient. 


DIMINISHED   PERISTALSIS    OP   THE    STOMACH. 
[Atony.) 

(a)  Pyloric  Relaxation  or  Incompetency. — This  is  a  rare  neurosis  that 
allows  the  partially  digested  gastric  contents  to  pass  the  portals  of  the 
stomach  prematurely.  It  likewise  permits  the  regurgitation  of  the  con- 
tents of  the  duodenum  into  the  stomach.  Its  recognition  is  possible 
upon  inflating  the  stomach,  when  gas  may  be  seen  to  pass  into  the  in- 
testines, and  also  (even  with  greater  certainty)  upon  the  regurgitation 
of  intestinal  contents  into  the  stomach. 

(b)  Insufficiency  of  the  Cardia. — This  condition  leads  to  eructations 
and  regurgitations,  and  when  these  are  of  aggravated  form  they  impair 
the  general  nutrition.      Ordinarily  no  ill-effects  follow. 

(c)  Atonic  Dyspepsia  (Atony). — This  may  occur  as  a  neurosis,  though 
oftener  it  is  secondary  to  chronic  gastritis.  It  implies  hypomotility  or 
insufficiency.  The  chyme  is  retained  in  the  stomach  beyond  the  natural 
time-limit.  There  is  an  epigastric  oppression  w'ith  a  distention  of  the 
organ  during  digestion  that  tends  to  become  permanent.  There  are 
eructations  of  gas,  an  impaired  appetite,  and  often  constipation.  The 
stomach  is  found  empty  in  the  morning,  and  six  or  seven  hours  after 
Leube's  test-meal  it  contains  some  chyme.  In  the  absence  of  pyloric 
stricture  the  hypomotility  may  be  show^n  by  the  administration  of  salol. 

Treatment. — The  diet  is  to  be  regulated  as  in  chronic  gastritis 
with  dilation.  It  is  rarely  necessary  to  restrict  the  solids  to  any 
marked  extent,  but  the  quantity  of  fluids  should  be  lessened.  The 
patient  must  be  taught  to  eat  slowly  and  masticate  thoroughly.  His 
hygienic  standard  of  living  must  be  high,  and  he  must  not  be  allow-ed 
to  over-use  his  mental  faculties.  Exercise  in  the  open  air  and  cold 
baths,  properly  regulated,  are  potent  for  good.  Of  medicines,  strychnin 
stands  first,  and  I  have  found  the  following  formula  of  great  service : 

I^.   Tr.  nus  vomicae,  f  Siiss  (10.0) ; 

Inf.  cascarillge,  q.  s.  ad  f  .^iv    (128.0).— M. 

Sig.  3ij  (8.0)  three  times  daily. 

50 


786  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Electricity  is  also  indicated,  and  it  is  in  these  cases  that  intragastric 
faradization  has  given  excellent  results.  The  constipation  is  to  be  over- 
come by  an  appropriate  dietary  (green  vegetables,  Graham  bread,  an 
abundance  of  fruit).     Lavage  deserves  a  prudent  trial. 


NEUROSES  OF  SENSATION. 

CARDIALGIA. 
( Gastralgia ;    Gastrodynia.) 

Definition. — Severe  paroxysmal  pain  in  the  epigastrium  in  the  ab- 
sence of  gastric  lesions.  There  are  two  other  forms  of  this  disease  that 
are  clinically  identical  with  gastralgia,  the  one  occurring  in  ulcer  and 
carcinoma  of  the  stomach,  and  the  other  in  certain  chronic  nervous 
diseases,  forming  the  so-called  gastric  crises,  which  have  been  considered 
elsewhere. 

Ktiology. — The  subjects  are  often  hereditarily  predisposed  to  neu- 
roses of  other  types.  Such  conditions  as  anemia,  exhaustion  from  re- 
])eated  hemorrhages,  and  syphilis  exert  a  predisposing  influence.  The 
female  sex  is  more  liable  than  the  male,  and  in  the  former  it  appears  to 
be  dependent  upon  disturbances  of  the  menstrual  function  or  quite  fre- 
quently upon  hysteric  conditions.  It  is  sometimes  excited  by  reflex 
irritation,  by  deep  grief,  worry,  and  great  anxiety.  Hypochondriasis 
and  hyperacidity  are  also  among  its  freijuent  causes. 

Symptoms. — These  are  sudden  in  their  onset  as  a  rule,  and  quite 
characteristic.  Occasionally  the  attack  is  preceded  by  anorexia,  or  it 
may  begin  Avith  a  sense  of  oppression  and  distention  in  the  epigastrium, 
lasting  for  a  few  minutes.  In  any  event,  the  onset  of  the  attack  proper 
is  marked  by  agonizing  p)(iins  in  the  epigastrium,  that  dart  through  to 
the  back,  and  at  times  also  pass  around  the  lower  ribs.  The  seizure  lasts 
from  a  few  minutes  to  an  hour  or  two,  and  terminates  with  eructations  of 
gas,  or,  less  frequently,  with  vomiting.  From  the  nature  of  the  causative 
factors  it  is  obvious  that  the  gastralgic  seizures  are  in  no  wise  dependent 
upon  the  character  of  the  food  taken  ;  hence  the  fact  that  they  occur  more 
frequently  when  the  stomach  is  empty  need  occasion  no  surprise.  Firm 
pressure  over  the  epigastrium  relieves  the  pain.  Nervous  phenomena, 
varying  with  the  etiology  of  individual  cases,  are  constant  attendants,  but 
cannot  be  detailed  here.  A  distinct  clinical  variety  is  found  associated 
with  that  form  of  nervous  dyspepsia  in  which  an  excess  of  HCl  is 
secreted  {vide  Hyperacidity) ;  this  occurs  at  varying  intervals.  Many 
purely  functional  nervous  disturbances  are  thus  subject  to  the  law  of 
periodicity.  I  believe  that  a  very  small  percentage  of  cases  are  caused 
by  malaria,  since  I  have  met  with  two  such  cases  in  a  malarial  district, 
both  of  which  yielded  readily  to  quinin.  Tlie  disease  took  on  a  des- 
ultory, periodic  character,  and  was  associated  with  other  malarial 
symptoms. 

Diagnosis. — The  history,  the  absence  of  any  local  causes,  together 
with  the  characteristic  gastralgic  attacks  and  their  time  of  occurrence, 
will  render  a  positive  diagnosis  easy  in  most  instances.  The  gastric 
crises  that  occur  in  locomotor  ataxia  must  be  excluded.  Cholelithiasis 
may  simulate  gastralgia  {lude  p.  855).     To  discriminate  this  condition 


HYPERESTHESIA   OF  THE  STOMACH.  787 

from  gastric  ulcer  is  sometimes  difficult,  but  stress  has  been  laid  upon 
the  differential  points  in  the  description  of  the  latter  disease  (vide  p. 
768). 

Prognosis. — This  depends  entirely  upon  the  causal  condition.  The 
disease  itself  has  no  intrinsic  fatal  tendency. 

Treatment. — This  is  to  be  subdivided  into  (a)  the  treatment  of  the 
attack  ;  (h)  the  management  of  the  intervals  between  the  seizures.  The 
pain  is,  as  a  rule,  sufficiently  intense  to  demand  morphin,  which  is  best 
administered  hypodermically  in  combination  with  atropin.  This  should 
not,  however,  be  repeated  unless  urgently  needed.  In  mild  attacks  the 
constant  or  the  faradic  current  often  affords  prompt  relief.  Under  these 
circumstances  counter-irritation,  together  with  the  internal  use  of 
Hoffman's  anodyne  or  chloroform  in  small  doses,  may  relieve  the  pain. 

(h)  The  Management  of  the  Intervals. — Here  the  physician's  efforts 
should  be  directed  to  the  detection  of  the  causes  and  their  removal  by  ap- 
propriate means.  In  hysteric  females  I  have  obtained  good  results  from 
the  prolonged  use  of  the  valerianates,  combining  with  them  iron  and 
arsenic,  thus : 

'Sf.  Zinci  valerianat.,  gr.  xviij   (1.16); 

Quininse  valerianat.,  gr.  xxvij  (1-74) ; 

Ferri  arseniat.,  gr.  ij         (0.129). 

M.  et  ft.  pil.  No.  xviij. 
Sig.  One  after  each  meal. 

A  change  of  air  is  often  highly  serviceable,  and  should  be  advised 
whenever  financial  considerations  permit.  These  patients  are  constantly 
in  a  more  or  less  exhausted,  anemic,  and  run-down  condition,  and  a  tonic 
plan  of  treatment  is  always  indicated.  In  the  intervals  between  the  at- 
tacks digestion,  as  before  stated,  proceeds  normally,  and  the  stomach, 
therefore,  requires  no  treatment.  Constipation,  if  present  is  a  condition 
demanding  relief,  not,  however,  by  the  use  of  purgatives,  but  by  such 
means  as  massage,  a  suitable  diet,  enemata,  or  laxative  suppositories. 
The  physician  must  carefully  regulate  the  sanitary  particulars  of  the 
patient's  daily  life. 

HYPERESTHESIA   OF   THE    STOMACH. 

This  is  met  with  in  functional  and  organic  diseases,  as  well  as  in 
chronic  gastric  catarrh  and  other  affections  of  the  stomach.  Again,  it 
may  occur  as  a  neurosis.,  most  frequently  in  chlorotic  girls  and  women. 
There  is  an  increased  gastric  sensibility,  so  that  the  mildest  irritant  pro- 
duces ^J)a^7^/'MZ  sensations  that  may  be  either  gnaAving  or  burning  in  cha- 
racter. A  feeling  of  fulness  and  nausea  are  among  the  common  features 
of  the  complaint.  Food  and  certain  articles  that  are  not  easily  digestible 
may  afford  relief,  and,  oppositely,  fasting  or  restriction  of  diet  may  aggra- 
vate the  condition.  The  complaint,  however,  is  often  aggravated  during 
digestion,  particularly  after  excessive  indulgence  in  certain  kinds  of 
food  (crabs,  lobsters,  oysters,  strawberries).  Cutaneous  symptoms,  as 
erythema  and  urticaria,  may  appear.  Hypochondriasis ^  neurasthenia, 
and  hysteria  are  often  associated.  The  above  symptoms  are  dependent 
upon  an  individual  idiosynci'asy. 


788  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Treatment. — At  first  a  restriction  of  the  diet  to  soft  and  liquid  arti- 
cles should  be  tried,  and  later  a  cautious  return  to  solid  food  is  to  be  made. 
Of  medicaments,  the  bromids,  given  for  a  period  of  tAvo  or  three  months, 
have  given  the  best  results  in  my  own  hands.  For  the  chlorotic  type 
iron  in  the  form  of  Blaud's  pill,  in  ascending  doses,  is  the  best  treatment. 


ANOREXIA. 

This  consists  merely  in  a  loss  of  appetite,  and  occurs  in  many  organic 
gastric  disorders.  It  may  also  be  a  primary  gastric  neurosis,  the  latter 
being  often  associated  Avith  gastric  hyperesthesia.  Anorexia  sometimes 
leads  to  a  repugnance  to  food  and  a  degree  of  abstinence  that  may  induce 
grave  nutritional  disturbance.  Among  exciting  causes  mental  shock  of 
any  sort  ranks  first.  In  other  instances  the  patient  may  experience 
hunger,  but  on  attempting  to  eat  anorexia  quickl}^  develops.  The  recog- 
nition of  anorexia  as  a  primary  neurosis  of  the  stomach  is  difficult  in 
the  extreme  after  the  general  nutrition  has  become  seriously  impaired. 
Chronic  dyspepsia,  phthisis,  and  other  diseases  associated  with  emaciation 
and  debility  must  be  excluded  before  the  diagnosis  is  established. 

HYPEROREXIA. 
( Excessive  Appetite. ) 

This  may  either  be  symptomatic  of  other  affections  {e.  g.  diabetes 
mellitus)  or  it  may  be  a  gastric  neurosis.  It  may  also  be  paroxysmal 
(bulimia).  The  patient  complains  of  burning  sensations  in  the  epigas- 
tric region  and  of  an  insatiable  hunger.  The  symptoms  of  neurasthenia 
and  hysteria  are  often  in  association.  The  local  and  general  symptoms 
are  relieved  by  food.  It  may  also  accompany  other  nervous  disorders, 
as  affections  of  the  brain,  exophthalmos,  and  migraine. 

In  bulimia  the  abnormal  sensation  of  hunger  may  come  on  at  any 
hour,  even  immediately  after  abundant  food  has  been  taken.  When  the 
morbid  sensation  of  hunger  develops  more  gradually  and  some  time 
after  meals  it  is  spoken  of  as  polyphagia. 

Pica  is  the  term  applied  to  the  craving  for  substances  not  used  as 
food  (slate-pencils,  dirt,  chalk). 

Malacia  represents  the  desire  for  highly  spiced  dishes  (mustard, 
salads,  pickles,  fruits). 

The  above  conditions  are  met  with  in  neurasthenia,  chronic  gastric 
affections,  and  chlorosis. 


VIII.    DISEASES  OF  THE  INTESTINES. 

METHODS  OF  DIAGNOSIS. 

Bxamination  of  the  Feces. — Although  the  results  are  in  most 
cases  unsatisfactory,  an  examination  of  the  feces  should  not  be  neg- 
lected, especially  in  the  more  serious  affections  of  the  intestine.  This 
embraces — (a)  a  macroscopic  ;  {b)  a  microscopic ;  (c)  a  chemical ;  and 
{d)  di  bacteriologic  examination. 


DISEASES  OF  THE  INTESTINES  789 

(a)  The  macroscopic  appearances  often  suffice.  A  thorough  inspec- 
tion of  the  stools,  a  matter  too  often  omitted,  furnishes  valuable  points 
in  regard  to  the  presence  or  absence  of  coarse  parasites,  fragments  of 
tumor,  foreign  bodies,  concretions,  blood,  bile,  pigment,  fat,  pus,  mucus, 
undigested  meat,  and  the  like. 

The  shape,  color,  and  consistence  of  the  stools  must  be  noted,  and  it 
is  to  be  remembered  that  in  these  particulars,  as  well  as  regards  their 
frequency,  they  exhibit  a  considerable  range  of  normal  variations, 
according  to  individual  peculiarities,  the  character  of  food  taken,  and 
so  on.  It  is  to  be  recollected  that  normal  stools  contain  fat  in  varying 
amounts,  for  the  reason  that  only  a  limited  quantity  can  be  emulsified 
and  taken  up  from  the  intestine.  The  naked  eye  may,  at  times,  detect 
its  presence  from  the  "peculiar  silvery  appearance  "  of  the  feces.  Fat 
in  the  stools  (steatorrhea)  is  often  pathologic,  and  the  separate  affec- 
tions in  which  it  is  met  Avith  will  be  considered  hereafter.  The  dejecta 
present  a  shining,  tallowy  appearance,  either  throughout  or  in  circum- 
scribed spots.  Again,  the  fat  may  occur  in  the  form  of  oil  floating  on 
the  surface  of  liquid  stools.  Mucus  is  also  visible,  either  as  slimy  or 
jelly-like  masses,  or  as  shreds  and  granules  (sago-grains).  Diarrheal 
stools  should  be  examined  macroscopically  with  great  care  for  gross  ad- 
mixtures (flakes  of  casein,  bits  of  meat,  etc.).  Constipational  dejections 
often  assume  a  rounded  form  (sheej/s  clung)  on  account  of  their  delay  in 
the  large  bowel.  They  may  attain  to  the  size  of  an  orange,  and  may 
be,  though  rarely,  enveloped  in  mucus  or  blood-streaked.  Their  color 
is  dark.  On  the  other  hand,  the  stools  may  be  colorless  in  cases  in 
which  the  bile-ducts  are  occluded ;  these  usually  contain  a  large  pro- 
portion of  fat,  though  not  invariably.  The  effect  of  certain  drugs  upon 
the  color  of  the  stools  is  to  be  borne  in  mind.  When  blood  is  inti- 
mately mingled  Avith  the  feces,  they  have  a  reddish,  dark-  or  blackish- 
brown  (tarry)  color,  according  to  the  quantity  and  the  time  allowed  for 
decomposition  in  the  intestine.  Blood,  either  clotted  or  fluid,  may  also 
be  passed  in  a  pure  state.  Its  source  is  usually  the  lower  boAvel,  though 
Avhen  peristalsis  is  augmented,  it  may  come  from  the  small  intestine,  as 
in  typhoid  fever.  Pus  may  occasionally  be  recognized  macroscopically. 
From  a  diagnostic  point  of  view,  it  is  most  important  to  examine  .for 
biliary  concretions  in  doubtful  abdominal  colic.  "  For  the  detection  of 
small  concretions  the  stools  should  be  passed  through  a  sieve ;  large 
concretions  are  easily  recognizable"  (Ewald). 

(b)  Microscopic  Examination. — Diarrheal  stools  can  be  examined  as 
discharged,  but  to  solid  and  mushy  dejections  a  solution  of  common 
salt  (J  per  cent.)  should  be  added  and  all  hard  masses  thoroughly 
broken  up.  Different  portions  of  the  stools  are  to  be  selected  for 
microscopic  examination.  Microscopically  we  are  enabled  to  detect  the 
eggs  of  parasites,  pus,  blood,  protozoa,  mucus  in  the  form  of  shining, 
vitreous,  homogeneous,  or  whitish  masses ;  and  in  the  interior  of  the 
latter  certain  pathogenic  bacteria,  various  crystals,  and  intestinal  epi- 
thelium may  be  seen.  Remnants  of  vegetable  food  may  stimulate 
mucous  islets,  but  the  former  strike  a  blue  color  on  the  application  of  the 
potassium-iodid  test.  Microscopically,  diarrheal  stools  show  undigested 
muscle-fibers,  fat-crystals,  vegetable  cells,  starchy  granules,  and  innum- 
erable bacteria.     Undissolved  starch  in  even  moderate  quantity  points 


790  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  catarrhal  enteritis  of  the  small  intestine.  On  microscopic  examina- 
tion of  the  dejections  in  constipation  we  find  "  a  copious  detritus  of 
brown  or  black  color,  usually  numerous  colorless  or  slightly  tinged 
triple  phosphates  (phosphate  of  ammonium  and  magnesium  crystal- 
lizing in  the  form  of  a  coflBn-lid),  or,  more  sparse,  crystals  of  neutral 
phosphate  of  lime."  Seldom  do  we  meet  with  the  rhomboid  plates  of 
cholesterin,  which  are  recognized  in  that  they  are  colored  from  a  red- 
dish-brown to  violet  by  dilute  sulphuric  acid  (1  :  5),  and  become  blue 
or  green  on  the  further  addition  of  a  solution  of  iodin.  Needle-shaped 
crystals  of  fat,  single  and  also  in  the  forms  of  tufts,  are  frequently  met 
in' obstruction  of  the  biliary  ducts.  Bile-pigment  cannot  be  detected. 
Remnants  of  food  are  sparsely  present  in  normal  feces.  Epithelium  from 
the  mucous  membrane,  pus-cells,  and  blood-corpsucles,  unless  they  come 
from  the  passage  of  the  fecal  mass  through  the  anus  (in  which  case  they 
are  simply  adherent  to  the  external  surface  of  the  scybala  and  are  but 
little  changed),  are  greatly  altered ;  they  are  fatty,  degenerated, 
shrunken,  and  hardly  recognizable.  Rhomboid  crystals  of  hematoidin 
may  be  at  times  observed.  The  microscopic  examination  for  animal 
parasites  will  be  referred  to  in  appropriate  sections  of  this  work. 

(c)  Chemical  Examination, — The  presence  of  bile-pigment  is  easily 
detected  by  the  Gmelin  reaction.  The  stools  must,  if  needful,  be  ren- 
dered fluid  by  the  addition  of  water,  then  filtered,  and  the  filtrate 
allowed  to  dry.  At  the  margin  of  the  drop  the  characteristic  green 
color  Avill  appear.  Urobilin  strikes  a  red  color.  The  stools  in  diarrhea 
may  contain  ferments  capable  of  digesting  albuminoids.  The  fatty  acids 
are  distinguished  from  fatty  soaps  by  the  solubility  of  the  former  in  ether. 

To  detect  a  very  small  amount  of  blood  that  may  be  intimately 
mixed  with  the  feces  the  test  of  Fr.  MUller  and  Weber  gives  the  most 
reliable  results.  Solid  or  mushy  stools  are  first  rubbed  up  with  water 
and  filtered.  A  portion  of  the  filtrate  of  liquid  feces  is  added  to 
5  cubic  centimeters  of  glacial  acetic  acid  and  ether,  and  the  Avhole 
well  shaken.  The  ether  generally  settles  clear,  but  if  it  does  not  a  few 
drops  of  absolute  alehohol  are  to  be  added.  The  presence  of  blood 
(hematin  acetate)  is  shown  by  a  reddish-brown  tint  given  to  the  layer 
of  ether.  The  indol-reaction  may  be  increased,  pointing  to  increased 
intestinal  putrefaction. 

(d)  A  bacterial  examination  of  the  intestinal  contents.,  and  particu- 
larly of  any  mucus  or  muco-pus  that  may  be  discharged,  may  decide 
the  diagnosis  of  certain  intestinal  disorders  (tuberculosis,  amebic  dysen.- 
tery).  For  the  method  of  carrying  on  these  investigations  the  reader 
is  referred  to  special  works  on  diagnosis  and  bacteriology. 

Physical  or  Bxternal  Bxatnination. — Inspection. — This  should 
be  made  with  tiie  patient  in  the  dorsal  position  and  with  proper  illumi- 
nation. Localized  prominences  are  to  be  noted,  though  the  fact  should 
be  remembered  that  these  may  be  simulated  by  localized  contractions 
of  the  various  abdominal  muscles.  The  influence  of  respiration  on 
these  circumscribed  bulgings  is  also  to  be  observed.  In  the  absence  of 
unusual  distention  of  the  abdominal  walls  it  is  of  great  value  to  inflate 
the  large  intestine  with  air  per  rectum,  and  to  note  the  progressive  dis- 
tention of  the  intestinal  coils  as  a  means  of  detecting  obstructing 
lesions  in  the  bowel ;  the  position  and  mobility  of  a  tumor  should  also 


DISEASES  OF  THE  INTESTINES.  791 

be  noted.  It  is  often  of  marked  aid  to  inspect  the  mucosa  of  the 
rectum  by  the  use  of  approved  specula.  The  volume  of  the  abdomen 
may  be  diminished  or  even  "scaphoid."  Abnormal  peristalsis  may 
rarely  be  noted  (important  if  associated  with  distention). 

Palpation. — This  is  of  first  importance.  The  patient  should  occupy 
the  dorsal  decubitus,  with  the  head  raised,  the  thighs  drawn  up,  and 
the  mouth  open,  so  as  to  relax  the  abdominal  muscles.  Something  may 
be  gained  in  this  direction  by  distracting  the  patient's  attention.  I 
have  found  that  placing  the  patient  in  the  lateral  decubitus,  with  the 
thighs  flexed  on  the  abdomen,  to  be  the  most  satisfactory  way  of  deter- 
mining the  degree  of  mobility  of  certain  tumors.  The  examiner  should 
not  fail  to  remember  the  knee-elbow  position  in  cases  in  which  it  is 
desired  to  palpate  the  parts  occupying  the  bottom  of  the  pelvic  cavity 
and  all  deep-seated,  movable  growths.  In  certain  cases  relaxation  of 
the  abdominal  muscles  is  only  obtainable  by  anesthetizing  the  patient, 
and  I  do  not  hesitate  to  do  this  in  cases  in  which  the  diagnosis  is 
important.  In  palpating  the  abdomen  for  abnormal  conditions  we  must 
keep  in  mind  steadily  the  relations  of  the  different  parts  of  the  intes- 
tines, and  also  that  the  latter  may  vary  considerably  in  position — a  fact 
particularly  true  of  the  transverse  colon  {vide  Enteroptosis).  In  this 
connection  Ewald's  statement  "  that  abnormally  situated  organs  or 
neoplasms  of  parts  other  than  the  intestines  will,  under  the  pressure  of 
the  intestines  filled  with  air  or  water,  return  to  the  position  that  the 
organ  normally  occupies,"  should  be  emphasized.  Ncav  growths  of  the 
pancreas,  of  the  spinal  column,  or  of  the  pelvis,  and  retroperitoneal 
tumors  will  remain  fixed.  Palpation  may  detect  pathologic  peristalsis, 
and  increased  resistance  if  the  coats  are  thickened  (as  in  chronic 
stenosis).  Tenderness,  localized  or  diffuse,  is  to  be  noted,  if  present, 
as  well  as  peritoneal  friction.  The  rectum  may  be  palpated  if  the 
symptoms  point  to  disease  of  that  organ. 

The  palpation  of  pathologic  conditions  of  the  intestines  will  be  con- 
sidered in  connection  Avith  the  separate  intestinal  affections. 

Percussion  detects  a  fluid  effusion  either  in  the  general  peritoneal  cav- 
ity, the  position  varying  with  the  position  of  the  body,  or  in  circumscribed 
localities;  the  latter  must  not  be  confounded  with  areas  of  dulness  that 
are  occasioned  by  splenic  and  hepatic  enlargements,  solid  new-growths, 
or  abscesses.  Air  in  the  peritoneal  cavity  {meteorismus  peritonei)  gen- 
erally gives  a  pure  tympanitic  note,  though  if  the  tension  be  very  strong, 
a  non-tympanitic  tone  may  be  elicited.  These  sounds  are  general,  even 
extending  up  to  the  fifth  or  fourth  rib,  and  hence  they  cover  the  regions 
of  the  spleen  and  liver.  The  best  results  when  the  abdomen  is  not 
tense,  however,  are  obtained  after  inflation  of  the  large  intestine  Avith 
air.  The  pitch  of  the  tympanitic  note  becomes  elevated  Avith  increase 
in  the  tension  of  the  gut ;  it  falls  Avith  relaxation  of  the  boAvel.  Hence 
the  large  cannot  ahvays  be  told  from  the  small  intestine  by  the  percus- 
sion-note. 

Auscultation. — Noises  are  often  audible  either  at  a  distance  or  by 
means  of  a  stethoscope  applied  to  the  abdomen.  They  are  sometimes  oc- 
casioned by  the  natural  peristaltic  movements  or  by  certain  voluntary  or 
involuntary  spasms  of  the  abdominal  muscle.  I  have  repeatedly  confirmed 
the  observation  of  EAvald,   who  frequently  fgund  in  those  suffering  Avith 


792  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

chronic  intestinal  indigestion  a  swashing  or  splashing  noise,  sounding 
as  though  air  and  'svater  were  being  forced  through  a  narrow  space  in 
the  ileo-cecal  region.  These  sounds  may  rarely  be  found  in  healthy 
persons.  Similar  noises  sometimes  have  their  seat  in  the  descending 
colon,  particularly  if  the  bowel  is  unnaturally  dilated  by  air  or  fluid. 
They  are  often  audible  prior  to  an  evacuation  in  cases  of  colitis.  Noises 
mav  also  originate  in  the  transverse  colon,  and  to  discriminate  these  it  is 
necessary  to  empty  the  stomach  if  we  would  avoid  confusion  Avith  iden- 
tical gastric  sounds.  Direct  auscultation  of  the  intestines  renders  aud- 
ible the  peristaltic  movements,  and  the  absence  of  the  latter  indicates 
paralysis  of  the  intestine,  which  may  be  local  or  general.  Friction- 
sounds  may  be  audible  when  inflammatory  exudates  are  present.  When 
obstruction  of  the  large  intestine  is  suspected,  auscultation  should  be 
practised  while  air  is  being  forced  into  the  rectum,  inasmuch  as  the 
decrree  of  permeability  can  be  thus  determined.  Metallic  tinkling:  and 
amphoric  noises  may  be  audible,  particularly  on  making  auscultatory 
pecus?ion,  but  these  are  without  real  diagnostic  value. 


ENTEROPTOSIS. 


Definition. — The  descent  of  the  intestines  from  their  normal 
position.  The  condition  occurs  coincidently  with  gastroptosis.  neph- 
roptosis, and  prolapse  of  other  viscera,  constituting  splanchnoptosis 
(Glenard's  disease). 

Ktiology. — It  is  linked  with  gastroptosis  and  other  forms  of  ptosis 
by  common  etiologic  influences,  such  as  sex  (being  most  common  in 
females),  tight-lacing,  traumatism,  muscular  strain,  numerous  pregnan- 
cies, rapid  emaciation,  anil  probably  the  wrong  use  of  cathartics.  Either 
the  small  intestine  alone  or  the  large,  or  both,  may  be  involved.  Pro- 
lapse of  the  colon  (coloptosis)  is  the  more  common,  and,  according  to  C. 
Meinert,  is  even  more  frequent  than  gastroptosis.  Lying  immediately 
above  the  symphysis  pubis,  it  is  sometimes  elongated  and  tortuous — 
"  S-  or  M-shaped." 

Symptoms. — The  condition,  even  when  pronounced,  may  exist 
without  symptoms.  On  the  other  hand,  in  the  majority  of  instances  the 
intestinal,  gastric,  and  other  bodily  functions  are  disturbed,  and  yet 
enteroptosis  is  usually  overlooked.  Chief  among  the  intestinal  symp- 
toms is  excessive  flatulence ;  not  rarely,  also,  there  is  membranous 
enteritis,  the  latter  probably  being  due  to  the  flexures  that  produce  an 
arrest  of  fecal  masses,  and  this  in  turn  causing  inflammation  (Boas). 
Constipation  generally  prevails,  and  sometimes  alternates  with  diarrhea. 
The  symptoms  of  gastroptosis  and  nephroptosis  are  often  associated ; 
they  are  loss  of  flesh  and  nervous  symptoms,  and  the  latter  may  simu- 
late those  of  neui'asthenia  or  hysteria. 

The  diagnosis  is  made  upon  the  afore-mentioned  points  and  upon 
the  results  of  a  careful  physical  examination.  The  position  of  the  colon 
may  be  determined  by  inflation  with  air  or  gas.  Again,  after  the  injec- 
tion of  Avater  (f  sviss-ixss — 200—300  c.cm.)  a  splashing  sound  is  audible; 
this  is  double  the  amount  of  water  required  in  the  normal  condition. 
Gldnard  has  pointed  out  that  a  transverse  cord  (which  he  believes  to  be 


INTESTINAL   CATARRH.  .  793 

the  colon)  can  be  felt  in  the  upper  part  of  the  abdomen.  Boas  and 
Ziemssen  assert  that  this  cord  is  the  pancreas,  rendered  palpable  by  the 
sinking  of  the  stomach. 

Treatment. — The  bowels  must  be  moved  regularly,  the  tonicity  of 
the  abdominal  walls  must  be  increased  by  electricity,  massage,  and  hydro- 
therapy, and  in  strongly  nervous  cases  the  treatment  of  neurasthenia, 
including  the  Weir  Mitchell  rest-cure,  must  be  instituted.  Supporting 
bandages  have  been  found  serviceable.  The  medicinal  treatment  aims 
at  meeting  certain  symptomatic  indications,  such  as  flatulence  and  fer- 
mentation. 


INTESTINAL  CATARRH. 

{Catarrhal  Enteritis;   Muco-enteritis .) 

Definition. — A  catarrhal  inflammation  of  the  mucous  membrane  of 
the  whole  or  of  any  anatomic  division  of  the  intestinal  tract.  It  may  be 
either  acute  or  chronic,  primary  or  secondary.  The  chronic  variety  oc- 
curs less  frequently  than  its  counterpart,  chronic  gastritis,  particularly  in 
adult  life. 

Pathology. — The  morbid  lesions  of  the  acute  variety  do  not  differ 
essentially  from  those  met  with  in  catarrhal  inflammation  of  any  other 
mucous  membrane.  The  first  stage  is  characterized  by  swelling  and  dry- 
ness of  the  mucosa ;  this  is  soon  folloAved  by  a  copious  exudation  of 
mucus,  and  more  rarely  of  pus,  which  bathes  the  membrane  more  or  less 
completely.  After  an  abundant  secretion  is  poured  out  the  membrane 
appears  rather  pale,  though  the  tips  of  the  valvulse  conniventes  in  the 
small  intestines  may  appear  reddened.  The  solitary  and  agminated 
glands,  as  Avell  as  Peyer's  patches,  may  stand  out  prominently,  owing  to 
their  corrugated  condition  (folUcuIar  enteritis).  The  apices  of  the  soli- 
tary glands  often  undergo  a  necrotic  change,  thus  forming  follicular  ulcers. 
The  remainder  of  the  mucosa  may  also  be  the  seat  of  rather  extensive 
areas  of  superficial  erosion,  though  this  must  not  be  confounded  with 
postmortem  softening  of  the  epithelium.  In  some  cases  the  desquama- 
tion of  epithelium  is  more  pronounced  than  the  abnormal  mucous  secre- 
tion. In  chronic  intestinal  catarrh  the  mucosa  presents  a  slaty  hue, 
with  a  more  or  less  dark  pigmentation  of  the  villi  and  follicles ;  it  is  in 
most  instances  thickened,  owing  to  an  increase  in  its  connective-tissue 
elements.  In  a  smaller  number  of  cases  it  is  thinned,  particularly  in  the 
intestinal  catarrh  of  children,  on  account  of  atrophic  changes  afi'ecting 
chiefly  the  glandular  and  muscular  layers.  Roughening  of  the  inner 
surface  of  the  bowel,  due  to  projecting  glands,  is  frequent  in  those  forms 
of  chronic  intestinal  catarrh  that  are  attended  with  thickening  of  the 
coats.     Polypoid  cysts  may  develop  in  long-standing  cases. 

Ktiologfy. — The  primary  form  is  produced  by  {a)  local  irritants, 
either  mechanical  or  toxemic,  that  find  their  way  into  the  intestinal  canal. 
The  chief  source  of  these  excitants  is  an  unsuitable  dietary,  and  especially 
is  this  the  case  in  children.  It  is  readily  seen  from  this  fact  why  the 
stomach  and  the  intestines  are  often  simultaneously  involved  in  a  catarrhal 


794  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

process,  (b)  Over-eating  may  be  productive  of  the  disease,  though  this 
often  excites  diarrhea  by  merely  increasing  intestinal  peristalsis,  (c) 
Idiosyncrasy  has  a  positive  influence,  the  ingestion  of  certain  substances 
not  difficult  of  digestion  being  invariably  followed  by  this  affection  in 
individuals  thus  predisposed,  (d)  Toxic  substances,  whether  in  the 
form  of  tainted  food-stuffs  (spoiled  meats,  ice-cream,  beer)  or  inorganic 
poisons  (mineral  acids,  caustic  alkalies,  mercury,  arsenic)  or  irritating 
cathartics,  often  produce  intestinal  catarrh,  (e)  Impure  water,  or  water 
to  which  individuals  are  unaccustomed.  (/)  Atmospheric  changes, 
particularly  a  prolonged  high  or  a  sudden  fall  of  temperature,  the  latter 
being  especially  apt  to  cause  it  in  children,  (g)  An  excess  or  a  lack 
of  biliary  .secretion.  Two  functions  of  the  bile  (its  antiseptic  properties 
and  its  power  to  stimulate  peristalsis)  must  not  be  forgotten  :  the  one 
explains  how  a  paucity  of  this  secretion  favors  the  abnormal  processes 
of  fermentation  that  are  capable  of  exciting  catarrh,  and  the  other  makes 
plain  the  possibility  of  a  bilious  diarrhea  being  due  to  an  excessive 
hepatic  secretion.  It  is  not  clear,  however,  that  the  latter  condition  is 
attended  with  an  actual'catarrhal  process.  The  same  is  true  of  diarrhea 
due  to  fright,  excitement,  or  other  nervous  influence.  (A)  Bacteria  are, 
doubtless,  among  the  excitants — e.  g.  the  normal  colon-bacillus,  under 
conditions  favorable  to  its  growth  and  development,  assumes  pathologic 
virulence  exciting  irritation. 

Secondary  or  complicating  forms  are  caused — (a)  By  direct  extension 
from  adjacent  organs  (ulcers,  gastritis,  peritonitis,  hernia,  and  invagina- 
tion); (6)  By  general  infectious  processes  (septicemia,  pyemia,  typhoid 
fever,  dysentery,  cholera,  tuberculosis,  pneumonia). 

The  chronic  forms  are  met  with — (a)  In  certain  cachectic  states  (car- 
cinoma, chronic  malaria,  chronic  Bright's  disease,  Addison's  disease,  and 
profound  anemia) ;  {b)  In  connection  with  disturbances  of  the  circulation, 
particularly  such  as  produce  stasis  in  the  terminal  branches  of  the  portal 
system  of  vessels :  among  the  chief  diseases  that  tend  to  prevent  the 
return  of  venous  blood  from  the  intestines  are  chronic  heart-affections, 
diseases  of  the  liver  (especially  cirrhosis),  and  emphysema;  {c)  Severe 
cases  of  clu'onic  diarrhea,  probably  due  to  the  protozoan  balantidium^ 
have  been  reported  recently. 

Among  predisposing  causes  is  the  age.,  children  being  particularly 
liable  to  the  disease.  Unfavorable  hygienic  surroundings,  especially 
when  a  high  temperature  prevails,  and  epidemic  and  endemic  conditions 
also  strongly  predispose  to  the  affection. 

Clinical  History. — From  a  clinical  standpoint  Ave  recognize  not 
only  acute  and  fhronic  forms  of  enteritis,  but  also  special  varieties  {vide 
infra). 

The  simple  acute  form  of  general  catarrh  of  the  intestines  (muco- 
enteritis)  has  for  its  two  most  characteristic  symptoms  slight  griping  or 
colicky  pains  in  the  abdomen  (sometimes  absent),  that  are  followed  soon 
by  diarrheal  stools.  The  discharges  consist,  at  first,  of  feculent  masses, 
and  later  of  a  watery,  highly  irritating  fluid.  Diarrhea  is  due  partlv  to 
increased  peristalsis  and  partly  to  the  abnormal  irritability  of  the  intes- 
tinal mucous  membrane.  Active  peristalsis  of  the  intestines  may  (vide 
ante)  be  of  purely  nervous  origin,  and  produce  a  diarrhea  that  is  to  be 
distinguished  from   that  due  to  catarrh.     Again   steatorrhoca   may  be 


\ 


INTESTINAL   CATARRH.  795 

present  in  cases  in  which  the  pancreatic  secretion  is  absent.  The  causes 
that  produce  the  catarrh  also  produce  the  undue  peristaltic  movements. 
If  it  be  true,  as  physiology  teaches,  that  the  stools,  owing  to  the  absorp- 
tion of  the  watery  portions  of  the  food,  are  normally  formed  in  the  large 
intestines,  then  catarrh  of  the  small  intestines  alone  does  not  excite  diar- 
rhea, though  both  large  and  small  are  involved  in  the  majority  of  the 
cases.  On  the  other  hand,  in  acute  colitis  diarrhea  is  conspicuous,  and 
forms  the  most  important  clinical  symptom.  The  vigorous  peristalsis  also 
accounts  for  the  gurgling  and  rumbling  sounds  {borhorygmib)  that  are 
often  felt  and  heard  by  the  patient  himself.  These  peculiar  noises,  if 
pronounced,  point  to  isolated  catarrh  of  ihe  small  intestines.  The  stools 
vary  in  number  from  two  to  ten  or  more,  being  increased  in  frequency 
after  taking  food ;  gases  are  also  formed,  causing  tympanites.  The  thin 
or  mushy  stools  either  present  a  bright-yellow  or  a  yellowish-brown 
color  and  emit  offensive  odors.  Occasionally  they  are  greenish  in  color 
from  the  presence  of  considerable  quantities  of  bile-pigment  or  from 
bacterial  action.  In  advanced  cases  of  considerable  severity  there  is 
painful  tenesmus;  the  stools  are  often  small  and  contain  mucus  and 
blood,  becoming  dysenteric  in  character,  especially  when  the  colon  is 
chiefly  affected. 

A  microscopic  examination  reveals  large  masses  of  epithelium  and 
mucus,  as  well  as  countless  microorganisms  and  isolated  leukocytes, 
crystals  of  calcium  phosphate,  oxalates,  remnants  of  food  (^starch- 
granules,  fat,  vegetable  and  muscular  fibers).  Flakes  of  yellowish- 
brown  mucus,  large  pieces  of  epithelium,  and  large  grayish-white  masses 
of  fat  may  often  be  seen  macroscopically .  The  stools  give  an  alkaline 
reaction  as  a  rule. 

The  physical  examination  reveals  on  inspection  slight  tympanitic  dis- 
tention as  a  rule.  Palpation  elicits  considerable  sensitiveness  in  the 
majority  of  cases,  though  during  the  colicky  pains  pressure  with  the 
palm  of  the  hand  often  affords  relief.  Fluctuation  may  be  detected  if 
the  intestines  contain  much  fluid.  Percussion  gives  an  exaggerated 
tympanitic  resonance,  varying,  however,  wdth  the  tension  of  the  bowel. 
Nausea  may  be  present,  and  the  appetite  is  often  greatly  impaired. 
There  is  marked  thirst  and  the  tongue  is  dry  and  furred. 

The  general  symptoms  are  often  entirely  Avanting,  save  for  a  slight 
feeling;  of  weakness  due  to  the  diarrheal  discharo-es.  Severe  forms  of 
infectious  origin  often  disturb  the  general  health  considerably.  The 
patient  is  languid,  and  prostration  is  prominent ;  he  suff'ers  much  from 
headache,  and  pyrexia  is  common,  the  temperature  often  reaching  100°— 
103°  F.  (37.7°-39.4°  C).  The  higher  temperatures  are  seen  among 
children.  Additional  evidences  of  a  systemic  affection  are  sometimes 
observed,  such  as  painful  enlargements  of  certain  joints  and  severe 
muscular  pains. 

Complications.  —  The  symptoms  of  gastric  catarrh  (vomiting, 
nausea,  and  pain  immediately  after  feeding)  are  often  associated  with 
those  of  enteric  catarrh ;  the  combination  is  then  spoken  of  as  gastro- 
enteritis. 

Special  Forms. — Though  the  anatomic  limits  in  the  more  or  less 
local  forms  of  intestinal  catarrh  cannot  be  made  out  definitely,  yet  the 
diff'erent  clinical  pictures  observed  often  enable  us  to  fix  the  location  of 


796  I)ISEASli:S  OF  THE  DIGESTIVE  SYSTEM. 

the  disease  Avitb  considerable  accuracy :  it  is  important,  moreover,  from 
the  standpoint  of  the  treatment,  to  accomplish  this  whenever  possible. 
The  folloAving  may  be  briefly  described : 

(a)  Duodenal  catarrh  {duodenitis),  in  Avhich  form  constipation,  often 
obstinate,  is  present  in  the  place  of  diarrhea,  the  colon  not  being  af- 
fected ;  merely  local  pain,  tenderness  on  palpation,  and  uneasiness  are 
complained  of.  These  symptoms  may  frequently  be  overshadowed  by 
those  referable  to  the  stomach  when  gastric  catarrh  coexists  {gastro-duo- 
denitis).  Without  the  presence  oi  jaundice,  due  to  the  occlusion  of  the 
common  bile-duct  in  consequence  of  the  swelling  of  the  duodenal  mucous 
membrane,  the  diagnosis  of  this,  affection  must  remain  highly  doubtful; 
but,  fortunately,  this  symptom  is  frequently  observed. 

(h)  Localized  catarrh  of  the  jejunum  and  ileum  cannot,  always  be 
diagnosticated  correctly.  The  condition  is  often  found  to  be  a  more  or 
less  prominent  feature  in  general  enteric  catarrh,  in  which  complaint 
diarrhea  is  a  prominent  symptom.  The  existence  of  this  special  variety 
may  be  safely  inferred  when  certain  enteric  symptoms  are  combined  with 
marked  gastric  disturbance.  Under  these  circumstances  the  symptoms 
indicative  of  inflammation  of  the  small  intestines  are  rumbling  noises 
(borborygmi),  colicky  pain,  swelling,  and  slight  tenderness  over  the 
abdomen  in  the  vicinity  of  the  umbilicus  or  over  other  regions  occupied 
by  the  small  intestines.  Finally,  an  examination  of  the  stools  furnishes 
valuable  points  for  differential  diagnosis.  It  must  be  kept  in  remem- 
brance that  in  catarrh  of  the  small  intestines  the  stools  may  be  quite 
solid,  despite  the  increased  peristalsis  caused  by  the  catarrhal  process 
(vide  ante).  More  frequently,  when  the  ileum  is  the  seat  of  catarrh 
the  colon  is  also  implicated,  this  combination  being  attended  with  diar- 
rhea, even  if  it  be  of  minor  severity.  The  thin  stools  "contain  food- 
remnants,  that  point  indubitably  to  implication  of  the  small  intestine." 
As  the  result  of  increased  peristalsis  of  the  small  intestines  their  con- 
tents are  passed  into  the  large  bowel  with  undue  rapidity ;  hence  the 
latter  contains  undigested  food-constituents  and  other  substances  that 
are  normally  found  in  the  small  intestines.  These  pass  from  the  rec- 
tum'unchanged.  They  are  mainly  starch,  fat,  and  masses  of  meat-fiber, 
the  latter  of  which  may  be  of  suflicient  size  to  be  seen  by  the  naked  eye. 
This  would  be  pathognomonic  evidence  of  the  form  of  catarrh  in  ques- 
,tion  if  it  were  not  true  that  increased  peristalsis  of  the  small  intestines, 
due  to  other  conditions,  as  anemia,  extreme  nervousness,  and  fever-con- 
ditions, that  are  not  seen  in  ileo-jejunal  catarrh,  causes  the  same  fecal 
peculiarities.  Microscopically/  the  stools  show  hyaline  particles  of  mucus, 
giving  rise  to  a  speckled  appearance. 

In  health  the  contents  of  the  small  intestines  give  the  characteristic 
color-reaction  for  bile-pigment,  whilst  the  contents  of  the  large  bowel 
and  the  stools  do  not.  There  is  quite  often  a  large  admixture  of  unde- 
composed  bile-pigment  (Striimpell)  that  responds  to  Gmelin's  test.'  a 
fact  of  considerable  value  in  diagnosis.  Xothnagel  has  called  forcible 
attention  to  the  fact  that  hile-stained  stools  and  small  pigmenfed  masses 
of  mucus  are  met  with,  and  are  highly  characteristic  of  the  diarrhea  that 
marks  catarrh  of  the  small  intestines. 

'  This  consists  in  bringing  a  few  drops  of  nitric  acid  in  contact  with  the  intestinal 
contents,  when  the  characteristic  play  of  colors  appears.  iSee  also  Methods  of  Diagnosis, 
pp.  786-789.) 


INTESTINAL   CATARRH.  797 

{c)  Colitis. — The  joint  appearance  of  abdominal  pain  and  diarrhea  is 
almost  pathognomonic  of  this  condition.  These  symptoms,  in  the  ab- 
sence of  the  more  prominent  and  above-mentioned  clinical  features  that 
have  special  reference  to  inflammation  of  the  small  intestines,  point  to 
the  fact  that  the  large  intestines  are  the  chief  seat  of  the  disease. 

Physical  examination  is  only  partially  confirmatory  of  the  rational 
symptoms.  The  chief  sign  is  tenderness  on  palpation  over  the  track  of 
the  colon.  An  ocular  examination  of  the  stools  furnishes  important  prac- 
tical results.  They  may  contain  blood  and  mucus,  and  the  latter  often 
in  masses  large  enough  to  be  readily  visible  to  the  naked  eye ;  it  is  not 
intimately  mixed  with  the  feces,  as  in  catarrh  of  the  small  intestines, 
but  forms  separate  masses.  The  feces  are  often  of  the  consistence  of 
soup.  "  If  the  catarrh  affects  the  loAver  portion  of  the  large  intestine 
chiefly,  it  may  be  that  the  intestinal  contents  are  already  formed  "  in 
firm  lumps,  which  may  sometimes  be  wholly  or  partly  enclosed  in  a 
layer  of  mucus  (Striimpell). 

Such  general  symptoms  as  loss  of  flesh,  weakness,  and  sallowness  of 
the  skin  are  often  observed.  Simple  diarrhea,  lasting  but  a  few  days,  as 
a  rule,  is  to  be  classed  with  catarrh  of  the  large  intestines,  since  these 
affections  imply  increased  peristalsis  of  the  large  bowel.  It  is  not 
always  easy,  however,  to  discriminate  diarrhea  due  to  purely  functional 
influences  or  to  catarrh  of  the  rest  of  the  intestinal  tract. 

{d)  Proctitis,  or  inflammation  of  the  rectum,  is  characterized  by 
painful  tenesmus  and  by  the  presence  of  large  quantities  of  mucus  and 
pus,  particularly  in  the  dejections.  The  disease  may  be  primary,  though 
more  often  it  is  secondary  to  morbid  lesions  either  in  organs  that  are 
adjacent  to  or  in  the  rectum  itself. 

Chronic  intestinal  catarrh  may,  comparatively  rarely,  be  a  primary 
disease,  developing  gradually.  It  may  also  be  secondary  (fide  Pathol- 
ogy) at  times  to  one  or  more  attacks  of  acute  intestinal  catarrh.  Gen- 
erally there  are  no  other  local  symptoms  to  call  attention  to  the  condi- 
tion than  (?Aro?n'c  c^farrAea.  More  rarely  there  are  in  addition  colicky 
pain  and  tenderness  over  the  abdomen.  The  diarrhea  often  alternates 
A^ith  constipation,  and  this  is  most  apt  to  be  the  case  when  the  disease 
is  of  idiopathic  origin  and  affects  only  the  large  intestine  (Nothnagel). 
Constipation  is  constant  in  those  cases  in  which  atrophic  alterations 
occur  in  the  glandular  and  muscular  coats,  as  Avell  as  in.  those  in  which 
the  lesions  are  in  the  small  intestines.  When  constipation  is  not  pres- 
ent the  stools  are  thin,  pale,  sometimes  fermented,  emitting  offensive 
odors,  and  vary  greatly  in  number  and  quantity.  There  is  com- 
monly present  visible  mucus.  When  the  small  bowels  are  also  impli- 
cated, food-remnants  are  found  in  the  dejections  (lienterie  diarrhea). 
Microscopically,  the  picture  does  not  differ  from  that  of  the  acute  form. 
That  form  of  diarrhea  occurring  in  organic  diseases. of  the  heart,  liver, 
and  lungs  demands  brief  special  mention.  Here  the  serum  of  the  blood 
is  made  to  exude  into  the  intestines,  owing  to  mechanical  obstruction 
to  the  return  of  the  venous  blood,  and  this  results  in  a  liquefaction  of 
the  feces.  The  stools  are  apt  to  be  most  copious  and  numerous  during 
the  morning  hours.  Sometimes  an  irresistible  desire  to  evacuate  the 
bowels  seizes  the  patient  as  soon  as  his  feet  strike  the  floor  on, rising  in 
the  morning ;  two  or  more  serous  discharges  follow  each  other  at  short 


798  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

intervals.  Subsequently,  all  discharges  cease  until  the  following  morn- 
ing, when  the  same  symptoms  are  repeated.  The  general  nutrition 
suffers  visibly  in  chronic  enteritis,  and  emaciation  eventually  becomes 
pronounced.  I  have  also  noticed  slight  pyrexia,  especially  in  the  even- 
ing hours. 

Differential  Diagnosis. — Among  the  diseases  likely  to  be  con- 
founded with  acute  catarrh  of  the  intestines  are  typlioid  fever^  dysentery 
(diseases  in  which  diarrhea  is  a  cardinal  symptom),  peritonitis,  and  colic. 
The  chief  differential  features  between  simple  colic  and  enteric  catarrh 
may  be  contra.sted  thus : 

Enteric  Catarrh.  Colic. 

Diarrhea  is  generally  present.  Constipation  is  present. 

Fever  may  be  slight  or  marked.  No  fever. 

Pain  is  griping,  and  followed  by  diarrheal  Pain  is  colicky,  more  severe,  and  is  not 

stools.  followed  by  diarrheal  discharges. 

Tenderness  in  the  intervals  between  pains.  Xo  sensitiveness  on  palpation. 

From  peritonitis  we  may  readily  distinguish  catarrh  of  the  intestines 
by  the  more  intense  pain  and  tenderness,  by  the  constipation,  the 
greater  tympany,  the  constitutional  disturbance,  and  more  especially  by 
the  anxious  face,  thoracic  respiration,  and  immobility  of  the  patient,  all 
of  which  characterize  the  former  disease.  When  the  characteristic 
symptoms  of  typhoid  fever  (the  typical  temperature-curve,  swelling  of 
the  spleen,  eruption,  Widal-test)  and  oi  dysentery  (scanty,  frequent  stools, 
tenesmus)  are  present,  they  are  easily  separable  from  enteric  catarrh. 
In  children,  however,  the  diagnosis  between  typhoid  fever  and  simple 
catarrh  of  the  bowels  offers  considerable  difficulty  ;  but  the  temperature- 
record,  if  carefully  kc]>t,  the  enlargement  of  the  spleen,  the  characteristic 
eruption,  and  the  Widal-reaction,  taken  unitedly,  will  warrant  the  diag- 
nosis of  typhoid  fever  and  exclude  acute  enteritis. 

In  diagnosticating  chronic  intestinal  catarrh  we  maj^  have  difficulty 
in  eliminating  lardaceous  disease  of  the  bowels  and  ulcerations.  The 
latter  condition  will  be  excluded  hereafter.  Amyloid  degeneration  is  a 
general  disease,  affecting  primarily  other  organs  than  the  bowel,  and 
hence  lardaceous  diarrhea  is  always  preceded  by  the  clinical  indications 
of  the  disease  (enlarged  viscera,  albuminuria)  elsewhere.  The  condition 
also  gives  a  definite  etiology  as  a  rule. 

Prognosis. — The  prognosis  in  uncomplicated  cases  is  favorable, 
though  the  possibility  of  a  merging  into  the  chronic  form  must  be  borne  in 
mind.  Occurring  in  weakly  subjects,  especially  at  the  extremes  of  life, 
and  in  the  course  of  debilitating  affections,  acvte  catarrh  of  the  intestines 
may  endanger  life.  Its  duration  varies  much — from  three  to  ten  days 
or  more — according  as  the  type  of  the  individual  case  is  mild  or  severe. 

The  prognosis  in  the  chronic  forms  is  moderately  good  as  to  life, 
though  as  to  cure  it  is  not  so,  the  disease  often  enduring  for  many  years 
together,  or  as  long  as  the  chronic  conditions  producing  it  remain  un- 
removed.  It  sometimes  exhausts  the  system  of  those  suffering  from 
serious  causal  affections  of  a  chronic  nature,  and  occasionally  it  ulti- 
mateh'  proves  fatal.  The  prognosis  will  depend  largely  upon  the  charac- 
ter of  the  etiologic  affection,  but  intestinal  catarrh  invariably  renders 
the  prospects  of  life  more  gloomy. 


^ 


INTESTINAL   CATARRH.  799 

Treatment. — Respecting  the  treatment  of  this  affection  the  views 
of  the  profession  have  undergone  many  changes,  even  within  recent 
vears  ;  hence  it  may  be  reasonably  inferred  that  our  present  therapeutic 
methods  are  by  no  means  satisfactory. 

Hygienic  and  Dietetic  Management. — If  the  cause  be  some  error  of 
diet,  all  injurious  articles  must  be  rigidly  prohibited.  In  the  milder 
cases  due  to  this  cause  a  mild  purgative,  followed  by  proper  dietetic 
treatment.,  is  all  that  is  required.  Albuminous  food  in  liquid  form,  such 
as  skimmed  milk,  weak  broths,  and  even  semi-animal  articles  of 
diet,  as  eggs,  oysters,  sweet  milk  with  seltzer,  are  usually  Avell  borne.  In 
the  severe  forms  predigested  liquid  foods  only  should  be  allowed.  When 
the  chief  seat  of  the  disease  is  in  the  large  intestine,  we  may  allow 
easily  digested  starches  and  certain  green  vegetables  (arrow-root,  sago, 
lettuce,  water-cress) ;  the  coarser  vegetables,  all  fats,  and  most  fruits 
should  be  withdrawn  absolutely.  Rest  in  bed  is  especially  beneficial  in 
that  it  serves  to  keep  the  abdomen  warm  and  mitigates  the  pain  and 
diarrhea,  and,  in  short,  cures  the  disease.  Sinapisms  should  be  ap- 
plied at  the  outset  until  the  skin  is  reddened,  succeeded  by  light  linseed 
poultices  until  the  local  sensitiveness  has,  in  a  great  measure,  subsided ; 
after  this  a  flannel  band  may  be  applied.  The  local  abstraction  of  blood 
by  a  few  leeches,  applied  to  the  abdomen  or  anus,  is  beneficial  in  the 
early  stages  in  severe  types  of  enteric  catarrh,  provided  the  patient's 
strength  is  good. 

Medicinal  Treatment. — It  is  sound  practice  to  prescribe  a  mild  ca- 
thartic (castor  oil,  calomel,  or  rhubarb,  followed  by  a  saline)  with  a  view  to 
getting  rid  of  decomposable  intestinal  contents.  Combined  gastric  lavage 
and  high  intestinal  irrigation  has  recently  yielded  excellent  results  in 
my  hands ;  it  is  an  appropriate  method  of  overcoming  the  fermentative 
processes  that  tend  to  excite  and  maintain  the  condition. 

If  the  chief  tenderness  be  localized  in  the  right  iliac  fossa,  corre- 
sponding to  the  course  of  the  colon,  a  simple  enema,  slowly  given,  will 
stimulate  the  bowel  sufficiently  and  cleanse  it  more  effectually  than  a 
cathartic.  Subsequently,  chief  reliance  is  to  be  placed  on  intestinal 
antiseptics  and  astringents,  though  it  must  be  recollected  that  the  selec- 
tion of  internal  remedies  must,  in  part,  be  influenced  by  the  etiologic 
indications.  For  instance,  if  the  cause  has  been  exposure  to  cold  or 
wet,  besides  the  efforts  directed  at  the  local  condition  diaphoretics  and 
febrifuge  mixtures  are  serviceable.  I  have  found  the  following  com- 
bination to  be  of  benefit  in  controlling  the  inflammatory  action  : 

^.  Salol,  3SS    (2.0); 

Creasoti,  mx  (0.666) ; 

Bismuthi  salicylat.,  .3J     (4.0). 

M.  et  ft.  capsulse  No.  xx. 
Sig.   One  every  three  hours. 

If  pain  be  troublesome,  opium  or  phenacetin  may  be  combined  with 
the  above  formula. 

In  many  instances  the  secretions  of  the  intestinal  tube  are  decreased 
for  a  considerable  period  after  the  most  active  symptoms  have  been 
subdued.  Here  we  must  supplement  the  natural  juices  of  the  bowel, 
as  follows : 


800  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

I^.  Pancreatin,  3j    (4.0) ; 

Sodii  bicarb.,  3ij  (8.0). 

M.  et  ft.  chart.  No.  xij\ 
Sig.   One  an  hour  after  meals. 

In  cases  in  which  the  large  intestine  is  chiefly  affected,  and  when  the 
condition  does  not  yield  to  internal  medicines,  treatment  per  rectum 
should  be  employed.  If  colicky  pain  be  severe,  morphin  (gr.  ^ — 0.008) 
should  be  given  hypodermically  in  addition  to  the  measures  before  sug- 
gested. If  the  diarrhea  shoAvs  no  tendency  to  abate  after  forty-eight 
hours  of  the  general  treatment  above  outlined,  large  doses  of  bismuth 
(gr.  XXX  to  Ix — 2.0  to  4.0)  every  three  or  four  hours  should  be  tried. 
In  my  own  hands  lead  acetate  (gr.  ij — 0.129),  with  the  extract  of  opium 
(gr.  ^ — 0.008)  in  pill-form,  has  proved  a  most  efficient  combination. 
When  there  is  reason  to  suspect  that  the  main  lesion  is  in  the  large 
bowel,  small  enemas  of  starch-w^ater  (sij — 64.0),  with  laudanum  (1TI  xx 
-XXX — 1.33-2.0),  every  four  to  six  hours,  are  efficacious.  The  thirst 
is  best  relieved  by  chipped  ice  in  small  quantities  or  by  carbonic  acid  and 
Apollinaris  waters.  For  distressing  flatulence  we  may  prescribe  the 
alkaline  carbonates,  or  spirits  of  ammonia,  and  some  carminative.  The 
oil  of  cajeput  is  a  most  valuable  drug  in  the  treatment  of  excessive  fer- 
mentation (Murrell). 

In  chronic  catarrh  of  the  intestines  the  local  treatment  is  of  para- 
mount importance.  Daily  irrigation  of  the  bowel  with  a  weak  solution 
of  some  antiseptic  agent,  as  salicylic  acid  (gr.  v-oj — 0.324-32.0), 
boracic  acid  (gr.  x-5J— 0.648-32.0),  creolin  {Vfl  v-5J— 0.324-32.0),  or 
Avith  some  such  astringent  as  tannin  (gr.  v-5j — 0.324 — 32.0),  or  finally 
Avith  an  alterative,  such  as  silver  nitrate  (gr.  ^.^j — 0.016-32.0),  Avill  be 
found  to  be  beneficial.  The  latter  solution  is  a  most  excellent  remedy, 
but  sometimes  excites  pain  if  used  in  excessive  doses.     To  obviate  this, 

1  have  often  used  a  mild  antiseptic  or  astringent  Avith  the  foregoing,  giv- 
ing them  on  alternate  days,  and  thus  obtained  most  happy  results. 
The  only  appliance  needful  is  a  fountain  syringe  Avith  a  soft-rubber  end- 
piece,  Avhich  should  be  gently  introduced  for  a  considerable  distance 
into  the  bowel.  The  fluid  used  should  be  warmed  to  90°  F.  (32.2°C.), 
and  the  quantity  administered  at  each   sitting  should  be  not  less  than 

2  to  3  pints  (1-1.5  liters)  ;  this  should  be  alloAved  to  floAv  in  slowly. 
The  patient  should,  as  a  rule,  assume  the  dorsal  decubitus,  though  if 
the  fluid  is  to  be  carried  as  high  up  as  possible,  the  knee-elboAv  position 
may  be  assumed  or  the  patient  may  be  placed  on  the  left  side  Avith  the 
hips  elevated. 

The  same  careful  attention  must  be  paid  to  hygienic  details,  and 
especially  to  the  diet,  as  is  directed  in  the  acute  form.  In  addition,  flan- 
nel should  be  Avorn  next  the  skin  both  in  Avinter  and  summer.  If  the 
strength  Avill  admit  of  it,  cold  batlis  are  useful. 

A  stay  at  a  suitable  spa  (Saratoga,  Bedford,  Virginia  Springs,  Carls- 
bad, Kissingen)  often  produces  most  satisfactory  results. 

Among  internal  agents,  zinc  oxid  (gr.  v  to  x — 0.324-0.648 — t.  i.  d.), 
silver  nitrate,  lead  acetate,  and  alum,  given  Avith  tonics,  such  as  strych- 
nia, arsenic,  and  iron,  are  especially  to  be  recommended. 

The  management  of  this  troublesome  malady  depends  upon  the  in- 


DIARRHEAS  OF  CHILDREN.  801 

dications  furnished  by  the  causative  affections.  No  method  of  treatment 
can  succeed,  however,  that  is  not  carried  out  patiently,  systematically, 
and  over  long  periods  of  time. 


DIARRHEAS  OF   CHILDREN. 

ACUTE   GASTRO-INTESTINAL   CATARRH. 

(Acute  Gastro-enteric  Infection ;  Summer  Diarrhea ;  Gastro-enteritis ;  Cholera  Infan- 
tum ;  Mycotic  Diarrhea. ) 

Definition. — This  is  the  usual  intestinal  trouble  that  prevails  during 
the  warm  summer  months.  It  usually  takes  the  form  of  an  epidemic, 
and  its  course  is  manifested  by  a  sudden  onset,  high  fever,  irritability  of 
the  stomach,  frequent  watery  evacuations,  symptoms  of  nerve-involve- 
ment. This  form  of  diarrhea  usually  follows  an  attack  of  acute  indiges- 
tion, in  which  it  very  frequently  has  its  origin  {acute  dyipeptic  diar- 
rhea). Acute  gastro-intestinal  catarrh  [cholera  infantum)  stands  midway 
between  acute  indigestion  and  ileo-colitis. 

etiology. — Two  important  conditions  seem  to  be  necessary  to  influ- 
ence the  disease — temperature  and  diet.  A  general  and  well-recognized 
belief  associates  special  danger  with  the  second  summer  of  children. 
Out  of  nearly  2000  fatal  cases  collected  by  Holt,  only  3  per  cent,  were 
exclusively  breast-fed.  Generally  speaking,  the  disease  has  its  origin 
in  some  irregularities  in  artificial  feeding.  Heat  is  an  important  ele- 
ment in  the  continuation  of  the  disorder  Avhen  once  commenced. 

Season  exerts  a  most  potent  predisposing  effect.  It  is  peculiarly  a 
disease  of  summer  (though  instances  are  not  uncommon  in  May  and 
September),  the  greatest  prevalence  occurring  in  July.  The  pauper 
element  of  large  cities  furnishes  most  instances,  although  it  may  be  met 
among  the  children  of  the  most  provident. 

Baginsky  inclines  to  the  belief  that  the  decomposition-products 
formed  by  the  different  varieties  of  microorganisms  found  in  the  intes- 
tines are  the  toxic  substances  that  give  rise  to  the  disease. 

The  proteus  class  of  bacteria  are  most  frequent,  and  are  most  likely 
to  possess  pathogenic  properties,  according  to  Booker,  who  has  made  a 
complete  study  of  the  subject.  With  him  are  in  accord  the  opinions  of 
Jeffris  and  Baginsky.  Escherich  has  shown  that  in  milk-fed  children 
the  normal  feces  constantly  contain  two  organisms — the  bacterium  coli 
commune  and  the  bacterium  lactis  aerogenes.  Later  investigations 
enabled  him  to  distinguish  between  these  normal  bacteria  and  those 
present  in  pathologic  conditions.  Escherich  maintains  the  specificity  of 
the  streptococcus  (violet  cocci  grouped  in  pairs  or  small  chains),  because 
it  displaces  the  normal  bacteria  of  the  intestines  during  the  disease  and 
disappears  as  the  disease  subsides.  Moreover,  it  is  found  in  the  mucous 
and  serous  elements  of  the  discharges  ;  also  during  life  in  the  blood  and 
urine,  and  finally,  after  death,  in  all  the  organs. 

Pathology. — A  catarrhal  swelling  of  the  mucosa  of  the  large  and 
small  bowel  is  present ;  tlie  mucosa  itself  is  pink  in  color  from  capillary 

51 


802  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

congestion.  Peyer's  patches  are  enlarged.  The  whole  intestinal  tube 
shows  an  early  stage  of  inflammation  (ileo-colitisV  In  addition  there 
is  most  likely  some  involvement  of  the  sympathetic  nerves,  leading  to 
dilatation  of  the  capillaries  and  transudation  of  serum  into  the  intestine, 
and  to  alterations  of  the  pulse,  temperature,  and  respiration.  Its  nature 
is  paralytic,  and  closely  resembles  in  its  results  experimental  sections 
of  the  sympathetic  nerves.  The  changes  in  the  other  organs  a're  slight. 
Broncho-pneumonia  frequently  occurs.  The  spleen  is  often  swollen,  the 
brain  is  anemic,  and  the  kidneys  are  congested. 

Symptoms. — Clinically,  we  recognize  three  forms  of  acute  enteric 
infection:  (1)  acute  dyspeptic  diarrhea;  (2)  cholera  infantum;  and  (3) 
ileo-colitis. 

(1)  Acute  Dyspeptic  Diarrhea. — There  may  be  merely  an  increase 
in  the  number  of  stools,  with  or  without  fever;  restlessness  is  usual  at 
night.  This  condition  may  continue  for  two  or  three  days,  when  the 
stools  become  more  frequent  and  offensive,  containing  undigested  food 
and  curds.  The  odor  by  this  time  is  very  pronounced.  Frequently  the 
disease  has  a  sudden  onset,  with  vomiting,  griping  pains,  and  fever, 
which  may  quickly  rise  to  104°,  105°,  or  106°  F.  (40°-41°  C).  Con- 
vulsions may  be  the  commencement  of  the  attack.  The  abdomen  is 
sensitive  and  swollen,  and  the  child  lies  with  its  legs  flexed  on  the 
stomach.  The  stools  consist  of  grayish  or  greenish-yellow  feces  (mixed 
with  gas,  curds,  portions  of  undigested  food)  and  some  fluid.  In  chil- 
dren two  years  of  age  and  older  the  stools  may  contain  unripe  fruit  or 
large  curds  from  excessive  drinking  of  milk.  Relapses  are  frequent, 
and  during  hot  weather  the  frequency  of  the  attacks  may  lead  to  the 
commencement  of  a  severe  entero-colitis. 

In  deliciite  children  a  severe  attack,  especially  if  it  is  accompanied 
by  convulsions,  may  prove  fatal.  From  the  fact  that  the  general  symp- 
toms may  be  few.  the  case  is  often  allowed  to  go  on  for  several  days, 
under  the  impression  that  the  child  is  ''only  teething." 

(2)  Cholera  Infantum. — The  initial  symptoms  are  sudden.  The 
child  voids  immense  stools,  at  first  fecal,  if  no  preceding  diarrhea  have 
been  present.  Soon  they  become  watery,  light  yellow  or  greenish  in 
color ;  frequently  they  are  so  thin  and  colorless  as  to  pass  through  the 
napkin  without  leaving  a  stain.  At  times  they  contain  a  few  yellow 
or  greenish  flocculi  or  a  mass  of  mucus,  and  in  all  cases  they  are  odor- 
less. Very  often  the  stools  are  brown  and  liquid,  with  a  small  quan- 
tity of  fecal  matter,  having  a  peculiar  musty  odor  that  clings  to  the 
napkin  and  child  for  days.  The  number  of  stools  per  diem  may  vary 
from  six  to  thirty,  and  a  most  remarkable  feature  is  the  fact  that  they 
are  evacuated  with  considerable  force. 

The  stomach  becomes  irritable,  refusing  everything;  even  ice  is  re- 
jected as  soon  as  swallowed.  The  appetite  is,  of  course,  entirely  lost; 
intense  thirst  prevails,  the  little  patient  drinking  at  every  chance  and 
following  the  receding  glass  with  eager  eyes.  The  tongue,  moist  at 
first,  soon  becomes  drv  and  pastv ;  the  abdomen  is  collapsed.  The 
temperature  is  always  high— 105°  or  even  108°  F.  (40.5°-42.2°  C); 
2indi  the  pulse  small  and  very  freijuent — 130  to  180  beats  per  minute. 
The  hreathinfi  is  shallow  and  irregular,  and  the  ejfes  anxious  and  staring, 
but  soon  becoming  dull.     The  urine  diminishes  in  quantity  daily 


DIARRHEAS  OF  CHILDREN.  803 

With  this  array  of  symptoms  there  is  a  striking  and  appalling  change 
in  the  child's  general  appearance.  Within  a  few  hours  smiling,  perhaps 
plump  and  rosy,  it  can  now  scarcely  be  recognized ;  the  face  has 
become  pale  and  pinched,  the  eyes  and  cheeks  sunken,  the  eyelids  and 
lips  wide  apart  from  loss  of  muscular  control,  the  muscles  flabby,  the 
bones  prominent,  and  the  skin  greenish  or  cadaverous,  hanging  in  loose 
folds  from  the  wasted  frame,  all  the  fat  having  melted  from  the  body. 

Collapse  comes  on  soon  :  the  hands,  feet,  nose,  and  breath  become 
cool,  the  respirations  more  unequal,  and  there  are  drowsiness  and  utter 
apathy.  When  life  is  near  its  close,  vomiting  stops,  the  whole  surface  be- 
coming cool  and  clammy  as  the  patient  sinks  into  a  state  of  coma,  with 
injected  eyes  and  contracted  pupils.  At  last  the  end  is  reached  quickly, 
preceded  perhaps  by  a  slight  convulsion.  The  duration  of  the  dis- 
ease is  short ;  it  may  prove  fatal  in  from  one  to  four  days. 

(3)  Ileo-colitis. — This  may  follow  acute  dyspeptic  diarrhea,  or  com- 
plicate the  acute  infections  of  childhood.  The  symptoms  develop 
acutely.  At  the  outset  there  may  be  vomiting,  but  it  is  not  persistent, 
and  the  stools  are  greenish,  feculent,  often  showing  masses  of  casein. 
Later  the  discharges  are  increased  in  frequency,  are  small,  and  contain 
also  blood  and  mucus.  In  severe  cases  pain  and  straining  are  distress- 
ing features.  The  abdomen  is  prominent  and  there  is  tenderness  along 
the  course  of  the  colon. 

The  course  is  variable.  It  may  be  acute,  terminating  either  in  con- 
valescence or  death  due  to  exhaustion.  In  other  instances  the  acute 
symptoms  subside,  particularly  the  fever,  while  moderate  diarrhea  con- 
tinues and  is  attended  with  marked  wasting,  debility,  and  sometimes 
hydrocephalus.  Gradual  recovery  may  ensue,  though  more  commonly 
relapses  occur  and  death  follows  from  broncho-pneumonia  or  an  inter- 
current acute  attack. 

Treatment. — The  treatment  of  acute  g astro-intestinal  catarrh  di- 
vides itself  into  hygienic,  dietetic,  and  medicinal  measures.  If  a  child 
is  attacked  in  the  city  during  the  summer  and  does  not  yield  to  treat- 
ment in  two  or  three  days,  it  should  be  sent  to  the  country  or  seashore. 
In  the  case  of  a  child  under  two  years  this  is  absolutely  imperative. 
Fresh  air  is  important  in  all  diarrheal  disorders  in  summer  both  in 
country  and  city,  and  all  cases  should  be  kept  out  of  doors  as  much  of 
the  time  as  possible.  Children  should  be  kept  quiet — not  permitted  to 
walk,  even  if  able.  Bathing  is  soothing  and  beneficial  in  that  it  en- 
sures cleanliness  and,  what  is  very  important,  reduces  the  temperature. 

Dietetic  treatment  is  of  great  importance.  It  should  be  remembered 
that  digestion  is  arrested  in  the  early  stage,  hence  to  give  food  at  this 
stage  is  to  do  harm.  Thirst  may  be  controlled  by  ice-  or  albumin-water, 
toast-water,  or  gum-water,  with  a  little  brandy. 

Medicinal  Treatment. — The  first  step  is  directed  against  the  acute 
indigestion  and  the  active  putrefaction  going  on  in  the  intestinal  tube. 
The  indication,  therefore,  is  to  empty  thoroughly  the  whole  alimentary 
tract  as  soon  as  possible,  and  no  other  treatment  must  be  thought  of  until 
this  end  has  been  accomplished.  Whenever  vomiting  persists  the  stom- 
ach should  be  washed  out;  usually  one  washing  is  sufficient.  In  older 
children  emetics  will  favor  complete  emptying  of  the  stomach,  but  are 
never  to  be  given  to  infants  under  two  years.    For  the  intestine  calomel 


804  DISEASES  OF  THE  DIGESTIVE  SYSTE3I. 

and  soda  may  be  used  ;  for  the  colon  Ave  may  use,  in  addition,  irrigation  : 
this  is  advisable  in  all  cases,  as  it  hastens  the  effect  of  the  cathartic  and 
removes  at  once  much  irritating  and  offensive  material.  Opium  should 
not  be  used  until  the  whole  intestinal  tube  is  clean,  and  then  cautiously. 
Spirits  of  chloroform,  or  camphor,  is  a  better  remedy  for  the  pain  than 
opium  in  any  form.  In  older  children  the  hypodermic  injection  of  mor- 
phin  and  atropin  in  appropriate  doses  most  frecjuently  controls  the  whole 
train  of  symptoms.  Bowles  has  used  lactic  acid  in  the  maximum  dose 
of  1^  grains  every  hour  in  60  cases  of  summer  diarrhea,  and  found  it  to 
control  the  symptoms  in  every  case  in  from  24  to  48  hours. 

Treatment  of  Cholera  Infantum. — In  this  form  of  infection  of  the 
intestinal  tract  Ave  are  likely  to  forget  that  Ave  are  called  upon  to  treat 
a  case  of  acute  poisoning.  The  toxic  material  acts  both  poAverfully  and 
quickly  as  a  cardiac  and  systemic  depressant.  It  also  acts  toxically 
upon  the  nerve-centers,  and  paralyzes  the  vaso-motor  nerves.  According 
to  Holt,  the  leading  indications  are — {a)  to  empty  the  stomach  and  intes- 
tines ;  (6)  to  supply  the  body  Avith  fluid  to  offset  the  great  loss  by  vomit- 
ing and  purging;  (c)  to  counteract  the  effect  of  the  poison  on  the  heart 
and  the  nervous  system  ;  {d)  to  reduce  temperature  ;  and  {e)  to  treat  the 
symptoms  as  they  arise.  In  the  first  condition  thorough  stomach  and 
intestinal  cleansing  is  absolutely  necessary.  Moreover,  Ave  cannot  depend 
on  emetics  or  purgatives  to  arrest  pain  and  to  limit  the  effect  of  the  poison 
on  the  nervous  system;  a  hypodermic  injection  of  atropin  and  morphin 
is  essential.  Morphin  must  be  given  Avith  discrimination  to  young  chil- 
dren, especially  when  the  vomiting  and  purging  are  slight ;  it  is  espe- 
cially contraindicated  Avhen  stupor  or  collapse  seems  near.  Small  doses 
repeated  are  better  than  larger  single  doses.  Holt  gives  gr.  y^^-  (0.0006) 
of  morphin,  Avith  gr.  -g^  (0.00008)  of  atropin,  as  the  first  dose  in  a  child 
one  year  old.  In  supplying  fluid  to  the  exhausted  tissues  it  is  useless  to 
attempt  to  give  them  by  the  mouth,  or  even  by  the  rectum,  as  by  both 
avenues  it  Avould  be  rejected.  An  injection  into  the  cellular  tissues  of 
the  buttocks,  back,  or  thighs  of  a  saline  solution  (40  grains — 2.59 — of 
common  salt  to  a  pint  of  sterilized  water)  is  the  best  Avay  to  meet  the 
drain.  One  pint  (half  liter)  may  be  used  every  twenty-four  hours,  and 
larger  quantities  may  often  be  used  Avith  advantage.  Baths  must  be 
given  to  control  temperature,  and  ice-bags  should  be  placed  to  the  head. 
Ice-Avater  injections  will  aid  in  the  control  of  temperature,  and  ice-sup- 
positories act  efficiently  Avhen  the  Avater  is  not  retained.  Stimulants 
may  be  ^ven  hypodermically.  During  the  active  stage  nothing  should 
be  alloAved  by  the  mouth  except  iced  brandy  or  champagne. 

The  dietetic  management  and  internal  treatment  of  ileo-eolitis  are 
similar  to  that  of  the  preceding  variety.  A  dose  of  castor  oil  or  of 
calomel  is  to  be  promptly  administered  and  folloAved  in  a  fcAV  hours  by 
copious  irrigations  of  the  colon,  preferably  Avith  tepid  saline  solution 
(strength  7  :  1000).  Later  a  small  quantity  of  a  thin  starch  solution, 
to  which  THj  to  iij  of  laudanum  has  been  added,  may  be  gently  thrown 
into  the  rectum,  to  be  repeated  once  or  tAvice  daily.  After  the  acute 
stage  is  over  a  weak  silver  nitrate  solution  may  be  employed. 


DIARRHEAS  OF  CHILDREN.  805 

CELIAC   DISEASE. 
{Diarrhoea  Alba;  Diarrhoea  C'hylosa.) 

Definition. — A  form  of  intestinal  catarrh  marked  by  copious  fetid 
and  frothy  discharges  resembling  gruel. 

Patliology. — Although  ulcers  have  been  noted  in  the  intestine,  the 
pathology  of  the  disease  is  not  known.  Says  Osier  :  This  affection  re- 
sembles someAvhat  the  disease  in  adults  known  as  "  hill  diarrhea  "  or  the 
"white  flux"  of  India. 

Ktiologfy. — The  disease  is  limited  chiefly  to  children  from  one  to 
five  years  old.  The  filaria  sanguinis  hominis  has  been  found  in  the  feces 
in  cases  of  diarrhoea  chylosa. 

Symptoms. — The  disease  is  of  slow  development,  and  the  character- 
istic feature  consists  of  copious  diarrheal  (though  not  watery)  stools,  re- 
sembling gruel  or  oatmeal-porridge.  These  are  also  frothy  (frog-spawn) 
and  horribly  fetid.  The  physical  signs  consist  of  a  moderate  distention 
of  the  abdomen  and  a  boggy  sensation  that  is  imparted  to  the  palpating 
finger.  The  general  features  may  be  summated  in  gradually  increasing 
emaciation,  debility,  and  pallor.     The  disease  terminates  fatally  as  a  rule. 

The  treatment  is  purely  symptomatic,  unless  the  presence  of  para- 
sites be  suspected,  when  large  antiseptic  enemata  should  be  given. 


PHLEGMONOUS  ENTERITIS. 

This  is  a  suppurative  inflammation  of  the  submucous  layer  of  the 
intestines.  It  is  among  the  rarest  of  grave  maladies,  especially  as  an 
irrelative  disease.  It  may  be  diffuse  or  take  the  form  of  a  circumscribed 
abscess.  Rarely  it  occurs  as  a  complicating  condition  in  septico-pyemia 
and  in  malignant  types  of  the  exanthemata,  resulting  in  the  formation 
of  abscesses  that  have  their  seat  usually  in  the  duodenum.  Phlegmon- 
ous enteritis  may  be  secondary  to  strangulated  hernia  or  intussusception. 

Symptoms. — The  local  signs  simulate  closely  those  of  peritonitis. 
Among  the  symptoms  vomiting  is  prominent,  though  not  diagnostic  ;  it  is 
always  severe,  and  may  become  stercoraceous.  Pain  and  tenesmus,  when 
due  to  obstruction,  are  intense.  Rigors  more  or  less  severe  have  been 
observed.  The  temjjerature  is  high,  and  its  curve  is  somewhat  typical 
of  the  fever  of  suppuration.  The  disease  is  very  fatal,  the  patient 
passing  from  a  condition  of  extreme  prostration  to  one  of  utter  collapse. 

Treatment. — The  physician's  task  is  confined  to  an  attempt  to  sup- 
port the  powers  of  the  patient  and  to  relieve  his  inordinate  suffering. 
The  surgeon's  aid  should  be  invoked  early  in  cases  of  obstruction. 


CROUPOUS  OR  DIPHTHERITIC  ENTERITIS. 

Definition. — An  intense  inflammation  of  the  intestinal  mucosa,  ac- 
companied by  a  croupous  exudate  ;  it  occurs  in  connection  with  widely 
various  conditions.  If  from  any  cause  the  epithelial  covering  is  de- 
stroyed, agents  that  set  up  local  inflammation  may  be  productive  of  croup. 

Pathology. — There  are  two  sets  of  morbid  lesions  to  be   distin- 


806  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

guished :  (1)  The  first  and  most  important  class  exhibits  a  croupous 
deposit  varying  greatly  in  thickness  and  in  superficial  area.  Its  color 
is  variable,  being  sometimes  of  a  grayish  or  f/rai/isJi-tvhite  hue,  though 
more  frequently,  perhaps,  grayish-yellow.  I  have  almost  invariably  seen 
these  lesions  in  the  colon.  (2)  In  the  second  group  the  solitary  follicles 
alone  are  inflamed,  and  the  diphtheritic  deposit  is  merely  coextensive 
with  their  mouths. 

The  etiologic  factors  may  be  (a)  mechanical  irritants  (impacted  feces, 
enterolitlis,  gall-stones) ;  (b)  chemical  irritants  (ammonia,  acids,  mer- 
cury, arsenic) ;  (c)  the  condition  may  be  secondary  to  acute  infectious 
diseases  and  certain  chronic  complaints  (Bright's  disease,  pyemia,  car- 
cinoma). 

Symptoms. — When  mechanical  irritants  give  rise  to  symptoms, 
they  do  not  differ  from  those  due  to  stercoral  ulcers,  and  there  is  no  way 
of  recognizing  the  croupous  deposits  unless  they  be  discharged />£'?'  rectum 
and  are  detected  in  the  stools.  In  cases  that  arise  from  the  action  of  irri- 
tant poisons  vomiting  and  purging  are  well  marked  and  the  dejections 
contain  blood-stained  mucus.  We  cannot  be  certain  about  the  presence 
of  croupous  deposits  in  toxic  cases  unless  they  be  found  in  the  dis- 
charges. When  phlegmonous  enteritis  occurs  as  a  complicating  condi- 
tion in  infectious  diseases,  the  symptoms  are  almost  completely  veiled. 
The  symptomatology  of  the  follicular  variety  cannot  be  separated  clini- 
cally from  that  of  follicular  ulceration. 

The  treatment  is  that  of  the  causal  conditions  or  affections. 


SPRUE. 

{Psilosis. ) 

This  has  been  defined  as  "  an  insidious,  chronic,  remitting  inflamma- 
tion of  the  whole  or  part  of  the  mucous  membrane  of  the  alimentary 
canal,  occurring  principally  in  Europeans  Avho  are  residing  or  have 
resided  in  tropical  or  subtro])ical  climates  "  (Manson). 

The  principal  morbid  changes  consist  in  patchy  or  general  destruc- 
tion of  "the  surface  of  the  mucosa  in  all  degrees,  from  slight  erosions 
to  complete  disintegration  of  the  villi,  glands,  and  follicles."  Conges- 
tive, catarrhal,  ulcerative,  and  cirrhotic  changes  may  be  all  combined  in 
one  and  the  same  case. 

The  etiology  is  unknown,  although  the  disease  is  probably  of  micro- 
organismal  nature.  Residence  in  hot  climates  and  previous  affections 
of  the  alimentary  tract  are  the  main  predisposing  causes. 

The  leading  Symptoms  are,  according  to  Manson.  irregular  action  of 
the  bowels,  and  the  passage  of  copious,  pale,  drab-colored,  yeasty-looking, 
sickly-smelling  stools.  The  oro-cavity  is  inflamed  and  the  seat  of  ero- 
sions, cracks,  and  superficial  ulcerations.  Brunton  has  pointed  out 
that  Indian  Hill  diarrhea  differs  from  sprue  in  that  soreness  of  the 
mouth  and  anus  is  absent  in  the  former. 

Early  appropriate  treatment,  which  is  principally  dietetic  (milk- 
diet)  and  hygienic,  checks  the  progress  of  the  disease. 


CHOLERA  MORBUS.  807 

CHOLERA  MORBUS. 

(Cholera  Nostras  ;  Sporadic  Cholera.) 

Definition. — A  self-limiting  disease,  characterized  by  serous  vomit- 
ing and  purging,  colicky  pains,  arid  often  muscular  cramps. 

Pathology. — No  constant  anatomic  changes  have  been  noted.  They 
are  analogous  to  those  seen  in  acute  gastro-enteritis,  though  eases  have 
terminated  fatally  in  which  no  morbid  lesions  were  found  postmortem. 

il^tiology. — Among  predisposing  causes,  the  age  and  the  season 
exert  the  most  prominent  influence.  The  condition  may  appear  in  sub- 
jects under  two  years,  when  the  term  "  cholera  infantum  "  is  employed, 
though  it  is  more  often  met  with  in  older  children  and  adults.  It 
is  almost  invariably  seen  during  the  heated  term  in  temperate  zones, 
from  the  latter  part  of  June  to  September,  and  it  is  especially  prev- 
alent during  the  months  of  July  and  August.  Bad  hygienic  environ- 
ment, foul  air  in  particular,  has  a  noticeable  eftect,  and,  though  not  as 
yet  absolutely  proved,  it  may  be  safely  inferred  from  the  clinical  his- 
tory and  the  usual  course  of  the  affection  that  it  is  of  microbic  origin. 
Among  other  factors  are  improper  food,  particularly  unripe  fruit,  cucum- 
bers, egg-plant,  and  exposure  to  cold  and  wet.  Various  organisms 
(especially  the  Finkler  and  Prior  spirillum)  have  been  found  present. 
No  one  variety,  however,  has  been  definitely  found  to  be  the  cause  of 
the  condition.  Virulent  specimens  of  the  bacillus  coli  commune,  and 
even  of  the  streptococcus,  have  been  noted. 

Clinical  History. — The  onset  is  often  sudden,  and  is  marked  by 
abdominal  pain,  vomiting,  and  diarrhea.  At  first  the  vomitus  consists 
of  food,  and  later  of  bile  and  mucus.  The  dejections  are  fecal  in  char- 
acter at  the  onset;  though  they  soon  become  watery,  and  may  resemble 
the  rice-water  stools  of  Asiatic  cholera. 

Physical  examination  reveals  only  tenderness  on  pressure  over  the 
abdomen,  particularly  the  epigastric  region. 

General  symptoms  are  not  wanting.  Cramps  in  the  calves  are  com- 
mon. The  thermometer  may  register  a  high  temperature,  though  it 
varies  greatly,  ranging  from  100°  to  106°  F.  (37.7°  to  41.1°  C).  The 
skin-surface,  however,  and  more  particularly  that  of  the  extremities, 
feels  cool,  and  owing  to  this  fact  the  rectal  temperature  should  be  re- 
corded. The  pulse,  as  the  case  progresses,  becomes  rapid  and  feeble. 
The  face  is  pale  or  even  cyanotic,  the  features  looking  pinched.  The 
extremities  lose  their  plumpness,  and  the  patient  usually  appears  pros- 
trated and  mentally  dull.  The  urine  is  apt  to  be  scant,  high-colored, 
and  sometimes  albuminous,  and  thirst  is  extreme.  There  is  a  group  of 
cases  that  develop  subacutely  and  the  symptoms  tend  to  persist. 

Differential  DiagfnosiS. — The  symptoms  of  cholera  morbus  re- 
semble so  closely  tRose  of  Asiatic  cholera  as  to  preclude  the  possibility 
of  a  differential  diagnosis  from  the  symptoms.  A  bacteriologic  ex- 
amination of  the  stools  alone,  however,  permits  a  certain  discrimination. 
During  a  cholera  epidemic  the  distinction  between  them  is  made  without 
difiiculty.  The  effects  of  certain  direct  irritants,  as  in  poisoning  by 
ptomains  and  toxic  doses  of  arsenic,  must  be  excluded  by  the  history. 

Prognosis  and  Duration. — The  duration  of  the  disease  varies 
from  three  to  four  hours  to  two  days.  It  is  rarely  fatal,  though  in  per- 
sons suffering  from  such  chronic  affections  as  Bright's  or  cardiac  disease, 


808  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  also  in  the  aged,  the  prognosis  is  only  guardedly  favorable.  A 
pronounced  algid  state  should  not  be  looked  upon  as  free  from  danger. 
An  element  of  danger  is  profound  collapse.  In  two  of  my  cases  a  con- 
dition of  marked  neurasthenia,  indigestion,  and  functional  heart-disturb- 
ance formed  a  series  of  sequelae  that  lasted  for  several  months.  Nearly 
all  cases,  however,  recover  without  sequelre. 

Treatment. — The  diet  must  be  rigorously  restricted,  and  predi- 
gested  milk  and  animal  broths  are  to  be  prepared  as  lightly  as  possible 
until  convalescence  has  been  fairly  established.  The  comfort  of  the 
patient,  as  well  as  the  cure  of  the  disease,  is  much  enhanced  by  keeping 
the  patient  at  absolute  rest.  Local  measures  are  useful  in  combating 
pain  and  vomiting.  A  large  mustard-paste  applied  to  the  stomach  and 
abdomen,  followed  by  linseed-poultices  that  are  to  be  worn  constantly, 
has  a  strong  influence  in  accomplishing  the  relief  of  the  symptoms 
before  mentioned.  If  indigestible  substances  have  been  taken  prior  to 
the  attack,  prompt  though  mild  laxatives  are  to  be  given  at  the  begin- 
ning of  the  treatment.  For  the  excessive  thirst  chipped  ice,  over  which 
a  little  brandy  has  been  sprinkled,  is  effective.  For  controlling  the 
morbid  sensitiveness,  on  which  the  pain,  nausea,  and  the  diarrhea  depend, 
"we  have  a  remedy  par  excellence  in  the  hypodermic  administration  of 
morphin.  The  dose  should  rary  (gr.  \  to  ^ — 0.016  to  0.032)  according 
to  the  severity  of  the  symptoms,  and  I  have  rarely  found  it  necessary 
to  give  a  second  dose.  Not  only  are  the  pain  and  diarrhea  subdued, 
but  the  peripheral  circulation  is  also  re-established.  It  has  also  been 
recommended  to  administer  opium  by  the  mouth  for  these  symptoms  in 
the  form  of  the  solid  extract  or  laudanum,  but  the  results  are  infinitely 
more  brilliant  when  the  drug  is  employed  subcutaneously.  The  other 
points  in  the  treatment  of  this  aff'ection  are  identical  with  those  discussed 
under  the  treatment  of  Gastric  and  Enteric  Catarrh. 


INTESTINAL  INFARCTION. 

A  FEW  instances  of  occlusion  of  the  superior  mesenteric  artery  by  an 
embolus  have  been  recorded  recently.  The  condition  produces  hemor- 
rhagic infarction  of  the  small  intestines,  and  is  marked  by  grave  and 
usually  fatal  symptoms.  Its  causes  are  sometimes  obscure.  The  cases 
that  have  come  to  autopsy  have  shown  inten.se  congestion,  with  a  swollen, 
blood-infiltrated  state  of  the  jejunum  and  ileum.  Osier  has  seen  three 
instances  :  in  one  there  Avere  numerous  vegetations  on  the  mitral  valves 
from  which  the  embolus  was  probably  derived ;  in  another  the  superior 
mesentery  was  plugged  at  its  orifice ;  and  in  the  third  the  artery 
was  blocked  by  a  portion  of  the  fibrous  clot  of  an  aneurysm  of  the 
aorta  near  the  diaphragm.  The  si/mptoms  are  urgent.  Quite  often 
diarrliea  is  present  from  the  first,  the  dejections  sometimes  becoming 
blood-tinged.  Soon,  however  the  characteristically  grave  symptoms  of 
intestinal  obstruction  supervene — viz.  great  pahi,  vomiting^  and  constipa- 
tion (less  commonly  diarrhea),  with  tympanitic  distention  of  the  abdo- 
men (generally).  The  condition  cannot  be  recognized  from  the  symptoms 
and  physical  signs  on  account  of  their  close  resemblance  to  the  various 
forms  of  obstruction,  yet  its  probable  existence  may  be  inferred  from 
the  presence  of  the  known  causes. 


INTESTINAL    ULCERS.  809 

INTESTINAL  ULCERS. 

DUODENAL   ULCER. 

Definition. — A  small,  round  perforating  ulcer  of  the  duodenum 
(vide  p.  7G3).      It  may  be  primary  or  secondary. 

Pathology. — The  morbid  characteristics  are  so  nearly  identical  in 
appearance  and  nature  with  those  of  peptic  ulcer  of  the  stomach  that 
they  scarcely  demand  a  separate  presentation.  The  seat  of  the  ulcer  is 
with  few  exceptions  above  the  orifice  of  the  common  bile-duct.  When 
these  ulcers  heal  the  resulting  cicatrix  produces  stenosis,  which. in  turn 
leads  to  dilatation  of  that  portion  of  the  duodenum  back  of  it,  and  finally 
of  the  stomach  also.  Progressive  cicatricial  contraction  may  completely 
close  the  ductus  commioiiis,  and  in  like  manner  the  pancreatic  duct  or 
the  portal  vein  may  be  occluded.  Protective  adhesive  inflammation 
between  the  duodenum  and  the  adjacent  parts  (pancreas,  gall-blad- 
der, liver)  often  prevents  complete  perforation  of  the  duodenal  wall : 
when  perforation  does  occur,  however,  the  peritoneal  cavity  may  be 
opened,  causing  peritonitis,  or  a  fistulous  communication  may  be  estab- 
lished with  the  gall-bladder,  liver,  or  pancreas. 

Ktiology. — Though  the  duodenal  ulcer  has,  as  a  rule,  the  same  mode 
of  origin  as  the  gastric  ulcer,  the  fact  should  be  prominently  mentioned 
here  that  extensive  burns  of  the  skin-surface  of  the  body  are  quite  prone 
to  be  followed  by  a  perforating  ulcer  of  the  duodenum,  while  gastric 
ulcers  are  seldom  caused  in  this  manner.  To  explain  this  form  of  ulcera- 
tion of  the  duodenum  is  difiicult.  It  is  quite  probable,  however,  as  in 
other  forms  of  duodenal  and  gastric  ulcers,  that  the  circulation  is  arrested 
by  an  embolus  (from  decomposing  masses  of  blood)  at  some  point  in  the 
mucous  membrane,  the  acid  gastric  juices  subsequently  digesting  the 
part  that  is  thus  deprived  of  its  blood-supply.  Ulcerations  of  the  duode- 
num have  recently  been  met  with  in  cases  of  chronic  Bright's  disease, 
and  also  found  associated  with  gall-stones. 

.The  influence  of  sex  and  age  as  causal  factors  is  notable  and  in 
striking  contrast  with  their  import  in  gastric  ulcer.  In  the  latter  dis- 
ease most  instances  occur  among  young  females,  while  in  duodenal 
ulceration  they  occur,  as  a  rule,  in  males  between  the  twentieth  and 
fortieth  years.  Of  64  cases  collected  by  Kraus,  only  6  sufferers  were 
females.  In  view  of  the  fact  that  the  pathology  of  gastric  and  duodenal 
ulcers  is  the  same,  these  differences  respecting  their  etiology  are  inex- 
plicable. The  ratio  of  cases  of  gastric  and  duodenal  ulcers,  however,  is 
about  as  30  to  1  in  favor  of  the  former. 

Clinical  History. — Perhaps  no  real  distinction  between  the  symp- 
toms of  gastric  ulcer  and  those  of  its  homologue  affecting  the  duodenum 
can  be  said  to  exist  in  most  instances.  A  probable  diagnosis  of  ulcer- 
ation of  the  duodenum  has,  however,  been  repeatedly  made,  and  some- 
times verified  by  the  subsequent  autopsy.  If  duodenal  ulcer  be  classed 
with  gastric  ulcer,  there  is  great  danger  that  the  true  nature  of  many 
cases  Avill  be  overlooked.  The  difference  in  the  symptomatology  in  the 
two  forms  of  ulceration  is  owing  solely  to  the  difference  in  localitv.  im- 
plying a  difference  in  nervous  and  blood  supply. 

The  distinctive  features  of  this  disease  may  be  shown  bv  presentinc" 
its  leading  symptoms  by  the  side  of  those  characteristic  of  gastric  ulcer  : 


810 


DISEASES  OF  THE  DIGESTIVE  SYSTE3I. 


Duodenal  Ulcer. 

Usually  occurs  between  20  and  40  years, 
except  when  due  to  external  burns. 

Males  are  more  frequent  sufferers  than 
females,  in  the  proportion  of  10  to  1. 

Onset  marked  by  intestinal  hemorrhaf;;e. 
which  may  recur  at  intervals  of  vary- 
ing duration. 

The  melena  may  be  preceded  by  or  ac- 
companied by  hematemesis,  though  not 
generally. 

Blood  in  the  discharges  often  is  bright 
red,  profuse,  sometimes  dark,  and  tarry 
from  the  action  of  acid  chj^me  when 
slight,  though  less  marked  than  when 
from  the  stomach. 

Pain  may  come  on  late,  two  to  four 
hours  after  meals;  more  often  it  is 
absent.  It  is  localized  in  the  right 
hypochondriac  region. 

Gastric  crises  of  great  violence  occur 
without  reference  to  time  of  taking 
food. 

Vomiting  inconstant,  without  relation  to 
ingestion  of  food,  and  affords  no  relief. 

Jaundice  occasionally  present  from  oc- 
clusion of  bile-duct. 

Less  marked  improvement  after  diet  has 
been  regulated. 

Dorsal  pain-point  absent. 


Gastric  Ulcer. 
May  occur  at  any  age  after  childhood. 
Females  are  the  chief  sufferers. 

Gastric  hemorrhage  often  occurs,  pre- 
ceded by  other  gastric  symptoms,  as  a 
rule. 

Blood  may  appear  in  the  stools,  usually 
after  hematemesis. 

The  blood  in  the  dejections  is  dark  and 
tarry  from  the  action  of  the  gastric 
juices. 

Pain  paroxysmal,  greatly  influenced  by 
taking  food.  Pain  sharply  localized  in 
the  epigastric  region,  about  two  inches 
below  the  ensiform  cartilage. 

Gastric  crises  come  on  soon  after  taking 
food. 

Vomiting  more  common  (during  painful 

crisis)  and  affords  relief. 
Jaundice  absent. 

Usually  a  marked  improvement  follows 
regulation  of  diet. 

Painful  point  (between  the  tenth  and 
twelfth  dorsal  vertebrae  on  left  side) 
usually  present. 

Finally,  "  whenever  a  young  man  in  apparently  good  health  is 
attacked  by  melena,  with  or  without  hematemesis,  it  is  probable  that 
the  ulcer  is  located  in  the  first  part  of  the  duodenum  rather  than  in  the 
stomach,  the  converse  being  the  case  in  young  women  "  (Fenwick). 

Of  the  symptoms  mentioned  under  Duodenal  Ulcer,  the  intestinal 
bleedings  and  violent  crises  (in  which  the  pain  is  referred  to  the  right 
hypochondrium,  and  comes  on  from  two  to  four  hours  after  meals)  are 
the  most  diagnostic.  "While  hemorrhage  is  the  leading  single  symptom 
in  this  complaint,  we  must  not,  in  attempting  to  estimate  its  significance 
in  any  case,  neglect  to  eliminate  hemorrhoids,  carcinoma,  tuberculosis, 
dysentery,  and  finally  the  hemorrhagic  diathesis — all  conditions  in  which 
melena  occurs  as  a  cardinal  symptom.  Recently  many  cases  have  been 
reported  in  which  there  was  an  entire  absence  of  symptoms  until  perfora- 
tion occurred,  followed  by  rapidly  fatal  suppurative  peritonitis  {latent 
duodenal  ulcer).  In  regard  to  these  accidents  we  may  refer  to  what  is 
said  in  the  description  of  the  latter  disease  (infra). 

The  signs  of  dilatation  of  the  stomach,  for  reasons  before  stated, 
sometimes  follow  the  healing  of  these  ulcers,  associated  usually  with 
chronic  gastro-duodenal  catarrh,  the  latter  being  due  to  mechanical 
causes.  Rarely,  stenosis  of  the  ductus  com)nunis  takes  place  as  the 
result  of  duodenal  ulcer  ;  more  frequently  tumors  either  compress  or 
occlude  the  lumen  of  the  bowel  below  the  mouth  of  the  duct.  The 
symptoms  presented  differ  widely  from  those  due  to  stenosis  above  the 
duct,  the  most  characteristic  being  the  continual  backward  flow  of  bile 
into  the  stomach,  sometimes  attended  by  constant  vomiting  of  biliary 


INTESTINAL    I'LCERS.  811 

secretions.  As  in  the  case  of  gastric  ulcer,  in  the  duodenal  form  there 
is  at  times  so  much  thickening  about  the  base  of  the  ulcer  as  to  give  rise 
to  the  signs  of  tumor.  This  is  especially  true  of  those  instances  in  which 
the  base  of  the  ulcer  becomes  attached  to  adjacent  organs;  in  such  cases 
the  resemblance  to  malignant  disease  may  be  striking. 

Prognosis. — The  risk  to  life  is  greater  than  in  gastric  ulcer,  since 
there  is  less  tendency  to  cicatrization. 

Treatment. — The  suggestions  made  in  the  treatment  of  gastric 
ulcer  are  entirely  applicable  to  the  duodenal  form  also. 

Follicular  ulcers  have  already  been  described  under  Catarrhal  Enteritis 
{vide  p.  793).  and  they  have  a  similar  pathology  and  etiology.  "When 
present  in  goodly  numbers  they  give  rise  to  a  symptom  peculiarly  their 
own,  and  hence  mav  be  dignified  by  a  separate  though  brief  mention. 
The  symptoms  of  the  condition  arising  in  the  course  of  chronic  enteritis 
often  escape  observation  for  a  long  time.  The  most  characteristic  man- 
ifestation is  the  appearance  in  the  stools  of  conical-shaped  masses  of 
mucus  resemblino;  •"boiled  sago.'"  Marked  weakness  and  emaciation 
rapidly  ensue.  Among  children  the  disease  is  common  and  assumes  an 
aggravated  form,  the  little  sufferers  Cjuite  frequently  reaching  their  end 
as  the  result  of  inanition.  An  unfavorable  termination  may  be  due  to 
perforation  followed  by  suppurative  peritonitis.  The  treatment  coin- 
cides with  that  of  chronic  enteritis. 

Stercoral  ulcers  are  the  result  of  the  mechanical  eft'ect  of  hard  fecal 
scybala  (often  enteroliths,  due  to  a  deposit  of  lime-salts)  upon  the  intes- 
tinal mucous  membrane.  They  occupy  the  sides  or  tops  of  the  normal 
folds  in  the  colon. 

Symptoms. — There  is,  as  a  rule,  a  clear  history  of  clironie  constipa- 
tion, though  the  physician  may,  notwithstanding,  be  called  on  account 
of  the  presence  of  diarrJiea ;  this  is  caused  by  the  retained  hardened 
feces  working  their  way  into  the  rectum.  A  digital  exploration  will 
now  clear  up  the  diagnosis.  There  are  tenesmus  and  colicT^y  pain  in 
the  abdomen,  the  latter  symptom  being  also  complained  of  when  no 
diarrhea  is  present.  The  pain  often  occurs  in  severe  paroxysms  that 
may  be  attended  with  the  discharge  of  thready  or  flaky  mucus,  pus, 
and  sometimes  blood. 

Phjisical  Examination. — Palpation  may  in  rare  instances  reveal  the 
presence  of  a  sausage-shaped  tumor  and  sharply  localized  tenderness 
over  the  seats  of  ulcers. 

Enteroliths  may  lie  in  the  intestines  for  years  together,  or  they  may 
finally  be  discharged  with  the  stools.  The  ulceration  that  is  thus  caused 
often  passes  unrecognized. 

The  prognosis  is  good  if  the  condition  be  not  overlooked. 

The  treatment  consists  in  thoroughly  evacuating  the  bowels  by  salines 
and  simple  enemata.  persistently  used.  Subsequently  these  cases  are  to 
be  managed  in  the  same  manner  as  other  non-specific  ulcers  of  the 
bowels. 

Simple  ulcerative  colitis  is  a  not  uncommon  complaint,  and  one  that 

is   frequently   associated   Avith    chronic  intestinal   catarrh.      The  ulcers 
may  be    quite  extensive,  removing  the  greater  portion  of  the  mucous 


812  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

membrane,  though  in  several  instances  I  have  observed  cases  at  the 
Episcopal  Hospital  that  were  superficial ;  these  were  confined  almost 
solely  to  the  mucosa.  The  muscular  layer  of  the  gut  was  greatly  hyper- 
trophied  and  its  lumen  increased  in  every  instance.  The  non-ulcerated 
portions  of  the  mucosa  looked,  in  part,  quite  pale,  and  in  part  quite  dark. 
Polypoid  growths  have  been  observed  situated  between  the  ulcers. 

The  etiology  is  obscure.  The  disease  is  met  with  most  frequently 
in  persons  past  middle  life,  and  it  is  quite  probable  that  chronic  enteritis 
sustains  a  causal  relation.  Those  whose  constitutions  have  been  enfee- 
bled by  previous  disease  or  an  improvident  hygienic  environment  are 
the  chief  sufferers. 

Symptoms. — The  clinical  features  are  ill  defined  at  the  onset,  and 
are  often  erroneously  ascribed  to  indigestion.  Diarrhea  (lienteric  in 
character)  is  its  most  prominent  symptom,  and  with  it  constipation  may 
alternate.  Pus  and  blood  are  absent  with  the  rarest  exceptions.  The 
general  health  soon  suffers  greatly,  the  patient  becoming  weak  and 
emaciated. 

The  course  of  the  disease  is  subacute,  tending  to  become  chronic. 

The  diagnosis,  apart  from  a  consideration  of  the  symptoms  above  men- 
tioned, requires  the  elimination  of  dysentery — an  easy  task  as  a  rule. 
The  disease  resembles  most  closely  the  amebic  form  of  dysentery,  hence 
in  dubious  cases  a  microscopic  examination  of  the  feces  should  not  be 
neglected. 

Prognosis. — This  is  unfavorable  during  the  earlier  stages  in  the  aged. 
The  tendency  to  chronicity  of  the  disease  must  be  considered. 

The  treatment  embraces  (a)  a  careful  regulation  of  the  diet,  consist- 
ing in  a  restriction  of  the  patient  to  licjuids  and  semi-solids  during  the 
acute  stage;  (b)  the  administration  of  a  gentle  laxative,  followed  by 
antiseptics  and  astringents  (bismuth  gr.  xxx — 2.0 — combined  with  salol 
gr.  V — 0.324 — every  four  hours);  (r)  the  more  serviceable  local  measures 
in  the  form  of  enemata,  among  the  best  being  silver  nitrate  (gr.  ^  ad  oj 
— 0.016  to  32.0)  or  creolin  (2  per  cent.). 

Solitary  Ulcers. — "  Two  instances  of  ulcer  of  the  cecum,  both  with 
perforation,  have  come  under  my  observation,  and  in  one  instance  a 
simple  ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis  "  (Osier). 

The  diffuse  catarrhal  ulcer  is  inseparable  from  acute  enteritis ;  the 
cancerous  ulcer  is  alluded  to  under  the  latter  head. 


APPENDICITIS. 


Definition. — A  catarrhal,  ulcerative,  or  interstitial  inflammation 
of  the  appendix  vermiformis.  It  must  be  confessed  that,  according  to 
our  present  views,  appendicitis  is  a  surgical  rather  than  a  medical  affec- 
tion, particularly  from  the  stand])oint  of  treatment.  Knowing  from 
personal  experience  and  observation,  however,  that  general  practitioners 
are  constantly  meeting  with  cases  of  appendicitis,  its  prompt  clinical  rec- 
ognition by  the  latter  is  not  only  a  matter  of  interest,  but  also  of  great 
practical  importance  for  two  reasons:  First,  in  order  that  surgical  inter- 


APPENDICITIS.  813 

vention  can  be  instituted  at  the  proper  moment ;  and  secondly,  because 
appendicitis  is  the  leading  serious  disease  of  the  intestinal  tract. 

The  term  "appendicitis"  includes  the  affections  typhlitis  (inflamma- 
tion of  the  cecum)  and  perityphlitis  (a  similar  involvment  of  the  connec- 
tive tissue  behind  the  cecum)  by  reason  of  the  fact  that  with  few  excep- 
tions when  the  symptoms  of  the  latter  affection  are  presented  the  ap- 
pendix vermiformis  is  the  part  primarily  affected.  To  the  physicians 
and  surgeons  of  America  belongs  the  credit  of  having  first  established 
the  truly  important  rank  of  appendicitis.^ 

Anatomic. — Without  any  known  function  the  human  appendix 
vermiformis  represents  the  remains  of  the  enormous  cecum  of  inferior 
animals,  especially  rodents  and  herbivora.  Clado  asserts  that  the  ver- 
miform appendix  is  kept  in  position  by  two  folds  of  peritoneum,  a 
meso-appendix,  which  is  attached  to  the  iliac  fossa,  and  a  second  fold, 
perpendicular  to  the  first,  which  is  attached  to  the  posterior  portion  of 
the  small  intestine.^  A  lymphatic  gland  generally  occupies  the  angle 
formed  by  the  appendix,  cecum,  and  the  small  gut ;  this  receives  all 
the  lymphatic  vessels  of  the  appendix.  The  size  of  the  latter  varies 
greatly.  Ferguson,^  after  measuring  200  appendices,  gave  as  the  aver- 
age length  4|^  inches  (11.4  cm.),  and  as  the  diameter,  that  of  a  No.  9  English 
sound — about  a  quarter  of  an  inch  (0.62  cm.).  Berry's  studies,  which  are 
partly  based  upon  personal  examination  of  100  bodies,  and  partly  upon 
comparison  of  his  own  results  with  those  obtained  by  other  investigators, 
gives  the  average  length  in  all  the  observations  as  9.2  centimeters  (3.6 
inches).  The  caliber  is  ordinarily  of  the  size  of  a  goose-quill.  Very 
exceptionally,  as  in  a  case  reported  by  Swan,  there  is  a  congenital 
absence  of  the  appendix.  Its  two  fibro-muscular  coats  (external  longi- 
tudinal and  internal  circular)  are  thick ;  its  mucous  membrane  contains 
lymphoid  elements  in  abundance.  The  blood-supply  is  derived  from  the 
ileo-colic  artery  at  the  valve,  a  single  branch  running  to  the  end  of  the 
appendix.  Shortly  after  middle  life  the  cavity  of  the  appendix  becomes 
obliterated.  Its  blind  extremity  points  most  frequently  toward  the  spleen. 
The  appendix  may  lie  behind  the  cecum,  and  sometimes  partly  to  its 
inner  side,  its  tip  almost  touching  the  liver  or  the  gall-bladder.  In  not 
a  few  instances  it  dips  downward,  passing  over  the  brim  of  the  pelvis. 
There  is  no  adjacent  organ  to  Avhich  it  may  not  become  adherent, 
and  in  rare  instances  it  is  twisted  like  a  loop  around  the  small  gut, 
causing  constriction  or  even  strangulation.  Osier  mentions  one  case  in 
which  the  appendix,  with  the  cecum,  entered  the  inguinal  canal,  curved 
upon  itself,  re-entered  the  abdomen,  and  was  adherent  to  the  wall  of  an 
abscess-cavity  just  to  the  right  of  the  promontory  of  the  sacrum. 

Pathology. — Three  pathologic  varieties  are  recognized  : 

(1)  Catarrhal  or  Obliterative  Appendicitis. — This  may  be  acute  or 
chronic.  The  term  "  catarrhal  inflammation  "  is  still  retained,  though 
scarcely  applicable,  since,  as  a  rule,  appendicular  inflammation  tends  to 
spread  quickly  to  all  the  coats,  including  the  serosa.      Obliterative  ap- 

^  The  following  names  will  long  be  connected  with  this  disease :  Pepper,  Fitz,  Mc- 
Burney,  Porter,  Willard  Parker,  Weir,  Sand,  Bull,  Warren,  Keen,  Morton,  Price,  J. 
William  White,  Deaver,  Senn,  and  many  others.  ^  Sajous'  Annual,  vol.  i.,  1893. 

^  "Some  Points  regarding  the  Appendix  Vermiformis,"  American  Journal  of  Medical 
Sciences,  Jan.,  1891. 


814  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pendicitis  is  descriptive  and  in  every  way  preferable.  The  mechanism 
of  the  inflammation  is  briefly  as  follows :  The  mesentery  being  too 
short,  the  exit  is  too  small,  and  in  consequence  of  swelling  of  the  coats 
(especially  the  mucous)  the  venous  return  is  greatly  impeded,  then  the 
arterial,  followed  often  by  abscess-formation.  In  the  female  a  branch  is 
supposed  to  be  furnished  by  the  ovarian  artery,  making  a  more  perfect 
blood-supply.  The  appearances  are,  in  the  beginning,  identical  with  those 
of  catarrhal  inflammations  elsewhere  in  the  bowel.  Within  twenty-four 
hours  all  the  layers  are  swollen,  with  marked  cellular  infiltration,  causing 
the  appendix  to  become  firm  and  often  rigid.  The  mucosa  may  be  de- 
nuded of  its  epithelium  and  present  a  granular  surface.  The  external 
coat  (serosa)  is  usually  hyperemic,  and  not  uncommonly  the  seat  of  fresh 
or  old  adhesions.  The  tube  may  become  completely  obliterated  by 
pressure,  resulting  in  a  union  between  the  granular  surfaces,  in  this 
manner  rendering  subsequent  attacks  impossible  (Hawkins).  It  is  in 
cases  in  which  this  fortunate  result  is  not  reached,  however,  that  acute 
appendicitis  leads  to  the  chronic  form  Avith  relapses.  Two  additional 
terminations  may  be  observed :  First,  an  obliteration  of  the  lumen  may 
occur  near  the  valve,  in  which  case  the  appendix  becomes  dilated,  and 
sometimes  enormously  so  (cystic).  The  contained  liquid  may  be  either 
serous  or  purulent.  Second,  obliterative  appendicitis  may  lead  directly 
to  ulceration  of  the  mucous  membrane,  and  often  in  the  absence  of  a 
fecal  concretion  or  foreign  body.  Again,  the  cystic  appendix  may 
ulcerate,  with  or  without  perforation.  Obviously,  the  more  marked  the 
stenosis  of  the  appendix  the  less  favorable  the  conditions  for  natural 
drainage,  and  the  greater  the  liabilitv  to  recurrences  of  attacks  of 
appendicitis.^  This  variety  then  may  end  in  resolution,  complete  oblit- 
eration, stenosis,  or  ulceration,  and  the  latter  sometimes  in  perforation. 

(2)  Ulcerative  Inflammation. — Like  the  preceding,  this  variety  may 
be  acute  or  chronic.  It  may  be  a  sequel  of  the  obliterative  form,  and 
often  accompanies  chronic  obliterative  appendicitis.  More  commonly, 
however,  it  is  seen  in  connection  with  concretions,  and  sometimes  with 
foreign  bodies  also.  By  no  means  invariably,  however,  does  the  pres- 
ence of  these  substances  excite  ulceration  of  the  appendix.  Micro- 
organisms play  an  important  role  in  this  variety  {vide  Etiology).  The 
submucosa  or  muscularis  usually  forms  the  base  of  the  ulcer.  The  ter- 
mination may  be  in  healing,  with  tendency  to  stricture.  When  obliter- 
ation is  complete,  dilatation  beyond  the  seat  of  the  latter  may  ensue. 
Again,  the  ulcer  may  extend  in   deptli   until  perforation  occurs. 

(3)  Interstitial  or  Parietal  Inflammation. — This  may  be  preceded  by 
the  obliterative  or  the  ulcerative  form,  which  may  be  followed  by  anemic 
necrosis  and  sloughing.  Concretions  or  foreign  bodies  are  often  found, 
though  specific  bacteria  are  of  greater  etiologic  importance.  The  gravest, 
most  common,  and  hence  the  most  important  lesions  are  the  gangrenous, 
which  are  usually  limited  to  a  circumscribed  part  of  the  tube.  Interstitial 
inflammation  has  a  single  termination — perforation — and  leads  to  appen- 
dicular peritonitis  of  a  virulent  and  infectious  type. 

It  may  be  that  neither  necrosis  nor  gangrene  may  supervene.  When 
perforation  occurs,  one  or  more  openings,  ranging  in  size  from  one  to 
several  millimeters,  may  be  observed,  while  the  remainder  of  the  appen- 
dix may  present  no  abnormalities ;  more  often,   however,  it  is  blood- 


APPENDICITIS.  815 

injected  and  swollen.  The  appendix  may  slough  en  masse.  The  histo- 
pathologic changes  may  be  characterized  by  intense  cellular  exudation, 
necrosis,  or  purulent  inflammation.  The  muscular  coat  is  hypertrophied, 
and  chronic  thickening  of  the  appendix  may  result. 

Consequences  of  Perforation. — A  common  result  of  all  forms  of  appen- 
dicitis is  a  localized  peritonitis,  and  this  is  a  constant  effect  of  the  severer 
forms,  either  leading  to  {a)  circumscribed  peritonitis  or  to  an  (6)  acute 
diffuse  peritonitis. 

(a)  Circumscribed  Peritonitis. — At  first  the  surface  of  the  peritoneum 
is  opaque  and  velvety.  Soon  a  fibrinous  exudation  covers  the  appendic- 
ular peritoneum,  and  quickly  establishes  adhesions  between  the  appendix 
and  the  adjacent  parts  (abdominal  wall,  intestinal  coils).  The  process 
may  not  proceed  any  further.  Generally,  however,  it  is  soon  followed  by 
a  serous  or  sero-fibrinous  exudation,  which  becomes  sero-  or  fibrino-puru- 
lent,  and  often  forms  the  so-called  perityphlitic  abscess.  The  seat  of  the 
abscess  is  always  near  the  tube,  and  is  as  varying  as  the  position  of  the 
appendix  ;  its  size  is  also  extremely  variable,  as  it  sometimes  contains 
enormous  amounts  of  pus.  Among  the  most  common  locations  are — 
McBurney's  point,  the  vicinity  of  the  cecum,  the  coils  of  the  small  in- 
testines (near  the  umbilicus),  and,  more  rarely,  in  the  pelvis  below. 
The  pus  contained  in  the  abscess  is  rarely  thick,  grayish-yellow  in  color, 
and  emits  a  fecal  odor ;  more  commonly  it  is  thin,  turbid,  dark-gray  or 
greenish  in  color,  and  has  an  extremely  fetid  or  even  gangrenous  odor. 
The  process  of  gangrenous  sphacelation  en  masse  is  often  completed  after 
the  limiting  wall  of  adhesion  has  formed,  when  the  entire  appendix  is 
found  free  in  the  pus-cavity. 

The  abscess  may  be  suh peritoneal,  as  when  perforation  occurs  into 
the  retro-cecal  connective  tissue,  and  the  term  "iliac  abscess"  was 
formerly  applied  to  these  extra-peritoneal  purulent  collections.  They 
are  rare,  however,  since  the  early  operation  has  been  employed.  Their 
situation  and  dimensions  depend  upon  the  direction  taken  by  the  ap- 
pendix. The  latter  may  pass  downward,  and  the  pus  is  then  apt  to 
accumulate  in  the  lower  part  of  the  iliac  fossa,  and  may  point  and 
finally  burst  in  the  neighborhood  of  Poupart's  ligament,  with  subse- 
quent recovery.  Occasionally  under  these  circumstances  a  fistula 
remains  for  an  indefinite  period  of  time.  The  appendix  may  touch 
various  abdominal  structures,  and  the  pus  in  folloAving  the  line  of  least 
resistance  may  cause  spontaneous  rupture  into  the  rectum,  bladder,  or 
the  vagina  when  it  points  inward ;  and  into  the  perinephric  region  or 
into  the  pleural  cavity  (through  the  diaphragm)  Avhen  it  points  upward ; 
or  even  into  the  cecum  or  colon.  The  contents  of  the  abscess  may  also 
find  their  way  through  the  abdominal  wall  in  the  vicinity  of  the  umbil- 
icus. The  psoas  muscle  may  conduct  the  abscess  downward,  and  it 
may  then  point  at  the  hip-joint  or  gain  the  gluteal  regions  or  the  scro- 
tum, producing  the  so-called  "scrotal  appendicitis."  The  appendix  has 
also  been  found  in  a  hernial  sac.  Among  the  rare  lesions  to  be  noted 
are  erosion  of  one  of  the  arteries  of  the  iliac  region  (causing  fatal 
hemorrhage)  and  pylephlebitis.  From  the  thrombi  in  the  mesenteric 
veins  in  the  latter  condition  infectious  emboli  may  be  conveyed  to  the 
liver,  giving  rise  to  hepatic  abscess ;  this  occurred  in  a  case  of  my  own 
at  the  Episcopal  Hospital.  Philadelphia.      The  abscess  may  also  be  due 


816  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  an  extension  of  the  thrombo-phlebitis  of  the  mesenteric  veins  that 
lead  from  the  appendix  to  the  portal  vein.  Thrombosis  of  the  iliac 
veins  with  edema  of  the  corresponding  leg  may  also  arise,  and  these^ 
veins  may,  during  the  process  of  healing,  become  compressed,  with 
a  resulting  edema  of  the  leg,  as  I  have  witnessed  in  two  cases.  It 
rarely  happens  that  suppurative  processes  are  both  extra-  and  intra- 
peritoneal. 

[b)  Acute  Diffuse  Peritonitis. — This  follows  perforation  when  previ- 
ous adhesions  have  not  taken  place  or  when,  having  formed,  they  yield. 
Generalized  peritonitis  may  also  follow  the  circumscribed  form,  the 
lesions  being  propagated  to  the  entire  membrane  by  direct  extension. 
The  morbid  changes  are  those  mentioned  in  the  description  of  Acute 
Peritonitis.  Since  the  early  operation  has  been  employed  peritonitis 
has  been  the  result,  usually,  of  direct  perforation  before  a  limiting  wall 
of  adhe.-^ion  has  been  formed. 

Ktiolog^''. — Predisposing  Causes. — (a)  Doubtless  certain  congenital 
structural  defects  aid  in  the  production  of  appendicitis.  Among  them 
are  unnatural  length,  location,  and  arrangement  of  the  organ ;  also 
the  shape  of  the  meso-appendix  and  Gerlachs  valve.  These  factors 
tend  to  obliterate  the  lumen  of  the  canal  by  producing  kinks  and  twists, 
thus  favoring  the  collection  of  material  within  the  appendix,  (b)  Stric- 
tures, particularly  near  the  cecal  end  of  the  tube,  and  adhesions  due  to 
old  inflammation,  especially  peritonitis,  operate  in  the  same  manner  as 
the  preceding,  only  with  greater  power,  (c)  Fecal  concretions  are  the 
main  cause  in  nearly  one  half,  while  foreign  bodies  play  a  small  role, 
having  been  present  in  7  per  cent,  only  of  1400  cases  (J.  F.  Mitchell). 
The  calculi  form  in  the  appendix  itself  (Rochaz).  The  foreign  bodies 
are  very  various,  and  consist  of  seeds,  worms,  gall-stones,  pills,  bristles, 
and,  more  rarely,  pointed  bodies,  as  fish-bones  or  pins.  The  presence 
of  fecal  concretions  and  foreign  bodies  is  often  tolerated  by  the  appen- 
dix without  symptoms  or  local  pathologic  changes ;  hence  they  are 
looked  upon  rather  as  a  predisposing  than  as  an  exciting  cause  of  ap- 
pendicitis, (c^)  Ulcers  (tuberculous,  typhoid,  and,  rarely,  actinomycotic) 
may  also  produce  this  affection,  (e)  Straining  Efforts  and  Traumatism. 
— Not  uncommonly  excessive  muscular  exertion,  traumatism,  or  jarring 
of  the  body  as  in  jumping,  act  as  favoring  causes.  {f)Age. — The  dis- 
ease is  especially  fre(iuent  in  young  adults  between  the  fifteenth  and  thir- 
tieth years.  It  is  not  very  infrequent  in  childhood,  however,  after  the 
third  year,  and  it  has  even  been  seen  in  persons  over  seventy  years  of 
age.  {g)  Sex. — Appendicitis  attacks  males  oftener  than  females ;  this 
fact  has  been  explained  {vide  supra).  In  the  female  it  is  rarely  of  ad- 
nexal  origin.  Adhesions  between  the  tube  and  ovary  and  the  appendix 
may  occur,  the  morbid  process  then  extending  to  the  latter,  (h)  Gastro- 
intestinal Disturbance. — Indiscretions  in  the  diet  may  precede  a  primary 
attack,  and  are  of  paramount  etiologic  importance  in  the  recurrent  forms 
of  the  malady.  (/)  Heredity. — That  this  plays  no  mean  role  in  many 
cases  of  appendicitis  I  have  long  felt  convinced.  This  serves  as  the 
explanation  of  those  cases  in  which  rheumatism  and  uric-acidemia  seem 
to  act  as  causal  agents,  (y)  Evidence  to  show  that  influenza  and  other 
affections  may  cause  appendicitis  is  not  wanting.     (A")  It  is  not  improb- 


APPENDICITIS.  817 

able  that  yoor  blood- supply  and  retrogression  of  the  organ,  plus  torsion 
and  the  like,  are  the  leading  predisposing  factors. 

Bacteriology. — The  combined  results  of  several  experimentalists  tend 
to  show  that  no  special  organism  plays  an  exclusive  role  in  this  disease, 
but  the  studies  of  Hodenpyl  indicate  that  the  bacillus  coli  communis  is 
the  bacterium  most  generally  present :  it  is  well  known,  moreover,  that 
this  bacillus  becomes  pathogenic  when  it  escapes  into  tissues  in  which 
it  does  not  naturally  belong.  A.  0.  J.  Kelly  found  this  organism  pres- 
ent alone  in  73.4  per  cent,  in  94  instances  of  acute  appendicitis ;  alone 
in  89.71  per  cent,  of  107  cases  of  chronic  appendicitis.  Barbacci 
emphasizes  the  etiologic  importance  of  the  passage  of  the  intestinal 
contents  into  the  peritoneal  cavity — i.  e.  the  chemical  factor.  Of 
other  specific  bacteria,  those  of  typlioid  and  tuberculosis  are  not  un- 
commonly found  to  be  present.  The  streptococcus  pyogenes  may  also 
be  found  to  produce  the  most  virulent  infection,  and  the  staphylococ- 
cus pyogenes  aureus,  the  p>roteus,  and  other  specific  organisms  have  been 
found.  The  great  frequency  of  appendicitis  is  rendered  appreciable  by 
the  numerous  favoring  factors  (including  the  congenital  conditions)  act- 
ing upon  the  appendix,  which  naturally  has  an  exceedingly  low  vitality  ; 
also  by  the  constant  presence  of  one  or  more  organisms  that  are  known 
to  become  pathogenic  in  the  presence  of  a  slight  lesion. 

Clinical  History. — Doubtless  many  cases  are  overlooked  because 
of  the  extreme  mildness  of  the  symptoms.  These  are  often  attributed 
to  intestinal  indigestion  or  to  a  "cold,"  to  which  the  patient  pays  little 
attention  unless  he  displays  unusual  susceptibility. 

The  onset  of  acute  appendicitis  may  be  slow  and  gradual,  but  oftener 
it  is  quite  sudden.  A  clear  history  of  some  obvious  cause  (an  error  in 
diet  or  muscular  effort)  may  be  obtainable.  Again,  preceding  the 
onset  of  the  definite  symptoms  and  extending  over  a  day  or  two,  there 
may  have  been  certain  prodromes,  as  impaired  appetite,  nausea,  consti- 
pation, or  diarrhea.  In  slow  cases  the  local  and  general  symptoms  are 
at  first  slight,  but  gradually  increase  in  severity  as  the  different  stages 
of  the  disease  are  evolved.  Indeed,  in  the  latter  class  the  patient  may 
go  about  his  customary  duties  during  the  attack  with  ill-defined  rational 
symptoms,  while  in  reality  suffering  from  periappendicular  abscess. 
These  patients  run  two  serious  dangers — first,  spontaneous  rupture  of 
the  abscess  into  the  peritoneal  cavity  may  occur ;  and  secondly,  the 
slow  septic  absorption  may  suddenly  overwhelm  the  system.  As  a  rule, 
the  sudden  cases  develop  in  seeming  perfect  health,  and  are  sometimes 
heralded  by  a  rigor  or  chilliness. 

The  characteristic  features  of  the  invasion  are  abdominal  pain,  fever, 
tenderness  over  McBurney's  point,  circumscribed  resistance,  gastric  dis- 
turbances, and,  as  a  rule,  constipation.  The  pairi  varies  in  intensity  from 
a  mere  feeling  of  soreness  to  that  of  the  most  agonizing  suffering.  It  may 
be  paroxysmal,  though  oftener  it  is  constant,  with  moderate  exacerba- 
tions. Severe  pain  points  to  an  involvement  of  the  peritoneum  and 
signalizes  a  danger  of  perforation.  At  first  the  pain  may  be  referred 
to  any  point  in  the  abdomen ;  later  within  forty-eight  hours  it  becomes 
more  distinctly  localized  in  the  ileo-cecal  region. 

Elevation  of  Temperature. — The    exacerbations  may  at  first  touch 

52 


818 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


102°,  103°,  or  even  105°  F.  (38.8°-40.5°  C),  and  particularly  in  chil- 
dreii ;  more  commonly  they  range  from  100°  to  102°  F.  (37.7°— 38.8°  C). 
The  degree  of  fever  is  unreliable,  however,  as  a  criterion  of  the  severity 
of  the  case,  since  the  worst  cases  may  have  a  subnormal  temperature 
througrhout. 


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Fig.  58.— Temperature-chart  of  a  case  of  appendicitis.    M.  M ,  aged  thirty-five  years;  motor- 
man.    Laparotomy,  by  Prof.  E.  Laplace,  disclosed  catarrhal  appendicitis  with  adhesions. 

An  elevation  of  temperature,  however  trivial,  is  most  significant, 
pointing  as  it  does  to  inflammation  as  the  cause  of  the  local  symptoms. 
The  pulse-rate  is  somewhat  higher  than  the  elevation  of  temperature 
would  lead  one  to  expect,  and  in  bad  cases  the  pulse  is  usually  much 
quickened.  Sometimes,  however,  it  remains  at  80  to  90  per  minute,  and 
may  be  full  and  soft,  even  though  the  patient  be  practically  moribund. 

Fixed  tenderness  is  practically  constant  on  pressure  over  a  limited 
area,  midway  on  a  line  between  the  anterior  superior  iliac  spine  and 
the  umbilicus  {McBurneys  point),  and  is  a  most  valuable  sign.  The 
seat  of  the  tenderness  may  rarely  be  found  at  other  points,  depend- 
ing upon  the  location  of  the  appendix.  I  have  twice  observed  it  in 
the  lumbar,  once  in  the  right  hypochondriac  region,  and  once  far  below 
the  usual  point,  in  the  right  iliac  fossa.  It  has  been  found  in 
the  umbilical  and  left  iliac  regions,  in  the  pelvis,  and  in  the  groin. 
In  several  instances,  although  I  have  found  it  elsewhere  in  the  early 
stage,  it  has  shifted  to  McBurney"s  point  later.  On  the  other  hand, 
it  may  move  from  the  usual  position  in  cases  that  are  allowed  to  drag 
on.  When  the  sensitive  area  is  at  McBurney's  point,  as  is  the  rule, 
the  gentlest  pressure  often  suffices  to  elicit  exquisite  tenderness,  but 
when  it  is  situated  elsewhere  firmer  pressure  with  the  finger-tips  is 
usually  required.  Deep  pressure  always  reveals  localized  tenderness  at 
some  point  in  the  abdomen  if  the  case  is  one  of  appendicitis.  Palpation 
also  detects  an  abnormal  tenseness  of  the  right  rectus  abdominis  muscle. 
On  or  about  the  second  day  a  circumscribed  induration  manifests  itself, 
followed  soon  by  a  fulness  and  swelling  tending  to  obliterate  the  depres- 


APPENDICITIS.  819 

sions  above  and  in  front  of  the  anterior  iliac  spine.  The  position  of  the 
indurated  area  varies  according  to  the  location  of  the  appendix,  but  is 
usually  found  at  or  in  the  vicinity  of  McBurney's  point.  Sometimes  a 
resistant  mass  of  the  shape  and  size  of  an  enlarged  appendix  is  palpable. 
In  such  cases  peritoneal  exudation  has  not  as  yet  occurred  to  any  great 
extent.  In  some  cases  the  induration  is  diffuse  at  first,  but  assumes  the 
usual  circumscribed  form  later ;  it  may,  moreover,  be  so  deeply  seated 
as  not  to  be  appreciable.  The  degree  of  tenseness  of  the  two  recti  mus- 
cles— right  and  left — should  be  compared,  though  an  absence  of  tension 
of  the  right  rectus  does  not,  I  feel  certain,  eliminate  the  possibility  of 
appendicitis.  The  results  of  percussion  furnish  no  certain  guide.  As 
a  rule,  the  note  on  light  percussion  differs  from  that  on  the  opposite 
side ;  on  deep  percussion  a  dull  tympany  or  a  circumscribed  area  of  dul- 
ness  can  be  outlined.  This  deadness  may  be  due  in  great  part  to  the 
presence  of  fecal  matter  in  the  adjacent  coils  of  intestine.  While  at  the 
start  the  abdomen  may  be  flattened  or  even  retracted,  tympanitic  dis- 
tention afterward  appears,  particularly  in  the  cecal  region,  giving  rise 
to  exaggerated  tympany  on  percussion. 

Less  characteristic,  though  still  of  diagnostic  worth,  are  certain 
other  symptoms.  At  the  beginning  vomiting  usually  occurs,  unless 
there  be  diarrhea,  and  is  attended  by  more  or  less  nausea ;  it  may  con- 
tinue throughout  the  course  of  the  attack.  In  most  cases,  hoAvever, 
after  a  few  fits  of  vomiting  the  symptom  disappears,  though  it  may 
recur  if  errors  in  diet  be  committed  or  if  peritonitis  supervene.  During 
the  attack  constipation  is  the  rule,  though  diarrhea,  w^hich  sometimes 
precedes  appendicitis,  may  also  occur  at  a  late  stage  as  a  septic  symp- 
tom. There  is  anorexia,  and  the  tongue  is  coated.  The  decubitus  is 
dorsal,  with  the  right  leg  flexed.  Frequent  micturition  (early)  and  re- 
tention of  urine  (later)  are  not  uncommon,  the  urine  having  a  deep 
color-tint,  and  sometimes  containing  albumin. 

The  case  may  follow  a  mild  course,  terminating  in  resolution  with 
recovery ;  or  it  may  be  of  a  severe  type  and  develop  perforation,  with 
the  formation  of  abscess  or  difluse  peritonitis.  As  graphically  stated 
by  Fitz,  it  is  impossible  to  obtain  statistical  evidence  on  a  large  scale  of 
the  relative  frequency  of  these  alternatives,  and  hence  the  frequency  of 
treatment  of  appendicitis  by  abdominal  section.  From  all  available 
data,  hoAvever,  it  would  appear  that  in  more  than  one-half  of  the  cases 
the  course  is  light  and  favorable. 

If  not  operated  upon  early,  the  fever  may  continue  for  three  to  five 
days,  and  then  subside,  with  simultaneous  abatement  of  the  severe  local 
and  general  symptoms  and  with  the  establishment  of  convalescence. 
The  same  amelioration  of  the  symptoms  may  be  brought  about  by  early 
free  purgation,  either  as  the  result  of  salines  or,  rarely,  spontaneously. 
In  these  instances  resolution  takes  place  even  after  invasion  of  the  peri- 
toneum. Small  abscesses  may  be  absorbed,  and  u.sually  in  cases  ter- 
minating in  resolution  perforation  has  not  occurred.  Infection  of  the 
peritoneal  membrane  directly  through  the  appendix  is  not  uncommon. 

In  severe  attacks  perforation  may  occur,  ivith  the  develojjment  of 
localized  peritoneal  abscess  or  generalized  peritonitis  (vide  Pathology), 
and  it  must  be  remembered  that  cases  that  begin  gradually  may  also 
show  a  tendency  toward  perforation.     When  this  event  occurs  early  in 


820  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  course  of  a  severe  attack  or  after  a  protracted  mild  appendicitis  the 
symptoms  of  local  or  general  peritonitis  are  superadded.  If  early,  the 
symptoms  pointing  to  peritonitis  are  intense;  the  abdomen  swells  quickly, 
and  is  exquisitely  tender,  though  the  physical  signs  of  a  tumor  are  ab- 
sent. The  temperature  often  falls,  and  the  characteristic  vomiting  and 
circulatory  collapse  appear.  Often  the  generalization  of  the  peritonitis 
is  marked  by  less  violent  symptoms.  Starting  from  the  seat  of  circum- 
scribed inflammation,  the  pain  and  tenderness  propagate  themselves 
noticeably  from  day  to  day  until  every  portion  of  the  peritoneum  has 
been  invaded.  Besides  progressive  augmentation  in  the  local  features, 
includincf  the  pain,  there  is  a  gradual  failure  in  cardiac  power,  as  shown 
by  the  condition  of  the  pulse  ;  vomiting  also  returns,  and  at  last  becomes 
fecal.  Death  results  from  asthenia,  and  sometimes  suddenly  when  un- 
anticipated. If  perforation  occurs  later,  sufiicient  time  has  been  allowed 
usually  for  the  inflammation  to  become  circumscribed,  in  which  case  the 
localized  abscess  is  generally  intra-peritoneal ;  it  may,  however,  rarely 
be  extra-peritoneal.  The  local  symptoms  intensify,  the  pain  becomes 
excruciating,  and  the  spot  of  tenderness  may  rapidly  extend  itself  in  all 
directions,  particularly  downward.  Vomiting  sets  in,  and  may  become 
troublesome,  and  constipation  is  absolute,  not  even  gas  escaping  from 
the  rectum.     Retention  of  urine  is  common. 

Physical  Signs  of  Localized  Abscess. — Inspection  shows  distention  of 
the  belly,  the  aftected  area  being  prominent,  with  an  obliteration  of  the 
natural  depression  in  the  right  iliac  region.  Palpation  discovers  indura- 
tion and  great  tension  that  soon  yield  to  pressure  (doughy),  and  edema 
of  the  skin.  If  the  abscess  is  superficially  seated,  fluctuation  may  be 
appreciated  on  bimanual  palpation.  Deep-seated  tumors  are  not  uncom- 
mon, and  then  fluctuation  is  detected  with  difficulty  or  not  at  all.  An 
examination  per  I'ectum,  with  a  view  to  determining  whether  the  abscess 
has  gained  the  pelvis,  is  highly  important.  Counter-pressure  above 
with  the,  free  hand  aids  materially.  In  doubtful  cases  bimanual  pelvic 
examination  should  not  be  neglected.  Percussion  reveals  dulness  if  the 
abscess  be  superficial.  A  tympanitic  note,  however,  is  often  elicited, 
due  either  to  an  intervening  coil  of  intestine  or  to  the  gas  contained  in 
the  sac  of  the  abscess. 

If  active  peritonitis  and  septicemia  do  not  develop,  the  constitutional 
as  well  as  the  local  symptoms  may  abate,  and  the  patient  leave  his  bed, 
carrying  with  him,  however,  the  abscess.  The  latter  may  point  some- 
where in  the  right  lower  quadrant  of  the  abdomen  or  in  the  lumbar 
region.  There  is  also  a  strong  tendency  toward  spontaneous  rupture 
into  the  rectum,  bladder,  vagina,  or  cecum.  Often,  preceding  the  dis- 
charge of  pus  into  these  organs,  the  latter  display  marked  irritability, 
particularly  the  rectum  and  bladder.  There  is  always  the  danger  that 
the  contents  of  the  abscess  may  find  their  way  into  the  general  perito- 
neal cavity.  The  symptoms  of  hepatic  abscess  may  develop  at  an  ad- 
vanced stage.  The  pus  may  traverse  the  abdomen  in  the  upward  direc- 
tion until  it  touches  the  diaphragm,  when  the  symptoms  of  subphrenic 
abscess  may  be  manifested.  Extension  through  the  diaphragm  may 
now  occur,  causing  pleurisy  or  pericarditis,  and  a  pleuro-fecal  fistula 
may  thus  be  established. 

The  general  symptoms  undergo  a  modification,  due  to  the  suppurative 


APPENDICITIS. 


821 


process.  Rigors  or  a  decided  chilliness  may  occur.  Diarrhea  often 
succeeds  to  previous  constipation,  and  drenching  sweats  to  a  dry  skin. 
Improvement  and  even  spontaneous  cure  may  ensue  if  spontaneous  rup- 
ture into  one  of  the  outlets  of  the  body  should  occur.     The  fever  (Fig. 


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Fig.  59.— Temperature-chart  of  a  case  of  appendicitis.    R.  C ,  aged  nineteen  years  ;  carriage- 
builder.    A  peritoneal  abscess  was  found,  while  the  appendix  was  becoming  gangrenous. 


59)  may  he  either  remittent  or  intermittent,  and  if  the  localized  inflam- 
matory process  be  active,  the  usual  pronounced  features  of  septicemia 
are  predominant  in  the  clinical  picture.  The  latter  specially  grave  con- 
dition often  drifts  into  an  extreme  typhoid  state  with  a  hopeless  course. 
Diagnosis. — Typical  cases  of  appendicitis  are  readily  diagnosti- 
cated. Their  recognition  rests  upon  a  few  cardinal  symptoms — viz.  the 
acute  development  of  severe  pain  in  the  right  iliac  fossa,  coming  on  in 
a  person  previously  healthy  and  usually  under  forty  years  of  age  ; 
appendicular  tenderness,  unilateral  induration,  fever,  vomiting,  and  con- 
stipation, or,  more  rarely,  diarrhea.  Atypical  cases,  however,  may  ofler 
difficulty,  although  Morris  affirms  that  errors  in  diagnosis  are  less 
frequent  than  in  almost  any  other  disease.  Often  the  pain  is,  for  a 
time,  referred  to  a  circumscribed  area  far  removed  from  the  usual  site 
of  the  appendix,  and  rarely  it  continues  w^ithout  a  change  of  situation 
throughout  the  attack.  In  the  latter  case  the  local  lesions  may  occupy 
the  usual,  though  oftener  they  have  an  unusual,  position.  Thus, 
when  the  pain  is  referred  "due  east,"  or  to  the  left  iliac  fossa,  with 


822  DISEASES.  OF  THE  DIGESTIVE  SYSTEM. 

bilateral  induration,  the  appendix  -will  be  found  in  the  pelvis  (Deaver). 
In  such  instances  a  rectal  and  a  bimanual  vaginal  examination  are  im- 
perative. It  should  be  an  unvarying  rule  in  all  cases  of  severe  abdom- 
inal pain  to  palpate  Avith  the  finger-tip  every  square  inch  of  the  abdomen 
if  necessary,  to  find  the  localized  tenderness  when  it  is  not  found  at 
McBurney's  point.  The  degree  of  tenderness  sustains  a  close  relation- 
ship to  the  severity  of  the  local  inflammation  as  long  as  the  condition 
remains  strictly  localized,  but  this  relationship  is  lost  Avhen  generaliza- 
tion occurs.  With  the  appearance  of  a  circumscribed  induration  and 
of  the  intense  local  tenderness  and  pain  it  is  reasonably  sure  that  per- 
foration either  has  occurred  or  is  impending.  Perforation,  however, 
may  occur  without  local  induration,  and  even  after  subsidence  of  the 
acute  pain  and  excessive  tenderness.  Gangrenous  appendicitis  is  most 
deceptive.  The  very  acute  symptoms,  including  the  fever,  may  disap- 
pear, and  unless  the  physician  be  upon  his  guard  the  patient  will  be 
considered  convalescent  and  be  allowed  to  go  about.  Rupture  of  the 
abscess  now  occurs  unexpectedly  into  the  peritoneal  cavity,  intestines,  or 
some  other  direction,  or  a  large-sized  abscess  develops  with  the  usual 
signs  and  symptoms. 

Differential  Diagnosis. —  Ti/phlitis,  and  especially  the  Massing  of 
Feces  in  the  Cecum. — These  are  truly  rare  conditions.  According  to 
McBurney,  99  per  cent,  of  all  typhlitic  abscesses  are  of  appendicular 
origin,  and  of  400  autopsies  by  Einhorn  91  per  cent,  had  this  origin. 
Ball  and  others  have  performed  laparotomy  for  ulcerative  cecitis,  but 
this  condition  cannot  be  recognized  during  life.  Stercoral  typhlitis  is 
discriminated  from  true  appendicitis  by  the  precedent  constipation, 
which  may  become  absolute,  by  the  dragging  character  of  the  pain,  the 
late-appearing  fever,  and  chiefly  by  the  physical  signs,  Avhich  indicate 
the  presence  of  a  superficial,  sausage-shaped  tumor  that  is  often  doughy 
and  extends  vertically  from  a  point  near  the  right  costal  border  "  south- 
ward "  throucrh  the  ileo-cecal  region.  Percussion  elicits  dulness  over  the 
seat  of  the  tumor.  The  localized  tenderness  and  circumscribed  resist- 
ance of  acute  appendicitis  are  wanting,  and  a  thorough  emptying  of  the 
large  intestine  usually  cures  stercoral  typhlitis.^ 

Renal  Colic. — The  absence  of  fever  and  of  a  localized  spot  of  ten- 
derness and  induration,  and  the  presence  of  hematuria  are  points  that 
distinguish  this  affection  from  appendicitis. 

Indigestion. — Digestive  disturbances,  and  particularly  pain  and  vom- 
iting, accompany  appendicitis.  When  they  occur  independently  of  ap- 
pendicitis, however,  they  can  be  relieved,  and  the  appendicular  region 
remains  free  from  fixed  pain,  tenderness,  or  tumor. 

Cholecystitis  ivith  Distention. — This  gives  rise  to  a  superficial, 
mobile,  pear-shaped  tumor,  with  or  w^ithout  jaundice — features  not 
met  with  in  appendicitis.  Osier,  however,  mentions  a  case  of  this 
sort  in  which  the  diagnosis  was  undetermined  until  laparotomy  was 
performed. 

Perinephric  Abscess. — Without  a  history  indicative  of  chronic  renal 
disease  or  of  nephro-lirhiasis  the  diftereutiation  cannot  be  made  except 
by  exploratory  incision. 

^  it  is  highly  probable  that  the  term  "stercoral  typhlitis"  is  synonymous  Avith  chronic 
appendicitis  with  retained  feces  in  the  cecum. 


APPENDICITIS.  823 

Acute  Peritonitis,  due  to  Ovarian  or  Tubal  Disease. — When  the  ap- 
pendix occupies,  not  its  usual  seat  in  the  iliac  region,  but  the  pelvic 
fossa,  then  the  distinctions  between  salpingitis  and  appendicitis  are  not 
easily  drawn.  Right  ovaritis,  owing  to  the  presence  of  pain,  tenderness 
in  the  right  iliac  fossa,  and  fever,  often  closely  simulates  appendicitis. 
In  the  former  tenderness  is  less  pronounced,  and  the  organs  of  utero- 
gestation  manifest  certain  disturbances  of  function.  A  clear  history, 
coupled  with  a  careful  pelvic  examination,  Avill  usually  complete  the 
clinical  separation  of  these  two  conditions. 

Extra-uterine  Pregnancy. — In  this  condition  the  menstrual  history 
furnishes  important  information.  There  is,  in  addition,  profound  col- 
lapse, due  to  hemorrhage,  when  rupture  of  the  adhesions  occurs.  Ele- 
vation of  temperature  is  absent.  The  localized  tenderness  and  in- 
creased resistance  are  lower  in  the  pelvis  than  in  appendicitis. 

Acute  Tuberculous  Peritonitis. — As  in  appendicitis,  so  in  tuberculous 
peritonitis,  pain,  tenderness,  and  fever  are  present,  but  in  the  latter  the 
onset  is  more  gradual,  and  the  signs  of  tumor  and  increased  resistance 
in  the  ileo-cecal  region  are  absent.  Movable  dulness  may  be  present  in 
the  tuberculous  affection,  but  not  in  appendicitis  until  the  peritonitis  is 
generalized.    The  lungs  generally  show  lesions  in  tuberculous  peritonitis. 

Acute  Intestinal  Obstruction. — When  this  is  due  to  intussusception 
there  may  be  signs  of  a  tumor,  but  not  at  McBurney's  point ;  the  ten- 
derness over  the  site  of  the  mass  is  less  intense,  w^hile  the  frequent 
bloody  discharges  that  are  seen  in  this  condition,  accompanied  by  tenes- 
mus, do  not  characterize  appendicitis.  When  obstruction  is  caused  by 
strangulation  stercoraceous  vomiting  is  apt  to  occur,  and  is  absent  in 
appendicitis.  Pain,  local  tenderness,  and,  not  uncommonly,  signs  of  a 
tumor  appear,  but  elsewhere  than  at  McBurney's  point.  Some  of  these 
instances,  however,  remain  obscure  till  celiotomy  is  performed. 

Acute  Hemorrhagic  Pancreatitis. — This  affection  simulates  appendi- 
citis with  generalized  peritonitis.  But  the  deep-seated  epigastric  pain, 
followed  by  circumscribed  resistance  in  the  same  region  (a  grouping 
absent  in  appendicitis),  should  arouse  strong  suspicion  of  pancreatitis. 

Hip-joint  Disease. — In  both  hip-joint  disease  and  appendicitis  the 
dorsal  decubitus  with  flexed  leg  is  noted.  If  the  patient  be  anesthet- 
ized, however,  full  extension  of  the  leg  and  a  normal  condition  of  the 
hip-joint  are  easily  demonstrable  in  appendicitis. 

Typhoid  Fever. — Mild  cases  of  appendicitis  with  accompanying  diar- 
rhea bear  a  close  superficial  resemblance  to  typhoid  fever.  In  typhoid 
fever,  however,  the  onset  is  more  gradual  and  the  fever-type  more 
continuous  than  in  appendicitis.  In  typhoid  the  stools  are  somewhat 
peculiar,  the  spleen  is  swollen,  there  is  dulness  of  intellect,  bronchitis 
and  the  characteristic  eruption  attend, — all  features  that  are  absent  in 
appendicitis.  The  diazo-reaction,  if  present,  would  strengthen  the  diag- 
nosis of  typhoid,  and  a  response  to  Widal's  test  would  be  conclusive. 
In  appendicitis  the  local  features,  and  in  typhoid  the  general,  are  pre- 
dominant. 

HietVs  Crises. — In  a  case  of  movable  kidney  which  I  saw  recently 
all  the  symptoms  pointed  to  appendicitis.  An  operation  was  about  to 
be  performed  when  a  sudden  subsidence  in  the  abdominal  swelling  and 
local  induration  occurred.  The  kidney  was  subsequently  detected  in 
an  abnormal  location  {vide  Mobility  of  the  Kidney). 


824  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHRONIC   APPENDICITIS. 
{Relapsing  Appendicitis.) 

Relapses  occur  in  nearly  one-half  the  total  number  of  persons  who 
have  suffered  from  a  primary  attack  of  appendicitis.  In  most  of  these 
cases  there  is  constantly  present  a  slight  local  discomfort  during  the  in- 
terval ;  in  a  small  percentage,  however,  there  is  an  entire  freedom  from 
uneasiness.  The  local  symptoms  in  those  having  had  an  antecedent 
peritonitis  are  more  pronounced  than  in  the  first  attack,  but  after  a 
number  of  recurrences  the  symptoms  are  likely  to  be  less  severe  Avith 
each  new  attack.  The  most  constant  symptom  between  attacks  is  a  sub- 
acute form  of  jxrin  that  is  liable  to  manifest  exacerbating  periods 
with  slight  fever.  Physical  fatigue,  a  strain,  and  errors  in  diet  causing 
gastro-intestinal  disorder  are  very  likely  to  induce  a  relapsing  appendi- 
citis. Chronic  appendicitis  strongly  favors  the  retention  of  fecal  mat- 
ter in  the  cecum,  thus  forming  so-called  stercoral  typhlitis.  This  asso- 
ciation was  formerly  mistaken  for  primary  typhlitis.  The  characteristics 
on  which  the  diagnosis  is  based  during  the  attack  are  similar  to  those 
detailed  under  Acute  Appendicitis ;  the  course  is,  however,  somewhat 
more  condensed  than  that  of  the  acute  form. 

In  the  intervals  between  the  attacks  the  appendix  can  be  readily  ap- 
pi-eciated  on  palpation,  the  method  employed  by  Edebohls  being  prefer- 
able :  "  The  patient  lies  upon  his  back  with  the  examiner  at  his  side ; 
the  latter  places  his  right  hand  upon  the  patient's  abdomen  over  the 
right  rectus  muscle,  opposite  the  anterior  superior  spine  of  the  ilium, 
and  presses  the  left  hand  upon  the  right,  so  that  no  force  is  used  by 
the  right  hand  and  the  tactile  sense  of  its  fingers  is  left  undisturbed. 
The  hands  are  drawn  slowly  outward,  allowing  the  contents  of  the  abdo- 
men to  slip  from  underneath  them.  The  coils  of  intestine  can  be  felt 
as  they  escape  from  under  the  hand  as  it  presses  against  the  posterior 
abdominal  Avail."  '  In  this  way  the  appendix  may  be  felt  as  an  elon- 
gated tumor  of  the  size  and  shape  of  the  little  finger.  If  there  be  only 
a  slight  exudation  present,  the  appendix  often  appears  to  be  immediately 
beneath  the  abdominal  Avail.  It  may,  hoAvever,  be  deep-seated,  even 
though  the  exudation  Avith  adhesions  be  absent.  Both  pain  and  tender- 
ness are  pronounced,  and  particularly  if  pus  be  present. 

The  results  of  chronic  appendicitis  upon  the  general  health  and  nu- 
trition of  the  patient  are  quite  noticeable,  and  tend  to  augment  as  time 
passes,  if  the  attacks  be  frequent  or  the  intervals  between  them  groAV 
shorter.  The  chief  symptoms  are  those  of  a  nervous  type ;  emaciation 
and  debility  are  also  observed.  The  associated  nervous  symptoms  are 
those  of  neurasthenia.  These  patients  often  become  introspective  and 
exceedingly  irritable,  the  mental  condition  being  accounted  for,  to  a 
great  extent,  by  the  consciousness  that  there  is  ever  present  the  over- 
hanging dangor  of  ;i  fresh  attack   Avith  serious  possibilities. 

Differential  Diagnosis. — Carcinoma  of  the  Cecum. — This  presents 
many  points  of  similarity  to  chronic  appendicitis.  I  have  under  my  care 
at  present  a  lady  aged  sixty  years  suffering  from  chronic  appendicitis, 
Avhose  case  had  been  diagnosticated  as  carcinoma  of  the  cecum,  and  for  a 
considerable  time  my  OAvn  view  coincided  Avith  that  of  my  predecessor. 

*  B.  Farquhar  Curtis :   Twentieth  Century  Practice  of  Medicine,  vol.  viii. 


RECURRENT  APPENDICITIS.  825 

The  occurrence  from  time  to  time,  however,  of  relapses,  during  which 
the  feces  were  massed  in  the  cecum  and  fever  arose,  soon  indicated  the 
correct  diagnosis.  Besides  the  absence  of  periodic  attacks  of  fever,  the 
general  features — loss  of  flesh  and  strength,  anemia — are  more  steadily 
and  rapidly  progressive  in  carcinoma  of  the  cecum.  The  history  of  the 
mode  of  onset  also  aids  in  the  distinction.  Pain,  tenderness,  and  a  re- 
sistant tumor  are  common  to  both  affections. 

Hypochondriasis  and  Hysteria. — Hypochondriasis  and  hysteria  may 
lead  to  the  manifestation  of  morbid  feelings  simulating  those  of  appendi- 
citis. Such  cases  may  show  merely  a  greatly  exaggerated  uneasiness, 
or  such  an  increase  of  sensibility  as  to  cause  the  patient  to  complain  of 
pain  in  the  right  iliac  fossa.  In  addition,  there  may  be  localized  ten- 
derness. I  recently  witnessed  the  removal  of  the  normal  appendix  from 
an  hysteric  female  in  whose  family  two  genuine  cases  of  appendicitis 
had  occurred  not  long  previously.  Hypochondriasis  and  hysteria  dis- 
tinguish themselves  by  the  antecedent  history  and  by  the  absence  of  a 
tumor-mass  and  of  increased  resistance  ;  there  is  also  an  absence  of 
localized  tenderness  if  the  patient's  attention  be  withdrawn.  In  such 
subjects  oxaluria  is  not  infrequent,  and  it  is  possible  that  irritation  of 
the  right  ureter  by  the  passage  of  crystals  of  calcic  oxalate,  as  men- 
tioned by  Cabot,  may  explain  the  localizing  of  the  discomfort  (Wood 
and  Fitz  ^).  I  recently  saw  a  ease  of  this  sort  in  a  neurasthenic  med- 
ical student. 

RECURRENT    APPENDICITIS. 

When  successive  attacks  occur  in  the  same  individual  at  intervals 
varying  from  several  months  to  a  year  or  more,  each  new  attack  is 
spoken  of  as  a  recurrent  appendicitis.  Severe  attacks  may  succeed 
light  ones,  or,  conversely,  mild  recurrent  may  follow  severe  preceding 
attacks.  I  recall  several  cases  in  which  rudimentary  appendicitis  (indi- 
cated merely  by  colicky  pain)  occurred,  and  lasted  from  a  few  hours  to 
a  day  or  two.  Often  the  illness  is  too  trivial  to  lead  the  patient  to  con- 
sult a  doctor.  An  absolute  diagnosis  demands,  besides  the  subjective 
symptom,  pain,  the  presence  of  localized  tenderness  (with  or  without 
induration),  and  elevation  of  the  temperature.  In  several  subjects  of 
recurrent  appendicitis  formerly  under  vaj  care  the  last  attack  occurred 
three  or  four  years  ago.  That  each  new  attack  may  be  the  last  is 
always  to  be  remembered. 

Prognosis. — In  forming  the  prognosis  in  a  given  case  of  appendi- 
citis the  same  rules  may  be  followed  as  in  the  case  of  acute  infectious 
diseases.  To  estimate  the  severity  of  the  type  of  infection,  however,  is 
not  a  simple  matter.  Unlike  many  of  the  acute  infectious  diseases,  the 
height  of  the  temperature  and,  to  a  lesser  degree,  the  rate  of  the  pulse 
are  unreliable  guides  in  appendicitis.  Broadly  speaking,  however,  in 
the  severer  forms  the  local  process  exhibits  a  strong  tendency  to  spread  ; 
the  temperature  and  pulse  are  relatively  high,  and  there  is  an  intense 
appendicular  intoxication.  These  are  the  cases  that  suppurate  or  result 
in  perforative  peritonitis  (often  rapidly  spreading),  and  in  pericecal 
abscesses.  They  are  among  the  gravest  of  known  conditions.  Of  this 
fatal  group  of  cases  not  less  than  68  per  cent,  die  before  the  eighth  day. 

^  The  Practice  of  Medicine,  p.  886. 


826  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

The  development  of  fulminant  'peritonitis  or  of  a  peritoneal  abscess  after 
perforation  is  attended  by  a  falling  temperature,  though  subsequently 
the  latter  may  mount  high  or  become  markedly  irregular. 

On  the  other  hand,  in  the  mild  forms  that  are  included  in  the  name 
catarrhal  appendicitis  recovery  is  the  unvarying  rule.  These  lighter 
cases  often  lead  to  adhesive  peritonitis^ — a  circumstance  that  strength- 
ens the  view  that  they  are  of  an  infectious  nature.  The  temperature 
is  only  moderately  elevated  as  a  rule,  and  the  pulse-rate  correspond- 
ingly quickened.  Both  pulse  and  temperature  indicate  marked  im- 
provement on  the  third  or  fourth  day,  while  the  pain  and  localized 
tenderness  disappear.  In  this  connection  the  deceptiveness  of  gan- 
grenous cases  must  be  recollected  {inde  supra.  Diagnosis).  The  com- 
plications that  are  most  likely  to  arise  and  other  points  of  prognos- 
tic significance  have  been  fully  stated  in  the  Clinical  History.  The 
general  mortality  of  appendicitis  is  about  14  per  cent.  (Fitz).  Im- 
proved methods,  chiefly  surgical,  of  dealing  -with  the  disease  have, 
however,  greatly  reduced  its  death-rate.  The  prognosis  in  chronic 
appendicitis  is  most  uncertain ;  after  the  patient  has  survived  several 
attacks  it  is  on  the  whole  more  favorable. 

Treatment  of  Appendicitis. — Whether  imminent  danger  of  per- 
foration exists  or  not,  the  physician  who  is  called  to  a  case  of  appendi- 
citis should  at  once  request  the  services  of  a  competent  surgeon.  Few 
surgeons  subscribe  to  the  doctrine  that  all  cases  demand  operation ;  but, 
since  it  may  become  necessary  to  perform  celiotomy  at  any  hour  there- 
after, the  latter  should  help  to  settle  the  important  question :  "  When  is 
it  necessary  to  operate  in  the  case  ?"  The  physician  who  does  not  pur- 
sue the  course  above  recommended  falls  short  of  his  duty,  both  toward 
the  patient  and  toward  the  surgeon  on  whose  skill  he  relies  to  remove 
safely  the  source  of  danger.  Surely,  in  a  disease  that  so  often  baffles 
both  physician  and  surgeon,  suddenly  developing,  as  it  sometimes  does, 
a  fatal  virulence  Avithout  previous  unfavorable  symptoms,  they  should 
stand  guard  together  from  the  moment  the  case  is  diagnosticated  or  ap- 
pendicitis is  strongly  suspected.  Unfortunately,  both  the  medical  and 
suro-ical  treatment  of  appendicitis  have  each  been  recommended  with 
great  earnestness  by  their  respective  advocates. 

With  rare  exceptions,  prompt  surgical  intervention  should  be  recom- 
mended. The  indication  for  an  immediate  operation  is  undoubted  in 
all  cases  of  acute  appendicitis,  whether  marked  by  sudden  and  severe 
or  mild  invasion-symptoms,  if  seen  at  the  beginning  of  the  attack,  and 
free  purgation  at  the  earliest  possible  moment  is  not  followed  by  de- 
cided relief.  A  waiting  policy  and  medical  treatment  are  also  peril- 
ous in  doubtful  cases.  Obviously,  the  conditions  are  less  favorable 
for  operation  after  a  case  has  progressed  to  the  beginning  of  abscess- 
formation — /.  e.  from  the  third  to  the  fifth  day  of  the  illness.  It  is 
at  this  period  that  the  peritoneal  inflammation  tends  to  circumscribe 
itself  by  the  formation  of  adhesions.  Hence,  as  Richardson  states, 
it  is  "too  late  for  an  early  operation,  and  too  early  for  a  safe  late 
operation,"  since  there  is  great  risk  of  infecting  the  general  peri- 
toneal cavity.  Whether  it  is  wise  to  allow  the  appendix  to  remain  after 
adhesions  have  been  formed  in  some  cases,  and  merely  to  drain,  cleanse, 


APPENDICITIS.  827 

and  pack  the  cavity,  cannot  be  discussed  here.  The  mild  attacks  that 
develop  in  the  course  of  chronic  appendicitis  after  numerous  previous 
seizures  need  not  excite  alarm.  Under  such  circumstances  operation 
should  be  undertaken  between  attacks,  when  the  mortality  is  practically 
nil.  On  the  other  hand,  in  cases  that  have  been  allowed  to  drag  on  un- 
til general  peritonitis  has  set  in,  treatment  by  operation  is  not  advisa- ' 
ble.  Moreover,  the  most  ardent  advocate  of  immediate  operative  treat- 
ment is  sometimes  compelled  to  rest  satisfied  with  medical  measures. 
Such  cases  are  those  in  which  there  are  associated  chronic  affections 
(advanced  diabetes,  Bright's  disease),  not  to  speak  of  those  in  which  the 
patient  declines  operation.  Hence  there  is  a  medical  treatment  of  ap- 
pendicitis, but  it  should  not  be  the  treatment  of  election. 

.  General  Management.-^^The  patient  should  be  kept  in  bed  in  a  quiet, 
well-ventilated  apartment,  and  in  no  affection  is  the  value  of  absolute 
rest  in  the  treatment  of  inflammation  greater  than  in  appendicitis.  The 
diet  should  be  liquid  and  nutritious,  consisting  chiefly  of  pancreatized 
milk  and  concentrated  broths.  All  articles  of  food  that  tend  to  undergo 
fermentative  changes,  and  all  carbonated  drinks,  should  be  prohibited, 
since  they  increase  meteorism.  The  patient  should  be  under-  rather 
than  over-fed.  At  the  start,  and  particularly  if  a  sausage-shaped  tumor 
be  present,  intestinal  irrigation,  oft-repeated  with  a  view  to  removing 
the  fecal  matter,  must  be  carried  forward  assiduously.  Saline  laxatives 
(Rochelle  salts,  3ij — 8.0 — every  hour  or  two,  preceded  by  a  dose  of 
castor  oil  or  a  few  fractional  doses  of  calomel)  are  to  be  administered 
until  the  evidence  of  their  action  upon  the  bowels  has  been  definitely 
noted.  There  almost  never  exists  a  contraindication  to  the  use  of  saline 
aperients  at  the  onset  of  the  attack,  and  they  constitute  the  best  known 
means  of  obviating,  as  well  as  limiting,  the  spread  of  peritonitis  by  de- 
•pleting  the  portal  system  and  emptying  the  bowels.  If  commenced  early, 
they  may  be  continued  throughout  in  doses  sufficient  to  produce  two  or 
more  daily  evacuations.  In  the  event  of  a  development  of  evidences  of 
peritonitis  with  pus-formation,  salines  should  be  pushed  vigorously,  unless 
an  operation  can  be  promptly  performed.  I  am  aware  that  many  authors 
advocate  withholding  purgatives  when  indications  of  suppuration  appear, 
but  I  have  yet  to  see  a  case  in  which  perforation  has  followed  an  active 
saline  treatment.  I  avoid  the  use  of  high  enemata  in  progressive  cases, 
since  they  are  more  apt  than  salines  to  induce  rupture  of  the  sac. 

As  regards  the  use  of  opium  professional  opinion  is  not  united, 
though  a  general  tendency  toward  the  limitation  of  its  use  to  the  mini- 
mum amount  necessary  to  alleviate  pain  is  happily  noticeable ;  unless 
demanded  by  excessive  sufl"ering  it  had  better  be  omitted  altogether. 
When  necessary,  it  is  best  administered  hypodermically  in  the  form  of 
morphin  (gr.  yV"! — 0.0054-0.0081).  The  greatest  objection  to  the  use 
of  opium  is  its  eff"ect  in  veiling  the  symptoms  that  assist  the  physician 
in  forming  a  judgment  as  to  the  prospects  and  progress  of  the  case. 

Local  Measures. — The  suspended  ice-bag  is  an  excellent  means  of 
combating  the  pain,  and  often  obviates  the  necessity  of  an  internal  use 
of  opium.  Instead  of  the  ice-bag,  cloths  wet  in  cold  water  may  be 
applied  and  changed  every  few  minutes.  In  the  early  stage  a  few 
leeches  may  be  beneficial  in  their  eff"ect  upon  the  local  inflammation. 
Blisters,  however,  are  rarely  advisable,  and  are  particularly  objection- 


828  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

able  should  the  patient  afterward  be  submitted  to  an  operation.  Mild 
forms  of  counter-irritants  (mustard-paste)  are  preferable,  though  these 
also  render  the  skin  and  underlying  tissues  hard  and  leathery. 

Management  of  Convalescence. — The  patient  should  not  be  allowed 
to  leave  his  bed  for  several  days  after  the  disappearance  of  all  symp- 
*toms ;  even  the  mildest  forms  of  exercise  should  not  be  undertaken  for 
at  least  one  week  subsequent  to  getting  out  of  bed.  During  convales- 
cence the  diet  must  be  carefully  guarded,  and  the  bowels,  at  all  hazards, 
kept  in  a  soluble  condition.  It  is  questionable  whether  drugs  Avill  aid 
in  the  absorption  of  the  exudate  or  assist  in  resolution. 


INTESTINAL  OBSTRUCTION. 

[Ileus.) 

Definition. — An  acute  or  chronic,  complete  or  partial,  occlusion  of 
the  intestinal  canal. 

Pathology  and  Etiology. — The  causes  of  intestinal  obstruction 
may  be  divided,  at  once  most  simply  and  practically,  into  the  (1)  acute 
and  (2)  chronic  forms.  In  the  former  variety  the  narrowing  or  closure 
develops  very  suddenly  or  rapidly,  and  usually  in  the  small  bowel ;  in  the 
latter,  the  large  bowel  is  commonly  affected  by  pathologic  conditions 
that  develop  gradually  and  narrow  its  lumen  (usually  in  advanced  years). 

Acute. — (a)  Strangulation. — In  the  order  of  frequency,  this  is  first 
among  the  causes  of  acute  intestinal  obstruction.  It  is  produced  most 
often  by  bands  of  adhesion,  the  result  of  a  former  recent  or  remote  peri- 
tonitis, and  is  most  commonly  situated  in  the  right  iliac  fossa.  Incar- 
ceration of  the  bowel  from  flexions  and  adhesions  not  rarely  follows  upon* 
abdominal  section  for  the  treatment  of  pelvic  disease  in  women. 

The  usually  free  end  of  Meckel's  diverticulum  is  sometimes  attached 
to  the  abdominal  wall,  and  may  thus  cause  constriction  of  a  loop  of 
bowel.  This  diverticulum  is  the  remains  of  the  fetal  omphalo-mesen- 
teric  duct,  and  arises  from  the  ileum  about  half  a  meter  (1.64  ft.)  from 
the  ileo-cecal  valve.  A  similar  constricting  band  is  formed  by  a  cord 
representing  one  or  more  of  the  obliterated  omphalo-mesenteric  vessels. 
The  adhesive  attachment  of  the  free  end  of  the  appendix  vermiformis 
may  also  form  an  opening  through  which  the  bowel  may  be  caught. 

Internal  strangulation  (hernia)  may  be  the  result  of  forcing  a  portion 
of  bowel  through  a  slit  in  the  omentum  or  mesentery,  or  into  peritoneal 
diverticula  and  openings,  such  as  the  duodeno-jcjunal  fossa  (Freitz's 
retro-peritoneal  hernia)  or  the  foramen  of  Winslow. 

Meyer  has  described  acute  obstruction  from  the  passage  of  the  small 
intestine  into  a  pocket  of  the  peritoneum  in  the  posterior  abdominal  wall. 

Diaphragmatic  hernire  are  not  of  extreme  rarity,  and  may  be  either 
of  congenital  or  traumatic  origin.  Most  cases  of  intestinal  strangulation 
occur  in  males  during  early  adult  life. 

(b)  Intussusception. — Invagination  is  the  descending  "telescoping  of 
one  section  of  the  bowel  into  another,"  probably  caused  by  a  circum- 
scribed, irregular  peristalsis  of  the  intestine.  The  effect  of  the  latter 
state  in  producing  invagination  may  be  either  a  thrusting  forward  of 


INTESTINAL   OBSTRUCTION.  829 

the  receiving  portion  by  a  contraction  of  the  longitudinal  muscular  coat 
(Nothnagel),  or  a  thrusting  inward  and  downward  of  the  portion  immer 
diately  above  by  means  of  an  increased  or  spasmodic  peristaltic  action. 
Thus,  a  cylindric  or  sausage-shaped  tumor  results,  varying  from  a  half 
inch  to  over  a  foot  (1.3-30  cm.)  in  length.  The  layers  met  with  in 
intussusception  are  the  outer  or  receiving,  called  the  intussuscipiens, 
the  middle  or  returning  layer,  and  the  inner,  called  the  mtussuseeptum. 
The  seat  of  invagination  is  most  commonly  at  the  ileo-cecal  valve,  though 
it  is  often  found  in  either  the  ileum  or  colon  alone.  Sometimes  the  in- 
tussusception occurs  and  is  detected  in  the  rectum.  A  lateral  or  partial 
invagination,  more  or  less  chronic,  may  also  occur,  due  to  the  attachment 
of  a  tumor  within  the  bowel. 

The  intussuscepted  portion  of  intestine  is  usually  the  seat  of  perito- 
neal adhesions  and  considerable  tumefaction,  so  that  in  pronounced  cases 
the  parts  are  so  firmly  agglutinated  that  reduction  is  wellnigh  impossi- 
ble. The  engorgement  may  pass  into  an  intense  local  inflammation, 
with  final  necrosis  and  sloughing,  and  even  the  discharge  per  7'ectum  of 
the  invaginated  portion ;  or  a  fatal  termination  may  be  ushered  in  by 
perforation  of  the  bowel. 

Intussusception  occurs  most  frequently  by  far  in  children  prior  to  ten 
years  of  age,  in  whom  also  the  disease  is  more  acute  than  in  adults. 
Males  are  more  subject  to  invagination  than  are  females. 

Invagination  is  asserted  to  be  an  occasional  consequence  of  the  ope- 
ration of  circular  enterorrhaphy  and  of  lateral  anastomosis  by  plates 
(Robinson).^ 

(c)  Volvulus. — Twists  of  the  intestine  are  met  with  most  commonly 
at  the  sigmoid  flexure  of  the  colon.  An  unusually  long  or  relaxed  mes- 
entery predisposes  to  the  condition,  so  that  the  axis  of  twisting  may 
either  consist  of  the  mesentery  itself  or  frequently  of  the  bowel.  Not 
rarely  the  pedicle  of  the  volvulus  contains  both  a  twist  and  a  sharp  bend 
in  the  bowel,  causing  complete  acute  strangulation.  The  latter  condition 
may  be  pronounced  in  such  cases,  or  at  least  be  hastened,  by  the  accumu- 
lation of  the  intestinal  gas  and  of  masses  of  feces,  or  by  bowel-adhesions 
to  an  adjacent  stump  of  omentum  (Nieberding).  The  passive  reactive 
pressure  of  the  coils  of  intestine  and  of  the  abdominal  walls  tends  also 
to  further  confine  the  enormously  dilated  and  twisted  loop  of  bowel  to 
its  abdominal  state.  Knots  may  be  formed  by  the  association  of  loops 
of  the  ileum  Avith  each  other  or  about  the  pedicle  of  a  twisted  cecum. 

Here,  again,  males  between  forty  and  sixty  years  of  age  have  been 
observed  to  be  especially  the  subjects  of  volvulus. 

Chronic. — (a)  Feeal  Impaction. — Intestinal  Concretions. — Accumula- 
tion of  feces  (coprostasis)  is  a  common  cause  of  intestinal  obstruction, 
the  impaction  taking  place  usually  in  the  cecum  or  sigmoid  flexure. 

Though  not  infrequent  in  children,  fecal  obstruction  is  more  common 
in  adults  (particularly  in  females),  in  the  hysteric,  the  demented,  and 
the  hypochondriac.  Congenital  dilatation  of  the  colon  may  predispose 
to  coprostasis,  and  an  acquired  dilatation,  which  in  some  cases  becomes 
enormous,  is  often  the  result  of  paresis  of  a  portion  of  bowel  caused  by 
over-distention  for  a  long  period  of  time.  The  retained  fecal  masses 
may  become  hard,  but  for  some  time  permit  the  passage  of  soft  or  liquid 

1  Med.  Record,  Aug.  13,  1892. 


830  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

material  through  the  interstices  of  the  accumulation,  until  finally  either 
complete  obstruction  takes  place  or  the  condition  is  relieved.  So  severe 
may  the  obstruction  prove  in  some  cases  as  to  result  in  inflammation, 
ulceration,   and  even  perforation  of  the  bowel. 

Among  other  causes  of  obstruction  due  to  abnormal  contents  may 
be  mentioned  enteroliths.  These  are  intestinal  concretions  formed  of 
various  nuclei,  as  gall-stones,  hardened  feces,  phosphates  of  lime  and 
maornesia,  various  foreign  substances,  and  ororanic  derivatives.  Balls 
of  tanorled  ascarides  mav  mass  sufficiently  to  cause  obstruction. 

Gall-stones  not  infrequently  become  impacted  in  the  duodeno-jejunal 
or  ileo-cecal  regions  after  ulceration  through  the  duct,  except  in  the 
case  of  very  small  stones,  which  enlarge  subsequently  by  accretion. 

Foreign  bodies,  as  pins,  buttons,  coins,  fruit-stones,  may  also  cause 
obstruction  of  the  bowel.  It  is  stated  that  even  insoluble  mineral 
medicines,  as  bismuth  or  magnesia,  have  caused  obstruction  by  accu- 
mulation in  the  intestines. 

(b)  Tumors. — Tumors  cause  a  form  of  chronic  obstruction  that  may  at 
any  time  develop  suddenly  into  the  acute  type.  They  may  do  so  either 
as — (1)  tiew  growths  in  the  wall  of  the  intestine  itself,  or  by  (2)  com- 
pression and  traction  from  without.  Again,  the  intestinal  neoplasms 
may  be  malignant  or  henign  in  nature.  Carcinoma  of  the  bowel  is  at 
once  the  most  frequent  and  important  of  these.  It  may  be  either  cir- 
cumscribed and  annular,  causing  a  gradual  narrowing  of  the  bowel- 
lumen,  or  a  diffused  infiltration  of  the  intestinal  wall,  commencing 
either  in  the  mucosa  or  in  its  glands  (cylindric  epithelioma).  Its  most 
common  seat  of  growth  is  the  large  bowel,  about  the  sigmoid  flexure. 
The  mesenteric  and  retroperitoneal  glands  are  usually  secondarily 
aff"ected.  Ulceration  of  the  bowel  and  catarrhal  inflammation  of  the 
mucous  membrane  above  the  carcinoma  may   coexist  late  in  life. 

Sarcoma  usually  attacks  the  small  bowel,  starting  beneath  the 
mucosa,  and  is  of  the  recurrent  variety.  Regional  infection  of  the 
mesenteric  and  retroperitoneal  glands  {Lohstein's  cancer)  is  also  a  usual 
consequence  of  sarcoma.     It  may  occur  in  children  or  in  young  adults. 

Benign  tumors  may  be  polypoid,  adenomatous,  fibromatous,  and 
lipomatous.  Intestinal  obstruction  due  to  compression  or  traction  may 
be  caused  by  tumors  (omental)  or  by  adhesions  of  the  pelvic  viscera. 

(c)  Cicatricial  strictures  cause  chronic  intestinal  obstruction,  as  after 
the  healing  of  various  ulcers,  the  cicatrices  of  which  slowly  contract. 
Cicatricial  stenosis  of  the  colon  is  commonly  due  to  the  cicatrization  of 
dysenteric  ulcers.  In  the  rectum  the  stenosis  is  usually  a  result  of  a 
syphilitic  lesion.  Tuberculous  and,  very  rarely,  typhoid  ulceration  may 
be  followed  by  stricture  of  the  small  intestine. 

('/)  Congenital  stricture  is  rare,  and  is  more  purely  surgical  than  the 
preceding  cases.  It  is  often  an  occlusion  or  an  imperforate  condition 
of  the  anus  (atresia  a7ii),  and  is  only  mentionable  in  this  connection. 

(e)  Paresis  of  Peristalsis. — This  condition — called  also  adynamic  ob- 
struction— while  it  is  a  functional  aflfection.  is  held  to  be  either  a  cir- 
cumscribed or  diffuse  paresis  of  the  intestinal  muscular  coat.  It  is 
caused  by  some  such  inflammatory  disturbance  as  enteritis  or  peritonitis, 
or  even  by  the  manipulations  employed  in  prolonged  abdominal  sections. 
In  such  cases  the  obstruction  is  due  to  an  accumulation  of  feces  and 


INTESTINAL   OBSTRUCTION.  831 

gases  in  the  paretic  portion  of  the  bowel,  causing  marked  tympanites, 
vomiting,  and  constipation. 

Special  Pathology. — The  pathologic  changes  that  accompany 
nearly  every  form  of  intestinal  obstruction  are  briefly  stated  as  follows : 
Accumulative  dilatation — with  hypertrophy  in  chronic  cases — of  the 
intestine  above  the  seat  of  disorder,  and  an  emptiness,  narrowing,  and 
even  atrophy  below  the  obstruction.  The  affected  walls  of  the  bowel 
are  inflamed,  and  there  is  a  surrounding  acute  or  chronic  peritonitis. 
Catarrhal  and  sometimes  diphtheritic  inflammation  of  the  mucosa  may 
develop.  Gangrene,  ulceration,  and  perforation  of  the  bowel,  with 
resulting  generalized  peritonitis,  may  also   ensue. 

Symptoms. — Acute  Obstruction. — There  is  a  suddenly  developed  ab- 
dominal jjain  that  may  follow  some  abrupt  or  severe  exertion.  Early 
vomiting  and  absolute  constipation  are  also  conspicuous  and  important 
symptoms.  If  the  obstruction  is  high  in  the  small  bowel,  distressing 
hiccough  and  eructations  may  precede  the  vomiting.  Except  for  the 
possible  discharge  of  the  intestinal  contents  below  the  seat  of  obstruc- 
tion, the  constipation  is  usually  complete  and  obstinate.  Accompanying 
the  latter  condition  there  is  tympanites,  which  is  most  marked  in  ob- 
struction of  the  colon.  Intermittent  and  colicky  at  first  (partial 
obstruction — Treves),  the  pain  soon  becomes  agonizing  and  constant. 
Vomiting,  also,  alternating  vf ith  painful  retching,  is  more  constant,  and 
severe  after  several  hours.  The  material  at  first  ejected  is  gastric  and 
mucous;  it  then  becomes  bilious,  and  finally  is  characteristically  ster- 
coraceous,  due,  most  probably,  to  the  putrid  decomposition  of  stagnated 
contents  above  the  obstruction. 

The  constitutional  symptoms  develop  early,  are  intensely  threatening 
to  life,  and  cause  rapid  and  profound  depression  and  collapse.  The 
pinched  and  pallid  features,  cool  and  moist  skin,  Hippocratic  expression, 
rapid  and  feeble  pulse,  the  usually  subnormal  temperature,  shallow  and 
accelerated  breathing,  marked  thirst,  scanty  urine,  great  anxiety  and 
prostration, — all  indicate  the  gravity  and  danger  of  the  condition. 

The  physical  examination  will  discover  a  swollen,  extremely  tender, 
and  tympanitic  belly.  Exaggerated  peristalsis  of  the  intestine  above 
the  obstruction  may  be  visible  on  the  surface  of  the  abdomen.  Bor- 
borygmi,  gurgling,  and  splashing  may  be  heard  on  auscultation. 

Chronic  Obstruction. — The  symptoms  are  more  dependent  upon 
the  special  causes  operating  than  in  acute  obstruction.  The  fact  that 
early  in  the  case  only  partial  obliteration  of  the  intestinal  lumen  may 
be  rightly  inferred  in  many  of  the  chronic  forms  of  obstruction  has 
given  rise  to  the  discriminating  term  of  intestinal  constriction.  In  gen- 
eral, the  clinical  history  is  one  of  increasing  and  intractable  constipa- 
tion, sometimes  alternating  with  diarrhea,  due  to  catarrhal  inflammation 
of  the  mucosa  above  the  obstruction.  Paroxysms  of  colicky  pain  and, 
later,  augmenting  tympanites,  vomiting,  and  prostration,  attend.  These 
symptoms  may  merge  suddenly  into  those  of  the  acute  form  of  obstruction. 
The  bowel-movements  in  chronic  obstruction  are  irregular,  infrequent, 
slight,  and  sometimes  accompanied  by  pain  and  tenesmus.  The  stools 
consist  often  of  small,  hard,  ribbon-like,  or  scybalous  masses,  and  may 
contain  blood  and  mucus.  When  the  stenosis  is  in  the  small  intes.tine 
the  constipation  is  less  apt  to  occur  on  account  of  the  fluidity  of  the 


832  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

contents.  Sometimes,  and  particularly  in  old  people,  the  rectum  be- 
comes distended  with  hardened  accumulations  of  feces ;  there  is  in  such 
cases  a  constant  feeling  of  fulness  and  a  harassing  desire  to  defecate, 
but  the  attempts  thereat  are  ineifectual.  The  pain  of  fecal  impaction 
may  be  due  either  to  colitis  or  to  peritonitis,  and  may  be  referred  to  the 
regions  of  the  cecum  or  sigmoid  flexure. 

In  malignant  and  in  cicatricial  stenosis  there  are  a  prolonged  and 
variable  history  of  constipation,  occasional  vomiting,  localized  pain, 
meteorism,  and,  in  cancerous  cases,  the  development  of  the  characteris- 
tic cachexia  and  the  progressive  emaciation. 

Physical  Examination. — Inspection  shows  the  abdomen  to  be  dis- 
tended from  meteorism,  the  movements,  and  contour  even,  of  the  coils 
of  intestine  in  active  peristalsis  above  the  seat  of  stricture  being  evi- 
dent. A  tumor  or  the  throbbing  aorta  (excited,  perhaps,  by  pressure 
of  the  distended  bowel  or  growth)  may  be  palpated.  Tympany  and 
borborygmous  noises  may  also  be  noted. 

Diagnosis. — Locality  of  the  Obstruction. — Given  the  symptoms  of 
a  sudden,  severe^  and  exacerbating  pain  in  the  abdomen  ;  of  marked, 
and  later  feculent,  vomiting ;  of  absolute  constipation  and  of  tympanites 
and  profound,  early,  systemic  depression, — a  diagnosis  of  acute  intestinal 
obstruction  may  be  easily  made.  The  determination  of  the  seat  of 
trouble,  however,  is  often  very  difficult.  First  may  be  mentioned  the 
differential  diagnosis  between  obstruction  occurring  in  the  small  and  in 
the  large  intestine.  It  may  be  noted  of  the  former  that  vomiting  occurs 
early,  is  scanty,  and  later  feculent,  while  in  the  latter  there  is  less  vom- 
iting and  the  vomitus  is  seldom  feculent.  Again,  in  obstruction  of  the 
small  gut  the  distention  is  both  less  marked  and  higher  situated,  while 
in  that  of  the  large  gut  tympanites  is  often  quite  marked,  is  more  cen- 
tral, is  associated  with  tenesmus,  and  sometimes  with  mucus  and  blood. 
If  the  cause  of  obstruction  be  a  tumor  or  stricture,  the  localitj'  may  be 
successfully  palpated  or  the  lower  limit  of  the  active  coils  of  hypertro- 
phied  intestine  may  be  defined. 

In  stenosis  of  the  duodenum  or  jejunum,  owing  to  the  stagnation 
and  decomposition  of  albuminous  substances,  the  products  of  which 
(indol  and  phenol)  are  absorbed  and  partly  excreted  by  the  urine,  use 
may  be  made  of  the  discovery  of  increased  amounts  of  indican  in  the 
urine  for  diagnostic  purposes.  On  the  other  hand,  in  stenosis  of  the 
large  intestine  the  urinary  test  may  be  negative,  since  the  albuminous 
elements  of  the  intestinal  contents  are  absorbed  before  they  reach  the 
stenosed  portion  of  bowel,  where  stagnation  and  putrefaction  can  take  place. 

Examination  per  rectum  with  the  finger  or  Avith  the  rectal  tube,  by 
means  of  li(iui(l  distention  or  gaseous  inflation  of  the  colon,  may  enable  us 
to  determine  the  seat  of  obstruction  in  certain  cases.  The  detection  of  a 
deeply-seated  incarcerated  hernia  (in  the  abdominal  fossae  and  pouches, 
diaphragm,  or  obturator  foramen)  is  often  made  only  postmortem. 

Nature  of  the  Obstruction. — This  is  even  more  difficult  of  discovery 
than  the  preceding.  The  following  causes  of  obstruction  with  their 
difterentiation  may  be  referred  to  in  attempting  a  diagnosis :  Strangu- 
lation often  affords  a  previous  history  of  peritonitis  or  abdominal  sec- 
tion or  of  recurrent  attacks  of  abdominal  pain,  occurring  mostly  in 
young  adults.     Early  fecaloid  vomiting  is  common. 


INTESTINAL   OBSTRUCTION.  833 

Jntussusceptw7i  usually  gives  a  negative  previous  history.  The  sud- 
denness of  the  attack,  without  appreciable  cause,  occurring  in  a  child, 
and  associated  with  colicky  pain,  tenesmus,  and  the  presence  of  mucus 
and  bloody  stools,  and  of  an  elongated  cylindric  tumor  in  the  right 
iliac  or  umbilical  regions,  however,  render  this  condition  easy  of  diag- 
nosis in  some  instances.  It  is  to  be  noted  that  absolute  constipation 
and  meteorism  here  are  unusual.  The  intussusception  may  be  felt  in 
the  rectum. 

In  volvulus  it  may  be  helpful  to  elicit  a  history  of  former  constipa- 
tion and  flatulence,  with  evidences  of  atony  of  the  bowel,  in  persons  of 
advanced  years,  along  with  marked  abdominal  tympany,  tenderness 
over  a  distended  coil,  which  may  perhaps  be  outlined  (Wahl),  a  rigid 
abdomen,  and  sometimes  dyspnea  from  great  gaseous  distention. 
,  The  history  in  cases  of  fecal  obstruction  is  nearly  always  one  of 
obstinate,  habitual  constipation,  and  occurs  especially  in  females  and 
neurotic  subjects.  The  onset  is  gradual ;  pain  is  less  acute;  and  tym- 
pany and  fecal  vomiting  are  less  prominent  and  late  in  appearance. 
Fecal  masses  in  the  colon  and  rectum  may  be  palpated,  and  even  in- 
dented, particularly  in  the  cecal  and  sigmoid  flexures.  Dulness  is 
present  on  percussion,  with  slight  tenderness  over  the  tumor. 

Obstruction  due  to  large  enteroliths  or  foreign  bodies  may  be  only 
surmised ;  especially  is  this  true  when  symptoms  of  appendicitis  arise. 

Biliary  calculi  may  give  a  history  of  previous  attacks  of  hepatic  colic 
and  jaundice. 

In  the  chronic  obstructive  form  of  stricture  of  the  bowel  due  to  cica- 
trices or  neoplasmata  the  history  of  dysentery,  tuberculosis,  sarcoma, 
or  carcinoma  should  be  considered.  The  detection  of  an  irregular  tumor 
and  the  cancerous  cachexia  point  to  malignancy. 

In  obstruction  caused  by  intestinal  j)  are  sis  there  is  generally  a  history 
of  a  previous  enteritis,  peritonitis,  or  celiotomy.  The  abdomen  is  smooth, 
though  tympanitic  throughout,  and  there  is  no  perceptible  peristalsis. 

Not  rarely  it  will  be  of  therapeutic  as  well  as  of  diagnostic  import- 
ance to  ascertain  whether  an  attack  of  acute  obstruction  is  primary,  or 
whether  it  is  the  terminal  exacerbation  of  a  chronic  condition,  such  as 
carcinoma  of  the  bowel.  Here  a  study  of  the  past  history  of  the  patient,  as 
well  of  the  present  signs  of  a  probable  nature,  will  afford  considerable  aid. 

Differential  Diagnosis. — Acute  intestinal  obstruction  must  be  discrim- 
inated from  acute  generalized  peritonitis. 

Acute  Generalized  Peritonitis.  Acute  Intestinal  Obstruction. 

Etiology. 
There  is  a  history  of  causal  conditions  or      There   is  a  history  of  previous  chronic 
diseases  (ulcer,  appendicitis,  pelvic  in-  obstruction   or   hernia.     (The  age   of 

fection).  the  patient  if  it  be  intussusception.) 

Symptoms. 

An  early  and  considerable  rise  of  temper-  No   early  rise  (except  in  volvulus),  but 

ature  ;  later  variable  or  may  be  absent.  later  with  advent  of  peritonitis. 

Pain  more  continuous  and  diffuse.  Pain  in  short  paroxysms  and  localized. 

Vomiting  is  characteristic,  but  not  ster-  Vomiting  becomes  characteristically  ster- 

coraceous.  coraceous. 

Collapse  occurs  later.  Earlier  onset  of  collapse. 

Slight  increase  of  indican  in  the  urine.  Excessive  indicanuria,  particularly  when 


the  small  intestine  is  obstructed. 


53 


834  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Physical  Signs. 

Distention  of  the  abdomen  is  usually  Less  marked  (sometimes  partial),  unless 
general  and  marked.  the  obstruction  be  situated  in  the  lower 

se<rment. 

Visible  peristaltic  waves  absent.  Present  and  pronounced  when  the  seat 

of  obstruction  is  low. 

Tenderness  general.  Tenderness  localized. 

Signs  of  eflFusion  appear.  Less  common,  due  to  secondary  perito- 

nitis-. 

Auscultation  negative.  Loud  gurgling  and  splashing  sounds  au- 

dible on  auscultation. 

Prognosis  almost  hopeless.  Not  so  if  operated  upon  early. 

It  must  also  be  differentiated  from  acute  enteritis,  in  which  (particu- 
larly when  due  to  toxic  minerals)  there  is  more  apt  to  be  diarrhea  with 
considerable  mucus  and  blood,  an  elevated  temperature,  intense  gastric 
pain,  associated  with  traces  of  the  poison  in  the  vomitus,  as  well  as  with 
its  effects  on  the  oral  mucous  membrane,  and  an  absence  of  marked 
tympanites  and  fecal  vomiting.  There  are  also  localized  pain,  tender- 
ness, and  tumor,  or  there  may  be  collapse. 

The  various  forms  of  abdominal  colic,  as  enteralgia,  hepatalgia,  and 
nephralgia,  should  not  be  mistaken  for  acute  intestinal  obstruction  after 
considering  the  history  of  the  cases,  the  character  and  locality  of  the 
pain,  and  the  absence  of  such  symptoms  as  obstinate  constipation,  fecal 
vomiting,  early  collapse,  intense  local  ]»;iiii  :nid  tenderness. 

Course,  Complications,  and  Prognosis. — A  case  of  acute  ob- 
struction usually  terminates  within  from  two  to  seven  days.  The  chronic 
form  may  last  weeks,  and  even  months,  with  progressive  emaciation  and 
anemia,  until  the  superaddition  of  more  or  less  acute  symptoms,  lasting 
from  ten  to  fourteen  days.  As  a  rule,  the  prognosis  is  wholly  unfavor- 
able, and  especially  in  the  acute  cases.  The  chronic  forms,  due  to  fecal 
or  other  imjjaction,  often  recover  with  the  discharge  of  the  disturbing 
intestinal  contents.  Life  may  be  prolonged  by  surgical  interference  in 
certain  cases  if  they  are  taken  in  their  inception. 

Complications  that  may  occur,  as  secondary  peritonitis,  gangrene, 
perforation,  septico-pyemia,  and  enteritis,  are  all  grave,  and  only  tend  to 
hasten  the  dissolution. 

Treatment. — Whilst  the  treatment  of  intestinal  obstruction  is 
sooner  or  later  essentially  surgical,  attention  to  the  medical  aspect  is 
frequently  of  prime  importance.  The  first  indications  for  therapeutic 
interference  in  acute  obstruction  are  presented  by  the  pain  and  the 
incessant  vomiting.  The  former  is  to  be  met  by  hypodermic  injections 
of  morphin,  which  at  the  same  time  tend  to  arrest  the  excessive  peri- 
stalsis. For  the  vomiting  no  other  measures  are  comparable  to  gastric 
lavage  and  starvation.  It  is  well  in  most  cases  to  withhold  food  for 
some  hours  to  prevent  retching  and  aggravation  of  the  condition.  The 
lavage  is  strongly  advised  by  Kussmaul.  who  claims  that  both  the  tension 
above  the  seat  of  stricture  and  the  inordinate  peristalsis  are  thus  greatly 
diminished  and,  exceptionally,  cured.  It  may  be  repeated  every  six 
hours.  A  diagnosis  of  intestinal  obstruction  having  been  made  with- 
out having  learned  the  cause  or  character  of  the  obstruction,  cathartics 
should  absolutely  not  be  given.  If  it  has  been  determined  that  fecal 
impaction  is  the  trouble,  it  is  still  prudent  to  avoid  purgatives  until  the 


CARCINOMA   OF  THE  INTESTINE.  835 

main  mass  has  been  moved,  as  in  many  cases  there  are  both  paresis  and 
inflammation  at  the  seat  of  impaction,  so  that  this  class  of  agents  would 
thus  be  useless,  if  not  harmful.  High  rectal  injections,  copious,  steady, 
and  regularly  repeated,  are  to  be  practised,  using  for  this  purpose  pre- 
ferably "a  warm  saline  solution  of  olive  oil"  (particularly  if  scybala 
be  present)  administered  while  the  patient  is  in  an  inverted  position 
by  means  of  a  fountairt  syringe,  so  that  the  flow  is  readily  controllable. 
The  abdomen  should  be  methodically  kneaded  (a  valuable  adjunct  in 
the  procedure)  and  the  patient  at  times  well  shaken.  This  method  of 
treatment,  by  hydrostatic  pressure,  can  and  must  be  carried  forward 
without  undue  violence,  and  if  it  be  unsuccessful,  the  intestines  are  to 
be  inflated  from  a  large  india-rubber  bag  with  air  or  hydrogen  gas 
(Senn),  of  which  two  to  three  gallons  may  be  cautiously  introduced- 
Thorough  manipulation  of  the  abdomen  from  below  upward,  particularly 
if  it  be  a  case  of  intussusception,  may  be  combined.  In  the  latter  con- 
dition inflation,  early  and  perseveringly  applied,  cures  the  majority  of 
instances.  In  cases  of  intussusception  or  strangulation  of  the  bowels 
these  efforts  should  be  continued  for  twenty-four  hours,  when,  if  the 
condition  is  not  relieved,  immediate  operation  is  to  be  encouraged  and 
advised.  Although  the  statistics  of  Fitz  show  the  mortality  in  cases 
without  operation  to  be  lower  (69  per  cent.)  than  with  operation  (83 
per  cent.),  I  am  convinced  from  personal  observation  that  the  less  favor- 
able results  from  abdominal  section  would  not  obtain  if  it  were  per- 
formed in  due  time.  To  relieve  the  excruciating  tympanites  the 
plunging  of  a  fine  trocar  and  cannula  into  the  intensely  distended 
bowel,  as  in   case  of  volvulus,  may  be  required. 

In  chronic  obstruction  the  treatment  of  the  underlying  or  etiologic 
conditions  and  various  complications  is  to  be  conducted  on  general  prin- 
ciples. Additionally,  the  patient's  dietary  is  to  be  arranged  Avith  care, 
and  the  bowels  moved  with  unfailing  regularity,  by  the  use  of  unirri- 
tating  laxatives  and  enemata.  During  the  periods  of  threatening  com- 
plete occlusion,  with  pain,  the  methods  advocated  above  for  acute  ob- 
struction are  appropriate.  If  total  obstruction  persist  despite  medical 
treatment,  surgical  treatment — enterectomy,  enterotomy,  or  other  opera- 
tion, as  the  circumstances  of  individual  cases  may  dictate — is  required. 

The  after-treatment  consists  in  keeping  the  bowels  active  and  regular 
by  habit,  diet,  and  an  aperient  pill  if  needed.  Massage  and  electricity 
to  the  abdomen  are  found  useful  at  this  time. 


CARCINOMA  OF  THE  INTESTINE. 

{Carcinoma  Intestinalis.) 

Carcinoma  of  the  intestine  is  perhaps  the  commonest  cause  of 
chronic  intestinal  obstruction.  The  stenosis  is  usually  partial,  and  is 
due  both  to  compression  and  to  direct  invasion  of  the  lumen  of  the  bowel 
by  the  growth.  Primary  intestinal  carcinoma  is  rare  in  comparison  with 
the  occurrence  of  gastric  carcinoma. 

Pathology. — When  carcinoma  attacks  the  intestine  it  is  usually  in 
the  form  of  a  cylindric-celled  epithelioma,  although  it  may  assume  the 


836  DISEASES  OF  THE  DIGESTIVE  SYSTEiM. 

various  forms  as  found  in  carcinoma  of  the  stomach — namely,  scirrhous, 
medullary,  and  colloid.  The  grov.th  may  be  annular  or  semipolypoid,  or 
it  mav  occur  as  a  diffuse  nodular  infiltration  of  the  bowel-walls.  Ulcera- 
tion of  the  surface  of  the  carcinoma  may  take  place,  and  the  glandular 
structures  of  the  abdominal  cavity  sometimes  reveal  metastatic  growths. 
The  most  frequent  seat  of  intestinal  carcinoma  is  the  rectum,  and  next 
in  order  of  frequency  are  the  sigmoid  flexure,  the  transverse  and  descend- 
ing colon,  the  papilla  duodenalis.  the  ascending  colon,  and  the  lower  and 
middle  portions  of  the  ileum.  The  bowel  is  dilated  above  the  constric- 
tion, and  is  usually  filled  with  an  accumulation  of  fecal  matter.  The 
muscular  coat  is  hvpertrophied.  Below  the  narrowing  the  intestine  may 
be  atrophied.  Rectal  adenoma  may  develop  into  carcinoma  (adeno- 
sarcoma). 

Btiologry. — Heredity  and  advanced  age  are  of  chief  importance  as 
predispo^iiiir  causes.  Whether  or  not  antecedent  intestinal  ulceration 
mav  afford  a  probable  nidus  for  carcinomatous  growths  is  doubtful. 

Symptoms. — A  description  of  the  course  of  rectal  carcinoma  belongs 
more  properly  to  surgical  works.  The  chief  symptoms  are  progressively 
increasing  distress  and  radiating  pain  in  the  rectum  ;  these  occur,  at  first, 
during  defecation  only,  but  later  almost  constantly.  There  may  be  diarrhea 
alternatino-  with  constipation,  and  the  feces  often  contain  blood  and  mucus. 
Grailual  hodilg  wasting  and  increasing  mental  anxiety  are  associated. 
Paralysis  of  the  anal  sphincter  and  consequent  incontinence  may  ensue. 

The  symptoms  of  carcinoma  of  the  bowel  above  the  rectum  are  often 
va<Tue,  and  vary  according  to  the  portion  involved  by  the  neoplasm. 
"With  or  without  an  appreciable  tumor  in  the  abdomen  the  clinical  his- 
torv  is  usually  that  of  chronic  obstipation  of  the  intestines.  There  are 
irregular  attacks  of  sharp,  colicky  pains,  especially  a  few  hours  after 
eating,  distressing  defecation,  obstinate  constipation,  perhaps  alternating 
with  diarrhea,  sometimes  vomiting,  which  may  be  feculent,  and  not  rarely 
slight  meteorism.  The  special  symptoms  of  carcinoma  of  the  papilla  of 
Vater  are  vomiting,  jaundice,  and  colic.  The  progressive  emaciation 
and  debility  of  the  patient  are  marked.  In  advanced  cases  of  stenosis 
the  feces  are  passed  in  small,  compressed  lumps  resembling  sheep's  dung. 

Physical  Examination. — Inspection  of  the  abdomen  may  show  the 
presence  of  a  tumor  along  the  line  of  the  sigmoid  flexure  or  colon  ; 
peristalsis  may  be  seen  above  the  site  of  the  carcinoma,  communicating 
its  movements  to  the  abdominal  walls.  Palpation  may  be  resorted  to 
in  order  to  confirm  the  above,  and  the  growth  is  then  frequently  found 
to  be  nodulated.  A  sign  which  is  practically  diagnostic  of  stenosis  is 
a  sudden  appearance  ofsmall  coils  of  bowel  which  vanish  very  quickly 
and  reappear  again  (Boas).  Percussion  may  give  either  dulness  or  a 
muftled  tympany  over  the  tumor  and  for  some  distance  above,  on  account 
of  accumulated  masses  of  feces.  This  area  of  impaired  intestinal 
tympany  may  be  sharply  defined. 

Diagfnosis. — This  may  rest,  in  some  cases,  upon  heredity,  the  age, 
the  evidences  of  the  cancerous  cachexia,  sharp,  radiating  abdominal 
pains,  bloody  stools,  and  the  detection  of  a  firm  and  nodular  tumor. 

Differential  Diagnosis. — ((/)  Carcinoma  of  the  bowel  above  the  rectum 
needs  to  bo  discriminated  from  other  abdominal  tumors.  The  presence 
of  the  following  may  render  the  diagnosis  of  carcinoma  during  life  well- 
nigh  impossible :  sarcomata,  fibromata,   myomata^  adenomata,  and  cys- 


CARCINOMA    OF  THE  INTESTINE.  837 

tomata,  all  of  which  may  produce  symptoms  of  obstruction  like  those 
due  to  carcinomatous  growths.  The  cancerous  cachexia  may  be  simu- 
lated by  other  conditions.  The  advanced  age  of  the  patient  and  the 
distressingly  rapid  and  downward  progress  of  the  disease  will,  however, 
point  toward  malignancy.  Fecal  tumors,  enteroliths,  foreign  bodies,  and 
peritonitic  adhesions  may  need  to  be  excluded  also.  It  is  to  be  recollected 
that  fecal  masses  may  exist  above  and  overshadow  the  presence  of 
carcinoma  of  the  intestine.  When  peritonitic  adhesions  are  present, 
inquiry  may  elicit  the  previous  existence  of  peritonitis  (Eshner). 

(b)  The  portion  of  the  bowel  involved  by  the  neoplastic  growth  is  also 
difficult  of  definite  diagnosis,  except  when  it  occurs  in  the  rectum,  when 
the  digital  and  visual  examination  of  the  parts,  supplemented,  it  may 
be,  by  microscopy,  are  sufficient.  The  locality  of  the  tumor  as  detected 
by  palpation,  associated  with  special  symptoms,  is  of  value  in  arriving 
at  a  diagnosis  of  the  diseased  portion  of  bowel.  Heulin  ^  has  studied 
carefully  primary  cancer  of  the  duodenum,  and  asserts  that  the  com- 
parative frequency  of  duodenal  involvement  is  due  to  limited  motion  of 
the  organ,  being  thus  subject  to  injury.  When  it  occurs  above  the 
papilla  of  Vater  the  symptoms  greatly  resemble  those  of  dilatation  of  the 
stomach.  An  important  point  separating  carcinoma  above  from  that 
below  the  papilla  is  the  presence  or  absence  of  bile  in  the  vomit,  being 
absent  if  situated  above.  When  the  carcinoma  involves  the  papilla  of 
Vater  symptoms  of  biliary  obstruction  necessarily  follow.  A  hard 
nodular  mass  may  sometimes  be  felt  in  the  lower  epigastric  region; 
this  coupled  with  increasing  gastric  dilatation  and  marked  persistent 
jaundice  would  indicate  carcinoma  of  the  duodenum.  It  is  apparent, 
however,  that  carcinoma  of  the  pylorus,  of  the  left  lobe  of  the  liver,  or 
of  the  omentum  or  mesenteric  glands,  or  a  thickened  cecum  might  all 
be  easily  confounded  wnth  carcinoma  of  the  bowel  at  various  adjacent 
parts  of  its  course.  The  injection  of  fluid  into  the  bowel  may  be  re- 
sorted to  in  locating  the  probable  situation  of  the  growth.  Thus,  if 
obstruction  from  carcinoma  exists  in  the  sigmoid  flexure,  liquid  will  be 
arrested  there  and  the  rectum  distended ;  while,  if  the  stenosis  be  high 
up  in  the  large  or  small  intestine,  the  colon  will  he  found  comparatively 
emptied  of  feces  and  will  be  distended  with  the  injected  liquid. 

Course  and  Complications. — Carcinoma  of  the  intestine  some- 
times runs  a  rapid  course,  and  may  last  but  a  few  months  or  even 
weeks ;  in  the  scirrhous  variety,  however,  the  disease  may  last  two  or 
three  years. 

Intestinal  carcinoma  may  perforate  the  bowel  and  cause  fatal  puru- 
lent peritonitis,  and  carcinoma  of  the  rectum  may  perforate  and  invade  the 
vagina  and  bladder,  causing  purulent  vaginitis  and  cystitis.  Or,  owing 
to  extreme  distention  by  fecal  accumulation  between  a  cancerous  stricture 
of  the  sigmoid  flexure,  for  instance,  and  the  resistant  ileo-cecal  valve, 
rupture  of  the  colon,  followed  by  a  terminal  peritonitis,  may  result. 
Extension  of  the  growth  into  surrounding  tissues,  with  ulceration,  may 
lead  to  cellulitis,  phlebitis,  and  pyemia. 

The  prognosis  is  almost  hopeless. 

Treatment. — This,  from  a  strictly  medical  standpoint,  is  simply 

1  Qaz.  hebdom.  de  Med.  et  de  Chir.,  Feb.  13,  1898;  These  de  Paris,  1897;  Saunders' 
Year-Book,  1899,  p.  194. 


838  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

palliative.  The  diet  should  be  highly  nourishing  and  easily  assimilable, 
but  Avhen  the  symptoms  of  acute  obstruction  supervene  the  administra- 
tion of  food  by  the  mouth  is  contraindicated.  Attention  to  the  state  of 
the  bowels  by  the  use  of  enemata,  or  of  the  aloin,  strychnin,  and  bella- 
donna pill  is  necessary  in  most  cases.  Opium  or  cannabis  indica  for 
the  pain,  and  stimulants  for  the  depression,  may  also  be  serviceable. 

Lavage  of  the  stomach  gives  decided  relief  when  decomposing  mat- 
ters tend  to  cause  regurgitation  on  account  of  the  damming  back  of 
accumulated  food-detritus. 

Carcinoma  of  the  bowel  may  be  treated  surgically  by  colotomy,  ex- 
cision, lateral  anastomosis  of  the  bowel,  enterostomy,  and,  if  the  growth 
be  situated  in  the  rectum,  by  extirpation  by  means  of  sacral  resection 
(Kraske's  operation). 


HABITUAL  CONSTIPATION. 

(  Costiveness.) 

Definition. — Chronic  fecal  retention,  habitual  infrequency,  irregu- 
larity, difficulty,  or  insufficiency  of  the  evacuations  of  the  bowels. 

Although  constipation  is  a  symptom,  and  although  habitual  consti- 
pation is  frequently  a  symptom  of  chronic  disease,  the  causal  elements 
of  the  latter  may  be  so  indefinite  and  obscure  that  the  former  takes  on 
all  the  individual  importance  of  a  functional  affection.  I  describe  habit- 
ual constipation,  therefore,  as  a  disease  sui generis  ("idiopathic"). 

Btiologfy. — In  the  majority  of  cases  habitual  constipation  is  the 
direct  effect  of  a  lack  of  expulsive  or  peristaltic  power,  and  also  of  a 
deficiency  of  the  hepatic  and  intestinal  secretions.  Two  sets  of  causes 
operate  to  bring  about  these  conditions  of  abnormal  defecation  : 

General  Causes. — (a)  Temperament :  it  has  been  observed  often  that 
people  of  a  nervous  and  "  bilious  "  or  motive  temperament,  of  the  dark 
type,  are  much  troubled  with  constipation.  Anemic  brunets — per- 
sons having  pale  skin  and  dark  hair  combined — are  particularly  so 
affected,  although  alternating  periods  of  diarrhea  may  supervene,  owing 
to  the  hydremic  state  of  the  blood.  "Torpid  liver"  and  "sluggish 
bowels  "  are  commonly  held  to  be  synonymous  with  these  physical  cha- 
racteristics. (6)  Habit:  a  sedentary  life  conduces  to  secretive  inactivity. 
Thus,  a  lazy  life,  in  which  the  calls  of  nature  are  irregularly  attended  to 
or  habitually  neglected,  leads  to  fre(iuent  over-distention  of  the  rectum 
and  paresis,  a  common  cause  of  chronic  constipation.  Again,  the  femi- 
nine false  modesty  (so  called)  that  prompts  a  postponement  and  suppres- 
sion of  the  desire  to  defecate  in  public  places,  as  well  as  the  habitual, 
hurried  performance  of  the  act  in  illy-kept,  uncomfortable,  and  unsani- 
tary closets, — all  these  tend  to  obtund  the  sensibility  of  the  bowel  to 
fecal  masses  in  the  rectum.  The  accumulation  of  these  fecal  masses 
causes  paralytic  over-distention,  their  hardening  into  scybala,  and  diffi- 
culty of  expulsion,  (r')  General  bodihf  tveakni'ss.  and  diseases,  as  neur- 
asthenia, hysteria,  anemic  brain-  and  spinal-cord  affections  (causing 
inhibitory  disturbances  of  the  intestinal  nerve-supply),  acute  fevers, 
hepatic  disorders,  especially  the  presence  of  jaundice,  and  the  habitual 


HABITUAL  CONSTIPATION.  839 

dependence  upon  and  use  of  purgatives,  (d)  Diet:  the  constant  use  of 
concentrated  articles  of  food,  as  meats,  in  which  little  residual  mat- 
ter is  left  to  stimulate  the  bowel  to  peristalsis.  On  the  other  hand,  a 
very  coarse  diet  may  leave  such  an  excess  of  residue  as  to  cause  fecal 
impaction,  (e)  A  change  of  drinking-water,  or  water  from  chalky 
regions.  »  (/)  Abundant  and  prolonged  diuresis  and  diaphoresis,  by 
causing  loss  of  fluids,  also  may  induce  chronic  constipation. 

Local  Causes. — (a)  Atoyiy  of  the  abdominal  muscles  from  obesity,  or, 
in  females,  as  a  result  of  many  pregnancies,  (b)  Atony  of  the  large 
bowel  (the  sigmoid  flexure  in  particular)  from  chronic  colitis,  (c)  Pres- 
sure by  tumors,  (d)  The  presence  of  intestinal  stenosis  from  external 
or  internal  constriction,  (e)  Congenital  stricture  or  giant  groivth  of  the 
colon,  with  coprostasis  (as  in  Formad's  case).  (/)  Tonic  contraction 
of  the  muscular  coat,   as  in  basilar  meningitis  and  lead-poisoning. 

Symptoms. — In  cases  in  which  there  is  no  adequate  cause  for  habit- 
ual constipation  other  than  a  constitutional  and  perhaps  an  inherent  pe- 
culiarity there  may  be  the  appearance  of  perfect  health.  Nothing  is 
complained  of  save  the  fact  that  an  evacuation  of  the  bowels  occurs  too 
infrequently.  It  should  be  borne  in  mind  here,  however,  that  the  term 
"  constipation  "  is,  individually  speaking,  almost  wholly  a  relative  one — 
i.  e.  one  person  may  enjoy  good  health  with  but  one  evacuation  every 
other  day,  another  with  two  passages  per  diem,  while  still  another  must 
have  one  stool  a  day,  cceteris  paribus,  to  feel  perfectly  well.  The  last  is 
usually  considered  an  average  normal  state  with  most  people.  Persons 
such  as  are  instanced  above,  in  apparently  good  health,  but  observing 
that  they  have  to  defecate  less  often  than  many  others,  sometimes  grow 
anxious,  worried,  and  even  hypochondriac,  until  assured  that  they  are 
not  truly  constipated  if  enjoying  perfect  physical  ease. 

Symptoms  of  habitual  constipation  may  be  direct  or  reflex.  Direct 
or  local  troubles  are  seen  in  the  feeling  of  fulness,  weight,  and  pressure 
in  the  perineum  and  abdomen.  Flatulence,  colicky  pains,  and  alterna- 
ting diarrhea  occur  not  infrequently.  The  hurried  and  inattentive  per- 
formance of  defecation  gives. rise  to  the  so-called  "cumulative  constipa- 
tion," in  which  the  accumulated  feces  are  but  partially  evacuated  with 
the  movement,  and  the  rectum  consequently  is  not  emptied.  A  sense 
of  fulness  then  remains,  and  complete  relief  is  not  felt  in  these  cases. 

Reflex  and  general  symptoms  are  malaise,  languor,  hebetude,  irrita- 
bility of  temper,  headache,  facial  flushing,  palpitation,  cold  extremities, 
anorexia,  vertiginous  attacks,  paresthesia,  menstrual  distress  in  women, 
sleeplessness,  and  bad  dreams.  Pressure  on  the  sacral  and  visceral 
nerves  may  cause  neuralgias.  The  tongue  is  coated.  Palpation  of  the 
abdomen  often  shows  the  presence  of  doughy-like  fecal  tumors  at  the 
cecum  or  at  the  hepatic,  splenic,  and  sigmoid  flexures,  or  of  bologna- 
like masses  at  intervening  places.  In  marked  cases  attacks  of  nausea 
and  vomiting,  with  diarrhea,  may  ensue  ;  fever  may  also  be  present,  and 
typhoid  fever  even  may  be  simulated  (Meigs). 

Complications  and  Sequelae. — Hemorrhoids,  ulcerative  colitis, 
perforation,  and  enteritis  may  be  associated  with  chronic  constipation. 
Not  rarely  do  we  have  as  results  dilatation  of  the  colon  or  sacculation, 
with  the  presence,  in  old  people  mainly,  of  enteroliths  (calcified  scyb- 
ala)  ;  also  intestinal  obstruction  and  typhlitis,  or  cerebral  hemorrhage 
or  hernia  from  violent  straining  efforts. 


840  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Diagnosis. — Bearing  in  mind  the  relativity  of  constipation  in  dif- 
ferent individuals,  the  diagnosis  is  read  at  sight.  The  detection  of  the 
causes  is  not  difficult,  though  sometimes  tedious.  Hypochondriasis  or 
melancholia  should  be  carefully  placed  either  as  precedent  to  or  conse- 
quent upon  chronic  constipation,  the  nervous  condition  often  acting  to 
produce  the  latter,  and  vice  versd. 

The  prognosis  is  usually  favorable,  but  should  be  guarded. 

Treatment. — Hygienic. — Causative  factors  must,  of  course,  be  re- 
moved, modified,  or  lessened.  Systematic  regularity  as  to  time  and 
fre(iuency  and  sufficiency  of  movements  of  the  bowels  should  be  en- 
joined u])on  and  practised  by  the  patient.  Exercise  is  of  signal  value,  and 
particularly  horseback  riding  or  gymnastic  motions  that  bring  the  ab- 
dominal muscles  into  play.  Attention  to  the  calls  of  nature  should  be 
esteemed  a  duty,  and  proper  time  and  heed  must  always  be  given  to 
the  completeness  of  defecation.  Young  girls  especially  should  be  in- 
structed in  this  regard.  The  wholesale  swallowing  of  cathartics  is  to 
be  vigorously  combated.  The  dietetic  regimen,  if  properly  looked  after, 
often  avails  much  in  relieving  this  affection,  and  foods  calculated  to  be 
easily  digestible,  but  leaving  a  moderate  residue  after  digestion,  are  to 
be  recommended.  Such  are  bread  made  of  unbolted  flour,  plenty  of 
vegetables  and  fruits,  butter,  and  such  laxative  articles  as  figs  or  honey. 
A  glass  of  cold  water  taken  regularly  at  bed-time  and  in  the  morning 
before  breakfast  is  efficacious  and  a  point  of  common  knowledge. 

Remedial. — The  methods  and  means  offered  for  the  cure  of  chronic 
constipation  number  legion.  From  the  little  aperient  pill  or  ''peristaltic 
persuader  "  to  the  cannon-ball  rolled  externally  along  the  course  of  the 
large  bowel  is  made  up  such  a  list  of  drugs  and  measures  as  to  leave  un- 
tenable any  plea  of  lack  of  resource  that  may  be  advanced.  Dtnigs 
occupif  a  subordinate  part  in  the  treatment  of  habitual  constipation. 
Indeed,  their  use  should  be  restricted  mainly  to  those  periods  when 
the  bowels  become  unusually  obstinate  and  when  a  more  or  less  free 
movement  is  urgently  needed.  That  the  constant  use  of  laxative  and 
purgative  drugs  tends  to  a  confirmation  of  the  condition,  and  its  ulti- 
mate resistance  to  the  action  of  cathartics  when  circumstances  will  have 
required  their  use,  is  familiarly  known. 

I  have  found  of  value  in  lithemic  and  dyspeptic  subjects  the  laxative 
bitter  Avaters  (Hunyadi  Janos,  Kissingen,   Friedrichshall,  Carlsbad). 

Drugs  employed  to  unload  a  filled  boAvel  may  at  times  be  used  spar- 
ingly and  in  the  smallest  adequate  quantities;  the  mildest  forms  should 
be  selected.  Since  the  constipation  is  only  temporarily  relieved  by 
catharsis,  the  frecjuent  use  of  strong  purgatives  in  large  doses  only 
tends  to  render  the  bowel  accustomed  to  their  use.  Creosote  in  large 
doses  has  recently  been  highly  recommended ;  it  probably  relieves  the 
constipation  by  overcoming  the  intoxication. 

Among  those  laxatives  and  cathartics  most  commonly  used  may  be 
mentioned  aloes,  rhubarb,  Rochelle  and  Epsom  salts,  compound  licorice 
powder,  castor  oil,  jalap,  senna,  mercury,  colocynth,  and  podophyllin. 
Important  adjuncts  in  combination  with  one  or  more  of  the  above  are 
the  extract  of  nux  vomica  (or  strychnin)  and  the  extracts  of  belladonna, 
hyoscyamus,  and  physostigma.  The  much-used  aloes,  strychnin,  and 
belladonna  pill  can  be  used  for  a  considerable  length  of  time  in  the  hope 


HABITUAL  CONSTIPATION.  841 

of  stimulating  a  normal  intestinal  and  sphincteric  activity,  and  thus  in- 
ducing even  a  cure  in  some  cases.  The  formula  may  be  made  up  as 
follows : 

:^.  Aloin.,  gr.  iij-v  (0.194-0.324); 

Strychnine  sulphat.,     gr.  f-J    (0.0216-0.0324); 
Extr.  belladonnse,  gr.  ij-ijss  (0.129-0162). 

M.  et  div.  in  pil.  No.  xx. 
Sig.   One  pill  at  bedtime. 

Sulphur  in  confection,  along  with  the  official  pill  of  aloes  and  iron, 
has  been  recommended  for  the  habitual  constipation  of  anemia.  In 
senile  atony  of  the  bowel,  with  much  flatulence,  a  laxative  pill  having 
in  combination  asafetida  or  capsicum  is  often  beneficial. 

The  subjoined  formulae  are  also  rationally  and  empirically  service- 
able in  chronic  constipation  : 

I^.  Ext.  cascar.  sagrad.,  3ss  (2-0) ; 

Ext.  nucis  vomicae,  gr.  iv  (0.259); 

Ext.  physostigmat.,  gr.  iij  (0.194); 

Ext.  belladonnge,  gr.  ij  (0.129). 

M.  et  ft.  in  pil.  No.  xx. 
Sig.   One  at  night,  or  night  and  morning. 

(Aloes,  gr.  j  (0.0648),  or  podophyllin,  gr.  ij-iij  (0.129-0.194),  or  ext. 
colocynth.  comp.,  gr.  ij-iij  (0.129—0.144),  may  be  substituted  for  cascara 
in  the  foregoing  formula.) 

The  meclianical  means  of  relieving  habitual  constipation,  as  by 
e7iemata,  are  injurious  if  long  continued,  by  reason  of  their  irritating 
effect  on  the  rectal  and  colonic  mucous  membrane,  as  well  as  on  account 
of  their  tendency  to  become  incompetent.  At  times,  when  the  stomach 
is  weak  or  irritable,  a  loaded  bowel  may  be  relieved  by  an  ordinary 
enema  of  soap  and  water  or  by  one  containing  -I-  to  1  ounce  (16.0— 
32.0)  of  castor  oil,  with  1  or  2  drams  (4.0-8.0)  of  oil  of  turpentine  if 
there  be  some  flatulence.  Glycerin  enemata,  containing  from  ^  to  2 
ounces  (16.0-64.0)  of  the  agent,  may  be  used.  Suppositories  of  soap, 
molasses  candy,  or  glycerin  are  included  in  the  armamentarium.  3Ias- 
sage  also  claims  an  important  part  in  the  relief  of  habitual  constipation. 
It  acts  by  stimulating  the  peristalsis  and  the  abdominal  muscles,  and 
should  be  employed  at  set  times  in  the  day  preceding  a  desired  evacu- 
ation of  the  bowels.  The  hand  of  the  masseur,  or  that  of  the  trained 
patient  even,  when  systematically  used  in  this  way,  may  be  effectual 
when  all  other  means  have  failed.  The  regular  rolling  of  a  metal  ball 
along  the  course  of  the  greater  gut  may  be  mentioned  for  its  novelty  as 
well  as  for  its  undoubted  efficacy.  The  application  of  the  faradic  cur- 
rent to  the  abdominal  walls  or  galvanization  of  the  lumbo-abdominal 
circuit  deserves  proper  trial  in  many  cases.  Hydro-therapeutic  meas- 
ures, or  cold  sponging  and  baths,  are  nearly  always  useful  adjuncts  in 
the  treatment  of  this  often  stubborn  affection. 


842  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

DILATATION  OF  THE  COLON. 

(Ectasia  of  the   Colon.) 

This  is  usually  a  chronic  condition,  though  not  rarely  it  is  acute.  It 
may  also  be  general,  but  in  the  majority  of  cases  it  is  confined  to  the 
colon,  and  particularly  to  the  sigmoid  flexure.  The  postmortem  findings 
are  those  of  hypertrophic  dilatation  of  the  bowel,  and  rarely  ulcerative 
and  catarrhal  lesions  of  the  intestinal  mucosa  are  noted.  The  sigmoid 
flexure  is  prone  to  become  dilated  in  subjects  in  whom  it  is  congenitally 
elongated.  Mya  '  believes  that  the  condition  is  due  to  a  faulty  develop- 
ment, and  not  to  fetal  disease.  Atony  of  the  muscular  coat  is  a  leading 
causative  element.  The  most  distinctive  features  are  co7istipation,  which 
generally  dates  from  infancy,  and  great  abdominal  distention.  In  the 
case  reported  by  Rolleston  and  Hayward  peristaltic  waves  were  visible 
upon  the  surface.  Cases  of  this  kind  have  been  mistaken  for  acute 
intestinal  obstruction.  The  condition  may  fluctuate,  constipation  alter- 
natintr  with  regular  dailv  movements,  and  the  distention  chancring  to  a 
normal  softness  of  the  abdominal  parietes  in  some  instances.  1  have 
recently  seen  a  case  of  this  kind  in  a  male  aged  twenty-seven,  in  whom 
the  aflfection  had  commenced  in  infancy.  In  the  treatment  of  the  con- 
stipation resulting  from  congenital  ectasia  of  the  colon,  lavage  of  the 
intestine  with  a  very  long  tube  is  superior  to  laxatives  or  purgatives. 
The  principal  aim  of  treatment,  when  possible,  is  to  overcome  or  check 
the  causative  conditions.  A  diet  calculated  to  prevent  or  relieve  con- 
stipation is  indicated  {vide  p.  840).  Vegetable  foods  leaving  a  gross 
residue  should  be  restricted  or  even  prohibited.  Massage,  galvanism, 
and  hydrotherapy  are  all  capable  of  beneficial  effects  in  suitable  cases. 
Strychnin  is  a  valuable  remedy,  and  in  cases  attended  with  constric- 
tion, operation  should  be  recommended  or  at  least  considered. 


NEUROSES   OF  THE  INTESTINE. 

As  in  the  case  of  the  stomach,  these  embrace  derangements  of  (a) 
secretion,  [h)  sensation,   and  (c)  motion. 

(«)  SECRETORY  DISTURBANCES. 

Unquestionably  the  intestinal  secretion  may,  through  a  purely  ner- 
vous influence,  be  augmented.  This  manifests  itself  most  frecjuently  in 
the  primary  morbid  secretion  of  mucus  (mucous  colic)  and  in  membranous 
enteritis.  Moreover,  the  fact  that  an  actual  catarrh  of  the  intestinal 
mucosa  may  supervene  as  a  secondary  event  is  undeniable. 

MEMBRANOUS    ENTERITIS. 
{Enteritis  Membranacea.) 

Definition. — A  peculiar  pathologic  condition,  chiefly  of  the  large 
intestine,  attended  -by  a  morbid  secretion  of  mucus. 

Pathology. — In  the  truly  primary  form  there  are  no  morbid  lesions 

*  Lo  Sperimentale,  1894,  fasc.  iii.  p.  215. 


NEUROSES  OF  THE  INTESTINE.  843 

discoverable  in  the  mucosa.  Osier  states  that  the  membrane  is  due  to  a 
derangement  of  the  functions  of  the  mucous  glands  the  nature  of  which 
is  unknown.  My  own  view  is  that  membranous  colitis  is  a  secretory  neu- 
rosis, and  that  the  catarrhal  process  may  develop  as  a  secondary  event. 

etiology. — Sex  has  a  decided  influence,  not  less  than  80  per 
cent,  of  all  cases  (W.  A.  Edwards)  being  noted  in  women.  Hysteric 
and  neurotic  females  are  the  most  frequent  victims  of  the  disease, 
which  is  rare  in  children.  W.  H.  Thomson^  emphasizes  direct  mechani- 
cal irritation  of  the  rectum  (horseback-riding,  bicycle-riding,  uterine 
fibroids,  hardened  scybala). 

Symptoms. — I  have  found  the  condition  to  be  invariably  associ- 
ated with  a  decidedly  constipated  habit — a  fact  that  may,  in  part,  ex- 
plain its  occurrence,  since  time  is  thus  allowed  for  the  formation  of  the 
membrane.  The  most  important  clinical  feature  is  the  passage,  at  vari/- 
ing  intervals,  of  long,  ribbon-like  threads  of  mucus,  or  of  more  or  less 
perfect  casts  of  the  gut,  the  act  being  attended  with  tenesmus  and  severe 
colic  kg  pains.  The  composition  of  the  stools  has  been  thoroughly  in- 
vestigated by  M.  Rothmann  and  0.  Rothmann  and  C.  Ruge.  They 
"  consist  of  a  uniformly  turbid  ground-substance,  which,  on  the  addition 
of  acetic  acid,  becomes  opaque  and  striped.  It  is  interspersed  with  a 
cellular  detritus,  consisting  partly  of  strongly  refractile  granules  and 
partly  of  cellular  elements,  desquamated  epithelial  cells,  round  cells,  and 
peculiar  glossy  flakes.  There  are  also  found  cholesterin-crystals,  needles 
of  fatty  acids,  triple  phosphates,  remnants  of  undigested  food,  pigment- 
granules,  many  bacteria,  and  occasional  red  and  white  corpuscles." 

The  individual  paroxysms  vary  in  duration  from  one  to  ten  days  or 
more.  In  one  case  observed  by  me  the  attacks  lasted  about  two  days, 
recurring  regularly  at  the  end  of  every  three  months.  Ordinarily  the 
recurrence  is  after  a  shorter  interval. 

Diagnosis. — It  is  important  to  make  a  microscopic  examination  of 
the  pieces  of  membrane.  If,  when  thus  examined,  mucus,  cylindric- 
celled  epithelium,  a  few  round  cells,  and  the  other  elements  already 
mentioned  are  found  present,  the  diagnosis  of  mucous  enteritis  is  un- 
doubted. It  is  to  be  recollected,  however,  that  membranes  are  not 
passed  with  every  attack. 

Course  and  Prognosis. — The  disease  pursues  a  very  chronic 
course  and  lasts  for  many  years.  The  bodily  nutrition  sufi"ers  consider- 
ably if  the  attacks  are  frequent  and  severe,  though,. as  a  rule,  this  does 
not  occur  until  a  late  stage  in  the  affection.     The  risk  to  life  is  slight. 

(6)  SENSORY  DISTURBANCES. 

It  may  be  noted  here  that  the  sensory  nerves  of  the  intestines,  as 
well  as  the  inhibitory  and  vaso-motor  dilators,  are  traceable  to  the 
splanchnics.     Increased  sensibility  of  the  sensory  nerves  produces — 

ENTERALGIA. 
(Neuralgia  of  the  Intestine.) 

Htiology. — This  is  commonly  met  with  in  hysteric,  neurasthenic, 
and  anemic  subjects.     It  occurs  as  a  reflex  neurosis,  as  in  the  case  of 

1  Med.  News,  June  2,  1900. 


844  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cold,  gout,  and  irritative  lesions  of  the  pelvic  organs  (kidneys,  liver). 
Enteralgia  is  symptomatic  of  many  local  affections  and  conditions 
that  induce  direct  irritation  of  the  sensory  nerve-filaments  of  the  in- 
testine; among  these  are  inflammation  of  the  mucosa,  foreign  bodies, 
gall-stones,  abnormal  distention  Avith  gas,  and  enteroliths.  Under  these 
circumstances  the  condition  is  associated  with  increased  activity  of  the 
motor  nerves  or  heightened  contraction  of  the  muscularis,  forming  true 
intestinal  colic.  In  lead  colic  it  is  probable  that  the  lead  acts  directly 
upon  the  nerves  or  their  ganglionic  cells.  I  have  repeatedly  observed 
the  action  of  certain  exciting  causes,  and  particularh'  of  nervous 
shocks. 

Symptoms. — Enteralgia  may  develop  very  suddenly,  but  oftener  it 
sets  in  less  abruptly,  and  is  then  attended  with  eructations  of  gas,  ex- 
pulsion of  flatus,  and  the  like.  In  the  fulh'-developed  attack  the  pain 
may  attain  to  great  violence,  causing  the  patient  to  ''  bend  double  "  or 
even  faint,  and  its  character  is  variously  described  as  borin<j,  tearing, 
or  cutting.  The  pain  may  be  confined  to  a  circumscribed  spot  or  may 
be  diffuse.  The  attacks  are  sometimes  brief,  or  they  may  be  character- 
ized by  a  sudden  subsidence.  At  other  times  they  last  for  days  or  per- 
haps weeks,  and  then  subside  gradually.  Recurrences  are  common,  but 
the  intervals  between  the  attacks  vary  extremely  in  duration. 

Hypogastric  neuralgia  is  a  term  applied  to  neuralgia  affecting  the 
sensory  nerves  lying  in  the  most  dependent  segments  of  the  intestine. 
Here  the  nerve-fibers  entering  into  the  hemorrhoidal  plexus  are  involved. 
It  is  caused  chiefly  by  tabes,  by  hemorrhoids,  and  by  the  neurotic  state 
so  common  to  females.  This  form  of  neuralgia  has  its  seat  in  the  hypo- 
gastric region,  and  is  accompanied  by  a  distressing  sensation  of  pressure 
in  the  rectum  and  bladder,  and  by  an  irresistible  desire  to  go  to  stool ; 
pains  also  radiate  to  the  sacrum,  thighs,  and  perineum. 

Diagnosis. — The  various  organic  diseases  and  conditions  mentioned 
under  Etiology,  in  the  course  of  Avhich  colic  is  a  common  symptom,  must 
be  separated  from  the  true  neurotic  enteralgia.  The  former  are  distin- 
guished from  the  latter  by  a  group  of  symptoms  peculiar  to  themselves 
(fever,  aggravation  of  the  pain  upon  pressure,  vomiting,  constipation, 
or  diarrhea),  and  by  the  usual  definite  causes  furnislied  by  the  history. 

Renal  and  hepatic  colic  bear  a  superficial  similarity  to  enteralgia. 
The  former  conditions,  however,  are  distinguished  first  by  the  seat  and 
direction  of  the  pain,  and  secondly  by  the  appearance  of  jaundice  in 
hepatic  colic  and  of  hematuria  in  renal  colic.  Rheumatism  of  the 
abdominal  muscles  is  easily  eliminated,  since  it  is  generally  combined 
with  rheumatism  in  other  parts  of  the  body ;  the  pain  is  also  greatly 
increased  upon  throwing  the  muscles  into  contraction,  as  in  stooping  or 
rising ;  finally,  it  vanishes  in  response  to  the  action  of  the  salicylates. 

DIMINISHED   INTESTINAL   SENSIBILITY. 

This  implies  diminished  peristalsis  or  constipation.  A  greater  or 
less  degree  of  anesthesia  of  the  bowel  attends,  with  a  loss  of  desire  to 
go  to  stool  and  an  accumulation  of  feces  in  the  rectum.  This  is  a  usual 
concomitant  in  many  diseases  of  the  brain  and  cord,  with  which  paraly- 
sis is  associated.     Motor  innervation  may  remain  intact,  and  when  atony 


NEUROSES  OF  THE  INTESTINE.  845 

of  the  intestine  is  absent  spontaneous  movements  of  the  bowels  occur ; 
when  atony  is  present,  however,  to  a  marked  degree  (motor  paralysis), 
the  feces  must  be  artificially  removed. 

(c)  DISTURBANCES   OF   MOTILITY. 

When  the  contractility  of  the  muscularis  is  increased  from  purely 
nervous  causes  the  result  is — 

NERVOUS   DIARRHEA. 

This  condition  presents  no  morbid  lesions.  The  increased  contrac- 
tility results  from  an  exaggerated  irritability  of  the  motor  nerves  of  the 
bowels.  It  may  also  result  from  morbid  processes  in  the  central  nervous 
system  and  in  other  organs  of  the  body ;  in  short,  the  condition  may  be 
a  reflex  one. 

Examples  of  this  sort  are  caused  by  tabes,  by  gastric  disturbances, 
as  after  certain  foods  and  drinks,  by  dentition,  and  the  like.  Most 
cases,  however,  are  encountered  in  persons  having  an  abnormally  irrita- 
ble nervous  organization — i.  e.  the  neurasthenic  and  hysteric  classes. 
In  such  the  effect  of  mental  excitement,  of  fright,  and  similar  psychic 
influences  is  to  induce  diarrheal  evacuations. 

Symptoms. — The  stools  vary  in  number  from  two  or  three  to 
twenty-four  or  more  daily.  In  rare  instances  they  are  soft — not  truly 
diarrheal — and  formed,  yet  they  may  be  €[uite  frequent.  Blood  and 
mucus,  pus,  and  other  morphologic  elements  are  absent  from  the  de- 
jections. It  is  characteristic  of  nervous  diarrhea  that  the  stools  follow 
one  another  in  rapid  succession,  usually  during  the  morning  hours,  and 
then  discontinue  for  the  greater  part  of  the  day.  The  bodily  nutrition 
is  often  well  preserved. 

In  the  diagnosis  organic  affections  of  the  bowel  are  to  be  carefully 
eliminated. 

ENTEROSPASM. 
{Spasm  of  the  Intestine.) 

By  this  term  is  meant  a  concurrent  spasm  of  both  the  longitudinal 
and  circular  muscular  fibers,  usually  inducing  spasmodic  constipation, 
and  sometimes  total,  though  temporary,  occlusion  of  the  boAvel. 

Its  causes  are  similar  to  those  of  nervous  diarrhea,  and  the  condition 
is  clinically  related  to  enteralgia.  Neither  pain  nor  constipation,  how- 
ever, is  a  constant  feature.  The  stools  may  assume  the  form  of  a  rib- 
bon or  of  large  rounded  masses  (sheep's  dung),  but  they  are  not  pathog- 
nomonic. They  may  also  be  covered  with  mucus.  Ewald  distinguishes 
between  an  idiopathic  and  a  secondary  or  syroptomatic  spasm,  the  lat- 
ter being  a  concomitant  of  basilar  meningitis  and  of  chronic  lead- 
poisoning  (see  also  Constipation,  p.  839).  Another  variety  affects  the 
rectum  [proctospasni),  and  is  generally  secondary  to  some  other  rectal 
affection,  as  fissure  of  the  anus ;  it  may,  however,  occur  as  a  neurosis  in 
the  hysteric  and  nervous  class  of  subjects. 

The  diagnosis  of  true  functional  enterospasm  can  only  be  made  after 
all  organic  causes  that  may  produce  spasm  of  the  bowel  have  been 
excluded. 


846  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CONSTIPATION. 

This  is  a  common  condition  as  a  functional  neurosis.  It  is  due  to 
an  abnormity  of  function  of  the  intestinal  nerves  that  leads  to  a  weak- 
ened peristaltic  action,  and  is  met  with  in  hysteria,  neurasthenia,  and 
in  those  suffering  from  the  various  forms  of  psychoses.  Central  nervous 
affections  often  manifest  atony  of  the  intestine  as  a  symptom  ;  hence 
this  form  is  not  a  disease  sui  generis.  Cases  of  this  class  do  not  respond 
to  any  variety  of  cathartics  (Ewald). 

Paralysis  of  tlie  external  sphincters  is  a  common  concomitant  in  a 
o^reat  variety  of  local  (catarrhal)  and  central  nervous  diseases.  Under 
these  circumstances  tlie  act  of  defecation  may  be  purely  reflex,  owing  to 
loss  of  control  of  the  voluntary  muscles  ;  or  it  may  be  voluntary,  ex- 
cept when  the  person  affected  is  not  upon  his  guard,  or  during  mental 
excitement,  micturition,  sneezing,  and  like  influences. 

Treatment  of  Intestinal  Neuroses. — A  suitable  change  of  en- 
vironment, including  an  appropriate  arrangement  of  the  dietary,  is  of 
primary  importance,  and  is  uniformly  applicable  in  this  class  of  sufferers. 
Further,  the  treatment  of  special  cases  has  peculiar  reference  to  the 
character  of  the  nervous  derangement.  After  making  an  accurate  diag- 
nosis a  search  for  the  factors  of  the  greatest  etiologic  importance  should 
be  made,  and  these  must  then  be  vigorously  assailed. 

In  the  secretory  neuroses  an  associated  membranous  enteritis  must 
be  corrected,  the  digestion  must  be  improved  if  faulty,  and  the  obstinate 
constipation  overcome.  For  the  latter  symptom  enemata  containing  ox- 
gall, either  alone  or  in  combination  with  salines,  are  especially  service- 
able. Kussmaul  and  Fleiner  have  obtained  the  best  results  from  reg- 
ular large  oil-enemata  administered  once  or  twice  dailv.  During  the 
painful  attacks  copious  enemata  of  normal  saline  solution  to  which  has 
been  added  oil  of  peppermint  (o  drops  to  the  pint  at  a  temperature  of 
100°  F.)  will  sometimes  bring  speedy  relief  from  the  pain  and  other  dis- 
tressing colonic  symptoms,  and  will  assist  nature's  efforts  at  separating 
the  adherent  membrane.     Pain  must  be  at  times  relieved  by  morphin. 

In  the  sensory  disturbances  in  Avhich  the  activity  of  the  sensory 
nerves  is  increased  (enteralgia  and  hypogastric  neuralgia)  the  treatment 
may  be  considered  under  two  headings  :  first,  the  relief  of  the  neuralgic 
pains  ;  and  secondly,  the  correction  of  the  causes  or  conditions  on  which 
the  enteralgia  depends.  If  the  pain  be  severe,  opium  or  morphin  may 
be  required.  Especially  good  as  an  antispasmodic  is  codein,  which 
may  suffice  in  all  save  tlie  severer  cases.  The  object  should  be  to  give 
the  minimum  amount  of  the  opiate  that  Avill  meet  the  necessities  of  the 
case,  with  a  view  to  obviating  a  resultant  constipation.  In  hypogastric 
neuralgia  I  have  found  suppositories  containing  opium  to  be  little  short 
of  magical  in  their  effects. 

In  cases  in  which  there  is  constipation  due  to  diminished  sensibility, 
with  a  loss  of  motor  innervation  (atony  of  the  bowel),  the  feces  must  be 
artificially  removed  unless  the  underlying  condition  can  be  successfully 
overcome.  It  is  es])ecially  important  that  the  environment — physical  and 
psychic — be  so  regulated  as  to  bring  about  an  improvement  in  the  gen- 


DISEASES  OF  THE  LIVER.  847 

eral  condition  of  the  patient.     It  may  become  necessary  to  employ  tonic 
preparations  of  strychnin,  iron,  or  arsenic. 

The  treatment  of  nervous  diarrhea  involves  the  same  principles,  so 
far  as  the  indication  presented  by  the  peculiar  nervous  organization  is 
concerned,  as  in  the  sensory  and  secretory  neuroses.  It  is  especially 
important  to  prevent  the  operation  of  the  direct  causes — fright,  mental 
excitement.  Astringents  and  intestinal  antiseptics  are  not  called  for, 
unless  the  bodily  nutrition  be  affected  thereby.  Enterospasm  is  to  be 
met  by  the  same  remedies  that  are  used  to  control  enteralgia. 


IX.   DISEASES  OF  THE  LIVER. 

ANOMALIES  IN  SHAPE  AND  POSITION. 

Altered  Shape. — Occasionally  malformations  of  the  liver  are  met 
with  that  materially  alter  the  shape  of  the  organ,  either  primarily  when 
the  result  of  disease,  or  secondarily  from  pressure  of  adjacent  structures. 
Of  the  latter  class  the  most  important  cause  is  tight-lacing,  met  with 
almost  exclusively  in  women  and  producing  the  so-called  "  corset  liver." 
The  lower  part  of  the  right  lobe  of  the  liver  is  usually  the  part  aifected ; 
the  hepatic  parenchyma  is  atrophied,  owing  to  continued  compression, 
and  shows  deep  grooves  that  correspond  to  the  position  of  the  lower 
ribs.  The  connective-tissue  capsule  and  the  peritoneal  coat  are  both 
thickened  at  this  point,  the  smaller  blood-vessels  often  being  entirely 
obliterated.  In  marked  cases  the  right  lower  lobe  may  become  con- 
verted into  a  dense  fibrous  band,  with  only  a  vestige  of  the  former  liver- 
structure  remaining.  Among  other  acquired  causes  of  anomalies  in  the 
shape  of  the  liver  may  be  mentioned  deformities  of  the  vertebrae  and 
ribs,  or  tumors  of  the  ribs  or  adjacent  structures  (the  pylorus,  omen- 
tum) pressing  against  the  liver. 

Diagnosis. — Rarely,  clinical  symptoms  are  present.  "  A  constant 
sensation  of  pressure  and  fulling  is  felt  in  the  hepatic  region,  and 
sometimes,  as  a  result  of  venous  stasis,  there  is  a  temporary  but  decided 
swelling  of  the  isolated  portion,  and,  possibly,  violent  pain  and  indica- 
tions of  irritation  of  the  peritoneum,  such  as  vomiting  and  an  approach 
to  collapse.  Jaundice  is  rare  in  consequence  of  this  deformity  "  (Strlim- 
pell).  The  danger  of  this  condition  lies  in  a  possible  mistaking  it  for  an 
abdominal  tumor  (Pepper),  amyloid  disease,  ptassive  congestion,  or  new 
growths  of  the  organ  (Strlimpell). 

Primary  alterations  in  the  shape  of  the  organ  may  be  due -to  active 
or  passive  congestion,  hereditary  syphilis,  hypertrophic  or  atrophic  cir- 
rhosis, acute  yellow  atrophy,  carcinoma,  abscess,  or  hydatid  cyst.  The 
accompanying  symptoms  would,  of  course,  be  those  of  the  disease  caus- 
ing the  deformity. 

Anomalies  of  position  are  not  infrequently  met  with,  the  organ 
being  displaced  upward,  downward,  or  laterally.  The  most  common  cause 
of  lateral  displacement  is  found  in  an  abnormal  lengthening  of  the  suspen- 
sory ligament.     The  organ  may  occupy  the  epigastric  region  or  be  dis- 


848  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

placed  into  the  lower  part  of  the  abdominal  cavity,  but  a  change  in  the 
posture  of  the  patient  or  external  pressure  is  often  sufficient  to  replace 
the  liver  in  its  normal  position.  The  symptoms  (if  present  at  all)  con- 
sist of  a  dragging  sensation,  often  amounting  to  pain  that  may  be  severe 
and  referred  to  the  right  shoulder.  On  physical  examination  palpation 
may  reveal  a  fissure  between  the  right  and  left  lobes,  together  with  a 
movable  tumor  presenting  the  size  and  normal  outlines  of  the  liver,  which 
by  manipulation  may  be  returned  to  the  right  hypochondriac  region. 
Percussion  gives  tympany  over  the  normal  area  of  liver-dulness,  which 
changes  to  flatness  when  the  organ  is  pressed  or  falls  into  its  natural 
position. 

Displacement  upward  may  result  from  gastric  or  intestinal  distention, 
marked  ascites,  or  an  abdominal  tumor ;  while  downward  displacement 
may  be  due  to  a  mediastinal  tumor,  an  emphysematous  lung,  or  a  pleural 
effusion. 

Diagnosis. — Among  the  conditions  likely  to  be  confounded  with 
movable  liver  may  be  mentioned  carcinoma  of  the  omentum  or  of  the 
pylorus,  dermoid  cysts,  tumors  of  the  ovary  and  uterus,  hydro-  or  pyo- 
nephrosis, tumors  of  the  kidney,  and  chronic  proliferative  peritonitis. 
By  a  careful  study  of  the  symptomatology,  and  in  the  absence  of  the 
normal  physical  signs  over  the  hepatic  area,  the  differential  diagnosis 
can  usually  be  firmly  established,  although  marked  fatty  degeneration 
or  atrophic  cirrhosis  may  coexist  with  any  of  the  above  conditions  and 
cause  marked  diminution  in  the  area  of  hepatic  dulness. 

The  treatment  of  movable  liver  is  merely  palliative,  and  consists  in 
the  application  of  a  suitable  bandage  for  preventing  the  displacement. 


JAUNDICE. 

{Icterus.) 

Definition. — A  condition  in  which  the  tissues  and  secretions  are 
stained  with  bile-pigments.  Jaundice  is  not  a  disease,  but  a  symptom. 
The  doctrine  of  a  hematogenous  jaundice  has  been  successfully  over- 
thrown by  the  investigations  of  Stadclmann,  Hunter,  and  others.  All 
forms  are  due  to  obstruction  (hepatogenous) ;  at  all  events  the  cases  of 
hematogenous  origin  must  be  extremely  exceptional. 

Hepatogenous  or  ohstructive  jaundice  is  more  commonly  seen  in — 
(1)  Inflammatory  swelling  of  the  duodenum  or  of  the  lining  membrane 
of  the  duct,  Avhieh  is  by  far  the  most  common  foctor  in  its  causation,  and 
demands  separate  consideration  {vide  infra.  Catarrhal  Jaundice) ;  (2) 
Foreign  bodies  within  the  ducts,  as  gall-stones  or  parasites  ;  (3)  Stric- 
ture or  obliteration  of  the  duct ;  (4)  Tumors  within  the  duct  or  ob- 
structing its  orifice ;  (5)  Pressure  on  the  duct  from  without,  as  by  a 
tumor  of  the  liver,  stomach,  pancreas,  or  omentum  ;  also  by  fecal  ac- 
cumulations, displaced  organs  {cfj.  floating  kidney),  a  pregnant  uterus,  en- 
larged orlands  in  the  fissure  of  the  liver,  and,  more  rarely,  by  ab<lominal 
aneurysm  ;  (6)  Lowered  blood-pressure  in  the  vessels  of  the  liver  favor- 
ing resorption  of  bile,  as  in  simple  icterus  of  the  new-born  (Frerichs). 


CATARRHAL   JAUXDICE.  849 

CATARRHAL   JAUNDICE. 

{Hejyatogenous  Jaundice;    Icterus    Ccdarrlialis :    Duodeno-cholangitis ;  Infiammation 

of  the  Common  Bile-duct.) 

Definition. — A  condition  characterized  by  a  discoloration  of  the  tis- 
sues from  retention  and  absorption  of  bile  and  resulting  from  a  catarrhal 
inflammation  of  the  lining  membrane  of  the  ducts,  more  especially  the' 
larger,  and  of  the  duodenum. 

Pathology. — On  examining  a  liver  and  gall-bladder  in  situ  the 
former  is  usually  found  enlai-ged,  lighter  in  color  than  normally,  and  of 
a  distinct  icteroid  tint.  On  making  a  longitudinal  section  drops  of  bile 
can  be  collected  on  the  edge  of  the  section-knife. 

■The  gall-bladder  is  found  distended  with  bile,  and  on  firm  pressure  a 
tough  plug  of  mucus,  is  usually  expelled  from  the  common  duct  into  the 
duodenum,  after  which  bile  flows  into  the  intestine  freely.  The  mucosa 
lining  the  ductus  communis  is  swollen  and  inflamed,  and  the  catarrhal 
process  may  extend  to  the  cystic,  and  in  some  cases  to  the  hepatic,  duct. 
As  a  rule,  that  portion  of  the  common  duct  lying  in  the  intestinal  wall 
is  more  frequently  and  more  deeply  involved.  If  the  disease  becomes 
chronic,  a  formation  of  connective  tissue  occurs,  owing  to  the  irritation 
caused  by  the  retained  secretion,  and  atrophy  of  the  liver-cells,  with 
biliary  cirrhosis,  may  result.     Suppuration  is  rare. 

Toxic  (hematogenous)  jaundice,  so-called,  has  for  its  lesion  extensive 
catarrh  of  the  intra-hepatic  bile-ducts  from  their  origin.  Here  duodenal 
catarrh  is  not  necessary  for  the  production  of  jaundice.  It  was  formerly 
assumed  that  the  pigment  (hemoglobin)  was  liberated  in  the  blood ;  but 
Stadelmann  and  others  have  shown  that  the  bile  containing  the  poison, 
or  its  irritant  products  (toxins),  excite  inflammation  of  the  finer  ducts. 

Htiologfy. — Simple  catarrhal  jaundice  results  in  a  majority  of  cases 
from  extension  of  inflammation  in  gastro-duodenal  catarrh,  and  the 
principal  predisposing  causes  are  as  follows :  (a)  Exposure  to  cold  and 
wet ;  (5)  The  use  of  improper  foods,  under  which  heading  may  also  be 
comprised  faulty  cooking  and  improper  mastication ;  (c)  The  excessive 
or  prolonged  use  of  irritants  (tea.  coffee,  alcohol) ;  (d)  Prolonged  anxiety 
and  mental  or  physical  overwork ;  (e)  Certain  acute  diseases,  as  pneu- 
monia, relapsing  fever,  typhoid  fever,  and  malaria  (toxic  jaundice,  vide 
suyrci) ;  ( f )  Portal  obstruction,  occurring  in  chronic  heart-  or  kidney- 
disease  ;  [g)  More  rarely  it  has  occurred  in  epidemic  form. 

Symptoms. — Preceding  the  development  of  the  distinctive  features 
by  several  days,  dyspeptic  symptoms  are  in  evidence  (vide  Gastro-hepatic 
Symptoms).  The  principal  symptoms  in  detail  are  :  (a)  Icterus,  or  tint- 
ing of  the  body  surface  may  be  the  first  symptom  noticed  in  this  condi- 
tion, appearing  usually  on  the  forehead  and  neck  and  rapidly  spreading 
over  the  entire  body.  The  conjunctivae  also  early  become  discolored,  and 
the  general  hue,  though  variable,  is  commonly  a  bright  lemon-yellow.  In 
chronic  cases  the  color  is  apt  to  change  to  a  bronzed  or  deep-green  tint. 

(h)  Secretions  and  Excretions. — The  urine  and  sweat  are  often  found 
to  contain  bile-pigment,  the  patient's  linen  frequently  being  discolored. 
In  extreme  cases  the  urine  may  be  dark-green  in  color,  while  in  those 
of  average  severity  it  is  of  a  lighter  or  deeper  greenish-yellow  hue. 
The  shaken    specimen  foams,    and   the  froth  has   a  yellow   color-tint. 

5-t 


860  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Often  the  presence  of  bile  is  detected  before  any  noticeable  coloring 
of  the  conjunctivae  occurs.  In  cases  of  intense  or  long-standing 
jaundice  albumin  and  tube-casts  may  be  present,  and  the  latter  may 
be  bile-stained.^  Hyaline  casts  are  often  found  in  cases  of  moderate 
intensity. 

The  bowels  are  constipated,  and  the  stools  are  pale-drab  or  slate- 
colored  ;  they  are  usually  very  fetid.  Diarrhea,  however,  may  be  pres- 
ent, owing  to  the  production  of  irritating  substances  and  decomposition. 

The  tears,  saliva,  and  milk  are  rarely  stained  with  bile-pigment.  The 
expectoration  also  is  rarely  tinted,  unless  pneumonia  or  some  form  of 
pulmonary  infiltration  coexists. 

(c)  Circulation. — The  pulse,  although  not  appreciably  altered  in  vol- 
ume or  tension,  is  usually  slow  (often  30  or  even  20  beats  per  minute), 
though  this  is  not  an  unfavorable  symptom. 

{d)  The  temperature  is  usually  normal,  although  slight  elevations 
may  occur  (100°-101^  F.— 37.7°-38.3°  C). 

(e)  Cf astro-hepatic  Symptoins. — Dyspeptic  symptoms — viz.  anorexia, 
a  sense  of  fulness  after  eating  with  flatulence,  acid  eructations,  nausea 
and  vomiting,  accompanied  by  a  dull,  heavy  pain  over  the  hepatic  area, 
Avith  some  tenderness  on  pressure — are  present.  These  often  develop  in- 
sidiously ;  more  rarely  they  occur  suddenly  with  a  severe  rigor  or  chill, 
violent  headache,  and  vomiting — e.  //.  at  the  onset  in  the  epidemic  form. 

(_f )  Cutaneous  Phenomena. — Pruritus  or  itching  often  becomes  a 
troublesome  symptom,  being  more  common,  however,  in  the  chronic 
forms.  Lichen,  urticaria,  furuncles,  and  sweatings  (diffused  and  local- 
ized) may  develop,  the  latter  being  often  limited  to  the  skin  covering 
the  abdomen  and  the  palms  of  the  hands. 

A  peculiar  disease  of  the  skin  called  .ranthclasma  or  bita  higoidea 
may  also  occur.  It  consists  of  bright-yellow  spots,  slightly  elevated, 
appearing  on  the  eyelids,  and  rarely  on  other  parts  of  the  body. 

In  the  more  severe  forms  spots  of  ecchymosis,  and  in  some  instances 
profuse  hemorrhages,  may  occur  into  the  skin  and  mucous  membranes. 
These  are  usually  associated  with  other  symptoms  of  a  grave  type. 

(//)  Nervous  Symptoms. — Headache  and  vertigo  are  common ;  irri- 
tability of  temper,  despondency,  and  wakefulness  or  mental  dulness 
almost  equally  so.  With  the  oncoming  of  darkness  vision  may  grow 
indistinct  (Jiemeralopia)  or  it  may  attain  unnatural  clearness  {nyc- 
talopia). Rarely,  objects  look  yellow  [xanthopsia).  The  nervous  phe- 
nomena observed  in  catarrhal  jaundice  are  attributable  to  the  effects 
of  the  bile-acids.  In  certain  cases,  however,  associated  with  destruc- 
tion of  the  hepatic  substance,  as  in  acute  yellow  atrophy,  carcinoma, 
cirrhosis,  and  fatty  degeneration,  grave  cerebral  symptoms  (acute 
delirium,  convulsions,  and  coma)  may  develop  suddenly  and  prove 
fatal.  This  class  of  symptoms  has  been  named  acholia,  cholemia,  or 
cholesteremia  (the  latter  owing  to  the  mistaken  supposition  that  cho- 
lesterin  is  the  poisonous  product).     The  true  nature  of  the  toxic  agent 

^  Tests  for  Bile. — Gmeliu^s  teM,  or  the  play  of  colors,  consists  in  bringing  a  few  drops 
of  urine  in  contact  with  the  same  quantity  of  commercial  nitric  acid  on  a  plain  wliite 
fjlab,  whereupon  various  shades  of  yellow,  green,  red,  and  violet  are  produced. 

Rosenhacli's  ted  is  made  by  filtering  the  suspected  urine  and  touching  the  filter-paper 
with  a  drop  of  nitric  acid.  If  bile  be  present,  a  green  circle  will  form  at  the  point  of 
contact.      (See  also  Choluria,  p.  948.) 


CATARRHAL  JAUNDICE.  851 

in  the  blood  is  unknown.  In  some  fatal  terminations  of  this  character 
death  Avas  due  directly  to  a  renal  complication. 

The  physical  signs  in  a  case  of  simple  catarrhal  jaundice  show  on 
palpation  and  percussion  an  increase  in  the  hepatic  area,  the  lower  bor- 
der of  the  liver  projecting  in  some  instances  several  fingers'  breadths 
below  the  ribs.  Rarely,  the  distended  gall-bladder  projects  below  the 
lower  lobe  of  the  liver,  as  when  there  is  complete  obstruction  near  or  at 
the  duodenum,  and  then  it  can  be  distinctly  palpated. 

Diagnosis. — The  etiology  (errors  in  hygiene  and  diet),  a  history 
of  previously  existing  gastro-intestinal  catarrh,  the  age  of  the  patient 
(young  adult  life),  and  the  appearance  of  the  jaundice  unaccompanied 
by  pain  or  general  emaciation,  together  with  an  absence  of  symptoms 
pointing  to  cirrhosis,  carcinoma,  or  acute  yellow  atrophy,  form  a  char- 
acteristic grouping  of  clinical  indications. 

Duration  and  Prognosis. — The  duration  of  catarrhal  jaundice 
varies  from  two  to  eight  weeks.  If  the  symptoms  continue  longer  than 
two  months,  grave  doubts  may  be  entertained  as  to  the  case  being  one  of 
simple  jaundice.  The  prognosis  is  guardedly  favorable.  A  rise  of  tem- 
perature usually  indicates  mischief  (Pepper),  while  hemorrhages  of  the 
skin  and  mucous  membranes  always  influence  the  issue  unfavorably. 

Treatment. — The  diet  and  hygiene  are  the  first  considerations  in  the 
treatment.  Rich,  highly  seasoned  foods,  rich  pastries,  fats,  and  sweets, 
are  to  be  interdicted ;  starchy  foods,  lean  meats,  bread,  soups  (contain- 
ing no  fat),  and  green  vegetables  may,  however,  be  used  in  moderation. 
Skimmed  milk,  butter-milk,  and  alkaline  drinks  (Vichy  and  Saratoga 
mineral  waters)  may  be  used  freely,  while  sour  wines,  lemonades,  and 
tamarind-water  are  allowable.  Systematic  bathing  (Turkish  or  Russian 
baths,  under  supervision)  and  regulated  hours  of  sleep  exert  a  bene- 
ficial effect.  The  free  use  of  pure  water  often  does  good  by  increasing 
the  flow  of  bile  and  by  dislodging  plugs  of  mucus. 

Gerhardt  and  Kraus  have  recommended  the  faradic  current,  applied 
over  the  region  of  the  gall-bladder ;  manipulation  has  also  been  tried 
with  a  view  to  removing  the  obstruction,  but  without  success. 

The  first  therapeutic  indication  is  to  keep  the  bowels  freely  soluble 
by  the  use  of  saline  aperients,  as  Hunyadi  water  or  Carlsbad  salts  {\  to 
1  teaspoonful  in  hot  water  before  meals).  The  latter  remedies  tend  to 
lessen  the  catarrhal  inflammation  by  depleting  the  mucous  membranes. 
In  obstinate  constipation  calomel,  rhubarb,  the  extract  of  colocynth,  or 
castor  oil  may  be  emploj'^ed. 

Conspicuous  among  other  remedies  may  be  mentioned  the  alkalies, 
sodium  bicarbonate,  salicylate,  and  phosphate,  which  tend  to  increase  the 
flow  of  bile  and  render  it  less  thick  ;  hydrochloric  acid  (which,  accord- 
ing to  Ew^ald,  by  aiding  digestion  prevents  the  formation  and  consequent 
absorption  of  toxic  substances),  in  combination  with  the  bitter  tonics — 
gentian,  quassia,  and  nux  vomica ;  ammonium  chlorid,  which  sometimes 
proves  beneficial;  and  silver  nitrate  (gr.  |-J — 0.008-0.016,  thrice  daily). 

Injections  of  cold  water  (60°-70°  F.— lo.5°-21.1°  C),  daily,  in 
quantities  of  1  or  2  quarts  (1-2  liters),  are  highly  recommended  as 
promoting  the  secretion  of  bile  ;  while  lavage,  practised  daily  and  over  a 
protracted  period  of  time  (one  to  two  months),  has  proved  highly  bene- 
ficial, especially  when  gastro-duodenal  catarrh  has  existed. 


852  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Itching. — This  troublesome  symptom  may  often  be  relieved  by  the 
external  application  of  a  solution  of  borax  or  sodium  bicarbonate  (oSS- 
Oj_16.0-ol2.0).  or  of  menthol  and  alcohol  (gr.  x-5J— 0.648-32.0). 
Internally,  large  doses  of  the  bromids  or  the  continued  use  of  pilocarpin, 
as  recommended  by  Witkowski.  are  worthy  of  a  trial. 

Flatulence. — To  this  end  it  is  important  to  regulate  the  diet,  avoid- 
ingr  starches  and  susfars.  Charcoal  tablets,  bismuth  subnitrate  or  salicv- 
late,  and  beta-naphtol  are  all  useful.  Irrigation  of  the  colon  with  some 
efficient  antiseptic  in  solution  is  often  a  factor  of  service. 

Headache  is  caused  by  the  circulation  in  the  blood  of  some  toxic 
principle.  Of  drugs,  caffein  citrate,  camphor  monobromate,  and  phe- 
nacetin,  either  singly  or  in  combination,  may  be  recommended. 

When  the  obstruction  is  due  to  mechanical  causes  (biliary  calculi, 
tumors  pressing  on  the  ductj  the  treatment  is  surgical. 

OTHER   FORMS    OF   JAUNDICE. 

Modern  experiments,  as  I  have  said  {vide  p.  848),  tend  to  show  that 
the  so-called  hematogenous  jaundice  is  always  hepatogenous — /.  e.  the 
blood-dyscrasia  probably  exerts  a  toxic  inHuence  on  the  liver-cells  and 
intra-hepatic  gall-ducts  ;  and  there  may  at  the  same  time  be  a  more  rapid 
blood-destruction  in  the  liver  (Neumeyer,  Stadelmann,  et  ah). 

There  are  instances  of  jaundice  in  which  active  hemolysis  is  an  ele- 
ment of  importance  (Stengel) :  (a)  Severe  infections,  as  septico-pyemia. 
yellow  fever,  acute  yellow  atrophy  of  the  liver,  and  the  jaundice  of  the 
new-born,  {b)  Grave  forms  of  anemia,  as  pernicious  anemia  and  chlor- 
osis, (c)  Certain  poisons,  as  the  venom  of  snakes,  chloroform-  and 
ether-poisoning;  also  in  poisoning  by  phosphorus,  arsenic,  mercury,  and 
other  minerals. 

Experiments  conducted  by  Miinzer,  Starling,  Hopkins,  and  others, 
tend  to  show  that  the  liver-function  is  not  suppressed  by  many  of  the 
conditions  and  affections  mentioned  above ;  but.  on  the  other  hand,  that 
increased  secretion  {polycholia)  and  increased  formation  of  bile-pigments 
{polychroraia)  may  prevail.  Again,  the  poisons  or  toxins  may  cause 
swelling  of  the  cells  and  compression  of  the  biliary  capillaries;  this 
"would  cause  obstruction  of  the  outflow  of  bile  and  the  subsequent  ab- 
sorption. Lastly,  circulatory  disturbances  (emotional  jaundice)  may 
lead  to  overproduction,  or  obstructive  retention,  of  bile. 


ACUTE  INFECTIOUS   CHOLECYSTITIS. 

Definition. — An  acute  inflammation  (infective)  of  the  gall-bladder. 
It  i.-  vjirc. 

Pathology. — Three  pathologic  varieties — catarrhal,  suppurative, 
and  phlegmonous — are  recognized.  The  gall-bladder  progressively 
enlarges  and  becomes  filled  with  muco-purulent  or  purulent  or  (rarely) 
hemorrhagic  material.  The  cystic  duct  is  often  occluded.  In  the  sup- 
purative form  (the  most  prevalent)  ulcers  may  coexist  and  perforation, 
followed  by  localized  peritonitic  abscess  or  acute  diffuse  peritonitis,  may 


ACUTE  INFECTIOUS  CHOLECYSTITIS.  853 

occur.  The  lesions  of  cholangitis,  either  catarrhal  or  suppurative,  may 
be  associated. 

Ktiologfy. — The  bacterial  excitants  include  the  streptococci,  staphy- 
lococci, the  pneumococcus,  the  colon  bacillus,  and  the  typhoid  bacillus. 

Among  predisposing  conditions  are  many  of  the  acute  infections,  as 
typhoid,  typhus,  malaria,  sepsis,  pneumonia,  puerpei^al  fever,  and  cholera. 

DaCosta  has  collected  58  cases  of  typhoid  cholecystitis.  His  figures 
show  that  it  may  occur  at  almost  any  age,  and  of  48  cases  in  which  the 
sex  was  stated,  26  were  males  and  22  females.  The  etiologic  import- 
ance of  gall-stones  has  been  greatly  overrated  in  the  past. 

Symptoms. — The  onset  is  abrupt,  with  pain-  (often  paroxysmal)  in 
right  side  of  the  abdomen  or  epigastrium.  The  region  of  the  gall-bladder 
is  acutely  sensitive,  and  with  the  development  of  spreading  peritonitis 
the  tender  area  grows  correspondingly.  Rigidity  of  the  right  rectis 
may  be  observed.  In  inany  cases  a  tumo?-  occupying  the  seat  of  the 
gall-bladder  is  present  and  has  marked  diagnostic  importance.  It  is 
detected  on  palpation  as  a  firm,  pear-shaped  tumor  or  as  a  "  mere  resist- 
ing mass  below  the  costal  margin."  The  latter  is  often  due  to  perito- 
nitic  abscess  following  perforation. 

Nausea  and  vomiting,  which  may  be  persistent,  are  usual  symptoms 
at  the  outset.  Jaimdice  occurred  in  17  out  of  58  cases  (DaCosta). 
Among  the  general  symjJtoms  chills  are  conspicuously  absent.  Fever 
may  be  present,  but  by  no  means  always ;  the  pulse  becomes  rapid  and 
feeble,  the  abdomen  distended,  and  prostration  profound.  In  the  suppu- 
rative form  a  blood  examination  generally  shows  leukocytosis.  This 
serious  affection  may  be  entirely  latent. 

Differential  Diagnosis. — Appendicitis  may  be  mistaken  for  chole- 
cystitis, particularly  if  the  appendix  be  situated  abnormally  high  up. 
The  discrimination  would  here  rest  upon  the  history  (following  typhoid 
or  other  infection),  the  presence  of  a  tumor  and  marked  sensitiveness  in 
the  region  of  the  gall-bladder,  corroborated  by  jaundice. 

Acute  intestinal  obstruction  may  be  closely  simulated  in  cases  in 
which  adhesions  between  the  gut  and  gall-bladder  are  present.  In  such 
cases  exploratory  celiotomy  is  to  be  advised  or  at  least  considered  with 
a  view  to  clearing  the  diagnosis.  Recurrent  cliolecystitis,  a  not  uncom- 
mon complaint,  gives  the  history  of  recurring  attacks  of  pain  simu- 
lating cholelithiasis.  In  one  of  my  cases  Laplace  operated  and  found 
the  gall-bladder  somewhat  enlarged  and  the  seat  of  catarrhal  chole- 
cystitis. Osier  suggests  that  in  some  of  these  cases  gall-stones  may 
have  been  present  and  have  passed  before  the  operation  (see  also  p.  856). 

Prognosis. — This  is  dependent  upon  the  special  variety,  although 
it  is  among  the  most  fatal  of  diseases.  A  fatal  result  is  the  rule  in 
purulent  and  phlegmonous  cholecystitis.  In  the  catarrhal  form  recov- 
ery is  not  infrequent  (DaCosta).  Pneumonia  may  be  the  immediate 
cause  of  death.     Phlegmonous  cholecystitis  may  end  in  gangrene. 

Treatment. — This  embraces  absolute  rest,  rectal  alimentation,  the 
relief  of  pain  by  the  judicious  use  of  morphine,  and  of  other  symptoms 
as  they  arise.  The  circulation  must  be  supported  by  stimulants  as 
a  rule.  If  the  diagnosis  of  suppurative  or  phlegmonous  cholecystitis 
can  be  established  surgical  intervention  is  imperatively  demanded  as  a 
rule. 


854  DISEASES  OF  TEE  DIGESTIVE  SYSTEM. 

BILIARY  CALCULI. 

{Gall-stones ;    Cholelithiasis.) 

Definition. — Concretions  formed  in  the  gall-bladder,  due  to  an 
altered  physiologic  function  or  pathologic  change ;  they  often  set  up 
characteristic  disturbances  {cJiolelithiasis). 

Ktiology. — As  a  result  of  biliary  retention  increased  consistency 
and  a  concentration  of  bile  occurs,  and  certain  constituents  that  -were 
before  held  in  solution  are  thrown  down.  Among  common  predisposing 
causes  may  be  mentioned :  (a)  Female  sex,  especially  between  the  ages 
of  forty  and  sixty.  Senac's  statistics,  out  of  a  total  of  311  individuals, 
give  227  women  (Dujardin-Beaumetz).  (b)  Irregular  meah  and  an 
excessiue  diet  of  starches  and  of  fats,  combined  with  a  sedentary  life. 
Among  minor  causes  are  constipatio7i,  tiglit-lacing,  pregriancy,  chronic 
ohstruetlon  to  the  flow  of  bile  (as  from  tumors,  catarrh  of  the  ducts,  or 
heart-disease,  as  mitral  stenosis),  and,  ruore  rarely,  the  rachitic  and 
lithic-acid  diathesis,  (e)  It  may  occur  during  childhood,  {d)  Inci- 
dence. Brockbank  found  among  13.047  completed  postmortem  records, 
7.4  per  cent,  \vere  gall-stones,     (e)  Infectious  cholecystitis. 

Composition  and  Appearance. — Water  comprises  from  2  to  5 
per  cent,  of  the  com]>osition  of  gall-stones,  the  chief  solid  constituent 
being  cholesterin,  and  the  remainder  being  composed  of  bile-pigment 
and  salts  (lime,  potash,  soda,  and  perhaps  traces  of  iron  and  copper). 
Pigment-lime  may  be,  though  rarely,  the  main  constituent.  In  size 
they  vary  from  the  smallest  particle  of  sand  to  that  of  a  goose-egg. 
Fagge  reports  a  calculus  weighing,  in  a  dry  state,  462  grains  (30.0). 
The  color  varies  from  Avhite  or  light-yellow  to  that  of  a  dark- 
green  (as  in  pigment-lime  calculi),  and  may  present  any  variation 
between  these  two  extremes.  The  nucleus  often  consists  of  cholesterin, 
the  outer  layer  being  usually  the  harder,  and  made  up,  for  the  most 
part,  of  lime-salts.  The  center  of  the  nucleus  generally  consists  of 
desquamated  epithelium  or  dried  mucus,  and  on  cross-section  concentric 
laminse  are  usually  developed.  The  cholesterin  gall-stones  cut  like 
wax,  are  white,  and  the  cut  section  presents  a  crystalline  appearance. 
Other  forms  are  apt  to  be  brittle.  The  surfaces  may  be  smooth,  stri- 
ated, or  hollowed  out,  solitar}^  calculi  being  usually  round  or  ovoid, 
while  multiple  stones  often  present  smooth  facets,  due  to  the  massing 
together  of  the  calculi  (Dujardin-Beaumetz).  They  are  usually  olive- 
shaped,  but  may  be  pyramidal,  cylindric,  lenticular,  pisiform,  cubic, 
finger-shaped,  or  olivary.  Their  seat  is  usually  the  gall-bladder,  but 
they  may  be  found  anywhere  along  the  biliary  passages. 

Symptoms. — There  may  be  no  subjective  symptoms.  Indeed,  in 
the  majority  of  cases  of  cholelithiasis  biliary  colic  does  not  occur.  The 
passage  of  a  calculus  through  the  duct,  if  it  sets  up  a  ''  perialienitis  " 
or  inflammation  of  the  structures  surrounding  it,  Avill  give  rise  to  hepatic 
colic,  whereas  a  permanent  blocking  of  the  duct  Avill  cause  symptoms  of 
chronic  obstruction  {vide  infra). 

Hepatic  Colic. — AVhen  a  gall-stone  becomes  impacted  in  a  bile-duct 
the  patient  experiences  agonizing  pain  (tearing,  cutting,  or  lancinating 
in  character)  in  the  right  hypochondriac  region,  radiating  to  the  right 


BILIARY  CALCULI  855 

shoulder,  and  accompanied  often  by  profuse  sweating,  vomiting,  and  a 
feeble,  running  pulse.  The  most  common  seat  of  the  pain  is  two  to 
three  inches  to  the  right  of  the  median  line  and  about  an  equal  distance 
beloAv  the  ensiform  cartilage.  Less  frequently  it  is  in  the  region  of  the 
gall-bladder.  This  happens  in  cases  in  which  the  gall-stone  is  impacted 
in  the  cystic  duct,  and  may  be  due  to  distention  of  the  gall-bladder, 
or  to  associated  cholecystitis.  The  pain  is  sometimes  so  severe  as  to  pro- 
duce syncope.  Hepatic  colic,  however,  may  occur  independently  of  the 
passage  of  biliary  calculi,  as  from  inflammation  of  the  gall-bladder. 
On  the  other  hand,  large  calculi  have  been  found  in  the  dejecta  Avithout 
having  excited  hepatic  colic.  I  recently  saw  an  instance  of  this  kind 
in  which  the  gall-stone  was  of  the  size  of  an  English  walnut.  A  rigor 
or  cliill  often  precedes  the  attack,  which  is  usuallv  accompanied  bv  mod- 
erate fever,  the  temperature  reaching  101°-102°  F.  (38.3°-38.8°  C). 
If  the  stone  passes  through  the  duct  without  becoming  impacted,  jaun- 
dice and  pain  may  either  be  only  slight  or  entirely  absent.  AVhen,  how- 
ever, occlusion  of  the  common  duct  occurs,  the  jaundice  becomes  intense. 
This  symptom,  however,  may  be  present,  though  less  marked,  before  the 
gall-stones  reach  the  ductus  communis.  Jaundice  occurs  in  about  50  per 
cent,  of  the  cases  (Fitz),  and  it  sets  in  from  eight  to  twenty-four  hours 
after  the  onset  of  the  attack  of  pain.  Physical  examination  reveals  on 
inspection  a  slight  prominence  in  the  hepatic  area,  and  on  palpation  the 
edge  of  the  liver  can  often  be  distinctly  felt  below  the  costal  margin — 
at  times  as  low  as  the  umbilical  level.  The  enlarged  liver  is  sensitive 
on  pressure,  and  particularly  the  gall-bladder,  which  can  be  often  pal- 
pated. If  the  latter  viscus  contains  many  calculi,  crepitation  may  be 
noticeable  to  the  palpating  fingers  (rarely),  and  a  friction-sound  may 
be  distinguished  on  auscultation.  The  swollen  organ,  after  the  cessation 
of  the  colic,  quickly  subsides.  Recurrences  of  the  painful  attacks  after 
varying  intervals  of  time  are  common.  Finally,  the  gall-stone  is  ex- 
pelled and  the  colic  ceases  to  return.  IMultiple  stones,  however,  may  be 
passed.      In  severe  cases  the  symptoms  of  profound  shock  may  develop. 

Rupture  of  the  duct,  followed  by  fatal  peritonitis,  has  been  known  to 
occur.  Attacks  of  biliary  colic  are  of  variable  duration,  lasting  from  a 
few  hours  to  a  few  days,  and  in  some  instances  one  or  more  weeks. 
Sudden  cessation  of  the  pain  is  usually  followed  by  rapid  disappearance 
of  the  jaundice  (Avhen  present)  and  the  discovery  of  the  stone  in  the 
feces.  Examination  of  the  urine  after  the  paroxysm  reveals  bile  and  an 
abundance  of  uric  acid  and  urates.  The  jndse  often  becomes  slowed. 
Exner  has  demonstrated  the  presence  of  about  0.4  per  cent,  of  sugar  in 
the  urine  in  39  out  of  40  cases  of  gall-stones.  On  the  other  hand, 
Kausch  has  found  glycosuria  in  only  one  of  85  cases  of  cholelithiasis. 

The  prognosis  of  biliary  calculi  as  regards  life  is  good,  but  as  re- 
gards recovery  only  guardedly  favorable.  Cardiac  distress  with  palpi- 
tation may  occur  during  hepatic  colic  and  form  a  serious  com23lication. 
Fatal  syncope  has  also  been  known  to  occur,  and  fatal  intussusception 
has  follow^ed  the  impaction  of  gall-stones  in  the  region  of  the  ileo-cecal 
valve.  If  evidences  of  an  infectious  inflammation  arise,  the  outlook  is 
then  more  serious. 

Diagnosis. ^The  diagnosis  of  gall-stones  is  sometimes  extremely 
difficult  on  account  of  the  obscure  clinical  symptoms  and  the  entire  ab- 


856  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

sence  of  physical  signs.  When,  however,  the  calculus  becomes  impacted 
in  the  duct,  symptoms  of  biliary  colic — intense  pain  in  the  epigastrium 
and  right  hypochondriac  region,  radiating  to  the  back  and  right  shoulder 
— usually  appear.  There  are  also  fever,  vomiting,  and  in  one-half  the 
instances  jaundice  and  the  finding  of  the  stone  in  the  dejecta. 

Differential  Diagnosis. —  G-astralgia  usually  occurs  in  individuals  with 
neurotic  tendencies,  and  is  characterized  by  severe  paroxysmal  pains  in 
the  epigastrium,  extending  to  the  back  and  base  of  the  chest.  It  occurs 
often  when  the  stomach  is  empty  and  is  relieved  by  eating.  Firm  press- 
ure over  the  epigastrium  often  alleviates  the  pain  temporarily,  and  the 
absence  of  fever,  jaundice,  stones  in  the  dejecta,  and  the  negative  urinal- 
ysis, together  with  the  history  of  former  attacks,  would  tend  to  differenti- 
ate it  from  hepatic  colic. 

Renal  CoHc. — The  pain  in  this  condition  starts  in  the  flank  of  the 
affected  side  and  is  transmitted  down  the  ureter.  The  testicle  and  in- 
ner side  of  the  thigh  are  very  painful,  the  former  being  often  retracted. 
Micturition  is  frequent  and  sometimes  painful,  and  the  urine  is  scanty 
in  amount  and  often  mixed  with  blood. 

Intestinal  Colic. — In  this  variety  the  pain  is  of  a  boring  or  twisting 
character,  usually  centering  about  the  umbilicus.  It  is  relieved  by  firm 
pressure.  Abdominal  distention  is  often  present,  and  relief  comes  with 
the  passing  of  flatus.  Usually  there  is  a  history  of  an  indiscretion  in 
diet.  When  due  to  lead-poisoning,  the  history,  the  blue  line  on  the  gums, 
and  the  presence  of  wrist-drop  would  tend  to  confirm  the  diagnosis. 

Reflex  colic,  due  to  uterine  or  ovarian  disease,  may  also  occur.  The 
recurrence  of  the  attacks,  together  with  causes  and  symptoms  pointing  to 
pelvic  disease,  would  establish  the  identity  of  the  condition. 

Pollatschek,  Riedel,  Stockton,  and  others  hold  that  biliary  colic  may 
arise  from  cholecystitis  (due  to  an  infection)  without  the  presence  of  any 
gall-stones.  With  the  cholecystitis,  localized  peritonitis  and  angiocho- 
litis  are  often  associated. 


CHRONIC    OBSTRUCTION    OF   THE   DUCTS   BY   GALL-STONES. 

The  obstruction  may  exist  in  the  ductus  choledochus,  in  the  cystic 
duct,  or  in  both. 

1.  Obstruction  of  the  Common  Duct. — Pathology. — The  result 
of  the  irritation  produced  by  the  presence  of  the  stone  is  a  catarrhal  pro- 
cess {cholanfiitis)  that  may  either  remain  chronic  or  terminate  in  suppu- 
ration {sujipurative  cholan(/itis).  In  a  case  of  simj)le  obstruction  the  gall- 
bladder is  often  moderately  enlarged,  though  rarely  extending  below  the 
lower  border  of  the  liver.  The  common  duct  is  greatly  distended,  the 
stone  being  usually  located  near  its  termination;  it  is  distinctly  felt  just 
beneath  the  mucous  membrane  of  the  descending  duodenum.  Occasion- 
ally  two  or  more  calculi  are  present,  completely  obliterating  the  canal. 
The  hepatic  duct  and  its  branches  are  greatly  dilated,  and  often  contain 
thin,  colorless  mucus,  the  membrane  lining  the  ducts  being  smooth  and 
clear.  The  liver  in  these  cases  is  firmer  in  consistency  than  normal, 
showing  some  increase  in  the  connective-tissue  elements  (biliary  cirrhosis). 
Following  moderate  enlargement  of  the  organ  progressive  atrophy  may 
rarely  occur.     When  suppuration  has  occurred  the  mucous  membrane 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  BY  GALL-STONES   857 

is  greatly  swollen  and  reddened,  and  in  some  instances  shows  erosions 
or  ulceration  (Ulcerative  Angiocholitis).  The  process  often  extends 
through  the  hepatic  and  cystic  ducts  into  the  liver  and  gall-bladder, 
giving  rise  to  the  localized  abscesses  in  the  former  and  to  empyema  of 
the  latter.  In  some  instances  the  gall-bladder  has  been  perforated  and 
abscesses  have  formed  between  the  liver  and  stomach.  Diverticula  are 
sometimes  found  postmortem,  containing  biliary  calculi. 

While  cholelithiasis  is  by  far  the  most  common  cause  of  catarrhal, 
suppurative,  and  ulcerative  angiocholitis,  it  not  rarely  complicates  hy- 
datid disease,  carcinoma  of  the  bile-ducts,  and  the  acute  infections, 
particularly  typhoid  fever  {vide  Acute  Infectious  Cholecystitis,  p.  853). 
Rarely  foreign  bodies  (fish-bones,  lumbricoids)  operate  as  excitants. 

Symptoms. — Chronic  obstruction  by  gall-stones,  with  coexisting  ca- 
tarrhal inflammation  (catarrhal  angiocholitis),  is  characterized  by  a  dis- 
tinctive group  of  symptoms,  among  the  most  prominent  of  which  are — 

Jaundice. — This  may  be  constant  and  very  intense,  or  intermittent 
and  slight,  depending  upon  the  amount  of  obstruction  present.  In  some 
cases  it  disappears  entirely  for  several  months,  and  then  recurs  with  vary- 
ing intensity  (ball-valve  action  of  the'  stone).  Itching  is,  as  a  rule,  a 
most  distressing  feature. 

Pain.,  occurring  in  paroxysmal  attacks  and  referred  to  the  region  of 
the  liver.  This  is  accompanied  by  fever  that  may  reach  a  high  degree 
(102°-103°  F.— 38.8°-39.4°  C),  also  by  chills  and  sweating,  resem- 
bling somewhat  the  paroxysms  of  malaria.  Painful  points  in  the  right 
side  posteriorly  may  be  annoying  ;  these  are  either  constant  or  par- 
oxysmal. 

The  chills  are  often  intense,  and  may  present  a  quotidian,  tertian,  or 
quartan  form.  The  temperature  of  the  intervals  is  normal.  The  pecu- 
liar exacerbations  of  temperature  were  first  described  by  Charcot,  and  to 
them  has  been  given  the  name  of  Charcot's  iyitermittent  fever.  Con- 
cerning their  nature  Murchison  writes  :  "  These  paroxysms  may  be 
more  or  less  periodic,  and  may  extend  over  several  months,  without 
necessarily  indicating  pyemic  hepatitis,  the  patient  ultimately  recover- 
ing." He  adds  that  they  are  probably  analogous  to  febrile  paroxysms 
produced  in  passing  a  catheter  along  the  urethra.  Charcot  believes  the 
etiologic  factor  to  be  a  septic  poison,  bacterial  in  origin  and  the  result 
of  chemical  changes  in  the  bile.  Various  microorganisms  have  been 
detected  in  the  bile  in  such  cases  (bacterium  coli  commune,  streptococcus 
pyogenes,  et  al). 

Giastric  Disturbances. — These  may  excite  alarm  during  the  par- 
oxysm. Intense  pain  is  complained  of  in  the  epigastrium,  accompanied 
often  by  persistent  nausea  and  vomiting,  which,  however,  usually  sub- 
sides at  the  close  of  the  paroxysm,  while  the  jaundice  at  this  time 
deepens.  The  attack  may  persist  for  years  without  progressive  failure 
of  health. 

The  symptoms  of  suppurative  cholangitis  are  intense.  The  par- 
oxysms of  fever  occur  more  frequently,  the  temperature  merging  into 
the  remittent  type.  Grave  constitutional  symptoms,  indicating  septico- 
pyemia, are  present,  and  the  case  rapidly  tends  to  a  fatal  issue.  The 
attacks  of  colicky  pain  occur  with  jaundice,  but  the  latter  symptom  is 
less  intense  than  in  the  catarrhal  form.     As  to  hepatic  enlargement,  the 


858  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

converse  is  true;  this  organ  takes  on  progressive  enlargement  and  "may 
descend  as  low  as  the  umbilicus,  the  swelling  being  uniform  and 
smooth  and  tender  to  pressure  "  (Robson).  It  should  be  borne  in  mind 
that  pain  may  be  absent  when  the  disease  is  not  dependent  on  gall- 
stones. Pneumonia  and  empyema  are  serious  and  not  uncommon  com- 
plications. In  ulcerative  angioclioUtis  severe  hemorrhage  may  occur, 
resulting  either  in  melena  or  hematemesis.  Mayo  Robson  reports  a 
case  in  which  hematemesis  was  the  only  anteraortem  symptom  and  had 
been  the  cause  of  death.  The  condition  being  associated  with  septic 
infection,  it  leads  to  the  constitutional  disturbances  of  septicemia  or 
septico-pyemia. 

2.  Obstruction  of  the  Cystic  Duct. — This  almost  invariably 
causes  distention  of  the  gall-bladder  (dropsy  of  the  gall-bladder),  Avhich 
may  be  felt  distinctly  below  the  lower  edge  of  the  liver  as  a  pyriform, 
fluctuating  tumor.  If  obstruction  of  the  cystic  duct  alone  occurs,  jaun- 
dice mav  be  entirely  absent,  the  bile  in  the  distended  tissues  being  re- 
placed  by  a  thin,  mucoid  fluid.  This  is  more  apt  to  exist  as  the  obstruc- 
tion becomes  more  chronic.  In  some  instances  the  distention  is  so  great 
as  to  reach  below  the  umbilicus,  and  the  dilated  viscus  has  even  been 
mistaken  for  an  ovarian  tumor.  Osier  records  a  case  in  which  18  oz. 
(556.0)  of  fluid  were  removed  from  the  gall-bladder.  The  contents  are 
neutral  or  alkaline  in  reaction,  albumin  being  often  present  in  abun- 
dance. Catarrhal  inflammation  of  the  gall-bladder  is  often  associated, 
causing  pain  and  sensitiveness  in  the  region  of  the  organ.  The  pain 
may  be  severe  and  simulate  biliary  colic  or  appendicitis.  The  examiner 
can/(?eZ  an  elastic,  gourd-shaped  tumor  closely  connected  with  the  liver, 
movable  in  respiration  in  the  vertical,  and  also,  under  the  influence  of 
the  palpating  fingers,  in  the  lateral,  direction.  I  have  observed  a  tongue- 
like projection  of  the  anterior  margin  of  the  right  lobe,  to  which  Riedel 
first  called  attention.  Given  a  gall-bladder  well  filled  with  stones  and 
a  relaxed  abdominal  wall,  gall-stone  crepitus  mav  be  detectable. 

The  writer  has  reported  some  cases  giving  a  more  or  less  character- 
istic clinical  history  of  cholelithiasis,  in  which  gall-stone  crepitus  on 
palpation  furnished  absolute  proof  of  stones  in  the  gall-bladder.  In 
one  case  he  combined  auscultation  Avith  palpation  and  detected  a  fjiint 
grating  sound.' 

If  the  obstruction  persist  for  a  length  of  time,  calcification  or 
atrophy  of  the  bladder  are  common  se(iuel«i.  Complete  obliteration 
of  the  cavity  of  the  gall-bladder  may  ensue. 

Among  rarer  seijuel*  of  chronic  obstruction  may  be  mentioned — (a) 
Empyema  of  the  G^aU-bladder. — When  this  takes  place  the  organ  be- 
comes greatly  distended,  and  has  been  known  to  contain  as  much  as  a 
])int  of  purulent  material.  The  symptoms  of  suppurative  cholecystitis 
simulate  and  accompany  those  of  purulent  cholangitis ;  the}"  are  some- 
times preceded  by  those  of  catarrh  of  the  gall-bladder  and  ducts.  Per- 
foration may  occur,  giving  rise  to  circumscribed  periportal  abscesses  or 
to  generalized  peritonitis  (see  also  Acute  Infectious  Cholecystitis.,  p.  854). 

More  Remote  Effects  of  Gall-stones. — These  will  be  spoken 
of  under  three  headings : 

1.  Stricture  of  the  duct,  resulting  from  ulceration  and  cicatrization 
produced  by  the  passage  of  a  stone. 

'  International  Medical  Magazine,  Dec,  1899. 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  BY  GALL-STONES.   859 

2.  Intestinal  obstruction,  due  to  impaction  of  gall-stones. 

3.  Biliary  fistulee  resulting  from  perforations. 

1.  Stricture  of  the  Duct. — Obliteration  of  the  common  duct  may  re- 
sult from  the  passage  of  a  gall-stone,  giving  rise  to  ulceration  and  cica- 
trization, or  the  stone  may  become  impacted  and  lead  to  adhesions  and 
permanent  closure  of  the  duct  below  it  (Murchison).  AVhen  due  to  ulcera- 
tion the  seat  of  the  stricture  is  usually  low  down  in  the  common  duct.^ 

Symptoms. — The  symptoms  are  those  of  chronic  obstructive  jaundice 
(Osier).  In  many  cases  there  will  be  an  antecedent  history  of  the  passage 
of  gall-stones.  In  all  cases  in  which  the  symptoms  of  gall-stones  are 
followed  by  permanent  jaundice  without  pain  it  may  be  suspected  either 
that  the  calculus  has  become  firmly  impacted  or  that  it  has  produced 
organic  stricture  or  closure  of  the  duct. 

2.  Intestinal  Obstruction  from  Impaction  of  Gall-stones. — The  ileum 
is  commonly  the  seat  of  obstruction  by  gall-stones,  that  may  give  rise  to 
intussusception  or  cause  ulceration  and  gangrene  of  the  bowel  with  per- 
foration and  fatal  peritonitis.  The  latter  event,  however,  occurs  more 
frequently  when  the  biliary  concretions  are  situated  in  the  cecum.  Rarely 
they  are  found  in  the  appendix,  causing,  as  other  foreign  bodies,  inflam- 
matory changes,  followed  by  ulceration  and  in  many  cases  by  perforation 
and  death.  Cases  of  impaction  in  the  rectum  of  biliary  calculi  have 
been  recorded.     I  have  recently  seen  a  case  with  Dr.   R.  Bruce  Burns. 

Symptoms. — If  the  impaction  occurs  in  the  small  intestine,  the  abdo- 
men becomes  tympanitic  and  tender  on  pressure.  The  contents  of  the 
stomach  are  first  vomited,  followed  by  bile  and  stercoraceous  matter. 
Obstinate  constipation  persists,  and  symptoms  of  peritonitis  develop  and 
continue  until  either  the  impaction  disappears  or  death  ensues.  Ileus, 
the  result  of  biliary  concretions,  is  common  in  females  of  advanced  age. 
The  history  of  previous  acute  attacks  would  tend  to  confirm  the  diagnosis. 
The  pain  is  intense.     The  duration  of  the  last  attack  is  often  short. 

3.  Perforation  may  occur  with  the  establishment  of  fistulous  com- 
munications between  the  gall-bladder  and  stomach,  intestinal  canal,  blad- 
der, vagina,  lungs,  abdominal  parietes,  or  portal  vein.  Fistulae  between 
the  gall-bladder  and  stomach  are  rare,  though  cases  are  recorded  by 
Oppolzer,  Frerichs,  Cruveilhier,  Murchison,  and  others.  Cruveilhier 
states  that  vomited  gall-stones  necessarily  reach  the  stomach  through 
fistulous  tracts,  as  the  passage  through  the  pylorus  would  be  impossible. 

Fistul?e  into  the  duodenum  are  of  much  more  common  occurrence, 
ulceration  taking  place  usually  in  the  fundus  of  the  gall-bladder  and  in 
the  descending  or  third  portion  of  the  duodenum  :  39  cases  are  recorded 
of  fistulous  communication  with  the  colon  (Osier).  I  have  reported  a 
fortieth  case."  In  6  of  9  cases  reported  by  Murchison  carcinoma  of  the 
gall-bladder  was  present.  Fistul^e  into  the  urinary  passages  may  occur, 
2  authenticated  cases  being  reported.  The  distended  gall-bladder  may 
come  in  contact  with  the  urinary  viscus,  or  the  stone  may  perforate  into 
the  pelvis  of  the  kidney  and  pass  through  the  ureter  into  the  bladder. 

Fistulous  openings  through  the  abdominal  parietes  are  the  most  com- 
mon of  all  fistulae,  the  place  of  exit  of  the  biliary  concretions  being 

^  In  vol.  ix.  pp.  22  and  130,  Pathologic  Transactions,  two  cases  are  recorded  in  wliich 
the  strictures  were  exactly  similar  to  those  of  the  urethra,  one  being  situated  in  the 
hepatic  duct  of  the  left  lobe  and  the  other  in  the  common  duct. 

^  Clinical  Lecture,  International  Clinics,  vol.  ii.  third  series,  p.  27. 


860  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

usually  in  the  region  of  the  gall-bladder  or  at  the  umbilicus,  to  which 
it  may  be  directed  1)y  the  suspensory  ligament  of  the  liver.  As  many 
as  600  stones  have  been  removed  from  the  gall-bladder  in  this  manner. 
Advanced  life  and  female  sex  are  said  to  be  predisposing  causes. 
Courvoisier's  statistics  show  184  cases,  in  78  of  which  recovery  took 
place. 

Fistulae  into  the  pleura,  bronchi,  and  vagina  have  been  recorded,  but 
are  extremely  rare.  Courvoisier  records  24  cases  of  fistulfe  into  the 
lungs,  only  7  of  which  terminated  in  recovery.  Fauconneau,  Dufoesne, 
Frerichs,  Bristowe,  and  Murchison  mention  cases  of  fistul^e  into  the  portal 
vein,  with  the  presence  of  biliary  concretions  in  the  latter. 

Diagnosis. — I  would  strongly  urge  an  exploratory  celiotomy  as  an 
accurate  means  of  diagnosis  in  obscure  cases. 

Treatment  of  Foregoing  Conditions. — The  indications  for 
treatment  in  cholelithiasis  are  (a)  to  remove  the  cause ;  {b)  to  relieve 
the  paroxysms  of  hepatic  colic ;  and  (d)  to  adopt  palliative  or  radical 
measures  for  the  removal  of  the  stones. 

Preventive  Treatment. — In  this,  as  in  the  treatment  of  jaundice,  diet 
and  iiygiene  play  an  important  part.  The  former  should  be  as  simple  as 
possible,  consisting  largely  of  skimmed-milk,  lean  meat,  eggs,  fruit,  and 
green  vegetables.  Fatty  foods,  sugars,  starches,  and  pastries  are  to  be 
strongly  interdicted.  x\ll  foods  should  be  thoroughly  masticated,  so  as 
to  digest  easily,  and  meals  should  be  taken  at  regular  intervals.  Syste- 
matic exercise  in  the  open  air  is  of  signal  value,  as  it  stimulates  the  flow 
of  bile.  Punkhauer  strongly  recommends  horseback-riding,  believing 
this  to  be  elficient  in  removing  obstructions  in  the  common  duct. 

Among  the  drugs  mostly  used  in  the  treatment  of  this  condition  I 
would  advise  the  following :  Sodium  sulphate,  combined  with  the  extract 
of  taraxacum  (Harley) ;  ox-gall  (Dubney),  in  5-  to  10-gr.  (0.324-0.648) 
doses,  three  times  daily  (to  relieve  flatulency  and  stimulate  the  biliary 
secretion) ;  sodium  salicylate  (gr.  x  to  xv — 0.648  to  0.'J72.  three  times 
daily) ;  and  sodium  chlorate  (gr.  iv  to  vj — 0,259  to  0.388)  three  times  a 
day'(Schiff'). 

The  bowels  should  be  kept  freely  soluble,  constipation  being  carefully 
avoided.  In  my  own  experience  a  dram  (4.0)  of  sodium  phosphate  or 
of  Rochelle  salts  in  concentrated  solution  in  the  morning  on  rising  has 
yielded  excellent  results.  Other  laxatives  whose  use  is  to  be  advised  and 
encouraged  are  cascara  sagrada,  podophyllin.  and  rhubarb. 

Treatment  of  the  Paroxysm  of  Biliary  Colic. — At  the  very  onset  of 
an  attack  of  hepatic  colic  the  prompt  exhibition  of  morphin  or  of  codein 
may  greatly  mitigate  an  attack.  The  former  may  be  given  hypodermi- 
cally  in  |-  to  \-gy-  (0.008-0.016)  doses  every  hour  until  relief  follows ; 
the  latter  is  exhibited  by  the  mouth  in  doses  of  1  gr.  (0.0648)  every 
hour.  Inhalations  of  chloroform,  with  morphin  hypodermically,  the 
former  being  continued  until  the  latter  has  taken  eflfect,  may  be  regarded 
as  the  typical  ti'eatment  during  an  attack. 

Hot  baths  and  hot  applications  (with  counter-irritation)  over  the  liver 
are  valuable  aids  in  the  treatment  of  hepatic  colic,  being  given  at  a  tem- 
perature of  98°  to  100°  F.  (36.6°  to  37.7°  C),  and  continued  for  twenty 
minutes  if  endurable,  so  as  to  effect  relaxation.  If  cardiac  depression 
results  and  the  pulse  becomes  weak,  the  baths  should  be  discontinued. 


CHRONIC  OBSTRUCTION  OF  THE  DUCTS  BY  GALL-STONES   861 

Hot  flaxseed-poultices,  cloths  wrung  out  of  hot  water,  hot  hop-hags,  or 
turpentine  stupes  may  be  applied  over  the  hepatic  region  until  the  attack 
subsides.     Ice-poultices  have  been  advised  by  Buchetan. 

If  shock  or  syncope  should  develop,  the  body-temperature  must  be 
maintained  by  hot  bottles  or  bricks  placed  in  contact  with  the  surface  of 
the  body,  together  with  strychnin  (gr.  gL — 0.0021),  atropin  (gr.  yi-g-  — 
0.00042),   and  brandy  (1   dram — 4.0)   hypodermically. 

Nausea  and  vomiting  may  be  reduced  by  15-drop  doses  of  spirits  of 
chloroform  every  half  hour ;  also  by  brandy  and  soda-water  or  cham- 
pagne. 

In  mild  cases  sodium  salicylate  (gr.  viij-xv — 0.518-0.972  in  twenty- 
four  hours),  recommended  by  Prevost  and  Binet,  or  codein  (gr.  j),  with 
phenacetin  (gr.  x),  every  few  hours  gives  relief.  The  free  use  of  olive 
oil  or  glycerin  in  hepatic  colic  has  been  followed  by  a  beneficial  effect 
(Rosenberg,  Groodhart).  The  former  is  given  in  quantities  of  4  to  6  oz. 
(128.0-192.0)  by  the  mouth  every  three  or  four  hours,  nausea  being  pre- 
vented by  concealing  the  taste  with  lemon-juice  ;  the  latter,  recommended 
by  Ferrand,  is  given  in  doses  ranging  from  1  to  2  tablespoonfuls,  repeated 
in  the  same  length  of  time.  Both  remedies  are  supposed  to  do  good  by 
increasing  the  flow  of  bile,  thus  forcing  the  stone  outward  toward  the 
bowel. 

Treatment  for  Removal  of  Gall-stones. — The  palliative  treatment 
consists  in  the  administration  of  agents  that  tend  to  increase  the  flow  of 
bile.  The  free  use  of  pure  water  by  the  mouth,  together  with  copious 
rectal  injections  daily  of  cold  water,  has  been  found  eff"ective.  It  may 
be  rendered  alkaline  by  sodium  bicarbonate  or  borate  in  a  3  per  cent. 
solution. 

A  course  of  alkaline  treatment  at  some  of  the  more  noted  mineral 
springs  (Bedford,  Vichy.  Carlsbad)  is  often  attended  with  good  re- 
sults. Perhaps  the  three  best  cholagogues  that  may  be  mentioned  are 
sodium  phosphate,  sodium  cholate.  and  ox-gall.  Olive  oil  and  glvcerin 
also  increase  the  secretion  of  bile. 

Willoughby  reports  a  case  in  which  prompt  recovery  ensued  from  the 
use  of  toluylenediamine  after  three  years  of  unsuccessful  treatment; 
he  began  with  1  grain  daily,  and  increased  to  2  grains. 

Agents  to  dissolve  the  stone  have  been  tried  at  various  times,  among 
them  being  Durandes  method  (turpentine  and  ether),  but,  so  far,  all 
such  methods  of  treatment  have  been  unsuccessful. 

Of  the  various  surgical  measures  for  the  removal  of  gall-stones  the  fol- 
lowing are  the  chief:  (a)  Removal  of  the  stone  from  the  common  duct 
(choledochotomy) ;  (6)  Removal  of  the  stone  from  the  cystic  duct  (cho- 
lecystotomy) ;  [c)  Establishing  a  fistulous  opening  between  the  gall-blad- 
der and  the  bowel  (cholecystenterostomy) ;  (cZ)  Extirpation  of  the  gall- 
bladder (cholecystectomy),  the  latter  operation  giving  a  mortality  of  17 
per  cent.,  according  to  Murphy's  statistics.  And  operative  procedure 
is  indicated  in  infectious  (suppurative)  cholecystitis  as  well  as  in  infec- 
tious (suppurative)  cholangitis. 

The  treatment  of  suppurative  cholangitis  has  for  its  principal  object 
evacuation  and  drainage  of  the  purulent  contents  of  the  biliary  passages. 
To  this  end  cholecvstotomy  should  be  advised  as  a  rule. 


862  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CARCINOMA  OF  THE  BILE-DUCTS. 

The  biliary  passages  may  be  the  seat  of  carcinoma,  which  may 
occur  primarily  and  exist  over  a  long  period  of  time  without  being 
recognized. 

Pathology. — The  gall-bladder,  as  the  result  of  obstruction  of  the 
duct,  is  often  greatly  distended,  measuring  as  much  as  7  inches  (17.7  cm.) 
in  length  (in  a  case  reported  by  Harley)  from  the  entrance  of  the 
duct  to  the  fundus,  and  being  filled  with  a  cloudy  liquid,  somewhat 
resembling  barley-water,  that  contains  flakes  of  epithelium,  granular 
matter,  and  particles  of  inspissated  bile.  If  the  growth  be  near  the 
duodenal  orifice,  the  common  and  cystic  ducts  are  often  greatly  dis- 
tended, and  the  dilatation  may  extend  into  the  hepatic  ducts  and  their 
branches.  The  liver  may  be  enlarged,  and  in  some  instances  presents 
the  secondary  nodules  that  are  characteristic  of  the  disease.  Micro- 
scopically, carcinoma  of  the  gall-bladder  exhibits  marked  variations 
in  different  cases ;  "  it  may  be  either  columnar  or  spheroidal-celled  " 
(Rolleston). 

Ktiology. — The  causes  of  carcinoma  of  the  bile-ducts  are  the  same 
here  as  elsewhere,  and  among  these  the  mechanical  or  inflammatory  theory 
of  Virchow  must  be  accepted.  Tight-lacing  and  mechanical  irritation  by 
gall-stones  are  followed  in  many  instances  by  cancerous  degeneration  ; 
Osier  states  that  "  biliary  calculi  are  present  in  at  least  seven-eighths  of 
all  cases."  Among  other  factors,  heredity  and  age  (after  forty)  play  an 
important  part.  Although  carcinoma  of  the  liver  undoubtedly  occurs 
more  frequently  in  males,  Musser  found  that  out  of  100  cases  of  carci- 
noma of  the  ducts,  15  were  female ;  and  Araes  found  the  ratio  to  be  4 
to  1  in  favor  of  females. 

Symptoms. — The  signs  and  symptoms,  according  to  Harley,  present 
nothing  characteristic  to  distinguish  them  from  other  causes  of  obstruction 
in  the  ducts.  On  palpation  in  the  early  stages  the  gall-bladder  is  found 
moderately  enlarged,  but  later  it  rapidly  undergoes  diminution  in  size. 
Jaundice  becomes  very  intense,  and  remains  permanent.  Throughout 
the  course  of  the  disease  all  the  symptoms  referable  to  chronic  obstruction 
of  the  duct  by  gall-stones  (paroxysmal  pain,  gastric  disturbance,  rise  of 
temperature,  Charcot's  fever)  may  develop. 

Examination  of  the  urine  and  feces  reveals  the  presence  of  bile-pigment 
in  the  former  and  its  absence  in  the  latter.  The  urine  often  shows  the 
presence  of  bile-stained  casts  {vide  Fig.  63). 

Ascites  not  rarely  occurs  during  the  later  stages,  with  the  involvement 
of  surrounding  organs  by  contiguity,  as  well  as  with  the  appearance  of 
secondary  nodules  in  the  liver  and  the  development  of  cachexia. 

Diagnosis. — Carcinomaof  the  biliary  ducts  cannot  always  be  detected 
by  physical  examination.  Distinct  evidence  of  chronic  obstruction  of  the 
duct,  as  persistent  and  intense  jaundice  (which  occurs  in  three-fourths  of 
the  cases),  the  development  of  cachexia  and  the  absence  of  cancerous  in- 
volvement of  other  organs,  however,  will  tend  to  characterize  it.  Often 
a  hard  tumor-mass  is  present  in  the  region  of  the  gall-bladder,  project- 
ing in  the  direction  of  the  umbilicus.  It  should  be  recollected  that  the 
bile-ducts  are  oftener  the  seat  of  the  primary  affection  than  the  liver. 
An  assured  diagnosis,  however,  is  often  impossible. 

Prognosis. — The  prognosis  of  carcinoma  of  the  bile-ducts  is,  like 


STENOSIS   OF  THE  BILE-DUCTS.  863 

that  of  other  organs,  absolutely  fatal,  though  the  course  of  the  disease  is 
not  so  rapid  as  that  of  carcinoma  elsewhere  until  secondary  involvement 
of  the  liver  occurs. 

Treatment. — The  treatment  is  merely  palliative.  Operative  meas- 
ures are  rarely  justifiable,  since  the  disease  is  rarely  recognized  before 
the  liver  becomes  involved.  As  seven-eighths  of  the  cases  follow  obstruc- 
tion of  the  duct  by  gall-stones,  the  preventive  treatment  of  the  latter 
should  be  carefully  observed  whenever  symptoms  of  disordered  liver-func- 
tion manifest  themselves. 

The  treatment  of  the  pain,  anemia,  and  emaciation  will  be  described 
in  the  discussion  of  Carcinoma  of  the  Liver  (vide  p.  899). 


STENOSIS  OF  THE  BILE-DUCTS. 

Stenosis  may  result  from  any  of  the  following  causes :  (a)  Houricl- 
worms  in  the  duct  (rarely) ;  (b)  Foreign  bodies,  as  seeds ;  (e)  Ulceration 
and  cicatrization  following  the  passage  of  gall-stones  (most  commonly) ; 
(d)  Pressure  from  without,  as  from  tumors  (carcinoma  chiefly)  of  the 
head  of  the  pancreas  and  pylorus  (rare) ;  (e)  Abdominal  tumors  ; 
(/)  Aneurysm  of  the  abdominal  aorta  or  of  the  celiac  axis  (rare);  (g) 
Secondary  enlargement  of  the  lymphatics  of  the  liver  (common) ;  (A) 
More  rarely  in  man  than  in  the  lower  animals  distoma  hepaticum  of 
liver-flukes  and  echinococci  ;  (/)  Adhesions  due  to  chronic  peritonitis. 

Pathology. — If  the  stenosis  is  of  recent  origin,  the  liver  is  enlarged 
and  shows  more  or  less  congestion,  with  some  increase  of  the  connective- 
tissue  elements.  The  substance  is  firmer  than  normal,  the  color  varying 
from  an  olive-green  to  a  deep  bronze.  If,  however,  the  obstruction  be 
of  long  standing,  the  presence  of  the  dilated  intra-hepatic  ducts  and  the 
increase  of  connective  tissue  cause  secondary  atrophy  of  the  hepatic 
cells,  with  a  diminution  in  the  size  of  the  organ. 

Symptoms. — The  symptoms  vary  greatly  according  to  the  cause  of 
the  stenosis,  but  in  the  main  they  are  those  of  chronic  obstruction  of  the 
duct — viz.  paroxysmal  pain  in  the  region  of  the  liver,  referred  to  the 
right  shoulder;  jaundice  of  varying  intensity,  but  gradually  deepening 
after  each  attack  ;  and  gastric  disturbance,  with  ague-like  paroxysms 
(fever  and  sweating),  the  latter  being  most  frequently  met  with  in  occlu- 
sion from  gall-stones. 

Diagnosis. — The  pathognomonic  symptoms  determining  the  nature 
of  the  stenosis  are  very  often  wanting,  and  the  diagnosis  is  rendered  cor- 
respondingly difficult.  On  the  other  hand,  stenosis  or  complete  occlusion 
of  the  bile-passages  calls  for  diagnosis  principally  on  account  of  the 
special  cause  or  causes  of  the  given  case. 

When  the  condition  is  due  to  lumhricoid  worms  reflex  symptoms 
usually  appear,  as  pruritus  of  the  nose  and  anus,  grinding  of  the  teeth 
during  sleep,  and  convulsions. 

In  carcinoma  of  the  head  of  the  'pancreas  or  the  pylorus  pressing  on 
the  ducts  the  growth  may  be  detected  by  palpation,  together  with  a  rec- 


864  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ognition  of  other  more  or  less  characteristic  features  {vide  infra,  p.  911), 
and  the  rapid  course  of  the  disease. 

Abdominal  ancun/sm  may  give  rise  to  obstruction  of  the  duct  Avithout 
being  evidenced  by  physical  signs.  Usually,  however,  "when  the  saccula- 
tion presses  against  the  bile-duct,  the  throbbing  in  the  epigastrium,  the 
tumor  (which  can  often  be  grasped),  and  the  expansile  pulsation  on  pal- 
pation will  tend  to  establish  the  cause  of  the  obstruction. 

When  due  to  cancerous  nodules  in  the  liver  there  is  usually  a  history 
of  primary  carcinoma  of  the  stomach,  mammary  gland,  rectum,  or  of  one 
of  the  pelvic  viscera.  Osier  records  a  case  in  which  jaundice  (thought  to 
have  been  catarrhal  in  origin)  developed  seven  weeks  previously.  On 
careful  examination  "  a  small  nodule  was  detected  at  the  umbilicus,  which 
on  removal  proved  to  be  scirrhus." 

When  the  stenosis  is  due  to  ideeration  following  the  passage  of  gall- 
stones, the  history  of  biliary  colic  and  of  the  presence  of  calculi  in  the 
dejecta,  and  the  paroxysmal  pain  with  jaundice  and  intermittent  fever, 
will  serve  to  establish  the  cause. 

If  the  fever  be  of  the  continued  type  and  the  liver  uniformly  enlarged, 
with  the  development  of  jaundice,  the  case  is  probably  one  of  liypertro-. 
pliic  cirrhosis  ;  whereas  if  the  enlargement  be  progressive  and  nodules 
can  be  detected  on  palpation  in  addition  to  the  appearance  of  cachexia 
and  jaundice,  carcinoma  is  undoubtedly  present. 

Physical  signs  aid  but  little  in  the  diagnosis,  as  obstruction  of  the 
common  duct  is  usually  unattended  by  any  great  enlargement  of  the 
gall-bladder. 

In  many  cases  only  by  remembering  the  various  causes  and  elim- 
inating them  carefully,  one  by  one,  can  the  diagnosis  be  positively 
made. 

Prognosis. — It  may  be  said  of  the  prognosis,  as  of  the  symp- 
toms, that  both  vary  according  to  the  cause  of  the  stenosis.  Gen- 
erally speaking,  the  outlook  is  rather  grave,  since  many  of  the  causa- 
tive conditions  are  fatal.  If  the  obstruction  is  due  to  cicatricial 
contraction,  the  prognosis  is  guardedly  favorable  as  to  life,  but  hope- 
less as  to  recovery.  If  the  obstruction  is  permanent,  the  case  ends 
fatally. 

Treatment. — The  treatment  of  occlusion  of  the  bile-ducts  varies 
according  as  it  is  due  to  cicatricial  contraction  following  ulceration  or  to 
foreign  bodies  (seeds  or  lumbricoid  worms),  or  to  gall-stones  or  tumors 
pressing  upon  or  involving  the  ducts  or  adjacent  organs  (pancreas, 
pylorus).  If  the  stenosis  folloAvs  ulceration  in  the  duct,  and  is  sufficient 
to  cause  almost  complete  occlusion  with  biliaiy  retention,  the  operation 
of  cholecystenterostomy  may  become  necessary  in  order  to  prevent  dila- 
tation of  the  gall-bladder  with  resorption  of  bile. 

Foreign  bodies  in  the  duct  may  be  removed  by  free  purging,  aided  by 
the  liberal  use  of  alkaline  mineral  waters.  In  critical  cases  the  operation 
of  cholecystotomy  has  been  practised. 

Gall-stones  form  the  most  frequent  cause  of  stenosis,  and  the  treat- 
ment, both  for  the  prevention  and  removal  of  calculi,  has  already  been 
described  in  the  discussion  of  Biliary  Calculi  {vide  p.  859). 


ICTERUS  NEONATORUM.  865 

ICTERUS  NEONATORUM. 

Definition. — Jaundice  occurring  in  the  new-born.  This  may  be 
either  pathologic  or  physiologic — a  slight  tinting  of  the  skin  occurring 
quite  commonly  in  the  new-born. 

Pathology. — The  morbid  anatomy  of  the  pathologic  form  varies 
with  the  cause  of  the  jaundice.  The  secretion  of  bile,  like  the  secretion 
of  urine,  begins  long  before  birth,  and  Zweifel  has  found  bile-pigment 
and  bile-acids  in  the  contents  of  the  intestines  of  a  three-months'  fetus. 
Hence  children  may  be  born  laboring  under  an  attack  of  well-marked 
jaundice. 

In  well-marked  cases  of  pathologic  jaundice  the  skin  presents  a  deep 
greenish-yellow  hue.  The  internal  tissues  are  also  stained.  Knop- 
fermacher  has  studied  the  condition  of  the  blood,  and  found  that  the 
red  cells  presented  no  signs  of  destruction,  but  rather  of  active  new- 
formation. 

Ktiology. — Of  the  physiologic  forms,  the  following  are  the  main 
causes  :  1.  The  ductus  venosus  may  remain  patulous,  allowing  some  of 
the  portal  blood,  containing  bile,  to  flow  into  the  systemic  circulation 
(Quincke).  2.  Diminished  pressure  in  the  portal  vessels  from  ligation 
of  the  umbilical  vein  causes  increased  tension  in  the  hepatic  capillaries 
and  absorption  of  bile. 

Pathologic  Icterus. — The  causes  are  the  following  :  (a)  Congenital 
stricture  or  absence  of  the  duct ;  (b)  Syphilitic  disease  of  the  liver ;  (c) 
Septic  processes  set  up  by  infection  through  the  umbilical  vein. 

Symptoms. — In  physiologic  jaundice  the  skin  is  tinted  greenish- 
yellow,  resembling  somewhat  that  of  chlorosis.  The  mucous  membranes 
are  pale  and  the  conjunctivae  pearly-white.  The  pulse  is  feeble  and  some- 
times rapid.  Auscultation  over  the  base  of  the  heart  often  reveals  a  soft 
systolic  murmur  transmitted  to  the  vessels  of  the  neck  and  associated  with 
a  venous  hum.  According  to  Murchison,  false  or  physiologic  jaundice 
differs  from  the  true  or  pathologic  form  in  that — 1.  The  conjunctiva  are 
of  a  natural  color ;  2.  The  urine  is  free  from  bile-pigment ;  3.  The  yel- 
low color  gradually  fades  from  the  skin  after  a  few  days ;  4.  The  child  is 
quite  well  and  the  bowels  are  acting  properly. 

In  jjathologic  jaundice  the  skin  and  conjunctivge  are  more  or  less  in- 
tensely icteroid,  the  urine  is  loaded  with  bile-pigment,  while  the  feces  are 
of  the  pipe-clay  variety.  Hemorrhage  from  the  cord  may  occur  and  de- 
struction of  life  may  be  rapidly  accomplished,  or  the  condition  may  last 
for  some  weeks  without  serious  impairment  of  the  general  health,  with 
final  recovery. 

Treatment. — In  the  milder  cases  calomel  in  minute  doses,  combined 
with  lactopeptin  and  sodium  bicarbonate,  can  be  recommended.  In  ma- 
lignant cases  treatment  is  of  no  avail. 

55 


866  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

VASCULAR  (CIRCULATORY)  AFFECTIONS  OF  THE 

LIVER. 

ANEMIA. 

The  physical  symptoms  of  this  condition  are  absolutely  nil,  and  its 
existence  only  discoverable  postmortem.  Its  most  common  causes  are 
those  of  general  anemia,  fatty  and  amyloid  degeneration. 

HYPEREMIA. 

Definition. — An  excess  of  blood  in  the  liver.  This  may  be  of  two 
varieties :   {a)  active  and  {h)  jMSsive,  the  latter  being  the  more  common. 

ACUTE    HYPEREMIA. 
{Active  Congestion.) 

Definition. — An  excess  of  arterial  blood  in  the  liver. 

!^tiology. — Among  the  common  causes  are  rich  living,  sedentary 
habits,  alcoholism,  traumatism,  acute  infectious  diseases  (typhus,  typhoid), 
and  pernicious  malaria.  The  condition  may  also  be  vicarious,  due  to  a 
sudden  cessation  of  menstruation  or  of  hemorrhage  in  other  parts  of  the 
body.  A  'physiologic  condition  is  the  temporary  hyperemia  that  occurs 
during  the  ingestion  of  a  full  meal. 

Symptoms. — There  are  no  symptoms  characteristic  of  this  condition ; 
those  present  in  the  different  cases  are  varied  and  referable  to  disturb- 
ances of  other  viscera,  as  in  coexisting  cardiac  hypertrophy  or  gastro- 
intestinal catarrh.  Often,  however,  there  is  a  sense  of  fulness  and  dis- 
tress in  the  right  hypochondrium  after  eating,  with  tenderness  on  palpa- 
tion over  the  lower  margin  of  the  organ. 

Prognosis  and  Course. — It  is  impossible  to  make  any  definite  state- 
ment as  to  the  course  and  prognosis  of  active  hyperemia,  these  depending 
wholly  upon  the  cause  of  the  affection.  When  due  to  errors  of  diet  and 
hygiene  the  condition  is  easily  remedied  ;  the  prognosis  of  hyperemia 
accompanying  hepatic  cirrhosis,  however,  is  decidedly  grave. 

PASSIVE   HYPEREMIA. 
{Passive  Congestion.) 

Definition. — An  increase  of  venous  blood  in  the  liver. 

Pathology. — The  organ  is  enlarged  in  size  and  changed  to  a  deep- 
red  color,  its  substance  being  firmer  than  normal.  The  center  of  the 
lobule  (the  area  of  the  hepatic  vein)  becomes  deeply  pigmented,  the  pe- 
riphery (occupied  by  the  portal  vein)  being  lighter  in  color,  sometimes 
owing  to  fatty  infiltration.  Because  of  its  mottled  appearance  this  has 
received  the  name  of  the  "nutmeg  liver." 

In  long-standing  passive  congestion  there  is  an  increase  of  connective 
tissue,  due  to  a  proliferation  of  round-cells,  causing  atrophy  of  the 
parenchyma.  The  blood  in  the  central  capillaries  becomes  altered,  the 
capillaries  themselves  are  distended,  and  brown  pigment  is  deposited 
about  the  center  of  the  lobules.  The  organ  becomes  very  much  darker 
in  color,  and  to  this  condition  the  name  "cyanotic  induration"  or 
"cardiac  liver"  has  been  given.     Later,  contraction  of  the  connective 


DISEASES  OF  THE  PORTAL    VEIN.  867 

tissue  occurs,  causing  a  diminution  in  the  size  of  the  organ,  and  forming 
the  so-called  "atrophic  nutmeg  liver." 

Ktiologfy. — The  causes  that  lead  to  passive  hyperemia  are  both  heal 
and  general.     Among  local  causes  may  be  mentioned  the  following  : 

1.  Pressure  over  the  portal  area  from  without,  as  from  a  tumor  or  cyst, 

2.  Disease  of  the  walls  of  the  veins,  as  in  syphilitic  phlebitis. 

3.  Coagulation  of  the  blood  in  the  veins  (thrombosis). 
Among  the  general  causes  are — 

1.  Chronic  valvular  disease  affecting  the  right  side.  Passive  hyper- 
emia is  also  common  in  mitral  disease. 

2.  Pulmonary  emphysema  and  cirrhosis  of  the  lung. 

3.  Intrathoracic  tumors,  which  by  their  mechanical  action  cause  an 
increased  pressure  in  the  efferent  branches  of  the  hepatic  veins. 

Symptoms. — Often  the  patient  experiences  a  sensation  oi  fulness 
and  iveigJit  in  the  region  of  the  liver  that  amounts  in  some  instances  to 
actual  ijain.  Jaundice  is  usually  present,  but  varies  in  intensity,  and  is 
due  to  obstruction  of  the  smaller  ducts  by  the  distention  of  the  hepatic 
venules.  Hematemesis  i?,  not  rare,  and  symptoms  of  gastro-intestinal 
disturbance  are  usually  present.  In  marked  cases  the  stools  are  clay- 
colored,  showing  the  absence  of  bile ;  the  urine  is  loaded  with  bile-pig- 
ment ;  and  jaundice  deepens  with  the  development  of  ascites  or  anasarca 
from  portal  obstruction.  On  palpation  the  organ  is  tender  and  increased 
in  size,  extending  in  some  instances  fully  a  hand's  breadth  below  the 
costal  margin.  In  marked  cases  the  whole  organ  pulsates,  owing  to  the 
regurgitation  of  blood  into  the  hepatic  veins  (see  also  p.  619). 

Diagnosis. — The  diagnosis  of  passive  congestion,  jyer  se,  is  often 
very  difficult,  but  w^hen  secondary  to  heart-  and  lung-diseases  it  is  ren- 
dered more  plain. 

The  prognosis  and  treatment  depend  wholly  upon  the  causal 
factors. 


DISEASES  OF  THE  PORTAL  VEIN. 

THROMBOSIS   AND   EMBOLISM. 

Pattiology. — In  the  early  stages  the  clot  presents  a  grayish-red  or 
yellowish  appearance,  and  on  loosening  it  is  found  to  adhere  more  or  less 
closely  to  the  inner  coat  of  the  vein.  Later  it  becomes  a  mass  of  small 
white  fibrin  tightly  adherent  to  the  sides  of  the  blood-vessel,  which  itself 
undergoes  fibroid  change,  giving  rise  to  the  so-called  adhesive  pylephle- 
bitis. Organized  thrombi  are  rarely  found,  except  in  the  smaller  branches 
of  the  portal  area.  If  the  thrombus  obstruct  the  vessel,  collateral  circu- 
lation may  be  established  for  years,  as  in  a  case  recorded  by  Osier.  Septic 
softening,  however,  is  a  very  common  result,  and  most  frequent  of  all  is 
pylephlebitis.  If  a  parietal  or  channelled  thrombus  be  formed,  partial  or 
complete  circulation  may  be  re-established  and  recovery  take  place.  Hem- 
orrhagic infarction  may  take  place,  but  is  very  rare. 

Ktiology. —  Tliroynhi  are  rare  occurrences  in  the  portal  vein.  Among 
the  causes  that  lead  to  their  occurrence,  however,  may  be  mentioned — {a) 
Traumatism  ;  {h)  cirrhosis  ;  {c)  carcinoma  of  the  liver,  involving  the  portal 
area ;  {d)  pressure  from  without,  as  in  proliferative  peritonitis  involving 


868  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  gastro-hepatic  omentum,  alDScesses,  enlarged  glands,  or  impacted  calculi 
pressing  on  the  veins  ;  (e)  it  may  be  occasioned  by  ulcerative  affections  of 
the  bowels  and  appendicitis,  ancl  pylephlebitis  may  precede  its  occurrence ; 
(/)  slowing  of  the  circulation  due  to  splenic  diseases,  such  as  marasmus. 

Symptoms. — Symptoms  may  be  almost  lacking  in  portal  obstruction, 
or  the  condition  may  simulate  cirrhosis  of  the  liver.  In  ordinary  cases 
the  symptoms  are  very  slight,  the  hepatic  circulation,  as  shown  by  Cohn- 
heim  and  Litton,  being  "sufficient  for  the  nourishment  of  the  liver  and 
secretion  of  the  bile"  (Henry). 

If  the  occlusion  be  comjjlete,  edema  follov.ed  by  the  I'apid  development 
of  ascites  may  occur.  In  such  cases  loss  of  strength  is  persistent  and 
progressive,  and  death  may  result  from  exhaustion.  Hemorrhages  due  to 
venous  stasis  may  occur  from  the  nose,  stomach,  and  intestines.  Jaundice 
and  diarrhea  occur  frequently,  the  former  being  the  result  of  obstruction 
to  the  biliary  passages  from  the  same  causes  that  produce  the  thrombosis 
or  the  diminished  pressure  in  the  portal  area.  On  pa^jation  the  liver  is 
found  slightly  enlarged  and  tender  on  pressure,  and  projecting  below  the 
lower  margin  of  the  ribs ;  the  spleen  is  also  enlarged.  Percussion  also 
reveals  enlargement  over  the  splenic  area.  If  ascites  is  present,  percus- 
sion will  reveal  dulness  in  the  flanks,  changing  with  the  position  of  the 
patient ;  and  on  gently  tapping  one  side  of  the  belly-wall,  with  the  hand 
on  the  opposite  side,  a  Avave  of  fluctuation  will  be  felt. 

Diagnosis. — The  diagnosis  of  portal  thrombosis  is  often  extremely 
difficult.  "A  suggestive  symptom,  hoAvever,  is  sudden  onset  of  the  most 
intense  engorgement  of  the  branches  of  the  portal  system  "  (Osier). 

Sequelce. — If  the  emboli  are  septic  in  origin,  an  abscess,  with  all  its 
accompanying  symptoms,  Avill  be  the  result.  Hemorrhagic  infarction 
may  occur,  but  is  very  rare,  since  a  free  anastomosis  exists  between  the 
lobular  plexuses  and  the  hepatic  artery. 

"  Pylethrombosis  may  be  regarded  as  probable  if  no  other  possible 
cause  of  the  portal  obstruction  seems  likely,  and  if  we  are  able  to  discover 
a  cause  for  thrombosis,  like  a  former  attack  of  circumscribed  peritonitis  " 
(Strlimpell). 

The  prognosis  is  always  unfavorable,  although  certain  cases  have 
been  dcnioustrated  by  autopsy  to  have  improved  temporarily. 

Course  and  Duration. — Nothing  definite  can  be  stated  in  regard 
to  the  course  and  duration  of  this  affection,  since  these  depend  entirely 
upon  the  cause. 

Treatment. — The  symptoms  resulting  from  portal  congestion,  due  to 
thrombi  in  the  portal  vein,  are  those  described  under  Cirrhosis  of  the 
Liver,  and  the  treatment  is  identical  with  that  of  interstitial  hepatitis. 
In  rare  instances  septic  emboli  give  rise  to  abscesses  that  are  usually 
multiple ;  when  these  occur  the  treatment  is  purely  symptomatic. 

SUPPURATIVE   PYLEPHLEBITIS. 

Definition. — A  purulent  inflammation  of  the  portal  vein  or  its 
branches. 

Pathology. — If  noted  in  the  early  stages,  the  coats  of  the  portal 
vein  are  distended  and  thickened,  and  the  connective  tissue  surrounding 
the  portal  area  is  infiltrated  and  the  seat  of  minute  ecchymoses.  The 
inflammation  usually  originates  in  the  smaller  veins  of  the  portal  system 


SUPPURATIVE  PYLEPHLEBITIS.  869 

or  in  tlie  hepatic  iDranclies  of  the  vein  itself;  the  main  trunk  is  attacked 
least  often.  Numerous  thrombi  are  found  obstructing  the  vein  and  its 
branches,  which  finally  undergo  suppuration.  From  these,  emboli  enter 
the  circulation  and  are  carried  to  all  parts  of  the  liver,  forming  meta- 
static abscesses.  In  advanced  cases  the  whole  organ  (especially  the  pe- 
ripheral parts)  becomes  infiltrated  with  pockets  of  pus,  that  communicate 
with  the  portal  vein  or  its  branches,  and  extend  in  some  instances  into 
the  mesenteric  or  gastric  veins.  A  single  large  abscess  may  be  present, 
but  multiple  abscesses  are  the  rule.  The  contents  may  be  very  fetid  and 
bile-stained,  or,  as  in  many  instances,  they  may  be  composed  of  thick, 
creamy  laudable  pus.  From  this  focus  of  suppuration  embolic  abscesses 
may  extend  to  the  lungs,  brain,  kidneys,  and  joints. 

The  macroscopic  appearance,  with  the  organ  in  situ,  is  sometimes 
practically  normal.  The  liver  may  present  a  uniform  enlargement,  the 
surface  being  of  normal  color  and  the  capsule  non-adherent.  More  com- 
monly, however,  the  cortex  presents  a  mottled  appearance,  and  numerous 
yellowish-white  spots  ai'e  seen  beneath  the  capsule. 

Ktiology. — The  most  frequent  source  of  purulent  pylephlebitis  is 
appendicitis  with  abscess.      Rarely  the  disease  arises  idiopathically. 

Among  other  causes  are  the  following  :  (a)  A  secondary  (becoming  a 
general)  pyemia,  (b)  Ulceration  of  the  intestines,  occurring  in  dysentery 
and,  more  rarely,  in  typhoid  fever,  (c)  Gastric  ulcer,  (d)  Pelvic  ab- 
scess ;  abscess  of  the  spleen,  (e)  Specific  infection  through  the  umbili- 
cus, occurring  in  the  new-born. 

Symptoms. — The  symptoms  vary  according  as  to  whether  the  case 
remains  one  of  suppurative  pylephlebitis  or  terminates  in  hepatic  ab- 
scess. If  the  condition  is  part  of  a  general  ]jyemia,  the  symptoms  refer- 
able to  the  liver  may  be  almost  negative.  The  liver  is  usually  enlarged, 
and  tender  on  pressure,  the  enlargement  being  most  marked  when  an  he- 
patic abscess  exists.  Though  j^ain  is  present,  in  many  cases  it  is  not  a 
marked  feature  ;  it  is  frequently  referred  to  the  epigastrium,  and  may 
radiate  laterally  or  downward.  Percussion  in  the  left  axillary  line  shows 
splenic  enlargement,  and  the  organ  can  in  some  instances  be  felt  below 
the  costal  margin,  constituting  the  '•^  acute  splenic  tumor"  of  septico- 
pyemia. 

The  fever  is  of  an  irregular  septic  type,  the  elevation  in  temperature 
is  accompanied  by  rigors  or  chills  and  followed  by  profuse  sweating. 
Jaundice  of  varying  intensity  is  present,  although  usually  it  is  not 
pronounced,  the  complexion  being  merely  doughy  or  muddy.  Diar- 
rhea is  not  an  infrequent  symptom  of  this  condition.  Nausea  and 
vomiting  are  often  marked.  As  the  case  advances  the  pulse  becomes 
rapid  and  small,  and  delirium  develops,  followed  by  stupor,  coma,  and 
death. 

Duration  and  Prognosis. — The  duration  of  suppurative  pylephle- 
bitis is  usually  from  one  to  three  or  four  weeks  or  longer.  The  prognosis 
is  absolutely  fatal. 

Diagnosis. — The  diagnosis  of  suppurative  pylephlebitis  is  sometimes 
extremely  difiicult,  unless  the  case  is  complicated  by  hepatic  abscess,  as 
enlargement  of  the  liver  is  not  constant  in  the  former  condition.  The 
etiology,  septic  temperature,  enlargement  of  the  spleen,  jaundice,  and  pain 
in  the  region  of  the  liver  would  all,  hoAvever,  point  to  this  afi"ection. 

The  differential  diagnosis  of  hepatic  abscess  will  be  spoken  of  later. 


870  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

Treatment. — Unfortunately,  the  treatment  of  suppurative  pylephle- 
bitis can  only  be  palliative.  Surgical  measures  are  rarely  curative,  unless 
the  abscess  is  single  and  localized  and  shows  signs  of  pointing.  The 
circulation  is  to  be  supported  by  free  stimulation.  The  leading  symp- 
toms should  be  met  as  they  arise. 

STENOSIS. 

Obstruction  of  the  portal  vein  may  be  due,  as  before  mentioned,  to  (a) 
thrombosis ;  (h)  cicatricial  contraction  from  cirrhosis  or  syphilis  of  the 
liver ;  and  (c)  tumors  pressing  on  the  portal  area.  The  first  cause  is  the 
more  common,  chiefly  because  mechanical  obstruction,  by  causing  a  stasis 
of  the  blood-current,  induces  the  formation  of  a  thrombus. 

The  Sytnptoms  of  portal  stenosis  may  be  tiil ;  if  the  stenosis  occurs 
slowly,  the  hepatic  artery  furnishes  sufficient  blood  to  carry  on  the  func- 
tions of  the  liver,  the  compensatory  circulation  being  established  by 
means  of  the  systemic  vessels.  If  due  to  thrombosis,  the  symptoms  of 
portal  engorgement  appear  suddenly  with  the  development  of  edema  and 
ascites.     The  liver  is  rarely  enlarged  in  this  condition. 

Prognosis. — This  depends  wholly  upon  the  cause  of  the  affection. 
Thrombi  in  the  portal  vein  often  give  rise  to  a  suppurative  pylephlebitis, 
terminating  in  hepatic  abscess ;  tumors  are  rarely  accessible ;  whereas 
fibroid  conditions  of  the  liver  causing  cicatricial  contraction  are  incurable. 
As  a  rule,  the  prognosis  may  be  said  to  be  guardedly  unfavorable. 


AFFECTIONS  OF  THE  HEPATIC  BLOOD-VESSELS. 

OsLER  records  a  case  of  stenosis  of  the  hepatic  veins  that  was  asso- 
ciated with  fibroid  obliteration  of  the  inferior  vena  cava,  with  a  greatly 
enlarged  and  cirrhotic  liver. 

Among  other  affections  of  the  hepatic  veins  are  [a)  Emboli,  orig- 
inating from  a  thi'ombus  in  the  right  auricle,  and  (b)  Dilatation,  from 
stasis  of  the  blood-current  flowing  to  the  right  heart,  due  to  enlarge- 
ment of  the  latter. 

Affections  of  the  hepatic  arteries  are  exceedingly  rare,  but  may  occur 
in  one  of  the  following  forms:  (a)  Aneurysm. — Only  10  or  12  cases  of 
aneurysm  have  been  reported,  [h)  Hypertrophy  and  Dilatation. — These 
may  occur  in  connection  with  general  hepatic  cirrhosis,  the  cicatricial 
bands  obstructing  the  lumen  of  the  artery,  and  causing  thickening  in 
some  places,  and  ampullae,  or  sac-like  dilatations,  in  others,  (c)  Sclerosis. 
— This  may  form  a  j>art  of  a  genei-al  arterio-sclerosis,  though  it  occurs 
oftener  in  connection  with  cirrhosis  or  syphilitic  hepatitis. 


ATROPHY  AND   HYPERTROPHY  OF  THE  LIVER. 

[a)  Atrophy. — Simple  atrophy  of  the  liver  may  result  from  pressure 
(corset-liver),   syphilis,   advanced   cirrhosis,  senility,  and  from  the  toxic 


HEPATIC  INFILTRATIONS  AND  DEGENERATIONS.  871 

action  of  phosphorus,  arsenic,  or  chloroform — all  factors  that  induce 
rapid  fatty  degeneration  with   cell-destru6tion. 

(6)  Hypertrophy  is  of  two  kinds — (1)  true  and  (2)  false.  (1)  True 
hypertrophy  may  be  subdivided  into  simple  and  numerical  (hyperplasia), 
the  latter  referring  to  an  increase  in  the  number  of  the  parenchymatous 
cells,  and  not,  necessarily,  implying  an  increase  in  the  size  of  the  organ. 

The  two  causes  of  simple  hypertrophy  are  active  and  passive  conges- 
tion. Among  the  causes  of  numerical  hypertrophy  may  be  mentioned 
the  following  :  Leukemia,  hypertrophic  cirrhosis,  atrophic  cirrhosis  (hyper- 
plasia), syphilis,  diabetes,  and  malaria. 

(2)  Pseudo-  or  false  hypertrophy  occurs  in  amyloid  and  fatty  infiltra- 
tion, carcinoma,  and  abscess,  and  consists  in  an  increase  in  the  tissues 
least  concerned  in  the  function  of  the  organ. 


HEPATIC  INFILTRATIONS  AND  DEGENERATIONS. 

AMYLOID    INFILTRATION. 
{Waxy,  Lardaceous,  Bacony,  or  Albuminoid  Infiltration ;  Amyloid  Disease.) 

Definition. — A  deposit  in  the  hepatic  connective  tissues  of  a  peculiar 
substance  having  some  of  the  reactions  of,  and  resembling,  starch.  A 
physiologic  example  of  amyloid  infiltration  may  be  found  in  the  corpora 
amylacece  of  the  prostate  gland,  in  which  there  is  a  concentric  arrange- 
ment somewhat  resembling  a  starch-granule. 

Pathology. — The  organ  is  larger  than  normally  and  of  firmer  con- 
sistence. The  edges  are  rounded  and  not  well  defined,  and  the  surface 
is  of  a  light  color,  presenting  in  some  instances  a  mottled  appearance. 
On  section  the  surface  presents  a  grayish-brown,  glistening  appearance, 
which  when  scraped  fails  to  exude   oil-droplets,   as   in   the  fatty  liver. 

On  microscopic  examination  the  connective-tissue  trabeculse  and  the 
intima  and  media  of  the  capillary  walls  (the  starting-points)  are  chiefly 
aff'ected,  the  lumen  of  the  latter  being  lessened ;  this  decreases  the  blood- 
supply  to  the  liver,  and  often  directly  induces  fatty  degeneration.  The 
hepatic  cells  may  be  atrophied  and  show  evidences  of  fatty  change. 
Amyloid  material  is  structureless,  and  appears  in  small  cloudy  masses 
under  the  microscope.  Chemically,  it  contains  small  amounts  of  potassium 
and  phosphorus  and  an  excess  of  sodium  and  chlorin. 

il^tiology. — Amyloid  infiltration  may  occur  primarily  in  the  liver, 
but  it  is  often  a  part  of  a  general  infiltration,  affecting  especially  the 
spleen  [sago  spleen)  and  kidneys.  It  is  also  found  in  some  syphilitic 
scars   and  in  certain  tumors  and  old  thrombi. 

Dickinson  believes  that  the  deposition  of  amyloid  material  is  due  to  a 
decrease  in  the  alkalinity  of  the  fluid  of  the  body,  the  pus  (in  cases  of 
long  suppuration)  having  removed  a  large  quantity  of  the  natural  potas- 
sium salts.  In  malarial  cachexia,  however,  such  losses  could  not  have 
occurred. 

It  is  a  frequent  sequel  to  long-standing  and  exhausting  suppurating 
and  cachectic  affections,  as  necrosis  of  the  bones,  hip-joint  disease,  and 


872 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


pyelitis ;  "  especially  is  this  the  case  when  they  occur  in  an  hereditary 
tuberculous  or  syphilitic  constitution  "  (Harley).  Amyloid  disease  may 
also  complicate  chronic  malaria.  In  children  tuberculosis  and  rachitis 
not  uncommonly  contribute  to  amyloid  infiltration. 

Tests  and  Characteristics  of  Aynyloid  3Iaterial. — Although  of  animal 
origin,  amyloid  matter  is  closely  related  to  a  vegetable  albuminoid  starch. 
It  is,  however,  slow  to  decompose,  and  is  not  acted  on  by  weak  acids  and 
alkalies,  whereas  strong  alkalies  dissolve  it.  lodin  gives  a  blue  color 
upon  the  addition  of  sulphuric  acid.  Lugol's  solution  (the  aqueous  solu- 
tion of  iodin  and  potassium  iodid)  gives  a  brown  tint  to  amyloid  liver- 
substance  and  stains  ordinary  hepatic  tissues  a  yellow  color.  Gentian- 
violet  gives  a  reddish  or  pinkish  hue  to  amyloid  substance,  while  normal 
tissue  is  stained  blue. 

The  following  is  taken  from  Harley's  Comparative  Table  of  Amyloid 
Tests  : 

Starch.  Amyloid.  Cholesterin. 


Water. 

Dissolves    on 

boil- 

Dissolves    on    boil- 

Unchanged. 

Ether. 

in.ii. 
Insoluble. 

ing. 
Insoluble, 

Dis.solves. 

Heat. 

Dries  up. 

Dries  up. 

Melts. 

Sulphuric  acid. 

Chars. 

Swells  up,  reddish- 
brown. 

Becomes    green, 
blue,  etc. 

Iodin. 

Becomes  blue. 

Blue  color  with  II.^- 

Remains      un- 

Sulphate of  indigo. 

S0^,  which  is  de- 
stroyed by  excess. 
Amyloid      tissue 
soaked    in    it   be- 
comes a  brilliant 
blue,    while  with 
ordinary  liver-tis- 
sues   the    blue 
fades    to    a    pale 
green. 

changed. 

Symptoms. — When  amyloid  disease  occurs  in  children  the  subjects 
are  poorly  developed  and  puny,  the  complexion  is,  as  a  rule,  muddy  or 
sallow,  and  the  abdomen  usually  prominent.  Occasionally  the  skin  is 
exceedingly  transparent.  At  any  age  (^astro-intestinal  symptoms  occur, 
prominent  among  which  are  marked  constipation  and  a  capricious  appe- 
tite. Mental  phenomena,  as  impairment  of  memory  and  inability  to  con- 
centrate, are  not  unusual  in  this  disease.  Pain  about  the  hepatic  region 
is  a  rare  symptom.  The  spleen  is  usually  enlarged  from  coexistent 
amyloid  infiltration.  The  urine  often  contains  albumin  (globulin  is 
nearly  always  present)  and  waxy  tube-casts  ;  it  is  of  high  specific  gravity, 
and  is  usually  scanty  and  dark  colored.  The  physical  signs  show  an  increase 
in  the  area  of  hepatic  dulness ;  the  edges  of  the  organ  extend  below  the 
costal  margin  and  have  a  rounded  outline.  Sometimes,  however,  the 
edge,  even  in  a  very  great  enlargement,  is  sharp  and  large.  Wilks 
speaks  of  an  amyloid  liver  Aveighing  14  lbs. — 6.35  kgms.  (Osier).  In 
rare  instances  the  liver  is  reduced  in  size. 

Diagnosis. — The  foregoing  symptoms  and  phA'sical  signs,  in  con- 
junction with  an  ordinarily  clear  etiology,  are  sufficient  to  establish  the 
diagnosis. 

Treatment. — As  amyloid  disease  is  almost  invariably  a  secondary 


FATTY  INFILTRATION  OF  THE  LIVER.  873 

condition,  the  treatment  must  be  directed  to  the  removal  of  the  primary 
cause,  whether  syphilis,  tuberculosis,  or  rickets.  The  diet  should  consist 
of  nitrogenous  or  animal  substances,  with  a  minimum  amount  of  fatty  or 
farinaceous  foods.  French  rolls  and  bran-  or  gluten-bread  are  allowable, 
together  with  lean  meat  and  green  vegetables.  Stimulants  are  to  be 
strictly  avoided.  Moderate  exercise,  with  the  judicious  use  of  Turkish 
(hot-air)  and  Russian  (hot-vapor)  baths,  is  also  of  great  value. 

Many  drugs  are  mentioned  in  the  treatment  of  this  disease,  among 
the  more  important  being  the  ammonium  salts  (the  chlorid,  gr.  v  to  x — 
0.324  to  0.648 — three  or  four  times  a  day),  and  other  alkalies,  together 
with  tonics  and  laxatives. 

When  syphilis  has  been  clearly  established  as  an  etiologic  factor  of 
the  disease,  the  tincture  of  iodin  in  10- to  15-minim  (0.666-0.999)  doses, 
well  diluted,  has  been  recommended  to  be  given  three  or  four  times  daily. 
Cod-liver  oil  as  a  nutritive  has  been  tried  with  good  effect.  Of  tonics, 
the  dilute  mineral  acids,  given  in  moderate  doses  over  a  long  period  of 
time,  have  probably  achieved  the  best  results. 

FATTY   INFILTRATION. 

Definition. — A  deposit  of  fat  in  the  hepatic  tissues  due  to  the  in- 
gestion of  fats  and  albuminates. 

Pathology. — The  infiltration  occurs  often  in  localized  areas,  and 
may  be  so  intense  that  the  organ  when  cut  presents  a  shiny,  oily  ap- 
pearance. The  liver  is  often  evenly  enlarged,  and  may  weigh  tAvelve  to 
fifteen  pounds.  The  edges  are  rounded  and  the  substance  less  firm 
than  normally.  Portions  of  the  liver-substance  float  in  water,  being  of 
low  specific  gravity.  The  jcolor  is  light-yellow  or  grayish.  On  micro- 
scopic examination  the  protoplasm  of  the  cell  is  seen  to  be  pushed  to 
one  side  by  the  fat-droplets,  which  tend  to  coalesce.  When  the  fat  is 
removed  the  cells  resume  their  normal  outline  and  appearance. 

!^tiology. — {a)  Fatty  infiltration  may  form  part  of  a  general  obesity 
or  it  may  follow  excessive  over-eating  or  sedentary  habits,  (b)  It  often 
occurs  in  wasting  diseases,  as  carcinoma,  syphilis,  chronic  malaria,  and 
tuberculosis,  and  often  accompanies  fatty  degeneration. 

Symptoms. — The  subjective  symptoms  of  fatty  infiltration  may  be 
entirely  wanting,  since  the  function  of  the  liver  is  not  impaired  to  any 
extent.  When  they  are  present  progressive  anemia  and  debility/  are 
noted,  and  are  accompanied  by  nervous  irritability  and  insomnia.  In 
marked  cases  the  cardiac  rhythm  is  disturbed,  causing  a  feeble  and 
irregular  impulse. 

The  phi/ steal  sigyis  are  usually  well  defined,  and  the  area  of  hepatic 
dulness  is  uniformly  increased,  extending  in  some  instances  as  low  as 
the  umbilicus.  The  enlargement,  however,  is  not  so  great  as  in  amyloid 
disease. 

Differential  Diagnosis. — Fatty  infiltration  of  the  liver  is  not  apt 
to  be  mistaken  for  any  other  aifection  of  this  organ.  The  occurrence 
of  general  obesity,  together  with  an  entire  absence  of  symptoms  of 
obstruction  to  the  portal  vessels  or  bile-ducts  or  of  other  evidences  of 
fatty  degeneration  (particularly  feeble  heart-sounds),  Avill  help  to  distin- 
guish it  from  this  latter  condition.  The  etiologic  factors  above  men- 
tioned will  also  aid  in  the  differentiation. 


874  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Prognosis. — This  is  decidedly  favorable,  as  the  function  of  the  liver 
in  many  instances  is  not  impaired  in  the  slightest  degree. 

Treatment. — As  the  disease  is  of  gradual  development  and  long 
duration,  a  modification  of  the  diet  constitutes  the  first  essential  of  the 
treatment.  That  prescribed  under  the  Treatment  of  Amyloid  Liver  is 
admirably  suited  to  this  aflfection.  Saccharine  and  farinaceous  articles 
of  food  (potatoes,  oatmeal,  and  sweetmeats)  must  be  eschewed.  Wheat- 
bread  must  be  partaken  of  sparingly,  and  in  its  place  gluten-  and 
bran-bread  or  crusts  of  French  rolls  should  be  used.  Fish,  lean  meats, 
fresh  vegetables,  and  fruits  are  also  allowable.  Alcoholic  beverages 
must  be  interdicted. 

Graduated  daily  exercise  and  Turkish  or  Russian  baths,  judiciously 
used,  are  important  factors  in  the  treatment.  Medicinally,  the  salts  of 
the  alkalies  are  highly  recommended :  sodium  sulphate  (in  dram — 4.0 — 
doses,  taken  on  an  empty  stomach)  and  ammonium  carbonate  (gr.  xv 
to  XXX — 1.0  to  2.0 — in  twenty-four  hours). 


FATTY  DEGENERATION  OF    THE  LIVER. 

Definition. — A  conversion  of  the  albuminates  of  the  cells  into  fat ; 
it  is  characterized  anatomically  by  a  destruction  of  the  liver-substance, 
with  atrophy  of  the  organ,  and  clinically  by  biliary,  gastro-intestinal, 
cardiac,  and  renal  symptoms. 

Pathology. — On  examining  a  liver  that  is  the  seat  of  marked  fatty 
degeneration  the  organ  is  found  smaller  than  normally,  and  the  sub- 
stance is  light  yellow  in  color,  soft,  pliable,  and  easily  torn.  On  section 
the  relation  between  the  interlobular  connective  tissue  and  the  acini  is 
lost,  the  latter  being  replaced  by  fat-cells  and  oil-droplets.  Scattered 
areas  of  pigmentation  may  be  observed  throughout  the  organ. 

Microscopically,  the  cells  lose  their  shape  and  become  globular  ;  the 
nuclei  tend  to  coalesce,  and  finally  disappear,  together  with  the  cell-wall, 
giving  rise  to  compound  globule-cells,  which  do  not  tend  to  coalesce  and 
are  stained  black  by  osmic  acid.  Crystals,  granular  debris,  Lener's 
spheres,  cholesterin,  tyrosin,  and  phosphatic  crystals  are  also  found  in 
this  form  of  granular  chanjje. 

Ktiology. — The  following  are  among  the  recognized  causes  of 
the  affection:  {a)  The  excessive  use  of  beer  or  alcoholic  liquors,  (b)  It 
may  be  a  sequence  of  amyloid  disease,  and  hence  result  from  any  of  the 
causes  of  the  latter,  (c)  Diminution  of  the  oxygen-supply  to  the  tissues, 
occurring  in  phosphorus-,  chloroform-,  or  arsenic-poisoning  and  in  certain 
wasting  diseases  (carcinoma,  phthisis,  and  chronic  dysentery),  (d)  It 
may  occuv  as  a  complication  in  the  grave  anemias,  especially  pernicious 
anemia,  and  in  acute  infectious  diseases  and  the  intoxications ;  also  as  a 
part  of  the  pathology  of  acute  yellow  atrophy  of  the  liver. 

Symptoms. — I  feel  convinced  that  partial  or  mild  cases  of  fatty  de- 
generation of  the  liver  present  no  morbid  symptoms  of  diagnostic  import. 
Pain,  jaundice,  and  ascites  may  occur  separately  or  conjointly,  but  form 
the  exception  rather  than  the  rule.     The  severe  forms  are  characterized 


PERIHEPATITIS.  875 

by  the  symptoms  seen  in  phosphorus-poisoning  and  acute  yellow  atrophy, 
to  the  discussion  of  which  the  reader  is  referred. 

Complications. — The  disease  may  be  complicated  with  fatty  change 
in  the  kidneys.  Under  these  circumstances  the  urine  is  diminished  in 
amount,  of  low  specific  gravity,  and  contains  an  abundance  of  albumin, 
fatty  or  oily  casts,  and  crystals  of  cholesterin,  leucin,  and  tyrosin.  In 
marked  cases  there  is  a  yqyj  feeble  and  irregular  cardiac  impulse,  accom- 
panied by  attacks  o^  vertigo  and  syncope,  the  latter  symptoms  indicating 
beginning  degeneration  of  the  cardiac  muscle,  Edema  of  the  lower  ex- 
tremities and  anasarca  may  occur  as  complications  of  this  condition. 

The  physical  signs  elicited  by  paljiatioji  and  percussion  show  increas- 
ing diminution  in  the  size  of  the  liver  as  the  disease  advances. 

Diagnosis. — The  chief  diagnostic  points  of  fatty  degeneration  may 
be  summated  thus :  («)  A  history  of  alcoholism,  of  poisoning  by  drugs 
(arsenic,  phosphorus,  or  chloroform),  or  of  an  acute  infectious  disease 
(acute  yellow  atrophy) ;  {b)  Grave  general  symptoms,  as  albuminuria, 
edema,  ascites,  cardiac  failure,  terminating  often  in  acholia  or  cholemia  ; 
{c)  Progressive  diminution  in  the  size  of  the  organ.  "When  these  occur 
conjointly  the  diagnosis  is  established  beyond  a  doubt. 

Prognosis. — The  prognosis  is  entirely  dependent  upon  the  cause. 
If  due  to  an  excessive  use  of  stimulants,  the  process,  if  recognized  early, 
may  be  arrested  ;  if  associated  with  acute  yellow  atrophy  or  other  infec- 
tious disease,  the  outlook  is  unpromising. 

Treatment. — The  indications  for  treatment  may  be  divided  into  the 
dietetic,  hygienic,  and  medicinal.  The  same  precautions  regarding  diet 
should  be  observed  as  in  fatty  infiltration.  An  open-air  existence,  short 
of  injurious  exposure,  aided  by  hot  salt-water.  Turkish,  or  Russian  baths, 
under  restriction,  is  sure  to  improve  the  general  condition  of  the  patient. 

The  medicinal  treatment  varies  according  to  the  cause  of  the  disease. 
If  due  to  grave  anemia,  iron  (tinct.  ferri  chlorid.  or  syrup,  ferri.  iodid.) 
may  be  given  in  ascending  doses.  Poisoning  by  drugs  that  produce  fatty 
degeneration  of  the  liver  is  to  be  combated  by  their  respective  antidotes. 
Gastro-intestinal  disturbances,  if  coexistent,  demand  appropriate  treat- 
ment. For  the  latter  Frerichs  recommends  highly  the  salts  of  the  alka- 
lies (sodium  sulphate  in  dram — 4.0 — doses  taken  on  an  empty  stomach 
and  ammonium  carbonate).  x\scites  and  cardiac  asthenia,  when  occurring 
as  complications,  must  be  met  by  suitable  measures. 


PERIHEPATITIS. 

ACUTE    PERIHEPATITIS. 
{ Pyo-pneumothorax  Subplirenicus.] 


Definition. — An  inflammation,  either  suppurative  or  fibrinous,  of 
the  peritoneal  covering  of  the  liver  and  the  corresponding  portion  of 
the  diaphragm. 

Pathology. — The  morbid  changes  may  consist  in  a  purely  plastic 
inflammation,  the  serous  layers  being  thickened,  opaque,  and  covered 
with  a  fibrinous  exudate  leading  to  adhesion.     In  the  majority  of  cases, 


876  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

however,  the  inflammatory  product  is  chiefly  purulent,  and  is  ribboned 
bv  fibrous  bauds  so  as  to  form  circumscribed  areas,  filled  with  pus,  lying 
between  the  liver  and  the  diaphragm  ;  this  constitutes  the  mhphrenic 
abscess.  The  latter  is  found  more  commonly  to  the  right  than  to  the 
left  of  the  suspensory  ligament.  It  may  contain  much  pus  (1  quart — 1 
liter — or  even  more),  which  in  most  cases  is  mixed  with  air  or  gas  de- 
rived from  the  gastro-intestinal  canal.  Rarely,  bilirubin-crystals  are 
found,  betraying  the  presence  of  bile.  If  the  latter  be  present  in  large 
amount,  the  pus  assumes  an  ocher-yellow  hue. 

l^tiolog^T'. — The  iihrinous  variety  may  result  from  the  direct  exten- 
sion of  one  or  other  of  the  acute  forms  of  inflammation  of  the  liver  (ab- 
scess, hydatid  cyst),  from  a  pleurisy  spreading  along  the  lymphatics  in 
the  diaphragm,  or  from  traumatism — particularly  a  blow.  The  suppura- 
tive form  [pyo-pneurnotliorax  suhphrenicus,  Leyden)  may  be  caused  in 
the  same  manner  as  the  former,  but  far  oftener — in  more  than  one-half 
of  the  instances — it  follows  perforation  of  a  gastric  ulcer,  and  far  less 
commonly  perforation  of  a  duodenal  or  colonic  ulcer.  Appendicitis  and 
penetrating  wounds  are  not  infrequent  causes.  Perihepatitis  is  a  grave 
complicating  event  in  carcinoma  (of  the  stomach,  esophagus,  and  intes- 
tines), in  lobar  pneumonia,  and  purulent  pleuritis. 

Symptoms. — Those  of  the  acute  fibrinous  variety  are  either  alto- 
gether missing  or  too  vague  to  admit  of  correct  interpretation.  The 
coappearance.  however,  of  severe />«?'».  increased  on  deep  breathing,  and 
tenderness  over  a  circumscribed  area  either  in  the  right  hypochondrium 
or  the  epigastrium,  after  the  action  of  some  known  cause  or  the  occur- 
rence of  one  of  the  causative  affections,  is  strongly  suggestive  of  this 
form  of  the  complaint.  A  friction-sound  may  at  times  be  heard  below 
the  seventh  rib  in  the  mammillary  and  the  ninth  rib  in  the  axillary 
line,  or  over  the  epigastrium,  as  in  two  cases  in  my  practice.  It  is 
of  short  duration,  and  is  limited  usually  to  the  end  of  inspiration. 
It  must  be  recollected  that  plastic  pleurisy  may  be  an  associated 
condition. 

In  suppurative  perihepatitis  the  symptoms  are  sometimes  screened  by 
those  characterizing  the  special  causative  complaint ;  but  in  my  experi- 
ence, in  cases  due  to  perforation — the  most  common  cause — the  onset  is 
rapid  and  severe,  and  is  marked  by  acute  pain  referred  to  a  circumscribed 
spot  in  the  hepatic  region,  great  tenderness,  rapid,  embarrassed,  and 
jyainful  respiration  (owing  to  implication  of  the  diaphragm),  hj  vomiting 
(often  bilious,  though  at  times  hemorrhagic)  or  nausea,  and  by  faint 
jaundice  in  some  cases.  Shortly  the  general  features  of  circumscribed 
peritoneal  abscess  also  appear — rigors,  irregular  fever,  sweats,  and  pro- 
gressivf  jirostration  and  emaciation. 

Physical  Signs. — Inspection  discloses  bulging  of  the  right  hypo- 
chondrium and  often  of  the  epigastrium.  The  same  regions  are  immo- 
bile, but  this  is  best  appreciated  by  palpation.  The  anterior  edge  of 
the  liver  is  felt  even  as  low  as  the  umbilical  level.  Percussion  reveals 
a  variable  increase  of  hepatic  dulness  upward,  sometimes  touching  the 
fourth  rib.  The  upper  level  of  the  fluid  is  movable  on  changing  the  po- 
sition of  the  patient,  and  this  is  particularly  striking  if  air  or  gas  is  con- 
tained in  the  abscess  ;  the  presence  of  the  latter  also  causes  a  zone  of 
tympanitic  resonance   above  the  dull  area,  while   overlying  the  latter 


CHRONIC  PERIHEPATITIS.  877 

there  is  the  semi-tympanitic  area  of  the  retracted  lung.  Auscultation 
reveals  an  absence  of  breath-sounds  and  of  the  vocal  resonance  over  the 
dull  and  tympanitic  areas,  while  the  respiratory  sounds  over  the  dis- 
placed lung  are  broncho-vesicular. 

Differential  Diagnosis. — Acute  perihepatitis  often  remains  unrec- 
ognized during  life.  It  may  be  confounded  with  empyema  of  the  right  side, 
but  the  two  conditions  have  different  modes  of  development.  Perihepatitis 
is  preceded  and  accompanied  by  abdominal  symptoms;  empyema  mani- 
fests thoracic  symptoms — e.  y.  cough  and  pleuritic  pain.  At  a  later 
stage  the  exaggerated  respiratory  murmur  above  the  dull  area,  the 
slighter  cardiac  displacement  toward  the  left,  and  the  greater  hepatic 
displacement  downward  in  suppurative  perihepatitis  aid  in  the  differen- 
tiation. The  introduction  of  the  trocar  in  the  seventh  or  eighth  inter- 
costal  space  in  the  mid-axillary  line  may  also  be  helpful,  especially  if 
the  exudate  be  found  to  contain  bile-pigment.  PfuhVs  sign — the  more 
ready  escape  of  the  fluid  during  inspiration  on  aspiration  of  abscesses 
below  the  diaphragm — may  not  be  without  value.  The  points  narrated 
above  may  likewise  serve  to  separate  pyo-pneumothorax  from  suppurative 
perihepatitis  (see  also  Pneumothorax,  p.  568). 

Course  and  Prognosis. — In  the  milder  or  fibrinous  variety  the 
outlook  is  favorable  and  the  course  is  brief.  On  the  other  hand,  the 
suppurative  type  due  to  perforation,  if  not  early  brought  under  proper 
surgical  treatment,  often  terminates  unfavorably  by  gradual  asthenia. 
Rarely  the  pus  is  resorbed,  or  it  may  find  an  outlet  through  the  lungs, 
abdominal  walls,  or  other  avenue,  followed  by  slow  recovery. 

The  treatment  is  the  same  as  for  localized  peritonitis.  The  first 
evidence  of  the  presence  of  pus  is  the  signal  for  appropriate  surgical 
interference — evacuation  and  drainage. 

CHRONIC   PERIHEPATITIS. 
{Zuckergussleber.) 

This  affection  is  a  chronic  inflammation  of  the  perihepatic  fibrous 
membrane,  which  becomes  opaque  and  thickened.  Contraction  of  this 
capsule  ensues,  with  compression  of  the  liver  and  atrophy  to  even  one-half 
the  size  of  the  normal  organ  (as  in  a  case  reported  by  Rumpf  ^),  and  par- 
tial or  total  occlusion  of  the  vessel  and  bile-ducts.  Perhaps  these  changes 
are  most  marked  in  cases  that  follow  acute  suppurative  perihepatitis. 
Genuine  instances  show  no  hyperplasia  of  the  interstitial  connective  tis- 
sue ;  hence  the  condition  is  closely  related  pathologically  to  "  Glissonian 
cirrhosis"  (vide  p.  886). 

The  main  causes  of  chronic  perihepatitis  are  great  and  protracted 
local  pressure,  as  from  a  corset,  and  certain  occupations.  It  may  rep- 
resent a  portion  of  a  more  general  chronic  inflammation  of  the  serosse. 
Finally,  I  am  of  the  belief  that  syphilis  is  the  leading  single  cause,  and 
could  discover  no  other  factor  present  in  two  cases  that  yielded  to  anti- 
syphilitic  treatment. 

The  diagnosis  is  generally  problematic.  Of  especial  clinical  worth 
are  the  etiology,  pain  in  the  right  hypochondriac  region — particularly 
in  cases  due  to  syphilis — absence  of  the  signs  of  stasis  of  the  gastro- 
intestinal tract,  and  the  very  protracted  course. 

1  Deutsch.  Arch.f.  klin.  Med.,  March  13,  1895. 


878  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  treatment  is  purely  palliative,  apart  from  the  effort  to  remove 
the  special  cause,  whether  this  be  syphilis,  occupation,  or  other  influ- 
ential factor. 


ABSCESS   OF  THE  LIVER. 

{Hepatic  Abscess;  Suppurative  Hepatitis.) 

Definition. — A  circumscribed  collection  of  pus  in  the  hepatic 
parenchyma. 

Pathology. — If  examined  m  situ,  a  liver  that  is  the  seat  of  ab- 
scess-formation is  usually  found  to  be  symmetrically  enlarged,  and  on 
careful  palpation  one  or  more  areas  of  fluctuation  (either  deep  or  super- 
ficial, according  to  the  location  of  the  abscess)  may  be  detected.  If 
single,  its  position  is  usually  in  the  right  lobe  near  the  convexity  of  the 
organ  (70  per  cent,  of  cases).  The  tissue  surrounding  the  abscess-wall 
is  usually  deeply  injected,  the  wall  itself  in  acute  cases  being  poorly 
defined,  but  grayish  in  color,  irregular  and  shreddy,  and  composed  of 
necrotic  liver-cells,  pus-corpuscles,  and  often  amebse.  In  chronic  cases 
it  becomes  greatly  thickened  and  often  cartilaginous  in  appearance. 

Microscopically,  the  hepatic  cells  are  altered  in  shape  and  devoid  of 
nuclei ;  they  undergo  rapid  degeneration.  A  round-celled  infiltration 
occurs  about  the  blood-vessels,  their  walls  being  filled  with  small  emboli 
containing  innumerable  staphylococci  and  streptococci.  As  the  sup- 
purative process  continues  liquefaction-necrosis  occurs,  resulting  in 
complete  destruction  of  the  hepatic  parenchyma. 

The  amount  of  fluid  contained  in  a  liver-abscess  may  exceed  2  or  3 
quarts  (2—3  liters),  and  its  color  varies  from  grayish-Avhite  to  a  creamy, 
reddish-brown.  The  collection  in  some  instances  resembles  healthy  pus. 
I  have  spoken  of  the  methods  of  infection  and  of  some  of  the  different 
varieties  of  hepatic  abscess  in  the  discussion  of  Dysentery  (see  p.  96). 

Various  odors  are  described,  depending  largely  on  the  extent  of  bac- 
terial invasion  and  the  degree  of  necrosis.  In  this  connection  it  may 
be  said  that  in  amebic  dysentery,  with  abscess  of  the  liver  as  a  compli- 
cation, the  abscess  is  often  single  (involving  more  often  the  right  lobe), 
whereas  other  forms  due  to  septic  infection  give  rise  to  multiple 
abscesses. 

In  the  latter  instances  the  surface  of  the  organ  presents  many  small 
yellow  areas  beneath  the  capsule,  varying  from  5  to  15  mm.  (-1—1  inches) 
in  diameter.  Usually,  in  such  cases  infection  has  taken  place  through  the 
portal  circulation,  and  on  section  the  appearances  of  a  suppurative  pyle- 
phlebitis present  themselves.  If  thrombi  have  formed  in  the  portal 
tributaries,  localized  necrotic  areas  are  the  result,  but  more  often  the 
invasion  affects  the  whole  portal  system,  the  liver  being  riddled  with 
abscesses.  If  the  abscess  is  secondary  to  obstruction  by  gall-stones  or 
inspissated  bile,  the  ducts  are  greatly  distended  and  the  gall-bladder  is 
filled  with  pus  mixed  with  bile. 

etiology. — Idiopathic  abscess  of  the  liver  is  rare  even  in  tropical 
climates.  The  affection,  even  when  excited  by  mechanical  causes,  as 
traumatism   or  obstruction   by  gall-stones,  is  invariably  septic  in  cha- 


ABSCESS  OF  THE  LIVER.  879 

racter,  and  the  infecting  material  reaches  the  interior  through  the 
hepatic  vessels  or  the  biliary  passages. 

Septic  emboli  enter  the  liver  by  means  of  the  vascular  system  through 
the  hepatic  artery  or  portal  vein,  the  latter  being  the  more  common 
channel  of  transmission.  Gastric  ulcers,  or  typhoid  fever,  typhilitis  (?), 
or  appendicitis,  may  be  followed  by  a  purulent  portal  pylephlebitis, 
resulting  in  abscess-formation.  On  analyzing  500  cases  of  suppurative 
hepatitis  Kelsch  found  that  in  85  cases  in  100  the  disease  was  associated 
with  dysentery  !  In  general  pyemic  processes  or  in  bone-suppurations 
of  long  standing  infection  occurs  through  the  blood  (hepatic  artery). 
Suppurating  wounds  of  the  head  are  not  uncommonly  followed  by  abscess 
of  the  liver.  Because  of  obstruction  of  the  common  duct  by  gall- 
stones and  resulting  pressure-necrosis  pathogenic  organisms  may  enter 
the  liver  and  cause  abscess-formation  through  the  medium  of  the  bile- 
ducts.  The  most  common  method  of  infection,  however,  is  through 
the  portal  vein.  Among  other  causes  may  be  mentioned  foreign  bodies 
travelling  up  the  ducts,  as  parasites,  round-worms,  liver-flukes ;  also, 
more  rarely,  suppuro-perforation  by  mechanical  irritants  (needles,  pins, 
fish-bones,  and  the  like),  and  suppuration  occurring  in  the  course  of  an 
hydatid  cyst.  Leick  has  tabulated  19  cases  of  hepatic  abscess  caused 
by  the  ascaris  lumbricoides. 

Symptoms. — In  a  typical  case  of  hepatic  abscess  the  most  promi- 
nent symptoms  are — hectic  temperature.,  pain,  tenderness,  and  enlarge- 
ment of  the  organ,  and  often  slight  jau7idice,  although  it  must  not  be 
forgotten  that  any  or  all  of  these  may  be  absent  during  the  development 
of  an  abscess.  The  multiple  abscesses  occurring  in  pyemic  conditions, 
which  are  frequently  diagnosed  when  in  view  upon  the  postmortem  table, 
form  an  instance  of  this. 

To  facilitate  the  subject  I  shall  consider  the  more  important  symp- 
toms seriatim  :  Pain  is  circumscribed  to  the  hepatic  region,  and  radi- 
ates to  the  right  shoulder  in  conjunction  with  the  other  symptoms  and 
physical  signs ;  it  is  very  characteristic,  although  not  pathognomonic  of 
hepatic  abscess.  In  the  earlier  stages  this  symptom  is  not  pronounced 
unless  the  abscess  or  abscesses  lie  superficially.  It  is  usually  of  a  dull, 
boring  character,  differing  in  severity  with  the  patient's  position  ;  it  is 
usually  aggravated  by  pressure  over  the  costal  margin  and  by  lying  on 
the  left  side,  this  tending  to  drag  the  liver  by  its  own  weight  from  its 
normal  position.  Luschka  explains  the  radiation  of  pain  to  the  right 
shoulder  by  stating  that  filaments  of  the  phrenic  nerves  that  distribute 
themselves  in  the  suspensory  ligament  and  Glisson's  capsule  are  irri- 
tated. The  phrenic  arises  from  the  third,  fourth,  and  fifth  cervical 
nerves,  and,  as  the  fourth  supplies  sensation  to  the  right  shoulder,  the 
impression  is  thus  transmitted  through  the  central  nervous  system. 

In  acute  cases  accompanied  by  rapid  destruction  of  the  hepatic  tis- 
sues the  temperature  usually  rises  rapidly,  reaching  103°  or  104°  F. 
(39.4°— 40°  C.)  in  the  course  of  from  twenty-four  to  thirtj-six  hours.  Its 
course,  however,  is  ii'regular  and  intermittent,  and  it  may  be  hectic  in 
character;  just  as  often  it  resembles  a  tertian  or  quartan  intermittent  or 
a  remittent  temperature.  Rigors  or  decided  chills  frequently  accompany 
the  rise  of  temperature,  and  during  the  decline  profuse  sweatings  may 
take  place,  thus  simulating  to  a  certain  extent  the  symptoms  of  malarial 


880  BISEASES  OF  THE  DIGESTIVE  SYSTEM. 

fever.  In  chronic  abscess  of  the  liver  pyrexia  may  be  entirely  absent. 
Less  commonly  the  temperature  may  remain  continuously  high,  -with 
slight  morning  and  evening  exacerbations  and  remissions.  The  ^x^Zsg 
is  usually  rapid  in  proportion  to  the  temperature. 

The  physical  signs  in  a  case  of  hepatic  abscess  are  always  present  to 
a  greater  or  less  degree,  and  are  often  pathognomonic. 

Inspection  may  reveal  nothing  during  the  entire  course  of  the  dis- 
ease, although  in  cases  accompanied  by  intense  congestion  in  which  the 
abscess  involves  the  anterior  surface  of  the  right  lobe,  bulging  of  the 
ribs  on  that  side  Avill  occur,  with  a  marked  prominence  in  the  hypo- 
chondriac region  extending  three  or  more  finger-breadths  below  the 
costal   margin. 

Palpation  confirms  inspection  and  reveals  tenderness  on  pressure 
below  the  costal  margin  in  the  mammary  line.  The  liver,  if  projecting 
below  the  edge  of  the  ribs,  is  usually  enlarged  uniformly,  unless  the 
abscess  involves  the  surface  of  the  margin.  As  the  upper  right  lobe  is 
more  often  involved,  especially  in  a  large  single  abscess,  the  increase  in 
size  is  in  an  upward  direction,  thus  rendering  palpation  negative.  In 
rare  instances  the  abscess  gives  rise  to  fluctuation  on  palpation,  and  if 
the  peritoneum  be  inflamed  a  friction  fremitus  may  be  detected. 

Percussion. — The  area  of  hepatic  dulness  may  be  increased  uni- 
formly, but  it  is  usually  most  marked  upward  and  to  the  right,  in  some 
instances  reaching  at  the  anterior  axillary  line  to  the  fifth  rib,  and  pos- 
teriorly to  the  level  of  the  angle  of  the  scapula.  This  high  position 
of  the  upper  boundary  of  dulness  which  starts  about  the  nipple-line 
serves  to  differentiate  abscess  from  other  aff"ections  of  the  liver,  in  Avhich 
the  enlargement  extends  in  a  downward  direction. 

Other  Symptoms. — The  skin  is  pale  and  shows  slight  icterus,  the 
conjunct ivd'  being  often  bile-stained;  '\ntQTi?,e  jaundice,  however,  is  rare. 
Progressive  loss  of  flesh  and  strength,  with  (/asti'o-intestinal  disturbance 
(fulness  in  the  epigastrium,  flatulence,  water-brash,  nausea,  and  occasional 
vomiting),  are  common  symptoms  at  the  onset.  The  ho^vels -dre  variable, 
and  constipation  usually  alternates  with  diarrhea,  the  stools  in  some 
cases  containing  the  ameba  coli.  Ascites  may  develop  from  pressure 
on  the  inferior  vena  cavse,  but  these  cases  are  rare.  The  spleen  may 
undergo  active  hyperplasia  in  acute  abscess-formation.  Pulmonary 
St/ mptoms  [severe  cough,  characteristic  reddish-brown  sputum,  resembling 
anchovy  sauce,  broncho-vesicular  breathing,  rales)  are  commonly  present; 
they  are  due  to  compression  of  the  base  of  the  lung  by  the  abscess  press- 
ing upon  the  diaphragm.  In  fatal  cases  certain  nervous  s/pnptoms  (mut- 
tering delirium,  cephalalgia,  subsultus  tendinum,  stupor,  coma)  make 
their  appearance. 

Complications  and  Sequelae. — The  abscess  may  perforate  into 
the  pleural  cavity  (pyothorax),  bronchi,  lungs,  intestinal  tract,  stomach, 
pericardium,  peritoneal  cavity,  or  externally  through  the  abdominal 
wall,  giving  rise  to  various  symptoms.  If  rupture  occurs  into  the 
intestinal  tract,  sudden  diarrhea,  with  the  discharge  of  large  (juantities 
of  pus,  takes  place  ;  there  is  then  an  amelioration  of  the  pain,  fever, 
and  other  symptoms.  If  the  rupture  is  into  the  lung,  the  physical  signs 
will  reveal  the  sudden  development  of  weak,  tubular  breathing  over  the 
base,  with   increased  tactile  fremitus  and  percussion-dulness,   together 


ABSCESS   OF  THE  LIVER.  881 

with  the  occurrence  of  profuse  and  typical  expectoration.  Reese  and 
Lafleur  found  the  ameba  coli  in  the  bronchial  discharge.  S.  Flexner 
has  reported  two  cases  of  amebic  abscess  of  the  liver  in  which  perfora- 
tion into  the  vena  cava  occurred.  Rupture  into  the  abdominal  cavity 
gives  rise  to  the  rapid  development  of  a  purulent  peritonitis  that  is 
often  fatal.  Rarely,  the  abscess  is  emptied  into  the  pericardium,  giving 
rise  to  fatal  acute  pericarditis.  Septic  emboli  have  been  known  to  lodge 
in  the  circle  of  Willis,  producing  fatal  brain-abscess. 

Diagnosis. — The  clinical  symptoms  of  hepatic  abscess  are  of  diag- 
nostic importance  only  when  taken  in  the  aggregate,  since  the  pain, 
fever,  enlargement,  and  even  hectic  symptoms  occur  singly  in  other 
conditions  unaccompanied  by  suppuration.  The  principal  points  in  the 
establishment  of  the  diagnosis  of  the  aifection  may  be  summed  up  as 
follows :  Residence  in  tropical  countries,  the  previous  existence  of 
typhoid  or  dysenteric  ulceration  (or  other  gastro-intestinal  inflamma- 
tion), the  characteristic  expectoration,  enlargement  of  the  liver,  Avith 
pain  and  tenderness  on  pressure,  and  in  some  instances  fluctuation  on 
palpation.  Lastly,  aspiration  may  reveal  pus-corpuscles,  hepatic  cells, 
staphylococci  and  streptococci,  the  ameba,  and  bile-pigment,  which  when 
found"^  are  pathognomonic ;  if  the  abscess  be  secondary  to  an  echinococ- 
cus  cyst,  the  presence  of  booklets  will  be  detected. 

Differential  Diagnosis. — Hepatic  abscess  may  be  misdiagnosed  for 
empyema,  malarial  fever,  and  hepatie  calculi. 

Empyema. — In  empyema  there  may  be  the  history  of  a  perforating 
wound  of  the  chest,  the  rupture  of  a  bronchiectatic  or  tuberculous  cavity, 
or  the  pre-existence  of  a  sero-fibrinous  pleurisy  ;  whereas  hepatic  abscess 
may  be  preceded  by  an  attack  of  amebic  dysentery  or  intestinal  ulcera- 
tion, or  it  may  follow  the  impaction  of  biliary  calculi.  In  both  there 
may  be  the  occurrence  of  a  hectic  temperature,  with  chills  and  sweating; 
but  in  empyema  cough  and  dyspnea  are  prominent,  and,  if  the  pleural 
cavity  communicates  with  a  bronchus,  profuse  muco-purulent  expectora- 
tion containing  pus-cells,  staphylococci,  streptococci,  and  in  many  cases 
elastic  tissue  and  tubercle  bacilli.  Rarely,  an  abscess  of  the  liver  pene- 
trates the  diaphragm,  and,  entering  the  bronchi,  is  expectorated.  The 
recognition  of  hepatic  abscess  under  these  circumstances  is  to  be  based 
mainly  upon  clear  evidence  of  the  afi"ection  prior  to  the  occurrence  of 
perforation,  and  copious,  blood-tinted,  purulent  expectoration.  The 
detection  of  the  ameba  coli  in  the  sputum  alone  would  set  the  diagnosis 
at  rest.  The  contents  of  hepatic  abscess  obtained  by  aspiration  consist 
of  the  micro-organisms  of  suppuration,  and  in  addition  broken-down 
liver-cells,  bile-pigment,  and  in  some  cases  the  ameba  coli.  Inspection 
in  empyema  reveals  bulging  of  the  intercostal  spaces  on  that  side,  while 
percussion  gives  absolute  flatness  over  the  base  of  the  chest,  rising  pos- 
teriorly and  changing  with  the  change  from  a  dorsal  to  a  sitting  position. 
In  abscess  of  the  liver  the  lung  is  slightly  displaced  upward,  being 
often  bound  to  the  diaphragm  by  adhesions ;  and  the  upper  boundary 
of  dulness  is  lower,  particularly  in  front,  and  is  not  changed  with  the 
decubitus  of  the  patient. 

»6 


882  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Hepatic  Abscess.  Malaria. 

History  of  traumatism,  dysentery,  intes-  History  of  previous  attacks.     Residence 

tinal  ulceration,  or  residence  in  tropi-  in   warm,   damp   climates   among   the 

cal  countries.  lowlands. 

Hectic  character  of  the  temperature —  Regulai'ly  recurrent  rise  of  the  tempera- 
high  every  evening  and  low  every  ture  (intermittent  or  remittent,  quotid- 
morning ;  irregular  chills,  followed  by  ian,  tertian,  quartan,  or  septinarian), 
fevers  and  sweatings.  and  the  rise  occurring  during  the  chill, 

followed   by  profuse    sweating ;   chills 
more  often  in  morning. 

An  irregular,  fluctuating  tumor  or  multi-  The  spleen  is  enlarged  :  also  there  is  a 
pie  nodules  in  the  liver  ;  no  splenic  en-  yellow-brown    coloration  of  the   skin, 
largement ;  rapid  emaciation,  with  or  more    or  less   marked  ;    and,  in    long- 
without  jaundice,  but  no  cachexia.  standing  cases,  the  occurrence  of  ca- 
chexia. 

Blood    shows  simple  anemia  and  leuko-  The  presence  of  the  hematozoa  of  Laveran 

cytosis,  and  in  marked  cases  disinte-  and  free  pigment  in  the  blood, 
gration  of  red  blood-cells. 

Abscess-contents  show  the  staphylococci.  Absent, 
streptococci,  amebae,   or   bacillus   coli 
communis,  and  pus. 

Impacted  Calculi. — In  this  condition  attacks  of  hepatic  colic  are  often 
first  noticed,  folloAved  by  jaundice,  and,  if  impaction  be  not  absolute,  by 
the  occurrence  of  stones  in  the  feces.  In  abscess  the  pain  is  not  parox- 
ysmal, but  dull  and  boring  in  character,  increasing  in  severity  as  the 
disease  progresses.  In  clironie  impaction  jaundice,  dull  pain  over  the 
hepatic  area,  distention  of  the  gall-bladder  (which  in  some  instances  may 
be  palpated),  and  clay-colored  feces,  constitute  the  principal  symp- 
toms. There  occurs  also  an  intermittent  fever  as  in  hepatic  abscess,  but 
it  is  occasional — i.  e.  the  febrile  paroxysms  recur  at  longer  intervals. 
Again,  the  course  of  intermittent  hepatic  fever  associated  with  biliary 
calculi  is  much  more  chronic  than  the  fever-stage  of  suppurative  hepa- 
titis. On  the  other  hand,  in  abscess  of  the  liver  jaundice  is  compara- 
tively rare,  and,  unless  the  abscess  rupture  into  the  gastro-intestinal 
tract,  the  stools  shoAV  nothing  abnormal.  In  some  instances  biliary  ab- 
scesses may  follow  impacted  calculi,  and  it  is  always  a  secondary  affection. 

Among  other  liver-conditions  that  are  liable  to  be  mistaken  for 
hepatic  abscess  may  be  mentioned  carcinoma.,  Ixypertropliic  eirrhosii<, 
and  hydatid  cy^t,  the  differential  diagnosis  of  which  will  be  spoken  of 
under  these  diseases. 

Prognosis. — The  prognosis  of  hepatic  abscess  is  unfavorable,  the 
disease  generally  progressing  to  a  rapidly  fatal  termination.  Prompt 
evacuation  of  the  abscess  when  its  location  can  be  detected,  however, 
may  be  successfully  performed.  The  mortality  ranges  from  50  to  60 
per  cent.  In  rare  cases  the  walls  of  the  abscess  become  calcified  and 
the  disease  remains  latent.  The  single  large  abscess  that  most  often 
follows  dysentery  offers  the  best  opportunity  for  surgical  measures. 

Treatment. — Barring  operation,  the  treatment  of  abscess  of  the 
liver  is  purely  symptomatic,  being  in  many  instances  identical  with  that 
of  septico-pyemia.  The  temperature  often  responds  to  repeated  spong- 
ings  Avith  cool  water  (65°  F — 1S.'3°  C).  For  the  pain  mustard-poul- 
tices, the  turpentine  stupe,  or  hot  fomentations  over  the  hepatic  area,  in 
conjunction  with  full  internal  doses  of  opium,  ])rove  beneficial.  Full 
and  free  stimulation  and  the  free  exhibition  of  (|uinin  as  soon  as  the 


ACUTE   YELLOW  ATROPHY.  883 

condition  is  detected  both  support  the  system  and  control,  in  a  measure, 
the  pyemic  process.  If  the  abscess  be  single  and  localized,  prompt 
evacuation  should  be  resorted  to.  Patients  yiho  have  been  thus  cured 
should  not  return  to  a  climate  in  which  tropical  dysentery  occurs  fre- 
quentlv,  since  as  in  a  case  reported  by  Marshall  another  attack  of 
dysentery  accompanied  by  abscess  may  ensue. 


ACUTE  YELLOW  ATROPHY. 

{Malignant  Jaundice  ;  Icterus  Gravis.) 

Definition. — An  acute  and  probably  infectious  disease,  character- 
ized by  a  rapid  destruction  of  the  parenchyma  of  the  liver  and  by  a 
diminution  in  the  size  of  the  oro;an  ;  also  bv  jaundice,  hemorrhage,  and 
grave  cerebral  phenomena. 

Pathology. — Macroscopically,  in  a  case  of  acute  yellow  atrophy  the 
liver  is  seen  to  be  much  reduced  in  size,  weighing  but  15  or  20  ounces 
(480.0-640.0),  instead  of  its  normal  weight  (50  oz.— 1.6  kgms.).  The 
capsule  is  shrivelled  and  the  organ  is  of  a  pulpy  consistence,  and  changed 
in  appearance  from  a  mahogany-brown  to  a  grayish-yellow  hue.  Some- 
times the  liver  is  primarily  enlarged.  The  cut  section  often  presents 
areas  of  red  and  yellow  discoloration,  the  so-called  '"  red  atrophy  "  and 
"  yellow  atrophy,"  the  former  being  a  later  stage  of  the  latter.  The  red 
appearance  is  due  to  an  excess  of  blood  in  the  capillaries,  with  free  pig- 
ment that  has  been  liberated  by  destruction  of  the  red  blood-cells. 
Microscopic  examination  reveals  destruction  or  necrosis  of  the  hepatic 
cells.  The  nuclei  have  disappeared,  and  the  cell-wall  contains  a  number 
of  fat-globules  of  various  sizes  containing  free  pigment.  In  advanced 
cases,  accompanied  by  total  disintegration  of  the  cells,  fat-droplets,  gran- 
ular debris,  cholesterin-plates,  leucin-spheres,  tyrosin-needles  (first  dis- 
covered by  Frerichs,  both  in  the  cells  and  in  the  blood-vessels),  and 
crystals  of  bilirubin  may  be  found.  Findlay  ^  found  the  fibrous  tissue 
to  be  increased  and  in  the  periphery  of  the  lobules  attempts  at  regenera- 
tion (proliferation  of  the  hepatic  cells).      The  common  duct  is  patulous. 

In  well-marked  cases  both  the  heart  and  kidneys  show  evidences  of 
fatty  degeneration.  The  spleen  is  greatly  enlarged  from  active  conges- 
tion, giving  rise  to  the  so-called  "'  acute  splenic  tumor."  The  splenic 
substance  is  soft  and  easily  torn.  The  skiyi  and  mucous  membranes 
may  be  the  seat  of  numerous  ecchymoses,  and  dropsy  of  the  serous  cav- 
ities is  frequently  noted.  The  hlood  is  dark  and  fluid  (disintegrated). 
Microscopically,  it  is  seen  to  contain  crystals  of  leucin  and  tyrosin. 

Ktiology. — The  causes  of  acute  yellow  atrophy  are  both  primary 
and  secondary.  Primarji  or  idiopathic  acute  yellow  atrophv  is  rare  and 
its  course  as  yet  unsettled.  Among  the  secondary  predisposing  causes 
may  be  mentioned  age  (fifteen  to  thirty-five  years),  female  sex,  parturi- 
tion, syphilis,  and  certain  acute  fevers  (puerperal  fever,  typhoid,  septic- 
emia, malaria).  Acute  phosphorus-poisoning  sometimes  presents 
changes  resembling  those  of  acute  yellow  atrophy.  The  disease  rarely 
accompanies  cirrhosis  of  the  liver,  and  may  follow  a  debauch.  Rarely, 
an  endemic  form  is  assumed,  but  the  exciting  cause  is  thus  far  unknown. 
The  disease  is  probably  microorganismal  or  toxic  in  nature,"  and 
1  British  Medical  Journal  June  2,  1900. 


884  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

although  various  germs  have  been  discovered,  their  claim  to  specificity 
has  not  been  established. 

Symptoms. — The  clinical  history  of  acute  yellow  atrophy  varies 
considerably  in  the  early  stages  of  the  disease,  the  graver  symptoms  of 
the  later  stage  alone  being  pathognomonic.  The  attack  is  usually 
ushered  in  by  headache,  malaise,  anorexia,  nausea,  and  vomiting,  mod- 
erate/Vrer,  and  after  a  few  days  jau7idice  appears.  Pliysical  examina- 
tion at  this  time  shows  the  area  of  hepatic  dulness  to  be  normal  or  only 
slightly  increased.  After  a  period  varying  from  a  few  days  to  two  or 
three  weeks  (during  which  the  typical  features  of  catarrhal  jaundice 
have  been  present),  grave  nervous  and  cerebral  symptoms  present  them- 
selves, as  restlessness  and  violent  headache,  followed  by  delirium,  which 
often  becomes  maniacal.  Convulsions  then  appear,  and  are  succeeded 
by  stupor  and  coma,  the  latter  occurring  usually  within  forty-eight 
hours  from  the  onset  of  the  period  of  cerebral  excitement.  Often  coarse 
tremors  are  noticed  in  the  voluntary  muscles,  and  with  the  onset  of  the 
second  stage  the  jaundice  usually  deepens. 

The  temperature  often  remains  normal  until  just  before  death,  when 
it  may  rise  one  or  two  degrees.  The  pulse  is  much  diminished  both  in 
volume  and  tension,  and  is  rapid  in  proportion  to  the  temperature.  The 
tongue  at  the  onset  is  covered  with  a  light  coating,  most  marked  on  the 
dorsum  and  tip.  Later,  it  changes  to  a  thick  yellow  color  and  becomes 
dry  and  fissured,  with  the  development  of  a  typhoid  state.  Vomiting 
appears  usually  during  the  premonitory  stage  and  often  becomes  in- 
tense ;  the  voynit  consists  at  first  simply  of  the  gastric  contents,  which 
later  in  the  disease  becomes  mixed  with  blood  (hematemesis).  Hemor- 
rhages also  frefjuently  occur  into  the  skin  (ecchymoses)  and  from  the 
mucous  membranes,  giving  rise  to  epistaxis,  hematuria,  melena,  he- 
moptysis, and  menorrhagia.  Constipation  with  clay- colored  stools  is 
common. 

The  urine  in  acute  yellow  atrophy  is  often  scanty  in  amount,  high  col- 
ored, and  shows  an  increase  in  specific  gravity  (1028-1032).  The  urea 
is  greatly  diminished,  but  bile-pigments  and  albumin,  tube-casts,  leucin 
and  ti/rosin  are  found  both  on  chemical  and  microscopic  examination. 
The  latter  can  be  easily  demonstrated  by  allowing  a  drop  of  the  urine  to 
evaporate  on  a  cover-glass  and  examining  under  the  microscope.  Tyrosin- 
crystals  are  deposited  in  the  form  of  sheaves  and  rosettes,  leucin  as 
globular  masses.  These  bodies  are  not  constantly  present.  Thus, 
out  of  34  cases  collected  by  Thierfelder,  in  which  the  urine  was  ex- 
amined in  this  relation,  "  in  7  the  result  was  negative ;  in  17  both  were 
found;  in  3  tyrosin  only;  in  7  leucin  only."  Among  other  products 
found  in  the  urine  worthy  of  mention  are  creatinin,  lactic  and  sarco- 
lactic  acids,  and  other  bodies  belonging  to  the  fatty  acid  series. 

Acute  yellow  atrophy  of  the  liver  is  a  striking  example  of  acid-intoxi- 
cation due^^to  rapid  and\videspread  destruction  of  proteids  as  the  source 
of  the  fatty  acids — sarcolactic,  lactic,  diacetic,  and  ;9-oxybutyric.  It  is 
probable  that  the  rare  nervous  phenomena  of  the  disease  are,  in  part  at 
least,  due  to  the  diminished  alkalinity  of  the  blood  arising  from  the  ab- 
normal metabolism. 

The  physical  signs  reveal  tenderness  over  the  hepatic  region,  often 
amounting  to  actual  })ain.     During  the  second  stage,  in  extreme  cases,  the 


THE  LIVER  IN  PHOSPHORUS-POISONING.  885 

edges  of  the  organ  cannot  be  palpated  under  the  costal  margin.  Per- 
cussion, moreover,  shows  a  great  diminution  in  the  size  of  the  liver,  the 
area  of  dulness  in  a  case  recorded  by  Harley  extending  over  but  1  inch 
(2.5  cm.)  in  the  mammary  line  and  1\  inches  (3.1  cm.),  measured  per- 
pendicularly, in  the  mid-axillary  line. 

The  left  lobe  is  often  the  first  to  show  physical  signs  of  atrophy,  per- 
cussion giving  tympany  instead  of  flatness  in  the  upper  epigastric  region. 
As  the  atrophy  continues  the  tympany  exends  below  the  seventh  rib  from 
above  and  advances  upward  from  the  costal  margin,  leaving  but  a  small 
circumscribed  area  of  hepatic  dulness.  The  atrophy  is  usually  progres- 
sive until  death  occurs,  although  favorable  cases  have  been  recorded  in 
which  the  liver  increased  in  size  perceptibly  during  recovery  (Harley, 
p.  260). 

Diag'trosiS. — The  symptoms  occurring  during  the  second  stage  of 
the  disease  are  usually  so  characteristic  as  to  leave  little  doubt  concern- 
ing the  diagnosis.  The  occurrence  of  gradually  increasing  jaundice 
with  vomiting,  grave  delirium,  hemorrhages,  the  presence  of  an  immense 
amount  of  bile,  with  leucin  and  tyrosin,  in  the  urine,  and  greatly  dimin- 
ished size  of  the  liver,  all  combine  to  form  a  typical  clinical  picture. 
Unfortunately,  leucin  and  tyrosin  are  also  found  in  the  urine  in  acute 
phosphorus-poisoning  and  rarely  in  severe  acute  infective  diseases. 

Differential  Diagnosis. — In  hypertrophic  cirrhosis  the  onset  is  more 
gradual.  There  is  generally  a  negative  previous  history  ;  and  examina- 
tion of  the  urine  fails  to  reveal  leucin  and  tyrosin  ;  fever  is  rarely 
present  in  cirrhosis,  and  the  physical  signs  often  show  a  considerable 
increase  in  the  area  of  hepatic  dulness. 

The  differential  diagnosis  between  this  disease  and  phosphorus- 
poisoning  is  given  under  the  latter  condition  {vide  infra). 

The  prognosis  is  almost  invariabl}^  fatal,  since  every  case  of  true 
yellow  atrophy  is  associated  with  a  destruction  of  liver-cells  that  is 
accompanied  by  acute  toxemia. 

Treatment. — As  yet  no  specific  treatment  has  been  discovered,  all 
remedies  used  being  directed  to  the  relief  of  symptomatic  indications. 
The  gastro-intestinal  system  should  be  relieved  at  the  onset  by  divided 
doses  of  calomel.  For  the  vomiting  cracked  ice,  with  1-minim  (0.066) 
doses  of  the  wine  of  ipecac  repeated  every  half  hour  or  divided  doses 
of  opium,  may  be  given.  Marked  nervous  phenomena  with  delirium 
I  have  seen  controlled  by  cool  baths  and  the  ice-cap,  together  with  cam- 
phor, chloral,  or  other  antispasmodics  used  internally.  Free  stimulation 
should  be  begun  early  and  persisted  in  throughout  the  course  of  the 
disease. 


THE  LIVER  IN  PHOSPHORUS-POISONING. 

Following  the  ingestion  of  a  dose  of  phosphorus  varying  from  gr.  \ 
to  gr.  1  (0.008-0.0648)  symptoms  of  poisoning  manifest  themselves 
(Taylor,  Wormley)  as  follows : 

After  a  period  of  time  varying  from  three  to  twelve  hours  a  sense  of 
wretchedness,  nausea,  abdominal  pain  (not  intense),  and  often  vomiting, 


886  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

occur.  The  vomitus  consists  of  the  gastric  contents,  with  bile,  and  dur- 
ing the  first  few  hours  it  may  contain  phosphorus,  which  gives  it  a 
luminous  appearance  in  the  dark. 

After  the  second  or  third  day  the  vomiting  usually  ceases  with  the 
appearance  of  jaundice,  which  may  become  intense  as  the  process  con- 
tinues. Later  in  the  course  of  the  case  emesis  recommences,  the 
vomita  consisting  of  altered  blood,  giving  rise  to  the  so-called  "  black 
vomit.""  At  this  stage  nervous  symptoma  usually  manifest  themselves 
(headache,  insomnia,  vertigo,  and  delirium,  with  convulsions  and  coma 
in  fatal  cases),  death  closing  the  scene  usually  in  from  thirty-six  to  forty- 
eight  hours. 

The  bowels  are  constipated,  although  attacks  of  diarrhea  may  super- 
vene, the  evacuations  being  in  some  instances  phosphorescent. 

Fever  is  irregular  and  usually  is  not  marked,  the  temperature  swing- 
ing from  99°  to  101°  F.  (37.2°-38.3°  C).  In  fatal  cases  the  temper- 
ature may  become  subnormal  just  before  death. 

The  urine  is  scanty,  of  high  specific  gravity,  and  contains  bile,  bile- 
acids,  albumin,  sarcolactic  acid,  and  in  rare  cases  leucin  and  tvrosin 
(Wood).  Renal  epithelium  and  free  fat-globules  have  also  been  found. 
When  occurring  in  pregnant  women,  abortion  or  miscarriage  invariably 
follows. 

Pliysical  examination  reveals  a  liver  uniformly  enlarged  and  tender 
on  pressure.  In  protracted  cases  atrophy  of  the  organ  mav  rarely 
occur. 

Htiology. — The  most  common  causes  are — (a)  Occupation,  Avorkers 
in  match-factories  being  the  most  frequent  suff"erers :  {h)  The  accidental 
swallowing  of  phosphorus  (e.  g.  rat-poison,  friction-match  heads). 

Pathology. — On  opening  the  abdominal  cavity  in  a  case  of  phos- 
phorus-poisoning the  liver  is  seen  to  extend  below  the  costal  margin,  its 
surface  being  lighter  in  color  than  normal  and  mottled  in  appearance, 
and  its  substance  softer  in   consistence  and  friable. 

The  cut  section  presents  marked  evidences  of  fatty  degeneration,  the 
acini  being  lighter  in  color  than  the  interlobular  tissue.  Portions  of 
the  hepatic  parenchyma  are  deeply  bile-stained,  and  on  scraping  the 
cut  surface  bile-  and  fat-globules  will  be  found  on  the  edge  of  the  knife. 
The  gall-bladder  may  be  either  full  or  empty.  Microscopically,  disin- 
tegrated liver-cells,  fat-globules,  granular  debris,  biliary  coloring-matter, 
leucin-spheres.  cholesterin-plates.  and  tyrosin-needles  are  noted. 

The  gastric  mucosa  is  found  thickened,  opaque,  and  yellow-white  in 
appearance,  due,  as  pointed  out  by  Yirchow,  to  a  universal  gastro-adeni- 
tis,  and  not  to  the  local  action  of  the  poison.  Ulcerative  or  erosive 
gastritis  is  very  rare  in   phosphorus-poisoning. 

The  kidneys  may  show  beginning  atrophy,  the  epithelium  in  the 
cortices  undergoing  granular  and  fiitty  degeneration,  with  final  destruc- 
tion of  the  cells. 

The  IJood  is  dark,  fluid,  and  not  easily  coagulable.  Concato  found 
that  during  life  the  white  corpuscles  are  increased  in  number,  and  that 
the  red  are  changed  in  shape  and  smaller  than  normal  (Wood).  Pete- 
chi?e  and  ecchymoses  frequently  appear  in  all  parts  of  the  body. 

Diagnosis. — The  diagnosis  of  acute  phosphorus-poisoning  is  alwavs 
extremely  diflicult  and  often  impossible.     The  disease  with   which  it  is 


CIRRHOSIS  OF  THE  LIVER.  887 

most  apt  to  become  confounded  is  acute  yellow  atrophy  of  the  liver. 
The  differential   points  may  be  summated   as  follows : 

Acute  Phosphorus-poisoning.  Acute  Yellow  Atrophy. 

There  is  a  history  of  accidental  ingestion  There  may  be  an  endemic  history. 

of   poison    (friction-match   heads,  rat- 
poison)  or  occupation. 

The   onset   is    sudden  ;    violent   nausea,  A  slow  onset — malaise,  slight  fever,  with 

vomiting,  and  pain  over  the  region  of  nausea  and  vomiting  ;  jaundice  is  a  be- 

the   liver.     Jaundice   appears   on   the  ginning  symptom. 

second  or  thii-d  day. 

Nervous    symptoms   appear   late  in  the  Nervous    symptoms   may    appear   early, 

disease — always  preceded  by  jaundice.  even  before  the  occurrence  of  jaundice. 

The  vomit  and  stools  are  phosphorescent.  Black  vomit   occurs   early   and   persists 

Black  vomit  precedes  death.  throughout. 

Temporary  arrest  of  symptoms  between  Progressive  march  of  symptoms  with  no 

the  occurrence  of  jaundice  and   black  remission. 

vomit. 

Sarcolactic  acid  is  present  in  the  urine,  Leucin  and  tyrosin  are  common  in  the 

and  rarely  leucin  and  tyrosin.  urine. 

Prognosis  and  Duration. — The  prognosis  in  phosphorus-poison- 
ing is  bad,  as  small  a  dose  as  gr.  -|-  (0.008)  of  white  phosphorus  having 
caused  death  (Wormley).  The  duration  is  usually  from  one  to  six  days, 
although  the  symptoms  have  been  known  to  persist  for  twelve  days  be- 
fore death.    In  violent  cases  the  end  may  come  within  twenty-four  hours. 

Treatment. — The  initial  plan  of  treatment  is  by  causing  emesis  to 
free  the  system  of  the  poison  that  still  remains  undigested.  For  this 
purpose  copper  sulphate  (gr.  x — 0.648)  in  divided  doses  (gr.  ij  or  iij — 
0.129  or  0.194 — every  five  minutes)  should  be  given  until  free  vomiting 
occurs.  As  copper  sulphate  is  a  chemical  antidote,  forming  with  phos- 
phorus black  copper  phosphid,  it  should  be  continued  in  less  frequently 
repeated  doses  (gr.  ij — 0.129 — every  half  hour)  and  guarded  by  morphin 
to  prevent  vomiting.  If  emetics  by  the  mouth  fail  to  afford  relief,  apo- 
morphin  muriate  (gr.  1 — 0.0129),  hypodermically,  may  be  resorted  to. 
The  free  evacuation  of  the  stomach  should  be  followed  by  the  adminis- 
tration of  the  French  oil  of  turpentine.  Wood  recommends  that  1  part 
be  given  to  every  100th  part  of  the  poison  ingested.  Ordinary  turpen- 
tine is  useless,  but  combined  with  mucilage  of  acacia  2  fluidrams  (8.0) 
of  French  oil  of  turpentine  may  be  given  every  fifteen  minutes  until  1 
ounce  (32.0)  has  been  taken. 

Alkalies  (magnesia)  have  been  given,  but  are  practically  valueless. 
Free  purgation  should  be  effected  if  possible  by  Rochelle  salts  or  mag- 
nesium citrate.  Demulcent  oils  are  never  allowable,  as  they  dissolve 
the  phosphorus  and  hold  it  in  solution.  After  absorption  of  the  poison 
and  degeneration  of  the  tissues  have  taken  place  all  known  remedies 
are  futile. 

CIRRHOSIS  OP  THE  LIVER. 

{Sclerosis  of  the  Liver  ;  Nutmeg  Liver  ;   Gin-drinker^ s  Liver ;  Interstitial  Hepatitis.) 

Definition. — A  chronic  disease  of  the  liver,  characterized,  patho- 
logically, by  an  excess  of  connective  tissue.  It  presents  various  biliary, 
gastro-intestinal,  circulatory,  and  cerebral  symptoms. 


888  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Pathologfy. — There  are  three  pathologic  varieties :  (a)  atrophic  cir- 
rhosis, or  ''gin-drinker's  liver"';  (h)  hypertrophic  cirrhosis;  and  (c) 
biliary  cirrhosis. 

(a)  AtropMc  Cirrhosis  (^Laennec  s^  or  alcoholic  cirrhosis)  is  the  most 
common  form,  at  least  in  the  earliest  stages,  as  Foxwell's  studies  teach ; 
the  alcoholic  (indurative)  liver  is  more  commonly  enlarged  than  decreased 
in  size.  Morse  ^  examined  the  records  of  37  cases  of  cirrhosis,  and  found 
that  among  these  there  were  13  instances  of  enlarged  liver,  11  of  nor- 
mal size,  and  12  smaller  than  normal.  In  typical  examples  the  capsule 
is  thickened,  the  organ  greatly  reduced  in  size,  hard,  granular,  and 
much  altered  in  shape.  On  section  (which  resists  the  cutting-knife) 
the  surface  presents  grayish-white  bands  of  connective  tissue  surround- 
ing yellowish  areas  (acini)  that  project  above  the  surface  from  com- 
pression (hob-nails);  hence  the  term   "hob-nailed  liver." 

Microscopicalhi^  the  process  is  seen  to  commence  as  an  increase  in 
the  connective-tissue  element  surrounding  the  terminal  branches  of  the 
portal  vein.  Compression  of  the  liver-cells  and  of  the  portal  veins, 
with  consequent  obstruction  of  the  circulation,  constantly  increases 
with  the  progress  of  the  proliferation  of  the  connective  tissue  and  its 
secondary  contraction.  Atrophic  changes  in  the  hepatic  cells,  however, 
are  often  comparatively  slight.  The  biliary  canaliculi  may  be  increased 
in  number.  AVeigert  and  his  disciples  contend  that  atrophy  or  degenera- 
tion of  the  acini  is  often  the  primary  change,  and  the  connective-tissue 
production  the  secondary — filling  the  gap,  so  to  speak. 

In  alcoholic  cirrhosis  the  liver  is  sometimes  large,  smooth,  or  slightly 
granular,  soft  rather  than  hard,  as  ordinarily  the  case,  and  presents  a 
light  yellow  color  {fatty  cirrhosis).  Histologically,  this  is  a  form  of 
true  cirrhosis,  as  shown  by  the  presence  of  an  increase  in  the  connective 
tissue,  with  which,  however,  fatty  infiltration  of  the  acini  is  associated. 

{h)  Hypertrophic  Cirrhosis  (Hanot). — On  examining  the  liver  in  situ 
during  hypertrophic  cirrhosis  the  organ  is  found  enlarged  (sometimes 
enormously),  the  lower  border  projecting  several  fingers'  breadths  below 
the  ribs.  The  margin  of  the  organ  is  Avell  defined,  the  substance  firmer 
than  normal,  and  it  cuts  with  difficulty.  The  organ  is  lighter  in  color 
than  in  health,  and  presents  a  yellow  or  mottled-green  appearance.  On 
treating  a  section  with  compound  iodin  solution  (Lugol's)  the  color 
changes  to  that  of  a  deep  mahogany-red.  The  acini  are  darker  in 
hue  than  the  interstitial  tissue. 

MicroscopicaUy .  the  peripheral  zones  of  the  acin^  are  first  seen  to  be 
the  seat  of  a  round-cell  infiltration,  with  the  formation  of  embryonal  tis- 
sue ;  later,  the  interlobular  connective  tissue  undergoes  hyperplasia,  caus- 
ing obstruction  of  the  biliary  ducts  with  retention  of  bile,  and  subsequent 
atrophy  of  the  liver-cells.     New-formed  bile-ducts  are  proliferated. 

{c)  Biliary  Cirrhosis. — French  writers  have  described  "  biliary  cirrho- 
sis "  as  opposed  to  a  '"portal  cirrhosis"  or  atrophic.  It  residts  from 
obstruction  of  the  bile-ducts ;  this  causes  retention  of  bile  with  swell- 
ing of  the  organ  as  a  consequence.  The  irritant  substances  that  are 
the  result  of  stagnation  of  the  bile  start  a  cirrhotic  process  around  the 
small  bile-ducts  (reactive  inflammation).  The  microscopic  appearances 
of  the  organ  simulate  those  of  hypertrophic  cirrhosis;  but  the  hepatic 

'  Boston  Med.  and  Surrj.  Journ.,  March  10,  1898. 


CIRRHOSIS   OF  THE  LIVER.  889 

cells  are  more  deeply  bile-stained.  Jlicroseopiealli/,  the  first  discover- 
able changes  are  spots  of  insular  necrosis  in  the  peripheral  zones  of  the 
acini  (Stengel).  These  are  shortly  replaced  by  proliferation  of  the 
interlobular  connective  tissues.  The  formation  of  ne'«--ducts  and  liver- 
cells  is  common. 

There  is  also  a  so-called  Glissonian  cirrhosis  (perihepatitis)  in  Vthich 
the  capsule  of  the  organ  is  surrounded  by  a  dense  white  fibrinous  mem- 
brane, which  contracts,  reducing  the  size  of  the  liver  and  altering  its 
shape.  This  I  have  described  elsewhere  (vide  Chronic  Hepatitis,  p.  877). 
Syphilitic  cirrhosis  of  the  organ  receives  special  consideration  in  the 
section  devoted  to  Syphilis  {vide  p.  334). 

Ktiology. — ('/)  Aurophic  Cirrhosis. — 1.  AlcoJioIis/'/i. — Freyhan,  Osier, 
and  I  myself  have  found  this  causal  factor  operative  in  nearly  all  cases. 
Clinical  history  tends  to  prove  that  the  stronger  the  alcoholic  beverage 
(e.  g.  raw  spirits)  and  the  larger  the  amount  consumed  the  sooner  cir- 
rhosis develops,  although  the  quantity  necessary  to  produce  the  disease 
varies  greatly  in  different  individuals.  Doubtless  by  the  side  of  alcohol- 
ism all  other  causes  combined  are  comparatively  insignificant. 

2.  Spicy  foods  are,  according  to  some,  classed  as  predisposing  agents. 
Tiraboschi  records  a  case  that  had  long  been  induced  by  the  use  of  spicy 
foods  and  by  over-eating.  In  many  cases  ptomains.  the  products  of  mal- 
assimilation  through  faulty  digestion,  are  supposed  tobethe  exciting  cause. 

3.  Male  Sex  and  Middle  Life. — The  cases  produced  by  alcohol  occur 
chiefly  in  males.  According  to  my  experience,  females  who  misuse 
potable  alcohols,  particularly  the  more  concentrated  liquors,  are  less 
susceptible  to  the  poison  than  males.  Two-thirds  of  the  fatal  cases 
occur  between  the  ages  of  35  and  50  (Hawkins),  although  cases  have 
been  known  to  occur  at  both  extremes  of  life.  In  children  the  disease 
is  mostly  caused  by  inherited  syphilis,  in  which  the  organ  is  the  seat  of 
a  general  fibroid  process.  It  may  follow  the  acute  infectious  diseases, 
notably  scarlet  fever,  in  the  young. 

4.  Certain  chronic  diseases  (syphilis,  rickets,  diabetes,  gout,  malaria, 
carcinoma,  tuberculosis)  that  favor  the  formation  of  connective  tissue 
are  apt  to  be  complicated  by  cirrhosis,   usually  partial. 

5.  Passive  concjestion.  secondary  to  chronic  cardiac  lesions  or  to 
obstructive  lung-disease,  not  infrequently  gives  rise  to  hepatic  cirrhosis. 

6.  Fatty  cirrhosis  results  from  the  abuse  of  malt  liquors  in  some 
cases,  and  is  often  associated  with  more  or  less  obesity. 

(5)  Hypertrophic  Cirrhosis  (Hanot). — In  most  cases  there  is  an  absence 
of  recognizable  causes.  Sex  is  a  strongly  predisposing  cause,  males 
being  the  most  frequent  victims,  in  the  proportion  of  6  to  1.  It  is  not 
uncommon  in  young  adults.  In  catarrhal  jaundice  the  morbid  processes 
may  rarely  extend  to  the  liver  and  there  persist,  giving  rise  to  hyper- 
trophic cirrhosis.  Cases  are  met  with  in  children,  in  Avhom  it  may 
follow  the  acute  infectious  diseases.  Alcohol  plays  an  unimportant  role 
in  the  causation  of  Hanot's '  cirrhosis.  The  disease  is  most  common 
among  the  inhabitants  of  warm  climates. 

(e)  Biliary  Cirrhosis. — This  form  is  produced  by  chronic  obstruction 
of  the  bile-ducts  (see  •also   Obstruction  of  the  Common  Duct.  p.  85b).'' 

Symptoms. — Atrophic  Cirrhosis. — The  symptoms  of  this  variety  of 
cirrhosis   mar  present   nothincr    characteristic   as   long   as  the  sclerotic 


890  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

process  does  not  interfere  with  the  portal  circulation.  In  some  cases 
the  collateral  (compensatory)  circulation  is  maintained  throughout  the 
long  course  and  symptoms  fail  to  arise.  Among  the  prodromal  si/mptoms, 
a  gradual  loss  of  flesh,  anorexia,  constipation,  a  coated  tongue,  slight 
jaundice,  dyspepsia,  and  occasionally  hematemesis  are  to  he  mentioned. 

As  the  obstruction  of  the  portal  circulation  becomes  more  marked 
the  mucosa  of  the  gastro-intestinal  tract  becomes  more  and  more  swollen 
and  congeste<l,  and  gives  rise  to  augmenting  nausea  and  vomiting  (most 
marked  in  the  morning),  and  hemorrhages  from  the  stomach  (hemateme- 
sis) and  intestines  (melena),  which  may  be  fre(juent  and  profuse,  but  are 
rarely  fatal.  Severe  hemorrhages  may  also  occur  from  enlarged,  vari- 
cose esophageal  veins.     The  tongue  is  coated. 

Owing  to  the  establishment  of  a  compensatory  circulation  the  super- 
ficial epigastric  and  internal  mammary  veins  enlarge,  forming  about  the 
umbilicus  the  so-called  "caput  Medusa." 

Hemorrhoids  also  are  not  uncommon,  and  are  due  to  passive  conges- 
tion of  the  inferior  hemorrhoidal  veins.  As  the  disease  progresses  the 
general  emaciation  becomes  more  marked.  The  face  assumes  a  pinched 
expression,  the  tip  of  the  nose  has  a  purple  tinge  from  distended  veins; 
the  eyes  are  sunken,  the  cheeks  hollow,  and  the  skin  presents  a  sallow 
tint  (hepatic  fades).  The  failure  of  the  compensatory  circulation  gives 
rise  to  ascites,  and  the  latter  causes  in  many  instances  hydroperitoneum, 
leading  to  enormous  distention  of  the  abdomen.  The  spleen  becomes 
enlarged.  At  any  stage,  although  generally  in  advanced  cases,  to.vemic 
sy)nptoms  may  develop,  due  to  some  poisonous  product  in  the  blood,  the 
exact  nature  of  which  is  unknown  :  these  are  violent  headache,  followed 
by  wild,  noisy  delirium,  convulsions,  stupor,  and  coma.  They  not  un- 
commonly occur  without  jaundice,  and  have  been  mistaken  for  uremia. 

Fever  may  be  absent  throughout  the  course  of  the  disease,  but  is  often 
present,  and  may  reach  100°-102°  F.  (37.7°-38.8°  C). 

Examination  of  the  urine  shows  it  to  be  of  increased  specific  gravity, 
loaded  with  urates,  and  containing  bile.  In  a  small  proportion  of  cases 
it  is  slightly  albuminous,  and  contains  casts,  though  out  of  28  urinalyses 
in  cases  of  cirrhosis  Henry  discovered  the  presence  of  albumin  in  but 
one.  The  amount  of  urea  is  constantly  diminished,  owing  to  the  dis- 
turbance of  the  urea-forming  function  of  the  liver.  An  excess  of 
indoxyl  sulphate  in  the  urine  is  a  fretjuent  occurrence. 

The  physical  examinafion  in  a  typical  case  of  atrophic  cirrhosis 
reveals  a  distention  of  the  abdomen  ;  there  may  be  also  an  extreme 
enlargement  of  the  superficial  veins  over  the  surface  of  the  body.  An 
icteroid  tint  of  the  skin  is  present  in  about  25  per  cent,  of  the  cases. 

Palpation  of  the  liver  and  spleen  may  be  greatly  interfered  -with  by 
the  large  amount  of  peritoneal  fluid  present.  On  withdrawal  of  the 
latter,  however,  the  spleen  is  found  greatly  enlarged  and  extending  in 
some  instances  to  the  epigastric  region. 

The  liver  may  show  slight  enlargement  in  the  beginning  of  the  dis- 
ease; but  it  soon  atrophies,  and  in  emaciated  subjects  with  lax  abdominal 
walls  its  finely  granular  or  nodular  edge  can  be  felt  above  the  margin 
*of  the  ribs.  Percussion  shows  its  vertical  diameter,  which  normally 
extends  from  the  sixth  interspace  to  the  costal  margin,  and  averages 
about  4  inches  (10  cm.),  diminished,  especially  toward  the  median  line. 


CIRRHOSIS  OF  THE  LIVER.  891 

Posterior  dulness  begins  lower  than  normally.     It  must  be  recollected 
that  the  liver  is  often  enlarged  in  otherwise  typical  cases. 

Fatty  cirrhosis,  in  which  the  organ  is  sometimes  enlarged,  may  be 
latent  and  remain  unrecognized  or  be  discovered  on  the  post-mortem 
table.  In  five  of  the  six  cases  that  have  fallen  under  my  observation, 
however,  the  symptoms  closely  resembled  those  of  the  ordinary  form  of 
atrophic  cirrhosis,  apart  from  the  alteration  in  the  size  of  the  liver. 

(b)  Hypertrophic  Cirrhosis. — In  this  variety  of  the  disease  there  is 
usually  an  absence  of  any  alcoholic  history,  and  it  is  apt  to  be  met  in 
young  adults  and  even  children  (^vide  Etiology).  Moderate  enlargement 
of  the  liver  may  be  present  before  any  subjective  symptoms  are  observed. 
The  latter  may  be  absent,  except  the  presence  of  slight  jaundice  and  an 
occasional  disturbance  of  digestion,  until  late  in  the  course  of  the  dis- 
ease. Intense  jaundice,  fever,  and  hepatic  enlargement  may  then  appear, 
with  the  rapid  development  of  a  grave  general  condition.  The  wrme  con- 
tains bile-pigment,  but  the  stools  are  not  typical  (pale  drab  or  slate  col- 
ored). Paroxysms  oi pain  resembling  hepatic  colic,  though  less  severe, 
may  occur  at  irregular  intervals.  Hemo7'rhages  into  the  skin  from  the 
mucous  surfaces  (due  to  passive  congestion)  are  also  common.  In  long- 
standing cases  albumin  and  tube-casts  may  be  present  in  the  urine. 
Leucin  and  tyrosin  have  also  been  found,  but  are  not  constant.  These 
symptoms  are  probably  due  to  recent  inflammatory  infiltration  arising 
in  the  course  of  an  old  cirrhosis.  Splenic  enlargement  occurs,  but 
ascites  is  exceedingly  rare.  The  cases  run  an  extremely  chronic 
course,  and  in  an  instance  under  my  care  in  a  lad  of  14  'years,  the 
grave  symptoms  mentioned  above  suddenly  developed  and  carried  oif 
the  patient  after  four  years  of  slight,  though  decisive  jaundice,  and 
moderate  hepatic  enlargement.  The  stools  were  dark  and  bilious  look- 
ing, and  hemorrhages  from  the  mucous  surfaces  frequently  occurred ; 
petechise,  with  urticaria  and  lichen,  marked  the  skin,  while  pruritus 
was  exceedingly  distressing.  There  was  a  leucocytosis.  Sicard  and 
Remlinger  speak  of  a  deformity — a  lowering  of  the  shoulder,  arm,  and 
side  of  the  chest  and  pelvis  on  the  right  side — but  this  has  not  been 
observed  in  any  of  my  cases. 

Physical  examination  shows  a  decided,  and,  in  some  cases,  a  uniform 
enlargement  of  the  organ  ;  the  lower  border  is  felt  distinctly  outlined 
below  the  costal  margin,  its  edges  being  rounded  and  in  some  instances 
finely  granular.      On  making  deep  pressure  tenderness  may  be  elicited. 

Percussion  shows  an  increased  area  of  hepatic  dulness,  most  marked 
anteriorly  toward  the  median  line,  extending  below  the  costal  margin. 

Late  in  the  disease,  in  addition  to  the  grave  symptoms  described 
above — icterus  gravis,  high  fever,  hemorrhages,  and  the  like — serious 
nervous  symptoms,  as  delirium,  convulsions,  stupor,  and  coma,  may 
supervene.  The  temperature  now  usually  ranges  from  102°  to  104°  F. 
— 38.8°-40°  C,  {febrile  jaundice) — although  fever  may  sometimes  be 
absent  throughout  the  course  of  the  disease.  Death  is  sometimes 
threatened,  also,  by  the  development  of  an  intercurrent  disease  or 
progressive  asthenia. 

(c)  Biliary  Cirrhosis. — Symptoms  and  Diagnosis. — The  clinical  in- 
terest of  this  form  centers  principally  around  the  symptoms  of  the 
causative  condition — chronic  obstruction  of  the  bile-ducts — which  have 


892  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

been  given  in  detail  elsewhere  (vide  p.  856).  With  the  latter  may  be 
associated  the  features,  both  local  and  general,  of  either  catarrhal  or 
suppurative  cholangitis.  Jaundice  is  usually  more  intense  than  in  the 
hypertrophic  form,  particularly  during  the  earlier  stages.  Intermittent 
hepatic  fever  is  commonly  observed.  The  phr/sieal  signs  are  similar  to 
those  of  Hanot's  cirrhosis. 

The  diagnosis  of  biliary  cirrhosis  rests  on  the  presence  of  the  char- 
acteristic features  of  prolonged  obstruction  of  the  bile-ducts,  from  im- 
paction by  gall-stones,  a  tumor  or  stricture  of  the  duct,  and  the  like, 
with  slow  and  gradual,  smooth,  or  slightly  granular,  hepatic  enlarge- 
ment. It  is  to  be  recollected  that  when  obstruction  of  the  gall-ducts 
becomes  complete,  or  •'acute  fermentative  changes"  are  set  up  in  the 
retained  bile,  the  cases  may  terminate  acutely  (c.  g.  in  acute  atrophy  or 
acute  fiUty  <legencration). 

General  Diagnosis. — {a)  Of  Atrophic  Cirrhosis. — An  assured  diag- 
nosis may  be  based  on  the  following  points :  1.  A  clear  history  of  thr 
most  common  causes  (inebriety,  male  sex  and  middle  life,  rickets,  dia- 
betes, gout,  malaria).  2.  The  combined  presence  of  ascites,  with  hyper- 
trophic facies.  and  diminution  in  the  size  of  the  liver,  as  shown  by  the 
physical  signs.  3.  Absence  of  the  characteristic  features  of  acute  dis- 
ease, and  the  negative  character  of  results  from  an  examination  of  the 
heart,  lungs,  and  kidneys.  It  is  to  be  recollected  that  the  volume  of 
the  liver  is  not  invariably  decreased  in  this  variety,  and  even  may  be 
slightly  increased. 

With  the  atrophic  form  of  cirrhosis,  chronic  peritonitis  7vith  effusion 
is  most  liable  to  be  confounded.  In  the  latter  disease  there  are  charac- 
teristic abdominal  tenderness,  fever,  and  usually  associated  tuberculous 
lesions  of  other  organs  (lungs,  kidneys,  intestines) ;  but  the  hepatic 
facies  and  clearly  indicative  history  of  atrophic  cirrhosis  are  absent.  A 
large  peritoneal  effusion  is  in  favor  of  cirrhosis 

(h)  Of  Hypertrophic  Cirrhosis. — The  principal  diagnostic  points  are 
an  absence  of  the  usual  aleoliolic  history,  slight  icterus,  extending  over 
a  variable  and  oftentimes  long  period,  paroxysms  of  pain,  mucous  and 
cutaneous  hemorrhages,  with  moderate  enlargement  of  the  liver,  and  the 
rapid  development  of  grave  symptoms  at  any  stage,  as  intense  jaundice, 
fever,  and  sometimes  marked  nervous  phenomena. 

Differential  Diagnosis  of  Hypertrophic  Cirrhosis. — This  may  be  con- 
founded with  carcinoma  of  the  liver.  Itydatid  cyst,  hepatic  abscess,  and 
the  biliary  form  of  cirrhosis. 

HvPERTROPHic  Cirrhosis.  Carcinoma  of  the  Liver. 

Absence  of  recosnizable  causes.  Hereditary  history. 

Occurs  in  young  aduhs  and  even  in  child-  Usually  occurs  after  forty  years  of  age. 

hood. 

Usually  a  primary  affection.  Often  occurs  as  a  secondary  growth. 

Jaundice   is   slight   unless  grave  symp-  Anemia  is  present,  and  also  the  develop- 

toms    suddenly   develop :    there   is  no  ment  of  a  typical  cachexia, 
cachexia. 

Paroxysms  of    pain.     The  case   runs  a  Pain  more  constant  with  rapid  emacia- 

slow    course,    usually    lasting    many  tion.      The    case    terminates    usually 

years.  within  one  year. 

Enlargement  is  uniform.  The   liver   is    irregularly    enlarged,   and 

contains  umbilicated  nodules. 
(See  Fig.  60.) 


CIRRHOSIS  OF  THE  LIVER. 


893 


Hypertrophic  Cirrhosis. 

History  negative  as  to  alcohol.  More 
common  in  warm  climates. 

Occurs  idiopathically. 

Fever,  jaundice,  and  ascites  may  be  pres- 
ent singly  or  together. 

Anemia  and  emaciation  slowly  progres- 
sive.    There  is  a  leucocytosis. 

Regular  enlargement  of  the  liver.  No 
fluctuation  nor  thrill. 

Aspiration  is  negative. 


MULTILOCULAR  HvDATID    CyST. 

History  of  ingestion  of  the  embryo  of 
taenia  echinococcus  with  improper 
food. 

Simultaneous  occurrence  in  colonies  or  in 
others  in  the  vicinity. 

No  fever,  pain,  jaundice,  or  ascites. 

Emaciation  not  marked  ;  no  leukocytosis. 

On  palpation  an  irregular,  fluctuating 
tumor  is  felt  over  the  hepatic  area, 
giving  an  "  hydatid  thrill." 

Aspiration  gives  a  clear,  serous  fluid, 
rich  in  chlorids,  and  containing  hook- 
lets. 


A^:--^ 


A 


:''-i  / 


Fig.  60.— Showing  approximate  enlargement  of  the  liver  corresponding  to  the  different  dis- 
eases described  in  the  text  (after  Eindfleisch) :  J,  position  of  the  diaphragm  to  the  maximum 
enlargement  (carcinoma) ;  II.  II.  normal  situation  of  the  diaphragm ;  //,  III,  relative  dulness ; 
IV,  border  of  the  liver  in  cirrhosis ;  T',  border  in  health ;  VI,  lower  border  of  the  fatty  liver ; 
VII,  of  the  amyloid  liver;   VIII,  of  carcinoma,  leukemia,  and  adenoma. 


Hypertrophic  Cirrhosis. 

Etiology  usually  negative.  May  rarely 
follow  acute  infectious  diseases. 

There  are  tenderness  on  deep  pressure 
and  paroxysmal  pain. 

Hectic  symptoms  absent  although  a  con- 
tinued fever  may  develop  usually  late. 

Runs  a  slow  course,  lasting  months  or 
years. 


Abscess  op  the  Liver. 

History  of  dysentery,  traumatism,  or 
pyemia. 

Severe  and  constant  pain  :  marked  ten- 
derness. 

Hectic  symptoms  appear  early  (fever, 
chills,  and  sweating). 

Runs  an  acute  course,  lasting  a  few 
weeks. 


894  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Hypertrophic  Cirrhosis  {continued).  Abscess  of  the  Liver  {continued). 

Slow  enlargement,   regular,   or    slightly      Rapid    development     of    a     fluctuating 

nodulated.     No  fluctuation.  tumor  in  the  hepatic  area. 

Aspiration  gives  negative  results.  The   aspirating-needle   reveals  the  pres- 

ence of  pus. 

So-called  fatty  cirrhosis  may  be  distinguished  from  abscess,  hydatid 
cyst,  and  carcinoma  of  the  liver  in  a  manner  similar  to  hypertrophic 
cirrhosis,  if  one  makes  due  allowance  for  its  etiology,  particularly  the 
wrong  use  of  alcohol. 

{c)  Biliary  eirrJiosis  causes  enlargement  of  the  liver,  but  to  a  much 
more  moderate  extent  than  hypertrophic  cirrhosis.  In  the  former  the 
symptoms  of  chronic  obstruction  of  the  bile-ducts  are  in  evidence,  so 
that  jaundice  is  usually  marked.  The  duration  of  biliary  cirrhosis  is, 
on  the  whole,  shorter  than  that  of  hypertrophic,  and  the  organ  is  more 
likely  to  undergo  terminal  diminution  in  size  (atrophy). 

Prognosis. — The  prognosis  of  the  atrophic  form  of  cirrhosis  is 
decidedly  unfavorable,  the  function  of  the  liver-cells  having  been 
impaired,  although  the  principal  source  of  danger  is  probably  the 
ascites ;  and  death  usually  takes  place  within  a  few  months  or  a  year 
after  symptoms  of  portal  obstruction  appear.  In  rare  cases  the  symp- 
toms abate,  owing  to  the  establishment  of  a  compensatory  circulation, 
and  may  remain  in  abeyance  for  months  or  years. 

The  prospect  of  life  is  much  enhanced  by  an  early  recognition  and 
removal  of  the  overshadowing  cause — alcoholism.  I  have  seen  a  few 
cures  made  in  this  manner.  Even  after  the  occurrence  of  jaundice, 
hematemesis,  and  toxic  symptoms,  under  appropriate  treatment  patients 
have  been  known  to  enjoy  comparative  health  for  years. 

Treatment. — The  prophylactic  treatment  consists  in  improving  the 
general  health  of  the  patient  and  in  removing,  if  possible,  the  cause  of 
the  affection.  Rest,  graduated  exercise,  systematic  bathing,  and  regular 
hours  for  eating  and  sleeping  should  be  inaugurated  and  strictly  adhered 
to.  Alcohol,  strong  coffee,  spices,  and  gastro-intestinal  irritants  of  every 
nature  must  be  interdicted.  H.  C.  Wood  states  that  tavern-keepers  and 
bartenders  Avho  are  unable  or  will  not  cease  using  alcohol  may  greatly 
prolong  life  by  substituting  hard  cider  for  all  other  drinks.  The  diet 
should  be  simple  and  easily  digestible.  An  exclusive  milk-diet  has  been 
highly  recommended  (Semmola). 

The  rnedichml  treatment  is  largely  symptomatic,  no  remedy  having 
been  discovered  to  prevent  the  formation  of,  or  remove,  the  new-formed 
connective  tissue.  The  chief  object  is  to  deplete  the  portal  system  and 
prevent,  if  possible,  the  occurrence  of  ascites.  The  bowels  should  be 
kept  freely  open  by  tho  use  of  saline  purgatives  (concentrated  solution 
of  Epsom  salts),  elaterium,  or  compound  jalap  powder.  The  skin  is  to 
be  kept  active  by  means  of  Turkish  or  Russian  baths  (under  supervision), 
and  in  extreme  cases  by  the  steam  bath  or  hot  pack,  employed  just  short 
of  the  point  of  exhaustion.  The  kidneys  should  also  be  kept  active 
by  the  hydragogue  diuretics,  as  potassium  acetate,  squills,  calomel, 
digitalis  in  the  form  of  the  infusion,  or  Niemeyer's  pill.  Klemperer 
and  others  have  also  recently  recommended  urea  as  an  efficient  diuretic, 
and  from  20  to  30  grains  (1.29-1.94)  may  be  given  in  solution.  Urea 
acts  best  after  paracentesis. 


CARCINOMA    OF  THE  LIVER.  895 

If  the  case  be  syphilitic  in  origin,  potassium  iodid  should  be  exhibited 
in  ascending  doses. 

Ascites,  when  it  appears,  calls  for  free  and  thorough  diuresis,  diapho- 
resis, and  catharsis ;  and  if  not  relieved  in  the  course  of  a  few  days,  tap- 
ping should  be  resorted  to. 

The  operation  of  jyaracentesis  abdommis,  if  performed  under  strict 
antiseptic  precautions,  is  free  from  danger.  The  bladder  having  been  emp- 
tied, a  spot  over  the  linea  alba  about  3  inches  (7.5  cm.)  above  the  sym- 
physis pubis  is  anesthetized  (preferably  with  a  compress  of  cracked  ice 
and  salt),  and  a  trocar  is  quickly  thrust  through  the  abdominal  wall  for 
a  distance  of  about  1  inch  (2.5  cm.).  The  distance  is  determined  by  the 
fore-finger,  which  is  placed  at  the  desired  distance  from  the  point  of 
the  cannula  before  its  insertion.  The  patient  must  be  in  a  sitting  or 
semi-reclining  position,  so  as  to  allow  the  ascitic  fluid  to  collect  by  grav- 
ity in  the  lower  part  of  the  abdominal  cavity.  A  tube  having  been 
attached  to  the  cannula  to  convey  the  liquid  to  a  receptacle,  the  trocar 
is  withdrawn,  the  fluid  allowed  to  run  out,  the  cannula  removed,  and  the 
wound  closed  by  antiseptic  gauze  or  a  pledget  of  cotton.  Turlington's 
balsam  is  then  smeared  over  the  site  of  puncture,  and  the  abdominal 
binder,  which  has  been  previously  applied,  is  tightened  (vide  Ascites, 
p.  927). 

Complications,  as  cardiac  hypertrophy,  tuberculous  peritonitis,  or 
chronic  meningitis,  demand  appropriate  treatment ;  this  is  described 
in  full  in  the  discussion  of  the  respective  diseases. 


CARCINOMA  OF  THE  LIVER. 

Definition. — A  malignant  growth  of  the  liver,  occurring  usually 
after  the  age  of  forty,  and  characterized  by  pain,  progressive  emaciation, 
cachexia,  and  the  appearance  of  a  nodular  mass  in  the  hepatic  paren- 
chyma. It  may  be  primary  or  secondary,  though  the  former  variety  is 
very  rare  as  compared  with  the  latter. 

Pathology. — Histologically,  the  cells  are  not  distinctive,  being  iden- 
tical with  those  of  carcinoma  elsewhere ;  they  are  epithelial  in  charac- 
ter, having  a  small  vesicular  nucleus  and  much  protoplasm.  They  are 
altered  greatly  by  pressure,  and  vary  in  shape,  being  hexagonal,  poly- 
hedral, or  amorphous.  Large  giant-cells  and  spots  of  pigment  known 
as  "brownish  granules  "  are  not  uncommonly  found  in  the  cancerous 
mass.  The  so-called  colloid  cancers  are  nearly  always  mucoid,  and  the 
cells  have  undergone  a  mucoid  change ;  the  stroma  of  connective  tis- 
sue surrounding  the  cancer-nests  in  some  instances  undergoes  hyaline 
or  myxomatous  degeneration.  In  other  instances  the  interstitial  tra- 
beculse  completely  surround  the  epithelial  nests,  which  are  separated  by 
a  basement  membrane  ;  to  this  variety  the  name  of  adeno-carcinoma  has 
been  given. 

When  examined  microscopically,  medullary  cancer,  either  in  a  large 
mass  (primary)  or  in  secondary  nodules  scattered  throughout  the  organ, 
is  the  most  common  variety  found  in  the  liver.  On  examining  a  liver  that 
is  the  seat  of  carcinoma,  one  of  two  conditions  usually  presents  itself: 
First,  the  organ  may  be  apparently  normal  with  the  exception  of  one 
lobe  (usually  the  right),  which  contains  a  dense  whitish  growth  of  firm 


896  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

consistence,  being  distinct  and  sharply  defined  from  the  surrounding 
liver-tissue.  On  section  the  tumor  is  often  of  uniform  density,  bluish- 
white  in  appearance,  and  exudes  a  milk-white  fluid  known  as  ''  cancer- 
juice,"  which,  when  examined  microscopically,  is  found  to  contain  large, 
nucleated,  and  irregularly-shaped  cells  containing  free  granular  matter. 
The  center  of  the  tumor  may  have  undergone  liquefaction-necrosis,  with 
the  formation  of  a  cyst,  or  it  may  be  the  seat  of  an  abscess.  Various 
smaller  nodules  may  be  scattered  throughout  the  organ  by  metastasis 
from  the  primary  growth.  The  speond  and  most  common  condition  is 
secondary  carcinoma  of  the  liver,  the  primary  lesion  being  situated  in  the 
mammary  glands,  pylorus,  or  the  cervix  uteri.  The  organ  is  greatly  en- 
larged, as  a  rule.  Numerous  nodules  are  scattered  throughout,  and  can 
usually  be  seen  projecting  beneath  the  capsule,  those  superficially  situ- 
ated having  received  the  name  of  "  Farre's  tubercles."  In  the  center 
of  these  nodules  characteristic  pits  or  umbilications  are  often  present, 
caused  sometimes  by  contraction  of  the  interstitial  trabecul?e  and  some- 
times by  a  central  softening.  On  section  they  are  usually  grayish-white 
in  color  and  of  firm  consistence,  although  cysts,  hemorrhages,  pus-cav- 
ities, or  areas  of  hyaline  and  fatty  degeneration  are  often  found.  The 
cells  are  identical  with  those  of  the  primary  growth,  and  are  composed 
for  the  most  part  of  cylindric  epithelium. 

In  rare  instances  carcinoma  occurs  simultaneously  with  cirrhosis  in  the 
same  liver,  the  organ  presenting  an  uneven,  nodular  appearance,  and 
being  slightly  increased  in  size  and  of  firmer  consistence  than  normal. 
When  examined  in  situ  the  external  appearance  does  not  differ  materi- 
ally from  that  of  cirrhotic  liver,  but  on  section  the  whole  organ  is  found 
to  be  infiltrated  with  various-sized  cancer-nodules  surrounded  by  bands 
of  cicatricial  tissue.  In  some  cases  the  excess  of  connective  tissue  and 
the  amount  of  contraction  are  extreme,  and  the  size  and  weight  are 
reduced  below  the  normal. 

Htiology. — Among  the  more  important  predisposing  factors  may  be 
mentioned — 

(rt)  Age. — The  disease  seldom  occurs  before  thirty-five  or  forty  years 
of  age,  although  cases  have  been  known  to  occur  in  children.  Descroi- 
zilles  reports  the  case  of  a  child  eleven  years  old  who  died  w  ith  a  tumor 
in  the  right  hypochondriac  and  iliac  region,  the  autopsy  revealing  a  liver 
studded  with  cancerous  nodules,  the  nature  of  which  was  demonstrated 
microscopically. 

{h)  Sex. — Men  are  more  often  the  victims  of  carcinoma  of  the  liver 
than  women.  When  occurring  in  the  latter  it  is  often  secondary  to  car- 
cinoma of  the  uterus  or  mammary  gland. 

(e)  Heredity  is  said  to  be  the  cause  of  hepatic  carcinoma  in  at  least 
20  per  cent,  of  all  cases,  and  is  one  of  the  strongest  arguments  in  sup- 
port of  the  diathetic  theory  of  the  disease. 

((/)  Traumatism  may  contribute. 

(e)  Mechanical  Obstruction. — Primary  carcinoma  of  the  gall-bladder 
and  bile-ducts  not  infrequently  follows  chronic  obstruction  by  gall- 
stones. 

Sytnptoms. — There  may  either  be  almost  no  symptoms  of  carci- 
noma involving  the  liver,  or  its  manifestations  may  be  intense  and  varied 
according  to  the  extent  and  location  of  the  growth  or  growths.     Associ- 


CARCINOMA    OF  THE  LIVER.  897 

ated  gastric  symptoms,  AYliicli  increase  as  the  disease  advances,  usually 
attend.  A  more  or  less  marked  cachexia  may  be  the  first  noticeable 
feature.      The  chief  symptoms  may  be  considered  in  detail,  as  follows : 

(a)  Jaundice. — Discoloration  of  the  skin  and  tissues  is  often  by  no 
means  intense,  and  may  be  entirely  absent.  Harley  states  that  true 
icterus  was  present  in  only  6  out  of  100  cases  seen  by  him,  though  few 
observers  agree  with  him  in  his  extreme  view  as  to  the  rarity  of  this 
symptom.  The  reason  given  for  its  lack  of  intensity  is  that  in  the  great 
majority  of  cases  the  growth  is  situated  in  the  right  lobe  of  the  liver, 
and  neither  compresses  the  bile-ducts  nor  destroys  the  secretory  cells  of 
the  liver. 

(h)  Pain  is  usually  present  to  a  marked  degree,  though  it  also  may 
be  entirely  wanting.  It  is  dull  and  boring  in  character,  and  localized 
generally  in  the  right  hypochondriac  region.  In  some  instances  (as  in 
the  case  of  impacted  biliary  calculi)  it  may  radiate  to  the  right  shoulder 
and  the  scapular  region.  It  usually  appears  as  the  hepatic  enlargement 
progresses,  although  cases  of  enormous-sized  cancerous  tumors  of  the 
liver  have  been  known  to  occur  without  pain.  The  character  and  loca- 
tion of  the  pain  are  of  diagnostic  importance,  and  will  be  spoken  of 
under  the  differential  diagnosis. 

(c)  Ascites. — When  the  cancerous  growth  compresses  the  portal  ves- 
sels, and  also  in  cases  of  cirrhosis  with  carcinoma,  obstruction  to  the 
portal  circulation  occurs,  and  results  in  the  development  of  ascites. 
This  may  cause  distention  of  the  abdominal  cavity  to  such  an  extent  as 
to  occlude  the  physical  signs  of  hepatic  enlargement.  The  cancerous 
growth  may  invade  the  peritoneum  and  cause  an  effusion.  This  symp- 
tom, however,  is  not  frequent,  at  least  t>vo-thirds  of  all  cases  terminating 
without  the  appearance  of  ascites. 

{d)  Fever  is  usually  absent  until  the  later  stages  of  the  disease.  It 
may  then  appear  and  rise  to  hyperpyrexia  (105°  F. — 40.5°  C),  but  it 
is  usually  moderate  in   degree,  irregular,  and  intermittent  in  type. 

(e)  Caeliexia. — In  every  case  of  carcinoma,  at  some  stage  of  the  dis- 
ease, cachexia  develops ;  when  pronounced,  it  is  almost  pathognomonic. 

(/)  Oerehral  Symptoms. — These  may  be  absent  throughout.  In  the 
advanced  stages,  however,  the  deleterious  products  in  the  blood,  due  to 
the  perverted  functions  of  the  liver  and  the  toxemic  condition  of  the 
patient,  often  produce  such  striking  symptoms  as  violent  headache, 
mental  hebetube,  or  delirium  (less  frequently)  which  may  be  maniacal 
in  character.  These  symptoms  resemble  those  of  cholemia  {vide  Hepatic 
Cirrhosis,  p.  887).     The  patient  may  die  in  sudden  coma. 

Physical  Signs. — Inspection  often  reveals  enlargement  of  the  super- 
ficial veins  over  the  abdomen,  and  a  prominence  in  the  upper  epigastric 
and  hepatic  regions,  varying  with  the  degree  of  enlargement,  may  also 
be  seen.  In  the  nodular  form  and  late  in  the  disease,  when  emaciation 
has  become  extreme,  elevations  that  are  movable  with  respiration  can 
be  noticed  beneath  the  skin. 

On  palpation  the  organ  can  be  distinctly  felt  projecting  below  the 
costal  margin  and  extending  in  some  instances  to  a  point  below^  the 
level  of  the  umbilicus.  During  deep  inspiration  the  liver  can  be  felt  to 
move  downward,  and  during  expiration  upward,  the  organ  being  under 
the  influence  of  the  diaphragmatic  excursions.  In  emaciated  subjects 
57 


898  BISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  cancer-nodules  are  readily  appreciable,  and  in  some  instances  the 
central  pits  or  depressions  are  palpable,  forming  a  pathognomonic  sign. 
Cancerous  infiltration  of  the  anterior  margin  is  most  easily  felt,  and 
in  any  enormous  enlargeuient  of  the  organ  I  have  frequently  detected 
them  on  the  posterior  surface  as  well.  Rarely  the  liver  is  found  to  be 
uniformly  large.  Palpation  may  also  show  splenic  enlargement,  due  to 
passive  congestion. 

Percussion  shows  flatness,  extending  in  many  cases  in  both  an  up- 
ward and  a  downward  direction.  In  primary  carcinoma  (usually  found 
in  the  right  lobe)  the  area  of  hepatic  dulness  is  increased  irregularly 
downward  and  generally  to  the  right.  Un  the  other  hand,  in  second- 
ary growths  (usually  massive)  the  nodules  are  oftener  distributed  equally 
throughout  the  liver.  In  such  cases  the  area  of  dulness  may  extend 
across  the  epigastrium  to  the  left  hypochondriac  region,  the  heart  and 
other  "viscera  being  now  displaced.  Posteriorly,  dulness  may  extend 
upward  on  a  level  with  the  fourth  rib,  and  anteriorly  downward  to  the 
iliac  fossa.  The  organ  may  now  Aveigh  from  15  to  20  lbs.  (6.5-9  kgms.), 
while  the  weight  of  cancerous  livers  in  ordinarv  cases  varies  between  3 
and  6  lbs.  (1.3-2.6  kgms.). 

Diagnosis. — In  forming  a  positive  diagnosis  the  family  tendency, 
the  histury  of  primary  carcinoma  elsewhere  in  the  body,  the  age  of  the 
patient,  the  localization  of  the  pain  in  the  right  hypochoudrium,  the 
cachexia,  and  the  progressive  enlargement  of  the  liver,  with  the  charac- 
teristic umbilicated  nodules,  are  the  most  reliable  points.  The  appear- 
ance of  jaundice  or  ascites,  or  both,  is  confirmatory. 

Differential  Diagnosis. — Among  affections  of  other  organs  that  are 
likely  to  be  mistaken  for  carcinoma  of  the  liver  may  be  mentioned — 
(1)  carcinoma  of  the  pi/Jorus  ;  and  (2)  carcinoma  of  the  colon  and  omen- 
tum. The  chief  diseases  of  the  liver  itself  apt  to  be  diagnosed  as  car- 
cinoma are — (</)  abscess,  (6)  sypliilis,  (c)  benign  groivtlis  {adenomata, 
angiomata),  (d)  hydatid  cysts,  and  {e)  hypertrophic  cirrhosis. 

(1)  Carcinoma  of  the  Pylorus. — In  carcinoma  of  the  pylorus  the  phys- 
ical examination  frequently  shows  a  hard  nodular  tumor  that  is  most 
plainly  outlined  in  the  epigastric  region.  In  a  typical  case,  on  deep  inspi- 
ration, the  tumor  is  pressed  downward  by  the  liver,  but  is  not  pulled  up- 
Avard  by  forced  expiration,  as  in  hepatic  carcinoma.  In  many  instances, 
however,  adhesions  bind  the  stomach  firmly  to  the  under  surface  of  the 
liver,  Avhich  may  be  the  seat  of  secondary  involvement.  The  absence 
of  early  nausea  and  vomiting  and  the  presence  of  jaundice,  as  well  as 

the  nesative  results  from  an  examination  of  the  gastric  contents,  would 

^     .  .  . 

tend  to  eliminate  pyloric  carcinoma. 

(2)  Carcinoma  of  the  Colon  and  Omentum. — Secondary  carcinoma  of 
the  intestine  affects  most  frequently  the  sigmoid  flexure.  The  symjitoms 
of  intestinal  obstruction  arise,  constipation  being  followed  by  attacks  of 
serous  diarrhea  due  to  irritation,  and  later  by  the  presence  of  blood  in 
the  stools.  In  carcinoma  of  the  liver,  on  the  other  hand,  the  bile-ducts 
may  be  obstructed,  causing  clay-colored  stools,  but  otherwise  the  dejecta 
are  normal :  the  seat  of  the  nodular  enlargement  and  pain  is  located  in 
the  right  hypochondrium.  Jaundice  and  ascites  are  absent  in  carcinoma 
of  the  colon.  The  tumor,  if  palpable,  in  the  latter  condition  is  more 
movable  and  is  less  under  the  influence  of  the  diaphragm.  •  It  does  not 


CARCINOMA    OF  THE  LIVER.  899 

give  an  absolutely  fiat  percussion-note,  as  does  hepatic  carcinoma.  Car- 
cinoma of  the  omentum  is  usually  secondary.  The  absence  of  small  mov- 
able tumors  in  the  umbilical,  lumbar,  or  hypogastric  regions,  ranging  in 
size  from  that  of  a  pea  to  a  walnut,  aids  in  the  elimination  of  carcinoma 
of  the  omentum.  As  the  latter  affection  advances  the  abdomen  be- 
comes distended  and  painful  to  the  touch,  the  boAvels  are  obstinately 
constipated,  and  the  physical  signs  reveal  the  presence  of  an  effusion 
which,  when  aspirated,  is  generally  serous,  but  sometimes  bloody.  Mi- 
croscopic examination  may  possibly  reveal  the  presence  of  cancer-cells, 
though  their  recognition  is  difficult.  The  liver,  unless  primarily  in- 
volved, is  not  enlarged,  and  cachexia  does  not  usually  appear  until  late 
in  the  course  of  the  disease. 

From  hepatic  abscess  the  points  of  differentiation  are — 

Carcinoma  of  the  Liter.  Hepatic  Abscess. 

Is  often  hereditary.    There  is  a  history  of  There  is  a  history  of  traumatism  or  of  in- 

a  primary  growth  or  chronic  irritation.  testinal  ulceration,  as  in  dysentery. 

Occurs  usually  after  the  age  of  forty.  Occurs  at  any  age. 

Jaundice  is  rare.  Jaundice  is  sometimes  present. 

Fever  is  absent  or  slight.  Hectic  temperature,  chills,  and  sweating. 

Cachexia  is  present  and  almost  pathog-  Anemia  may  be  present,  but  never  ca- 

nomonic.  chexia. 

Pain  is  dull  and  boring  in  character,  and  Pain  is  sharp,  lancinating,  and  paroxys- 

more  constant.  mal. 

A  nodular,  umbilicated  tumor  or  tumors  A  fluctuating  tumor  may  sometimes  be 

may  be  detected.                 •  detected  below  the  costal  margin. 

The  enlargement  is  downward.  The  enlargement  usually  upward. 

The  duration  is  a  few  months  to  one  year.  The  duration  is  usually  a  few  weeks. 

Microscopic  examination  reveals  disinte-  The   microscope   reveals  pus,  liver-cells, 

grated  liver-cells,  cancer-nests,  and  in  staphylococci     and     streptococci,   the 

some  cases  the  micro-organisms  of  sup-  bacillus  coli  communis  or  the  amoeba 

puration.  coli. 

Benign  G-roioths  (Adenomata,  Angiomata\ — Occasionally  growths 
are  detected  in  the  liver,  and  may  occur  at  any  age ;  when  these  are 
present  at  or  about  the  age  of  forty,  they  may  be  mistaken  for  carci- 
noma. The  absence,  however,  of  a  primary  growth  in  some  one  of  the 
other  viscera,  together  with  the  duration  of  the  growth  and  the  absence 
of  cancerous  cachexia,  would  tend  to  differentiate  them  from  cancerous 
involvement.  An  examination  of  the  blood  may  be  of  service,  leuko- 
cytes being  more  common  in  carcinoma. 

The  prognosis  is  invariably  fatal,  the  disease  terminating  rapidly 
in  from  a  few  months  to  a  year.  The  most  rapid  course  is  run  by  sec- 
ondary carcinoma  of  the  organ. 

Treatment. — The  treatment  is  purely  symptomatic.  An  easily 
digested,  nutritious  diet  should  be  given,  together  with  active  stimulation 
to  support  the  system.  The  pain  may  be  relieved  by  the  free  use  of 
morphin,  given  by  the  mouth,  rectum,  or  hypodermically.  For  the 
nausea  and  vomiting  that  are  apt  to  supervene  the  carbonated  waters, 
cracked  ice  with  champagne,  or  repeated  doses  of  creasote  (beechwood), 
dilute  hydrocyanic  acid,  or  wine  of  ipecac  (2  minims — 0.133 — every 
hour  until  relieved)  may  be  given.  If  violent  delirium  should  occur 
during  the  later  stages  of  the  disease,  cold  compresses  to  the  forehead 
or  vertex,  and  bromids  and  chloral  hydrate  given  in  rectal  enemata, 
may  prove  efficient. 


900  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

OTHER  NEW  GROWTHS  IN  THE  LIVER. 

(a)  Angioma,  Adenoma,  and  Cyst. 

Occasionally,  benign  growths  occur  in  the  liver,  and  often  with  an 
absence  of  symptoms  unless  their  increase  in  size  gives  rise  to  mechan- 
ical obstruction.  One  of  the  most  common  of  these  is  angioma,  which 
is  often  found  in  the  livers  of  old  people.  Angiomata  consist  of  tortu- 
ous and  dilated  capillaries  in  the  hepatic  connective  tissue ;  they  rarely 
attain  to  a  size  larger  than  a  crab-apple,  and  usually  cause  no  symp- 
toms. Although  most  common  in  adults,  they  have  been  known  to 
occur  in  children. 

Adenomata  and  cystomata  may  also  occur  in  the  liver.  They  are  both 
benign  growths.  The  former  is  of  the  tubular  variety,  consisting  of 
connective-tissue  nests  lined  with  cylindric  epithelial  cells.  Von  Berg- 
man removed  a  portion  of  a  tuberous  adenoma  of  the  liver  with  perfect 
recovery  and  non-recurrence  of  the  growth.  Cysts  are  quite  rare.  Lipp- 
mann/  who  searched  the  literature,  found  reported  3  retention  cysts,  9 
cystic  adenomas.  1  lymph  cyst,  and  3  cases  that  could  not  be  classified. 

{h)  Sarcoma. 

Of  the  many  varieties  of  sarcomata,  those  occurring  most  commonly 
in  the  liver  are  the  small  and  large  round-celled  and  the  melanotic  vari- 
ety, the  latter  often  being  secondary  to  sarcoma  of  the  choroid  coat  of 
the  eye.  These  grow  rapidly,  causing  a  widespread  destruction  of  the 
liver-structure,  with  a  change  in  the  size  and  shape  of  the  organ  that  is 
often  demonstrable  by  palpation.  E.  R.  Axtell  reports  a  case  in  which 
at  the  jJostmorteni  the  upper  two-thirds  of  the  liver  revealed  an  entire 
absence  of  hepatic  structure,  and  consisted  of  three  tumor-masses  which, 
on  microscopic  examination,  were  found  to  be  small  round-celled  sar- 
comata. On  section  the  tumor  is  seen  to  be  of  firmer  consistence  than 
the  surrounding  liver-tissue,  and  presents  a  dark,  grayish-white,  striated 
appearance.  If  the  growth  be  of  the  pigmented  variety,  patches  of  a 
deep  black  or  of  different  shades  of  pigment  may  be  scattered  through- 
out the  mass.  Metastasis  is  rapid  and  widespread  (lungs,  kidneys, 
heart,  skin),  as  is  shown  by  the  fact  that  other  organs  are  invariably 
found  involved  at  the  time  of  the  growth  and  development  of  the  sar- 
coma in  the  liver. 

The  symptoini<  are  those  of  mechanical  obstruction,  and  consist  of 
gastro-intestinal  disturbances  due  to  passive  congestion,  edema,  and 
ascites.  Anemia  and  emaciation  may  become  marked  late  in  the  disease, 
but  cachexia  does  not  develoj).  The  passage  of  an  intensely  dark-col- 
ored urine  (melanuria)  has  been  noted  in  some  cases.  Secondary  nod- 
ules may  appear  on  the  skin-surface. 

The  diagnosis  can  often  be  made  from  the  primary  growth  (melano- 
sarcoma  of  the  choroid  or  sarcomata  of  the  lymphatic  glands)  and 
from  the  rapid  development  of  th.e  tumor.  From  carcinoma  of  the  liver 
melanosarcoma  may  be  distinguished  by  the  presence  of  ocular  symp- 
toms, particularly  blindness  of  one  eye,  by  the  rapid  widespread  meta- 
stasis, the  melanuria,  perhaps,  and  by  the  absence  of  a  true  cancerous 
cachexia. 

The  prognosis  is  absolutely  fatal,  and  the  treatment  merely  palliative. 

*  Deutsche  Zeitschrij't  fur  Chirurgie,  February,  1900. 


DISEASES  OF  THE  SPLEEN.  901 


X.  DISEASES  OF  THE   SPLEEN. 

Diseases  of  the  spleen  are  mostly  secondarv  to  other  diseases,  the 
consideration  of  which  embraces  an  appropriate  description  of  the  as- 
sociated splenic  disorders.  The  intimate  relation  between  the  spleen 
and  blood  accounts  for  the  frequency  with  which  this  organ  is  involved 
in  many  of  the  blood-diseases. 

DISLOCATION  OF  THE  SPLEEN. 

{Floating  Spleen.) 

Ktiology. — This  may  be  either  congenital  or  due  to  the  increased 
weight  of  an  enlarged  spleen,  to  tight-lacing,  to  relaxation  of  the  liga- 
ments, or  to  traumatism,  and  is  met  in  splanchnoptosis.  Carcinoma- 
tous enlargement  of  the  left  lobe  of  the  liver  caused  it  in  a  case  I  saw 
recently. 

Symptoms. — The  symptoms  are  vague,  and  are  the  result  of  press- 
ure. By  physical  examination  we  discover  with  the  touch  the  spleen 
as  a  mobile  tumor  pendant  from  the  left  hypochondrium ;  the  tumor  is 
superficial,  blunt-edged,  and  notched  on  its  anterior  border,  and  may  be 
replaced  by  the  hand  nearly  in  its  normal  position.  On  percussion  over 
the  splenic  area  the  normal  dulness  is  found  to  be  absent. 

Diagnosis. — It  is  important  to  distinguish  between  jioatiyig  spleen 
and  simple  enlargement ;  also  between  the  former  and  movable  kidney. 

The  prognosis  is  guarded  as  to  cure,  though  favorable  as  to  life. 
Twisting  of  the  pedicle  of  a  floating  spleen  has  been  followed  by  stran- 
gulation and  consequent  necrosis. 

The  treatment  must  be  mechanically  supportive,  consisting  of  pads 
and  bands.     Splenectomy  has  given  excellent  results. 


SPLENIC  HYPEREMIA. 

Acute  or  active  hyperemia  may  be  found  as  the  result  of  the  acute 
infectious  diseases,  giving  rise  to  the  acute  splenic  tumor,  or  as  the  result 
of  amenorrhea,  or  of  injuries  and  inflammation  {circumscribed  hyper- 
emia). The  organ  is  uniformly  enlarged  (except  in  the  last-named  cases), 
and  is  darker  in  color  and  softer  in  consistence  ;  the  capsule  also  is 
tense.      This  condition  merges  insensibly  into  acute  sjylenitis. 

Cluroiiic  or  passive  hyperemia  is  due  to  some  mechanical  obstruction 
of  the  portal  circulation  caused  by  tumors,  cardiac,  hepatic,  and  pulmo- 
nary disease,  and  pylephlebitis.  The  spleen  is  enlarged,  firm,  dark-red 
in  color,  and  the  capsule  is  somewhat  thickened. 

The  symptoms  are  vague,  and  may  consist  of  simply  a  sense  of  weight. 
fulness,  and  pressure,  and  some  tenderness  in  the  left  hypochondrium. 
In  cases  of  extravasation  of  blood  and  rupture  of  the  spleen  the  symp- 
toms of  intestinal  perforation,  hemorrhage,  and  collapse  may  supervene. 

On  physical  examination  the  edge  of  the  spleen  may  be  palpated  be- 
low the  margin  of  the  ribs.      The  percussion-dulness  is  increased  in 


902  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

area,  especially  downward  and  forward,  and  may  encroach  upon  the 
slightly-curved  umbilico-axillary  "resonant  line." 

The  detection  of  acute  or  chronic  splenic  hyperemia  (enlargement) 
is  often  of  invaluable  aid  in  the  diagnosis  of  the  causative  disease. 

The  prognosis  and  treatment  are  embraced  in  those  of  the  disease 
causing  the  congestion. 


SPLENITIS. 


Definition. — This  term  comprises  acute  and  chronic  (hypertrophic) 
proliferative  splenitis  and  suppurative  inflammation. 

Pathology. — Next  to  the  kidneys,  the  spleen  is  the  favorite  seat 
of  metastatic  inflammation  and  embolic  infarction.  Splenitis,  due  to  a 
benign  embolus  originating  in  the  left  side  of  the  heart  or  from  the 
aorta  above  the  splenic  arteries,  is  usually  circumscribed  to  a  zone  of 
sero-hemorrhagic  infiltration  about  the  resultant  infarct.  The  latter  is 
hemorrhagic  at  first,  and  later  becomes  particolored  or  mixed,  and  is  of 
a  yellow  color,  owing  to  partial  fatty  degeneration  ;  still  later  it  may 
become  whitish  and  remain  as  a  wedge-shaped  (the  base  being  periph- 
eral), cheesy  (necrotic  softening),  or  even  calcareous  mass  or  as  a  fibrous 
cicatrix.  Infection  of  the  infarcts  by  pus-micrococci  leads  to  the  devel- 
opment of  small  abscesses,  and  the  trabeculae  surrounding  the  latter 
may  give  way  until  several  abscesses  or  one  large  pus-sac  may  be 
formed. 

Perisplenitis  generally  follows,  and  sometimes  with  adhesions  attached 
to  adjacent  hollow  organs,  as  the  stomach  and  colon,  through  which 
the  perforating  abscess  may  discharge  its  purulent  contents.  An  unfor- 
tunate termination  is  the  bursting  of  the  abscess  into  the  peritoneal 
cavity ;  a  more  fortunate  ending  results  in  an  external  opening.  In 
acute  splenic  tumor  there  is  an  active  congestion,  with  round-cell  infil- 
tration and  some  proliferation  of  the  splenic  cells.  The  spleen  is  mod- 
erately enlarged,  dark,  soft,  pulpy,  and  friable. 

In  cases  of  intense  vascular  engorgement,  as  in  the  acute  splenic 
tumor  of  severe  typhoid  fever,  intermittent  fever,  and  epilepsy  (during 
the  paroxysm),  hemorrhagic  extravasation  may  occur,  and  there  may 
finally  be  even  a  rupture  of  the  capsule  and  a  passage  of  the  blood  into 
the  peritoneal  cavity.  In  chronic  splenic  tumor  there  is  a  persistent 
hyperplasia  of  the  splenic  cells,  and  freiiuently  also  of  the  trabecular 
cells,  minus  the  acute  engorgement.  CirrJwsis  of  the  spleen  (chronic 
interstitial  splenitis)  diff"ers  characteristically  from  that  of  other  organs 
(as  the  liver  and  kidneys)  in  that  there  is  enlargement  instead  of  con- 
traction. Added  to  the  increase  in  the  size  of  the  spleen,  there  are  in 
both  forms  of  chronic  splenitis  thickening  of  the  capsule,  patches  often 
of  old  perisplenitis,  and  a  slaty  color  of  the  tissues,  with  more  or  less 
pigmentation. 

Htiology. — The  disease  probably  never  starts  primarily  in  the 
spleen  itself.  Acute  proliferative  or  hjperplastic  splenitis  (acute  splenic 
tumor)  is  seen  as  the  result  of  the  acute  infectious  diseases  (typhoid, 
typhus,  relapsing,  malarial  fevers.)  Chronic  proliferative  splenitis 
{chronic  splenic  tumor)  is  due  to  chronic  malarial  infection  or  repeated 


SPLENITIS.  903 

acute  attacks,  to  splenic  anemia,  chronic  passive  congestion  of  the  spleen, 
and  leukocythemia.  The  leukemic  spleen  represents  a  somewhat  differ- 
ent form  of  chronic  proliferative  splenitis  from  the  ordinary  forms. 
Acute  suppurative  splenitis  (abscess),  either  diffuse  or  circumscribed,  is 
usually  secondary  to  infectious  (pyogenic)  emboli,  as  in  ulcerative  endo- 
carditis and  pyemia.  Again,  as  the  result  of  simple  valvulitis  of  aortic 
thrombosis,  embolic  infarction  of  the  spleen  may  be  found,  which  may 
soften  and  break  down  in  abscess-formation  from  subsequent  infection. 
Abscess  of  the  spleen  may  also  follow  traumatism,  perforation  of  a  gas- 
tric ulcer,  and  the  extension  of  adjacent  inflammation. 

Symptoms. — These  are  indefinite  or  absent  in  most  cases.  Usually 
there  is  no  pain  or  tenderness  unless  perisplenitis  exists.  Considerable 
enlargement  of  the  spleen  may  be  attended  with  a  sense  of  weight,  ten- 
sion, or  distress  in  the  left  hypochondrium,  and  perhaps  by  slight  dys- 
pnea. Any  suppurative  fever  present  will  most  probably  be  disassociated 
'  from  the  idea  of  abscess  of  the  spleen,  provided  the  local  signs  of  pus 
be  absent.  Sudden  pain  appearing  in  the  gastric  region,  followed  by  the 
vomiting  of  pus  and  blood,  in  the  course  of  an  infectious  disease,  with 
splenic  enlargement,  may  be  due  to  the  rupture  of  an  abscess  of  the 
spleen.     Ascites  may  also  be  present. 

The  physical  examination  may  reveal  some  bulging  on  inspection, 
and  a  fluctuating  tumor  may  be  palpated.  The  enlargement  may  be 
sufficient  to  enable  the  examiner  to  feel  the  notch  in  the  spleen,  and 
also  the  anterior  and  loAver  borders,  reaching  even  to  the  umbilicus  and 
to  a  level  with  the  pelvic  brim.  The  percussion-dulness  is  correspond- 
ingly increased. 

Diagnosis. — This  may  be  made  from  a  consideration  of  the  physi- 
cal signs  in  conjunction  with  a  study  of  the  primary  disease.  In  cases 
in  which  pus  is  suspected  an  exploratory  puncture  may  clear  the  diag- 
nosis. The  splenic  inflammation  is  rather  an  aid  to  diagnosis  than  a 
condition  essentially  needful  of  recognition  in  itself,  by  reason  of  its 
almost  invariably  secondary  nature. 

Differential  Diagnosis. — Acute  suppurative  splenitis  might  be  xm&- 
taken  for  gastric  or  pOMcreatie  disease  ;  but  the  previous  history  in  the 
former,  as  contrasted  with  that  of  the  latter  affection,  conjoined  with  the 
local  symptoms  that  are  more  or  less  characteristic  of  the  organ  involved, 
will  generally  furnish  an  accurate  means  of  differentiation. 

The  huge  enlargements  of  chronic  splenitis  may  be  confounded  with 
hepatic,  renal,  omental,  or  ovarian  growths.  Here  a  careful,  discriminat- 
ing observation  of  the  constitutional  state  and  of  the  physical  signs  is 
requisite  for  a  diagnosis  ;  even  then  it  is  often  puzzling  and  difficult  to 
attain.  Care  must  be  taken  that  splenic  enlargement  be  not  assumed 
when  a  large  ptleural  effusion  on  the  left  side  is  causing  the  depressed 
lower  border  of  the  organ  to  be  felt.  Finally,  fecal  accmmdation  in 
the  splenic  flexure  of  the  colon  may  be  mistaken  for  moderate  enlarge- 
ment of  the  spleen.  The  former  gives  an  irregular,  doughy  tumor, 
tympanites,  vomiting,  and  a  history  of  constipation  alternating  some- 
times with  diarrhea ;  there  is  no  increase  in  the  splenic  area  of  dulness. 

Prognosis. — This  will  depend  upon  the  primary  systemic  condition 
in  most  cases.  Abscess  of  the  spleen  is  always  a  very  grave  complica- 
tion, the  main  danger  consisting  of  rupture  and  fatal  peritonitis.  Even 
in  acute  splenic  tumor  of  a  violent  type  there  may  be  a  hemorrhagic  ex- 


904  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

travasation  so  severe  as  to  burst  the  capsule.      Chronic  splenitides  are 
not  in  themselves  grave  disorders. 

Treatment. — This  is  to  be  directed  mainly  at  the  causative  condi- 
tion. Quinin  and  arsenic  are  often  useful  in  the  malarial  form,  and  the 
chalybeates,  iodids,  and  ergot  have  been  recommended  for  the  various 
chronic  splenic  enlargements-  Abscess  must  be  treated  by  splenotomy 
and  drainage.  Splenectomy  may  be  useful  in  certain  cases  of  simple 
hypertrophy,  but  records  show  only  about  20  per  cent,  of  recoveries 
from  the  operation.  The  state  of  the  patient  must  be  well  considered. 
Splenectomy  is  probably  never  justifiable  in  leukemic  enlargement. 


AMYLOID  DEGENERATION   OF  THE   SPLEEN.- 

{Sago  Spleen.) 

This  occurs  as  a  part  of  the  cachectic  condition  attending  amyloid 
or  waxy  degeneration  of  other  organs  (liver  and  kidneys).  The  con- 
dition develops  in  the  course  of  cases  of  prolonged  and  wasting  dis- 
charges (phthisis,  empyema,  suppurative  ostitis,  syphilis,  chronic  peri- 
tonitis, chronic  entero-colitis).  The  spleen  is,  as  a  rule,  greatly  enlarged, 
putty-like,  and  rotund.  The  capsule  is  tense  and  glistening.  There  are 
two  forms  of  waxy  degeneration — namely,  the  so-called  '•'sago''  spleen 
and  the  diffuse  luaxy  or  lardaceous  spleen.  In  the  former  the  Mal- 
pighian  bodies  are  chiefly  affected  and  appear  on  section  like  sago- 
granules  ;  in  the  latter  the  whole  splenic  pulp,  and  even  the  trabecuh«, 
are  more  or  less  degenerated,  and  on  section  the  spleen  appears  pale, 
smooth,  and  homogeneous  (boiled-liani  appearance).  This  may  be  but  a 
late  stage  of  the  "  sago  "  spleen. 

The  symp)toms  are  those  of  general  cachexia,  and  the  diagno.ns  rests 
upon  the  detection  of  an  enlargement  of  the  organ  associated  with  evi- 
dences of  amvloid  disease  in  other  organs. 

The  jjrognosis  is  unfavorable,  and  the  treatment  does  not  differ  from 
that  indicated  for  the  underlying  and  causative  disease. 


MORBID  GROWTHS  OF  THE  SPLEEN. 

The  principal  new-growths  are  the  granuloniata,  as  tubercles  and 
syphilitic  gunnnata  ;  also  secondary  carcinoma,  melanotic  sarcoma,  and 
hydatid  and  other  cysts.  Lymphadenoma  {e.  g,  in  leukemia)  may  be 
included  among  tumors  of  the  spleen  (Stengel). 

These  affections  of  the  spleen  arc  all  of  rare  occurrence,  and  are  not 
readily,  if  at  all,  discoverable  during  life.  They  are  of  no  clinical  or 
therapeutic  interest  apart  from  the  general  or  primary  disease.  It  may 
be  stated  that  carcinoma  of  the  spleen  is  always  secondary  ;  it  may  be 
diagnosticated  by  a  physical  examination.  shoAving  the  organ  to  be  en- 
larged, with  the  unmistakable  signs  of  the  primary  carcinoma,  as  of  the 
stomach.  Secondary  sarcoma  is  more  common,  and  is  recognized  by  an 
irregular  enlargement  and  the  presence  of  a  primary  tumor. 

jSgphilitic  gummata  of  the  spleen  are  often  associated  with  amyloid 
degeneration  and  enlargement. 


DISEASES  OF  THE  PANCREAS.  905 

RUPTURE  OF   THE  SPLEEN. 

This  may  occur  as  the  result  of  an  intense  hyperemic  engorgement, 
both  in  splenitis  from  the  rupture  of  an  abscess  and  from  traumatism. 
In  the  acute  splenic  tumor  of  typhoid  fever,  in  malaria,  and  during  an 
epileptic  paroxysm,  rupture  of  the  capsule  has  been  known  to  occur  on 
account  of  the  extravasation  of  blood.  The  symptoms  are  usually  mis- 
taken for  those  of  intestinal  perforation  with  internal  hemorrhage.  The 
treatment  is  palliative. 


XI.  DISEASES   OF  THE   PANCREAS. 

ACUTE  PANCREATITIS. 

Investigations  of  late  years  have  rendered  it  probable  that  this 
disease  is  not  so  rare  an  occurrence  as  was  formerly  presumed,  when  it 
was  not  so  readily  recognized,  owing  partly  to  insufficient  clinical  and 
pathologic  data,  and  partly  to  an  indifference  as  to  its  existence. 

HEMORRHAGIC  PANCREATITIS. 

Pathol Ogfy. — The  pancreas  is  enlarged,  usually  firm,  and  somewhat 
chocolate-colored.  Irregular  areas  show  the  circumscribed  as  well  as 
the  diffused  form  of  hemorrhagic  infiltration  of  the  interstitial  fat-tissue, 
with  thrombosis  of  the  pancreatic  veins  in  some  cases  (Day).  There 
is  also  an  infiltration  Avith  round-cells  of  the  interlobular  tissues.  Some 
cases  are  examples  of  degeneration  (non-inflammatory).  The  adjacent 
tissues  may  also  be  found  to  be  hemorrhagic,  as  the  mesentery,  meso- 
colon, omentum,  and  perinephric  tissues.  The  gastro-intestinal  mucosa 
may  be  hyperemic,  ecchymotic,  or  in  a  slightly  catarrhal  state.  Evi- 
dences of  a  localized  peritonitis  (^ peripancreatitis)  are  not  frequent, 
though  they  should  be  looked  for. 

Disseminated  fat-necrosis  is  quite  commonly  associated  with  hemor- 
rhagic pancreatitis.  Small  areas  of  a  peculiar  (tallo\v-like)  substance, 
ranging  from  the  size  of  a  miliary  tubercle  to  that  of  a  pea  or  even  larger, 
are  found  scattered  in  the  fatty  interlobular  pancreatic  tissue  in  the 
omentum,  mesentery,  and  sometimes  in  the  abdominal  fat.  H.  U.  Wil- 
liams and  Katz  and  Winkler,  from  experimental  researches,  conclude 
that  some  substance  in  the  pancreas,  probably  the  fat-splitting  ferment, 
is  capable  of  causing  changes  similar  to  fat-necrosis.  Flexner's  experi- 
ments render  it  probable  that  the  escape  of  pancreatic  secretions  into 
the  peri-  and  parapancreatic  tissues  is  the  origin  of  the  fat-necrosis. 

Mention  should  be  made  here  of  the  fact  that  as  the  result  of  the  in- 
fectious fevers  we  find  the  pancreas  showing  diffuse,  parenchymatous, 
and  granular  degenerative  changes.  Chiari  has  also  recently  pointed 
out  the  fact  that  postmortem  digestion  is  very  frequent  in  the  pancreas. 

Htiologfy. — Most  of  the  cases  reported  have  occurred  in  men,  and 
in  persons  past  fifty  years  of  age.  An  especial  nredisposition  to  the 
disease  seems  to  be  the  result  of  cases  of  severe  and  obstinate  dyspepsia 
(gastro-duodenal),  alcoholism,  glycosuria,  gall-stones  (Fitz),  and  trau- 


906  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

matism.  Hemorrhage  into  the  pancreas  may  lead  to  subsequent  pan- 
creatic inflammation.  It  is  seen  occasionally  postmortem  in  cases  of 
acute  tuberculosis,  of  the  specific  fevers,  and  of  septico-pyemia.  The 
direct  cause  is  probably  an  infection  through  the  ducts  of  the  gland. 
Flexner^  injected  acids,  alkalies,  and  bacterial  cultures  into  the  duct  of 
Wirsung  and  the  interstitial  tissue,  and  produced  hemorrhagic,  suppu- 
rative, and  necrotizing  pancreatitis,  often  -with  fat-necrosis. 

Symptoms. — The  onset  is  sudden  and  violent.  It  is  character- 
ized by  excruciatinf/,  deep-srated  2)(iin,  usually  in  the  epigastrium  or 
between  the  xiphoicl  and  umbilicus.  There  arc  also  nausea  and  severe 
retching  and  vomiting,  constipation,  and  speedy  collapse,  ending  fatally 
within  a  few  days  (second  to  the  fourth — Fitz).  The  vomitus  may  con- 
sist at  last  of  slimy  mucus  or  dark  blood.  Fever  is  generally  slight  at 
first,  though  it  may  touch  103°  or  104°  F.  later.  Dyspnea  and  a  rapid, 
feeble  p/nlsc,  with  jactitation  and  marked  anxiousness  or  an  afebrile  de- 
lirium, may  perhaps  be  present.  In  some  cases  there  may  be  diarrhea, 
with  thin  and  watery  stools  containing  free  fat.  Instances  may  be  re- 
peated in  which,  owing  to  the  coincident  presence  of  gall-stones,  there 
mav  he  jaundice  and  colicky  pains  over  the  right  hypochondrium.  The 
jaundice,  however,  may  sometimes  be  due  to  a  considerable  swelling  of 
the  head  of  the  pancreas,  which  ])resses  upon  the  common  bile-duct. 
Ti/mpanites  occurs  in  a  majority  of  the  cases.  Hiccough  and  albumin- 
uria have  also  been  noted.  The  pain  and  collapse  may  be  due  either  to 
a  circumscribed  peritonitis  or  to  pressure  upon  the  solar  plexus. 

Diagnosis. — This  is  at  all  times  difficult,  since  many  or  all  of  the 
symptoms  enumerated  may  be  present  in  other  affections.  A  careful 
inquiry  into  the  previous  history  is  important.  The  sudden  develop- 
ment of  an  intense,  deep-seated  pain  in  the  epigastrium,  folloM'od  by 
vomiting,  collapse,  abdominal  distention,  with  circumscribed  resistance 
in  the  epigastrium,  and  the  presence  of  constipation  and  slight  fever, 
should  point  strongly  to  hemorrhagic  ])ancreatitis.  The  detection  of  free 
fat  in  the  dejections,  and  the  discovery  of  scattered  points  of  tenderness, 
wlieii  tliev  occur,  are  also  of  corroborative  significance. 

Differential  Diagnosis. — The  temperature  is  apt  to  be  higher  and  the 
pain  and  tenderness  less  localized  and  more  constant  in  peritonitis.  Fecal 
vomiting  would  indicate  obstruction  of  the  bowel.  Here  also  we  may 
determine  the  patency  of  the  bowel  by  injection  or  inflation.  Intestinal 
obstruction  is  of  comparatively  rare  occurrence  in  the  epigastrium,  where 
the  pain  and  distention  of  acute  pancreatitis  are  localized  ;  there  are 
likely  to  be  present  more  marked  and  general  tympany,  including  the 
flanks,  and  a  circumscribed  distention  of  the  intestinal  coils. 

In  perforating  gastric  or  duodenal  ulcer  there  is  a  history  of  pain 
after  eating,  hemorrhages  from  the  digestive  tract,  and  of  anemia  or 
chlorosis  occurring  more  commonly  in  the  young  female. 

Corrosive  poisons  may  be  excluded  by  the  history  of  the  case  and  by 
an  examination  of  the  mouth  and  vomitus.  Hepatic  colic  must  be 
excluded;  the  pain  is  intermittent,  and  referred  more  to  the  right  side 
than  in  pancreatitis.     There  is  in  pancreatitis  also  an  early  collapse. 

Acute  gastro-duodenitis  is  characterized  by  fever,  by  a  history  of 
injudicious  eating,  followed  by  mild  inflammatory  symptoms  within  a  few 
1  "Experimental  Pancreatitis,"  Festschrift  in  honor  of  Win.  Henry  Welch. 


SUPPURATIVE  PANCREATITIS.  907 

hours,  and  by  an  absence  of  the  sudden  prostration  and  collapse  so  com- 
mon to  hemorrhagic  inflammation  of  the  pancreas. 

Prognosis. — Acute  hemorrhagic  pancreatitis  in  m.ost  cases  ends  in 
death.  It  is  but  fair  to  state,  however,  that  in  view  of  the  ease  with 
which  the  disease  may  be  overlooked  it  is  quite  possible  that  certain  cases 
of  a  less  severe  type  may  often  recover ;  in  these  the  recovery  has  been 
said  to  follow  an  entirely  different  affection.  Osier  reports  a  case  diag- 
nosticated as  one  of  intestinal  obstruction  in  which  abdominal  section  was 
performed  and  recovery  followed.  Thayer  and  Korte  have  also  reported 
cases  of  cure  in  which  a  celiotomy  decided  the  diagnosis. 

Treatment. — This  must  needs  be  merely  palliative  and  symptomatic. 
The  treatment  as  for  shock  by  the  use  of  external  heat  and  of  warm 
saline  solutions  (by  injection),  hypodermics  of  morphin,  atropin,  strych- 
nin, and  of  diffusible  stimulants  may  probably  be  of  some  avail. 

SUPPURATIVE   PANCREATITIS. 

Pathology. — The  suppuration  may  be  diffuse,  with  numerous  small 
abscesses ;  more  commonly  a  single  abscess  may  exist  in  the  head  or 
body  of  the  pancreas,  which  may  be  considerably  enlarged  and  the 
glandular  structure  extensively  destroyed.  The  abscess  may  communi- 
cate with  peripancreatic  areas  of  suppuration,  or  it  may  evacuate  either 
into  various  organs  (stomach,  duodenum,  peritoneal  cavity)  or  exter- 
nally. Pylephlebitis  and  hepatic  abscess  or  pyemia  may  follow.  A 
disseminated  fat-necrosis  is  not  found  so  frequently  as  in  hemorrhagic 
pancreatitis. 

Htiology. — Most  of  the  cases  collected  have  occurred  in  adult  males 
prior  to  fifty  years  of  age.  Intemperance,  debauchery,  gluttony,  trauma, 
and  dietetic  errors  are  among  the  predisposing  causes.  Infection  takes 
place  through  the  ducts,  or  from  extension  of  neighboring  septic  foci. 

Symptoms. — These  may  be  acute,  subacute,  or  chronic.  Acute 
cases  occur  less  frequently  than  the  latter,  there  being  a  marked  ten- 
dency of  the  disease  to  chronicity.  Acute  suppurative  pancreatitis 
usually  begins  suddenly,  with  severe  ejngastric  pain,  vomiting,  hiccough, 
chills,  and  an  irregular  pyemic  temperature,  progressive  tympanites  (at 
times  limited  to  the  left  half  of  the  abdomen),  and  perhaps  acute  splenic 
enlargement.  Constipation  may  be  followed  later  by  diarrhea  (some- 
times fatty),  and  slight  jaundice  or  glycosuria  may  appear.  Prostration 
is  generally  great,  and  death  may  set  in  within  one  week  from  the  onset. 

Not  seldom,  however,  the  course  is  prolonged  to  three  or  four  wrecks, 
the  symptoms  persisting  with  progressive  emaciation  and  final  exhaustion. 
Rupture  of  the  circumscribed  peritoneal  abscess,  evidenced  by  copious 
dejections  in  which  the  sloughing  pancreas  has  been  found,  and  rapid 
diminution  in   the  size  of  the  abdomen,  may  take  place. 

Again,  the  onset  may  be  less  severe,  and  yet  the  case  progresses  steadily 
downward  with  little  pain,  slight  suppurative  fever,  anorexia,  anemia, 
and  gradually  increasing  debility,  lasting  for  months  or  even  a  year,  and 
ending  in  anasarca  and  death.      A  pancreatic  swelling  is  rarely  palpable. 

Diagnosis. — A  limitation  of  the  pain  and  tympany  to  the  epigas- 
trium, irregular  fever,  and  the  constitutional  indications  of  suppuration 
are  probably  all  that  can  be  relied  upon  in  arriving  at  a  diagnosis.  In 
fact,  the  diagnosis  is  hardly  made  antemortem. 


908  •        DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

For  the  differentiation  from  circumscribed  Y>eritomtis,  perforative  gas- 
tric ulcer,  and  acute  obstruction  of  the  botvel,  vide  Hemorrhagic  Pan- 
creatitis. 

The  prognosis  is  fatal  and  the  treatment  surgical. 

GANGRENOUS   PANCREATITIS. 

Pathology. — The  pancreas  may  be  found  in  various  stages  of  necro- 
sis, depending  upon  the  duration  of  the  disease.  It  may  be  a  dark-brown, 
flabby,  soft,  friable,  shreddy,  and  putrid  mass,  with  areas  of  hemorrhagic 
infiltration  and  yellow  softening,  and  surrounded  by  a  dirty-greenish, 
thin,  purulent,  and  ichorous  fluid.  In  cases  lasting  for  from  three  to  seven 
weeks  the  gland  may  be  found  completely  sequestrated,  lying  in  the 
omental  cavity  as  a  small,  thin,  brownish-black,  shreddy,  and  foul-smell- 
ing detritus,  soaked  in  a  dark-colored,  ichorous,  and  purulent  fluid.  The 
peri-  and  para-pancreatic  tissues  are  usually  involved  with  acute  peritonitis. 
Splenic  thrombo-phlebitis  is  commonly  associated,  and,  as  in  the  hemor- 
rhagic, so  in  the  gangrenous  pancreatitis,  disseminated  fat-necrosis  is  fre- 
quently seen.  The  sloughed  pancreas  may  be  discharged  into  the 
intestine. 

Ktiology. — Males  and  females  seem  to  be  equally  liable,  and  per- 
sons past  thirty  years  of  age  are  most  commonly  affected.  Hem.orrhagic 
pancreatitis  is  the  most  frecjuent  antecedent  of  the  gangrenous  form. 
The  disease  may  result  also  from  perforative  ulceration  of  the  gastro- 
intestinal or  biliary  tract,  or  from  the  extension  of  a  catarrhal  inflam- 
mation of  those  tracts  into  the  pancreatic  duct  (Fitz).  Traumatism  is  a 
cause,  though  rare. 

Symptoms. — These  are  essentially  the  same  as  those  of  hemorrhagic 
pancreatitis.  The  course  may  last  longer,  however,  so  that  death  may 
not  occur  until  the  second  or  fourth  week,  preceded  by  symptoms  of 
collapse.  The  necrotized  pancreas  may  be  discharged  per  rectum,  fol- 
lowed in  some  cases  by  recovery. 


CHRONIC  PANCREATITIS. 

Pathology. — The  pancreas  is  indurated  from  an  increased  develop- 
ment of  interstitial  fibrous  tissue.  The  secreting  glandular  substance 
may  be  nearly  obliterated,  or  at  least  considerably  changed,  and,  owing  to 
occluding  pressure  upon  the  duct  of  Wirsung,  small  pancreatic  cysts  may 
be  formed.  Interstitial  hemorrhages  and  peripancreatic  adhesions  may 
be  present.  In  chronic  suppurative  pancreatitis  there  may  either  be 
several  small  circumscribed  abscesses  or  one  large  pyogenic  cyst. 

Btiology. — Chronic  pancreatitis  may  be  due  to  several  attacks  of 
the  acute  disease.  Chronic  inflammation  of  the  pancreatic  duct — often 
secondary  to  gastro-duodenal  catarrh — is  the  most  frequent  cause.  Per- 
sistent inflammations  of  contiguous  structures  and  frequent  irritation 
from  biliary  calculi  may  excite  it.  Chronic  alcoholism  and  syphilis 
probably  lead  to  this  disease.  The  condition  may  be  limited  to  a  part 
of  the  organ. 

Symptoms  and  Diagnosis. — The  symptoms  are  hardly  indicative 
of  the  disease.     For  a  long  time  the  symptoms  of  chronic  gastric  catarrh. 


PANCREATIC  HEMORRHAGE.  909 

frequently  attended  by  diarrhea,  may  compose  the  clinical  picture.  Later 
there  may  be  paroxysms  of  deep  epigastric  |jam,  and  slight /ever,  with 
great  anxiety  and  faintness,  occurring  at  irregular  intervals.  Some 
ascites  and  occasional  jaundice,  due  to  pressure,  may  be  observed.  The 
detection  of  free  fat  in  the  dejections  (without  jaundice),  and  the  occur- 
rence of  glycosuria  and  lipuria,  would  be  of  distinct  diagnostic  value. 
The  presence  of  glycosuria  in  this  variety  of  pancreatitis  probably  indi- 
cates an  extreme  degree  of  destruction  of  this  gland  (Fitz).  A  cachectic, 
emaciated  appearance  may  be  associated.  Circumscribed  resistance  on 
palpation  in  the  pancreatic  area  has  been  noted.  Evidences  of  hepatic 
cirrhosis  or  of  chronic  renal  and  arterial  disease  may  be  present. 

The  prognosis  is  grave.  It  is  to  be  recollected,  however,  that  the 
greater  portion  of  the  gland  may  become  functionless,  as  the  result  of 
progressive  fibrous  change,  without  much  impairment  of  the  general 
health. 

Treatment. — The  major  treatment  is  dietetic.  Fats  and  starches, 
since  they  demand  the  pancreatic  ferment  for  their  conversion,  are  to  be 
interdicted,  or,  if  permitted,  are  to  be,  so  far  as  may  be,  artificially 
digested  by  the  administration  of  tablets  of  pancreatin  and  soda  (gr. 
v-x — 0.324-0.648)  fifteen  or  twenty  minutes  after  meals.  Malt  diastase, 
combined  with  alkalies,  should  also  be  tried.  Becher  has  found  that 
carbonated  waters  stimulate  pancreatic  secretion  in  dogs,  and  hence 
their  use  may  be  advised.  Minced  pancreas  promotes  the  digestion  of 
fat  (Abelmann). 

PANCREATIC   HEMORRHAGE. 

{Pancreatic  Apoplexy.) 

It  is  only  in  recent  years  that  this  fatal  affection  has  been  clearly  iso- 
lated and  defined,  and  mainly  through  the  observations  of  Zenker,  Draper, 
and  especially  Fitz. 

Pathology. — The  pancreas  may  or  may  not  be  enlarged ;  it  may  also 
be  soft  and  friable.  The  hemorrhage  is  apt  to  occur  into  circumscribed 
areas  of  the  gland,  particularly  its  head,  the  interstitial  and  subperi- 
toneal tissues  both  usually  being  the  seat  of  hemorrhagic  infiltration  of 
a  dark-purple  color.  Extensive  hemorrhage  may  be  found  in  the  omen- 
tum, transverse  mesocolon,  in  the  retroperitoneal  fat-tissue,  and  sur- 
rounding the  kidney  even.  Hemorrhages  into  the  adjacent  mucous 
surfaces  have  been  detected  in  some  cases.  Secondary  reactive  inflam- 
mations and  necrosis  are  commonly  noted. 

Ktiologfy. — Slight  hemorrhages  into  the  pancreas  may  be  found  that 
are  secondary  to  excessive  chronic  passive  congestion  or  to  hemophilic  or 
purpuric  cases,  and  they  may  be  met  with  in  acute  infective  diseases. 
These  have,  however,  no  clinical  import.  The  precise  cause  or  causes  of 
marked  hemorrhage  into  the  pancreas  are  not  known.  Most  cases  have 
occurred  in  males  (in  25  of  34  instances  collected  by  the  writer),  and  in 
adult  or  advanced  middle  life  (the  age  in  13  of  30  cases  having  been 
over  forty-five  years).  In  the  majority  of  cases  the  previous  health  was 
apparently  good.  Traumatism  may  be  a  direct  cause.  Again,  some 
local  vascular  weakness  or  lesion  [e.  g.  necrosis),  superinduced  by  alco- 
holic habits  or  a  rich  diet  in  an  atheromatous  person  ;  or  some  corrosive 
action  of  the  pancreatic  secretion  may  operate  as  causes.     There  was  a 


910  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

history  of  chronic  alcoholism  in  12  of  18  cases  (66.6  percent.)  in  which 
reference  to  this  habit  was  made.  Severe  symptomatic  pancreatic 
hemorrhage  is  dependent  on  a  variety  of  primary  affections  of  the  gland 
— ('.  g.  acute  pancreatitis  and  carcinoma.' 

Symptoms. — The  patient  may  have  been  in  apparently  robust  health 
when  the  attack  comes  on  with  sudden  and  startling  gravity.  The  most 
prominent  early  .symptom  is  intense  pai7i  located  in  the  epiga.stric  region 
or  in  the  lower  chest,  together  with  a  sense  of  constriction.  Nausea  and 
vomiting  may  be  associated,  and  the  latter  is  usually  obstinate  and  gives 
only  temporary  relief.  Tympanites  may  also  occur.  There  are  early  and 
constant  general  evidences  of  internal  bleeding — an  anxious  countenance, 
restlessness,  depression,  yawning,  pallor,  cold  sweat,  a  lowered  surface- 
temperature,  and  a  small,  rapid,  and  weak  pulse.  Prostration  and  syn- 
cope follow,  and  death  ends  the  case  in  from  half  an  hour  to  twenty-four 
hours.  Death  is  caused  by  reflex  paralysis  of  the  heart,  due  either  to 
some  coincident  vascular  affection,  or  to  pressure,  perhaps  upon  the  solar 
plexus  and  semilunar  ganglion  (Zenker). 

My  table  of  cases  includes  24,  exclusive  of  16  reported  by  Fitz,  in 
which  the  condition  led  to  speedy  death  from  shock  or  possibly  from 
compression  of  the  solar  plexus.  Owing  to  its  apparently  "■'  idiopathic  " 
character  in  many  cases,  its  suddon  development,  and  (|uick  destruction 
of  life,  pancreatic  hemorrhage  assumes  intense  medico-legal  interest  and 
importance.      A  small  percentage  of  cases  reach  death  more  gradually. 

Diagnosis. — Uiven  the  sudden-developed  signs  of  a  concealed  in- 
ternal hemorrhage,  with  pain  referred  distinctly  to  the  epigastrium,  and 
vomiting  and  rapid  collapse,  a  probable  diagnosis  may  be  made. 

Treatment. — This  consists  in  relieving  the  pain  by  opiates  and  in 
overcoming  the  collapsed  condition  by  free  stimulation. 


CARCINOMA    OF    THE  PANCREAS. 

Pathology. — Primary  carcinoma  is  the  more  freiiuent  variety.  It 
is  of  the  scirrhous  form  in  most  cases,  and  usually  involves  the  head  of 
the  gland,  which  may  attain  to  the  size  of  a  child's  head.  Not  rarely  the 
adjacent  organs  are  found  affected,  either  by  direct  or  metastatic  exten- 
sion of  the  disease,  or  by  the  pressure  of  the  growth ;  the  liver,  perito- 
neum, stomach,  portal  vessels,  bile-ducts,  and  aorta  may  thus  be  involved. 
The  pancreatic  duct  may  be  occluded,  so  as  to  form  retentoin-cysts.  In 
1000  autopsies  at  the  Johns  Hopkins  Hospital  there  were  5  cases  of 
secondary  carcinoma  of  the  pancreas.  Simple  extension  of  carcinoma 
of  the  .stomach  or  of  the  duodenum  may  involve  the  pancreas. 

!^tiology. — Men  past  forty  years  of  age  are  most  liable  to  carci- 
noma of  the  pancreas,  though  it  has  been  met  with  even  in  the  neiv-born. 
Mirallie  has  collected  113  cases  of  primary  carcinoma  of  this  viscus  (Fitz). 

Symptoms. — These  are  scarcely  ever  sufficient  to  indicate  the  dis- 
ease with  any  certainty.  There  are  usually  a  stubborn  dyspepsia,  a 
progressive  loss  of  flesh  and  strength,  anemia,  and  a  didl.  or  sometimes 
neuralgic,  epigastric  pain.  Nocturnal  paroxysms  of  pain  are  common,  and 
are  often  accompanied  by  signs  of  collapse.    In  some  cases  vomiting  and 

'  "Pancreatic  Hemorrhage,"  Journal  American  Medical  Association,  Dec.  2,  1899,  by 
the  writer. 


CARCINOMA    OF  THE  PANCREAS.  911 

diarrJiea  are  present.  The  stools  may  be  liglit  in  color  and  greasy,  and 
may  contain  blood.  There  may  also  be  found  an  abundance  of  undigested 
muscular  fibers  in  the  stools  in  the  absence  of  diarrhea;  this  is  an  incon- 
testible  proof  of  faulty  pancreatic  digestion.  Steatorrhoea  is  not  com- 
monly present.  Among  the  pressure-effects  due  to  carcinoma  of  the 
head  of  the  pancreas  there  may  be  jaundice  (due  to  pressure  upon  the 
common  duct),  which  persists  and  "  is  associated  with  an  enlargement 
of  the  liver  and  gall-bladder."  Ascites  may  appear  from  pressure  on 
the  portal  vein.  Chylous  ascites,  from  pressure  upon  the  thoracic  duct, 
has  been  observed  in  2  cases.  The  inferior  vena  cava  may  be  com- 
pressed, causing  dropsy  of  the  lower  half  of  the  body ;  also  the  duode- 
num, followed  by  gastr'ectasis  or  by  signs  of  intestinal  obstruction. 
Carcinoma  of  the  tail  of  the  pancreas  may  be  a  cause  of  hydronephrosis 
of  the  left  kidney,  from  pressure  upon  the  ureter  (Fitz).  Marasmus 
and  the  cachexia  grow  from  bad  to  worse,  and  emaciation  may  become 
so  extreme  as  to  permit  of  a  satisfactory  palpation  of  the  tumor,  which 
occupies  a  position  near  the  median  line  above  the  umbilicus.  Very 
often,  however,  the  growth  is  too  deep-seated  to  be  felt,  being  palpable 
in  about  one-third  of  the  cases  only.      Glycosuria  may  be  associated. 

Diagnosis. — Carcinoma  of  the  pancreas  is  probably  present  in  a 
given  case  in  which  there  are  rapid  and  progressive  emaciation,  deep- 
seated  epigastric  pain,  muscular  fibers  in  the  stools  without  diarrhea,  late 
persistent  jaundice,  and  enlargement  of  the  gall-bladder,  and  the  detec- 
tion of  a  deeply-situated,  fixed,  and  firm  tumor  in  the  region  of  the  gland. 
The  quantity  of  indican  in  the  urine  is  diminished. 

Aortic  abdominal  aneurysm  may  be  mistaken  for  carcinoma  of  the 
pancreas  because  of  the  transmission  of  the  aortic  pulsation  to  the  tumor. 
But  in  aneurysm  the  impulse  is  expansile  instead  of  to  and  fro,  and  the 
contact  is  neither  so  sharp  nor  so  sudden ;  moreover,  the  cancerous 
cachexia  is  absent  in  aneurysm,  and  the  history  of  the  case  may  be 
clearly  indicative. 

It  is  sometimes  difficult  to  differentiate  a  malignant  tumor  of  the  pan- 
creas from  carcinoma  of  the  pylorus,  of  the  stomach,  or  of  the  transverse 
colon  or  omentum  ;  the  following  points  will  help  in  the  differentiation 
of  the  former  two  : 

Carcinoma  of  the  Pancreas.  Carcinoma,  of  the  Pylorus. 

The  tumor  is  deep-seated  and  fixed  ;  later  The  tumor  is  more  freely  movable,  and 

it  becomes  slightly  movable.     It  is  not  is  usually  associated  with  dilatation  of 

associated  with  gastric  dilatation.  the  stomach. 

Symptoms  of  chronic  dyspepsia  manifest  There  are  more  marked  gastric  symptoms, 
themselves. 

The  Tomitus  is  ?jilious  :   rarely  contains  There  is  "  coffee-ground  "  vomitus  :  it  is 

blood ;  often  is  that  of  gastrectasis.  seldom  bilious. 

HCl  is  present,  while  there  is  an  absence  HCI  is  absent  from  the  gastric  contents ; 

of  lactic  acid.  lactic  acid  is  present. 

The    stools    contain    undigested    muscle-  Usually  the  bowels  are  constipated,  with 

fibers.     There   is   an  absence  of  pan-  occasional  diarrhea.      The    stools    are 

creatic  secretions.    The  urine  may  con-  black  after  a  hemorrhage.     The  urine 

tain  sugar.  does  not  contain  sugar. 

There   is   usually  jaundice;    sometimes  Usually  there  is  no  jaundice  or  ascites. 
ascites  is  present. 

Inflation  of  the  stomach  shows  the  absence  Inflation  shows  the  presence  of  a  pyloric 

of  a  pyloric  growth.  tumor. 

The   course  is  more  acute.     Death  may  The  course  is  more  chronic,  and   second- 
occur  within  a  few  weeks  or  months.  ary  growths  p.ppear  in  the  liver. 


912  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

Neoplastic  groivths  of  the  transverse  colon  are  also  more  often  super- 
ficial, and  are  movable  and  definable  with  the  palpating  fingers.  There 
are  symptoms  of  intestinal  obstruction  here,  and  inflation  of  the  colon 
will  show  the  relation  of  the  tumor  to  the  gut.  In  carcinoma  of  the 
colon  the  urine  generally  contains  an  increased  amount  of  indican. 

A  discussion  of  the  prognosis  and  treatment  of  carcinoma  of  the 
pancreas  is  obviously  unnecessary. 

Other  Tumors  of  the  Pancreas. — Exceptionally,  sarcoma, 
adenoma,  and  lymphoma  occur.  Sarcoma  is  very  rarely  primary. 
Secondary  nodules  are  somewhat  more  frequently  observed.  Accord- 
ing to  Korte,  of  10  cases  of  tumor  of  the  pancreas  operated  upon 
of  late  years,  6  recovered. 


PANCREATIC  CYST. 

Pathology. — Pancreatic  cysts  may  be  single  or  multiple,  and  large 
or  small.  When  large  they  develop  chiefly  to  the  left  of  the  median 
line.  Single  cysts  may  grow  to  an  enormous  size,  containing  as  much 
as  several  gallons  of  fluid.  The  contents  may  at  first  consist  simply  of 
retained  pancreatic  juice,  and  usually  the  liquid  is  dark  gray  or  dark 
brown,  alkaline,  and  hemorrhagic  or  albuminous.  A  hematoma  may  be 
converted  into  a  serous  cyst.  The  specific  gravity  is  from  1010  to  1024. 
Atrophy  of  the  pancreas  may  ensue.  Examined  microscopieall//,  the 
contents  reveal  leukocytes,  red  blood-corpuscles,  oil-drops,  fatty  degen- 
eration of  the  epithelium,  and  crystals  of  fatty  acids  and  cholesterin. 

Ktiology. — Cysts  of  the  pancreas  may  be  due  to  occlusion  of  the 
pancreatic  duct  or  its  branches  by  compression  from  within  or  without 
the  gland.  They  may  also  be  due  to  tumors,  to  impaction  of  biliary  or 
pancreatic  calculi,  to  cirrhosis  or  angular  displacements  of  the  gland,  or 
to  the  obstructive  swelling  from  extension  of  catarrh  of  the  bowel 
(Krecke).  Of  121  cases  collected  by  Korte,  33  were  traced  to  trauma- 
tism. Lloyd  suggests  that  the  cysts  that  follow  local  injury  are  in 
reality  instances  of  encysted  peritonitis  involving  the  lesser  omentum  or 
that  portion  covering  the  pancreas  ( pseudocysts).  Cysts  of  the  pancreas 
usually  occur  in  adults — in  66  of  116  cases  in  the  third  and  fourth 
decades  of  life  (Korte).  Railton.  however,  met  a  case  at  six  months 
of  age. 

Symptoms. — Pain  may  be  absent,  or  it  may  occur  as  colicky 
paroxysms,  referred  either  to  the  epigastrium,  the  left  hypochondrium, 
or  even  the  left  shoulder.  Jaundice  and  ascites  are  present  in  large 
tumors.  Vomiting,  constipation,  or  fattj/  diarrhea  (rarely),  with  undi- 
gested muscular  fibers  in  the  dejecta,  or  clay-colored,  pasty,  and  off'ensive 
stools,  may  be  present.  Allnimin  and  sugar  maybe  found  in  the  urine. 
Emaciation  is  not  infrequent.  Intestinal  hemorrhage  may  occur  and 
recur.  A  late  and  constant  symptom  is  a  feeling  of  pressure  in  the 
epigastrium.  Rarely  there  is  increased  salivary  secretion  (pancreatic 
salivation).  Occasionally  all  subjective  symptoms  are  absent,  and  these 
cysts  may  temporarily  disappear. 

On  physical  examination  a  smooth,  elastic,  lobulated  tumor  is  discov- 
ered in  the  region  of  the  pancreas  if  the  growth  is  moderate  in  size. 


PANCREATIC  CALCULI.  913 

Sometimes  a  very  large  cyst  develops  in  a  remarkably  short  space  of 
time — ^.  e.  in  a  few  weeks.  When  very  large  in  size  fluctuation  is  easily 
elicited.  It  may  be  slightly  movable  in  the  grasp  and  during  inspiration. 
It  usually  presents  between  the  stomach  and  transverse  colon  an  area  of 
dulness,  and  unless  the  tumor  be  of  large  size  it  is  surrounded  by  tym- 
panitic resonance  of  deeper  timber  above  than  below.  Auscultation  may 
reveal  a  murmur  caused  by  compression  of  the  aorta.  When  the  cyst 
attains  enormous  dimensions  the  usual  mechanical  pressure-effects  are 
produced.  Korte  points  out  that  cysts  without  any  inflammatorv  or 
traumatic  etiology  may  exist  for  many  years  or  even  decades. 

Diagnosis. — The  diagnosis  rests  on  the  typical  physical  signs — the 
discovery  on  palpation  of  a  smooth,  elastic,  lobulated,  or  rounded  tumor 
that  is  slightly  movable,  and  on  percussion  of  a  dull  area  that  is  not  con- 
tinuous above  with  the  spleen-  and  liver-dulness.  Resort  has  been  had 
to  filling  the  stomach  with  air  and  the  colon  with  water  (after  purging), 
and  thus  proving  by  palpation  the  deep-seated  situation  (behind  the 
stomach  and  omentum)  of  the  tumor.  If  pancreatic  fluid  be  obtained 
from  the  supposed  cysts,  it  will  digest  albumins  and  emulsify  fats.  This 
test  is  not  wholly  reliable,  however.  A  pancreatic  cyst  may  be  mistaken 
for  an  ovarian  cyst,  for  renal  tumors  (cysts),  dropsy  of  the  gall-Madder, 
and  retroperitoneal  sarcoma  (Lobstein's  cancer).  The  differentiation 
must  be  made  by  a  careful  study  of  all  the  points  in  the  case. 

The  prognosis  is  good  under  proper  treatment — incision  and  drain- 
age.    Of  31  reported  cases  thus  treated,  only  2  proved  fatal. 


PANCREATIC   CALCULI. 

Pathology. — These  are  grayish-white,  rounded  concretions,  consist- 
ing principally  of  calcium  carbonate.  The  calculi  may  be  as  fine  as 
dust  or  as  large  as  an  almond.  Among  their  pathologic  effects  are  fis- 
tulous communications  with  the  colon,  peritoneal  cavity,  and  stomach  ; 
also  cystic  dilatations  of  the  duct  and  abscess-formation.  Atrophy  of  the 
organ  and  carcinoma  due  to  irritation  of  the  stones  may  be  associated. 

Ktiology. — Pancreatic  calculi  presuppose  a  catarrhal  condition  of 
the  pancreatic  duct,  with  retention  of  secretion,  anomalies  of  the  pancre- 
atic secretion,  or  the  presence  of  cysts  or  some  other  form  of  obstruction 
of  the  pancreatic  duct.      The  condition  is  comparatively  rare. 

The  symptoms  are  developed  when,  during  the  passage  of  the  stones 
along  the  duct  to  the  duodenum,  the  latter  excite  inflammation.  In  con- 
sequence, paroxysms  of  pain  occur  [pancreatic  colic)  that  are  usually 
attributed  to  gall-stones,  and  we  are  often  unable  to  differentiate  the  two 
conditions.  The  radiation  of  pain  along  the  lower  left  costal  border  to 
the  back  rather  than  to  the  right  side,  and  possibly  the  detection  of  free 
fat  in  the  stools  or  glycosuria,  may  aid  markedly  in  the  diagnosis. 

The  finding  of  characteristic  calculi  in  the  stools  is  entirely  confirm- 
atory. Minnich  has  reported  a  case  in  which  the  calculi  were  found  in 
the  stools  following  an  attack  of  colic. 

The  prognosis  is  mainly  dependent  upon  the  associated  lesions  and 
upon  certain  sequelte — pancreatic  cysts  and  chronic  pancreatitis. 

The  indications  for  treatment  do  not  differ  materially  from  those  of 
hepatic  colic.      Surgical  intervention  should  be  considered. 

58 


914  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

XII.  DISEASES   OF  THE    PERITONEUM. 

ACUTE  PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneum.  The  con- 
dition may  be  primary  or  secondary.  Clinically,  two  varieties — general 
and  circumscribed — are  recognized,  while,  pathologically,  the  disease  is 
classified  according  to  the  nature  of  the  exudate. 

Anatomic  and  PhysioJogie  Pecnliarities. — The  surface  area  of  the 
peritoneum  is  quite  extensive,  being  almost  equal  to  that  of  the  skin. 
Fluids  of  all  sorts  are  rapidly  absorbed  by  the  peritoneum,  and  thus,  if 
they  be  poisonous,  constitutional  infection  is  speedily  propagated. 

Pathology  — Upon  opening  the  abdomen  in  acute  generalized  peri- 
tonitis vascular  injection  both  of  the  serous  covering  of  the  intestine 
and  of  the  parietal  layer  is  observed.  Even  in  the  most  recent  cases 
the  coils  of  intestine  may  be  feebly  glued  together  by  lymph,  while  in 
those  of  longer  duration  the  adhesions  are  (juite  firm.  As  in  the  analo- 
gous inflammation  of  the  pleurae  or  pericardium,  Ave  distinguish  the  fol- 
lowing forms  pathologically  :  {a)  A  plastic  or  Jibrinous,  in  Avhich  there 
may  be  also  a  small  amount  of  serum  present.  (A)  Sero-fibrinous  (inflam- 
matory ascites),  chiefly  characterized  by  considerable  sero-fibrinous  fluid; 
additionally,  the  coagulated  fibrin  forms  a  covering  for  the  parietal  and 
visceral  layers  of  the  peritoneum,  (c)  Purulent  (most  frequent).  The 
amount  of  inflammatory  exudate  varies  greatly,  and  is  frequently  enor- 
mous, exceeding  30  liters  (quarts).  Putrefactive  decomposition  of  the 
pus  may  occur,  especially  in  cases  due  to  gangrene  of  the  gut  or  to 
puerperal  peritonitis  (violent  forms),  giving  rise  to  a  thin  fluid  that  is 
grayish-green  in  color,  is  sometimes  distinctly  sanious,  and  ill-smelling. 
Off'ensive  gases  are  present  with  relative  frequency.  These  may  come 
from  the  intestinal  canal,  following  the  track  of  perforations ;  or  they 
may  be  due  to  decomposition  of  the  purulent  exudate,  [d)  Hemorrhagic. 
This  form  is  common  in  cases  that  are  of  a  cancerous  or  tuberculous 
nature,  and  in  subjects  whose  vitality  has  been  lowered  by  various  other 
aff'ections.     It  may  also  be  of  traumatic  origin. 

Clianges  in  the  Intestines. — The  eff"ect  of  acute  peritonitis  is  to 
thicken  the  coats  by  inflammatory  edema ;  soon  tire  musculature  is 
paralyzed.  An  associated  catarrh  of  the  mucosa  of  the  intestine  is 
sometimes  observed. 

The  different  pathologic  varieties  above  described  may  be  limited  to 
definite  portions  of  the  peritoneal  sac,  when  they  are  termed  ''encapsu- 
lated "  or  localized  acute  peritonitis  (vide  supra).  In  localized  purulent 
peritonitis  further  extension  of  the  process  is  arrested  by  the  rapid  for- 
mation of  circumscribed  adhesions  due  to  the  exudation  of  lymph  ;  there 
are  also  undoubted  instances  of  circumscribed,  aplastic  peritoneal  ab- 
scesses. The  milder  forms  of  limited  plastic  and  sero-fibrinous  perito- 
nitis pursue  a  slower  course  than  the  purulent  variety,  and  commonly 
lead  to  the  development  of  firm  adhesions  [adhesive  peritonih's).  Since 
the  histolofric  chanjies  in  acute  peritonitis  do  not  diff"er  from  those  ob- 
served  in  other  inflammations  of  serous  membranes,  the  reader  is  referred 
to  the  section  on  Pleurisy  (p.  541)  for  their  consideration. 

^Etiology. — The  irritants  causing  acute  peritonitis  may  be — (a)  Or- 


ACUTE  PERITONITIS.  915 

ganized  inflammatory  agents  [haeteriologic  irritants).  These  may  be  spe- 
cific or  non-specific.  Among  the  non-specific  agents  are  the  pyogenic  bac- 
teria. .Grawitz  has  shown  that  the  latter  can  only  cause  peritonitis  under 
certain  conditions  :  they  excite  the  disease  when  injected  into  the  perito- 
neal cavity  or  when  poured  out  from  the  diseased  or  injured  membrane 
more  rapidly  than  the  peritoneal  tissue  can  dispose  of  them  ;  also  when  the 
epithelial  layer  has  from  any  cause  been  removed.  Absorption  may  be 
interfered  with,  while  the  pyogenic  micrococci  continue  to  enter  from  the 
bowel  or  other  viscera  in  great  numbers.  Unfortunately,  the  clinical 
practitioner  often  meets  with  cases  of  peritonitis  in  Avhich  these  pyogenic 
organisms  are  the  only  positive  agents.  These  essential  conditions  obtain 
when  the  membrane  is  wounded  by  the  perforation  of  gastric  and  intesti- 
nal ulcers,,  and  also  in  perforation  of  the  gall-bladder,  in  rupture  of  the 
liver,  kidneys,  and  spleen,  Avhen  the  latter  are  the  seat  of  abscesses,  and, 
with  uncommon  frequency,  in  appendicitides,  in  purulent  inflammation  of 
the  ovaries  and  of  the  Fallopian  tubes.  "  There  are  instances  in  which 
peritonitis  has  followed  rupture  of  an  apparently  normal  Graafian  follicle  " 
(Osier).  These  perforative  forms  of  peritonitis  are  at  the  same  time  the 
most  serious  and  the  most  important.  "Death  may  result  from  the  in- 
jection into  the  peritoneal  sac  of  putrid  liquid  if  the  dose  be  large 
enough;  but  it  is  practically  the  same  whether  the  fluid  is  injected  into 
the  blood-stream  at  once  or  allowed  to  find  its  way  into  the  peritoneal 
cavity,  and  the  result  follow'S  nearly  as  quickly  in  the  one  case  as  in 
the  other"  (Moullin).  The  rapid  absorption  of  liquid  substances  gives 
full  opportunity  for  the  phagocytic  action  of  the  white  blood-corpuscles. 

Among  specific  organic  irritants  the  tubercle  hacillus  deserves  especial 
mention,  though,  as  before  intimated,  a  discussion  of  its  characteristics 
is  not  in  place  here.  The  streptococcus  pyogenes  is  probably  responsible 
for  the  most  violent  forms  of  peritonitis  (e.  g.  those  occurring  in  puerperal 
sepsis  and  post-operative  varieties).  The  stapJiylococcus  pyogenes  aureus 
(or  albus)  has  also  been  found  in  such  instances. 

The  bacterium  coli  commune  (always  present  in  the  intestinal  tract)  is 
frequently  the  leading  factor  in  peritonitis  of  intestinal  origin,  and 
usually  in  association.  -The  streptococcus  is  often  present  also  in  these 
cases.  In  12  cases  of  primary  peritonitis,  11  were  instances  of  mono- 
infection ;  and  in  operations  upon  the  peritoneum  (not  involving  the  in- 
testine), 25  of  33  cases  were  mono-infections,  the  staphylococcus  aureus 
being  present  alone  in  12  and  the  streptococcus  in  5  (Flexner).  Occa- 
sionally other  organisms,  as  the  pneumococcus,  the  bacillus  of  Fried- 
lander,  or  the  bacillus  pyocyaneus,  typhosus,  &nd  proteus,  the  gonoeoccus, 
the  aerogenes  capsulatus,  and  the  anthrax  bacillus,  have  been  found. 

Multi-infection  is  quite  common.  Some  contend  that  all  forms  of 
peritonitis  are  due  to  bacteria  or  their  toxins. 

[b)  Chemical  Irritants. — These  are  rather  numerous  and  varied,  though 
all  produce  their  eff'ects  in  one  of  two  ways.  First,  the  irritant  acts 
upon  the  membrane,  exciting  an  exudation  of  lymph.  Here  constitu- 
tional intoxication  is  secondary.  Secondly,  the  chemical  irritant  may 
be  quickly  absorbed,  and  produce  systemic  intoxication  immediately 
(rare). 

((?)  Mechanical  irritants,  as,  for  example,  a  hernia,  which  may  produce 
a  localized  peritonitis. 

{d)  Peritonitis  may  be  due  to  a  direct  extension  of  infective  processes 


916  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

from  the  intestinal  tract  or  other  adjacent  organs  {secondary  peritonitis). 
The  bacteria  often  penetrate  the  intestinal  wall  and  gain  the  peritoneum 
by  way  of  the  lymph-channels.  The  disease  is  often  secondary  to 
pleurisy,  the  irritants  passing  through  the  diaphragm  along  the  course 
of  the  lymphatics.  Peritonitis  may  be  secondary  to  chronic  Bright's  dis- 
ease, gout,  and  arterio-sclerosis ;  in  such  cases  the  special  irritants  prob- 
ably reach  the  membrane  through  the  general  circulation.  In  most 
cases  this  variety  is  protective  in  character  and  results  in  local  adhesions. 

{e^  The  disease  is  very  rarely  primary  (idiopathic).  It  has  been 
attributed  to  exposure  to  cold  or  wet  (rheumatic  peritonitis).  These  so- 
called  idiopathic  cases  are  probably  instances  of  cryptogenetic  infection. 

Clinical  History. — The  symptoms  are  both  of  a  local  and  a  general 
nature.  In  sthenic  cases  of  perforative  peritonitis  they  occur  simul- 
taneously with  great  severity  and  suddenness.  On  the  other  hand,  in 
asthenic  cases,  such  as  occur  frequently  in  those  already  afflicted  Avith 
some  serious  disease  that  is  apt  to  result  in  perforation  (for  example, 
typhoid  fever),  both  the  local  and  constitutional  symptoms  are  more  or 
less  overshadowed  by  the  disturbances  due  to  the  primary  affection.  Again, 
circumscribed  abscesses  of  the  peritoneum  often  lead  to  difiuse  suppura- 
tive peritonitis,  and  the  change  may  take  place  so  insidiously  as  to  defy 
detection.  These  anomalies  from  the  typical  onset  and  course  of  the 
disease  are  by  no  means  exceptional,  and  should  ever  be  distinctly  borne 
in  mind  by  the  physician. 

Local  Symptoms. — Among  these,  pain  is  the  chief.  At  the  commence- 
ment its  seat  of  greatest  intensity  corresponds,  in  most  instances,  with 
the  seat  of  origin.  Hence  the  character  of  the  causal  disease  is  often 
betrayed  by  the  location  of  the  chief  pain.  For  instance,  if  this  ap- 
pears in  the  region  of  the  stomach  and  is  referred  to  the  back  or  shoul- 
ders, we  would  think  of  gastric  ulcer ;  if  in  the  ileo-cecal  region,  of  ap- 
pendicular disease ;  and  so  on.  It  follows  that  quite  commonly  the 
severest  pain  is  in  the  lower  half  of  the  abdomen.  It  is  almost  constant, 
increases  in  severity,  and  finally  becomes  general  and  excruciating  ;  it 
is  also  much  increased  by  deep  respirations,  by  pressure,  and  by  bodily 
movements.  It  remits,  but  does  not  intermit,  though  it  may  be  slight 
in  asthenic  cases.  Here  the  patient  is  excessively  Aveak,  while  his  sen- 
sibilities are  greatly  blunted.  Gastro-intestinal  symptoms  are  prominent, 
more  particularly  vomitinr/,  which  occurs  early  and  is  apt  to  recur  with 
comparative  fre(iuency.  It  may  follow'  the  taking  of  food,  though,  in  my 
own  experience,  it  has  more  frequently  taken  place  spontaneously ;  the 
vomitus  then  consists  of  a  watery  li((uid  greenish  in  color  and  contains 
mucus.  In  rare  instances  the  matter  vomited  is  a  dark-brown  liquid. 
Vomiting  may  sometimes  be  absent,  however,  owing  to  the  presence  of 
marked  asthenia  or  coma.  Eructations  are  common,  and  constipation  is 
usually  present  and  may  become  exceedingly  obstinate.  On  the  other 
hand,  there  may  cither  be  diarrhea  throughout  the  disease,  or  this  symp- 
tom may  precede  the  constipation.  Constipation  is  due  chiefly  to  paral- 
ysis of  the  musculature  of  the  intestine.  It  is  to  be  a.scribed  to  an  in- 
creased peristalsis  due  to  intestinal  catarrh.  The  ape.r  of  the  heart  is 
elevated ;  the  tongue  at  first  is  furred  and  moist,  and  later  it  is  dry, 
brown,  and  often  fissured. 

Constitutional  Symptoms. — At  the  onset  the  patient  in  sthenic  cases 
is  seized   with  a   rigor  that  may  be  repeated.     The  shock  sustained  by 


ACUTE  PERITONITIS.  917 

the  nervous  system  in  acute  peritonitis  is  most  intense  ;  the  temjier- 
ature  rises  immediately,  though  it  does  not,  as  a  rule,  attain  to  a  high 
level,  and  it  frequently  presents  a  curve  more  or  less  characteristic  of 
suppuration.  The  rectal  temperature  is  often  relatively  high  ;  the 
respirations  are  shallow  and  much  accelerated,  ranging  from  thirty  to 
forty  per  minute.  We  have,  as  factors  to  account  for  this  increased 
frequency,  (a)  a  crowding  upward  of  the  diaphragm,  (h)  the  greatly  en- 
feebled heart,  and  (c)  the  pain  occasioned  by  throwing  the  diaphragm 
into  action.  The  heart  early  becomes  excessively  weak,  and,  as  would 
be  expected,  the  pulse  is  rapid,  small,  and  soft.  The  pulse  toward  the 
close  becomes  exceedingly  frequent  (130  to  150  beats  per  minute)  and 
is  almost  imperceptible ;  during  the  early  stages  the  pulse  ranges  from 
100  to  130.  Other  evidences  of  more  or  less  marked  circulatory  col- 
lapse soon  manifest  themselves.  The  patient  wears  an  anxious  facial 
expression,  the  eyes  are  sunken,  the  features  pinched  and  cool,  the  lips 
cyanotic,  and  the  extremities  are  likewise  cold  and  somewhat  livid.  The 
patient  invariably  assumes  the  supine  position,  with  the  lower  extrem- 
ities drawn  up,  so  as  to  lessen  the  tension  of  the  abdominal  muscles,  and 
thus  to  secure  the  greatest  possible  comfort.  The  urine  is  scanty  and 
high-colored,  and  contains  indican.  There  may  be  a  retention  of  urine ; 
though  oftener,  perhaps,  micturition  is  more  frequent  than  in  health. 
Marked  nervous  symptoms  do  not  appear ;  indeed,  the  mind  usually 
remains  quite  clear  to  the  close.  Moderate  delirium,  however,  which 
sometimes  gives  way  to  mild  stupor,  is  met  with  occasionally.  In  con- 
nection with  these  facts  it  should  be  pointed  out  that  in  the  asthenic 
fo7'm  of  acute  peritonitis  the  constitutional  features  differ  from  those 
above  described.  The  temperature  is  usually  subnormal  (except  in  the 
rectum),  the  pulse  is  exceedingly  feeble  and  running,  and  the  signs  of 
collapse  are  well  marked  from  the  onset. 

Physical  Signs. — Inspection  reveals  the  gradually  increasing  abdom- 
inal distention,  that  frequently  becomes  excessive  if  the  intestinal  walls 
are  more  or  less  completely  paralyzed.  Often  the  amount  of  effusion 
soon  becomes  large,  when  the  abdomen  appears  widened.  The  degree 
of  distention  bears  a  definite  relation  to  the  severity  of  the  inflammatory 
process,  and  is  in  inverse  ratio  to  the  development  of  the  abdominal 
muscles.  Thus,  when  the  latter  are  poorly  developed  or  greatly  relaxed 
the  expansion  is  enormous.  On  the  other  hand,  when  they  are  strong 
the  muscles  are  apt  to  be  quite  tense,  permitting  of  a  relatively  slight 
enlargement;  the  abdomen  may  even  show  a  small  concavity,  in  which 
case  the  walls  are  of  a  board-like  hardness.  The  cardiac  apex-beat  is 
displaced  upward  and  outward,  occupying  the  fourth  interspace. 

Palpation  elicits  extreme  tenderness,  more  particularly  in  the  vicinity 
of  the  umbilicus.  Rigidity  of  the  abdominal  wall  is  the  most  import- 
ant symptom  in  perforative  peritonitis  (J.  C.  Wilson).  In  not  a  few 
instances  of  acute  peritonitis  have  I  been  able  to  detect  a  distinct  fric- 
tion-rub. Percussion  gives  at  first  an  exaggerated  tympanitic  note. 
There  is  often  an  absence  of  liver-dulness  in  the  mammary  line,  and 
rarely  also  it  is  absent  in  the  mid-axillary  line.  In  pneumo-peritoneum, 
resulting  from  perforation  of  the  gut  or  stomach,  we  often  meet  Avith  an 
absence  of  liver-dulness,  especially  when  a  large  purulent  effusion  co- 
exists. Again,  a  great  diminution  in,  or  even  the  total  effacement  of, 
the  dull  area  may  be  caused  by  coils  of  intestine  forcing  their  way  up 


918  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

between  the  anterior  surface  of  the  organ  and  the  inner  surface  of  the 
abdominal  wall.  When  air  is  present  within  the  abdominal  cavity  and 
the  patient  lies  upon  his  right  side,  splenic  dulness  disappears  from 
displacement  by  the  air.  The  lower  level  of  cardiac  dulness  is  as  high 
as  the  fifth  rib. 

By  means  of  percussion,  sooner  or  later,  fluid  effusions  are  usually 
detectable  in  sthenic  cases.  On  the  other  hand,  there  may  be  in  mai'k- 
edly  asthenic  cases  an  amount  of  liquid  exudation  present  that  is  often 
too  small  to  admit  of  detection.  When  the  eifusion  is  considerable 
in  quantity,  there  is  dulness  on  percussion  over  the  most  dependent 
parts ;  when  tympanitic  distention  is  excessive,  however,  even  a  copious 
effusion  may  be  so  effectually  hidden  as  to  elude  discovery  in  this  way. 
I  have  elsewhere  reported  one  such  instance.'  When  the  decubitus  can 
be  altered,  the  line  of  dulness  will  be  found  to  be  movable,  but  the  degree 
of  mobility  varies  exceedingly,  depending  upon  the  extent  of  the  peri- 
toneal adhesions  present.  The  effused  material  is  partly  contained  in 
pouches,  giving  rise  to  areas  of  circumscribed  dulness. 

Course  and  Prognosis. — Asthenic  forms  of  diffused  peritonitis  are 
perhaps  invariably  fatal.  Though  the  local  symptoms  and  signs  are  not 
marked,  the  characteristic  evidences  of  collapse  or  of  general  septicemia 
appear  and  grow  in  intensity  to  the  end.  The  duration  in  sthenic  cases 
rarely  exceeds  one  or  two  days ;  in  asthenic  cases  it  is  longer,  lasting 
from  four  or  five  to  six  or  eight  days.  Death  sometimes  occurs  quite 
suddenly,  owing  to  cardiac  exhaustion  or  primary  shock.  The  clinical 
peculiarities  and  the  course  of  an  individual  case  are  greatly  influenced 
by  the  etiology.  Acute  generalized  peritonitis  arising  from  perforative 
appendicitis,  from  perforation  of  a  gastric  ulcer,  puerperal  sepsis,  or 
from  external  injuries,  is  usually  of  a  violent  form  and  ends  fatally. 
Prompt  operative  intervention,  however,  is  powerful  in  saving  life  in  a 
small  percentage  of  the  latter  class.  When  the  disease  is  traceable  to 
rheumatism  or  exposure,  recovery  may  take  place.  A  case  occurred  in 
my  own  practice  in  which  acute  sero-fibrinous  peritonitis  with  consider- 
able effusion  was  associated  with  acute  articular  rheumatism  and  organic 
lesions  of  the  aortic  segments ;  the  patient  recovered. 

Peritonitis  in  Children. — -Syphilitic  peritonitis  maybe  congenital, 
and  septic  peritonitis  caused  by  an  inflamed  cord  may  be  met  in  the 
new-born.  In  children  the  most  common  causes  are  trauma  and  appen- 
dicitis. 

The  symptoms  differ  from  those  presented  in  the  adult.  However 
severe  the  pain  the  child  merely  utters  a  short  cry  or  whine.  Constipa- 
tion and  vomiting  are  less  conspicuous  features.  Meteorism  is  pro- 
nounced and  fever  high.  Convulsions  not  rarely  occur.  The  condition 
is  extremely  grave  in  young  children. 

LOCALIZED    OR   PARTIAL   PERITONITIS. 
{Circimiscribed  Peritonitis;    Visceral  Peritonitis.) 

This  is  a  localized  form  of  inflammation  of  the  peritoneum  that  is 
coextensive  only  with  the  serous  covering  of  single  organs,  and  involves 
a  limited  portion  of  the  membrane.     Hence,  to  the  various  forms  of  cir- 
International  Medical  Cliriics,  vol.  iii.,  second  series,  p.  82. 


LOCALIZED    OR   PARTLAL  PERITONITIS.  919 

cumscribed  peritonitis  such  terms  as  perihepatitis,  perisplenitis,  peri- 
nephritis are  applied.  The  condition  is  found  in  its  most  important 
form  in  ap2)endicitis,  but  the  points  that  are  characteristic  of  localiza- 
tion in  this  disease  have  been  mentioned  elsewhere  [vide  Appendicitis,  p. 
819).     Localized  peritonitis  may  also  be  caused  by  carcinoma. 

Pyo-pneumothorax  suhphrenicus  is  the  term  applied  to  a  circum- 
scribed peritoneal  abscess  containing  air,  situated  between  the  liver  and 
diaphragm.  The  condition  is  described  under  the  heading  Acute  Peri- 
hepatitis (p.  875). 

Local  pelvic  peritonitis  (perimetritis)  is  the  most  frequent  variety, 
and  is  secondary,  as  a  rule,  to  inflammation  about  the  uterus,  Fallopian 
tubes,  and  ovaries.  The  leading  causes  are  tuberculosis,  puerperal  septi- 
cemia, and  gonorrhea.  F.  Billings  points  out  that  when  abdominal 
rigidity  is  absent  in  this  form  rectal  examination  will  disclose  rigidity 
of  the  pelvic  muscles. 

Symptoms. — The  local  clinical  features  do  not  differ  from  those 
described  under  the  diff'use  form,  but  their  area  of  distribution  is 
more  or  less  strictly  limited  to  definite  regions.  By  eliciting  i\\ep>hysical 
signs  with  care  fluid  collections  are  sometimes  demonstrable.  The 
constitutional  symptoms  are  likewise  similar  in  character,  though  less 
marked  than  those  belonging  to  the  diffuse  variety.  There  may  be 
rigors,  and  pyemic  symptoms  appear,  together  with  the  temperature- 
curve  peculiar  to  this  condition.  The  danger  of  involvement  of  the 
general  peritoneal  cavity  as  the  result  either  of  rupture  or  of  an  exten- 
sion of  septic  inflammation  is  a  constant  menace.  When  the  peritonitis 
remains  localized  these  cases  may  pursue  a  subacute  or  even  a  chronic 
course,  though  grave  constitutional  disturbance  finally  develops. 

Diagnosis. — In  attempting  to  diagnosticate  acute  generalized  peri- 
tonitis it  is  of  great  importance  for  the  clinician  to  keep  in  remembrance 
the  sthenic  and  asthenic  forms  of  the  aff"ection.  The  character  and 
gravity  of  the  symptoms,  both  general  and  local,  are  such  as  to  render 
the  diagnosis  of  the  sthenic  form  entirely  easy.  Especially  valuable 
features  are  the  constant  pain,  the  marked  tympany,  the  excessive  ten- 
derness under  pressure,  and  the  vomiting  at  intervals  of  a  greenish 
fluid  material.  Of  equal  importance  are  the  serious  general  disturbance 
previously  depicted,  and  in  particular  the  cool,  sharpened  features  and 
the  ever-increasing  weakness  and  rapidity  of  the  pulse.  These  clinical 
manifestations  clearly  foreshadow  cardiac  exhaustion  or  fatal  collapse. 
When  the  cases  are  not  seen  until  the  advanced  stage  has  arrived,  how- 
ever, the  diagnosis  presents  many  difficulties.  Nothing  is  now  more 
important  than  the  consideration  of  the  history  from  the  time  of  onset, 
also  of  the  previous  history,  with  a  view  to  determining  the  point  of 
origin  and  the  probable  cause  of  the  disease  (usually  some  such  primary 
disease  as  appendicitis  or  gastric  ulcer). 

The  smaller  number  of  cases  belonging  to  the  adynamic  type  are 
from  the  start  extremely  difficult  of  diagnosis.  Here  a  history  that  is 
clearly  indicative,  the  presence  of  moderate  tenderness,  and  augmented 
tension  of  the  abdomen,  with  profound  collapse,  would  point  to  this  con- 
dition. It  must,  however,  be  confessed  that  a  positive  opinion  is  often 
unwarranted,  owing  to  the  absence  of  the  more  characteristic  clinical 
indications. 


920  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

General  Differential  Diagnosis. — Hysteric  peritoyiitis  (so-called)  simu- 
lates in  every  leading  particular  the  genuine  form  so  closely  as  to  make 
the  distinction  an  insurmountable  difficulty,  unless  there  be  present 
other  hysteric  manifestations.  In  my  experience  the  tenderness  has 
been  out  of  proportion  to  the  gravity  of  the  constitutional  disturbance. 
The  patient  often  complains  bitterly  before  the  abdomen  has  been  touched ; 
on  the  other  hand,  when  his  attention  has  been  otherwise  engaged  firm 
and  prolonged  pressure  can  be  made. 

Acute  generalized  peritonitis  occasionally  supervenes  on  typlioid  fever. 
In  such  cases  it  is  caused  either  by  perforation  of  the  intestine  or  by  a 
direct  extension  of  inflammation  from  a  deep  typhoid  ulcer.  If  con- 
sciousness be  retained,  sudden  severe  pain,  tenderness  followed  by  ex- 
cessive tympany,  and  signs  of  collapse  will  establish  the  diagnosis. 
Peritonitis,  however,  develops  more  often  in  those  grave  cases  of  typhoid 
that  are  attended  with  coma,  marked  meteorism,  and  profound  adynamia, 
and  under  such  conditions  it  often  remains  unrecognized  {vide  Typhoid 
Fever,  p.  35). 

In  acute  enteric  catarrh  the  meteorism  and  sensitiveness  under  press- 
ure are  usually  less  pronounced ;  the  disease  also  lacks  the  marked  con- 
stitutional symptoms  of  acute  peritonitis.  The  pain  is  colicky,  is  cha- 
racterized by  exacerbations,  and  even  intermits  in  entero-colitis,  while 
it  is  constant  in  peritonitis.  The  pain  in  acute  enteric  catarrh  is  often 
followed  by  diarrheal  stools. 

Intestinal  colic  is  distinguished  from  peritonitis  by  the  flatulence,  the 
borborygmi,  and  the  wandering  pain  in  the  absence  of  all  other  phe- 
nomena. 

Rheumatism  of  the  abdominal  muscles  excites  pain,  which,  however, 
is  superficially  located  (the  disease  being  an  affection  of  the  muscular 
layer),  and  is  frequently  associated  with  rheumatism  in  other  parts  of  the 
body.     There  may  also  be  a  clear  history  of  previous  rheumatic  attacks. 

Tubal  prcfinanry  [after  rupture)  has  also  been  confounded  with  acute 
peritonitis,  but  its  differential  diagnosis  is  fully  discussed  and  must  be 
looked  for  in  special  works  on  gynecology  and  obstetrics. 

Rupture  of  an  abdominal  aneurysm  and  embolism  of  the  sujyerior 
mesenteric  artery  are  also  conditions  that  give  rise  to  peritonitic  symp- 
toms— meteorism,  recurrent  vomiting,  and  collapse — all  appearing  with 
explosive  violence. 

Acute  generalized  peritonitis  in  its  symptomatology  bears  a  close 
resemblance  to  acute  intestinal  obstruction,  and  the  discriminating 
points  hav(?  already  been  tabulated  {vide  \).  831). 

Prognosis. — This  is  less  grave  than  in  the  diffused  form,  and  re- 
covery may  often  be  expected.  Timely  surgical  intervention,  particu- 
larly if  a  tendency  to  spreading  be  shown,  may  render  the  outlook  en- 
couraging or  even  lead  to  prompt  recovery. 

Sequelae — If  recovery  should  take  place,  the  inevitable  result  is  the 
formation  of  adhesions  and  fibrous  bands,  the  contraction  of  which  may 
cause  constriction  of  the  bowels,  bile-ducts,  and  other  structures. 

Treatment. — Hygienic  and  Dietetic. — The  patient  should  be  placed 
in  the  position  that  will  give  him  most  comfort,  and  should  be  kept  ab- 
solutely undisturbed.  The  sick-room  should  be  of  good  size  and  well 
ventilated.;    the   temperature   should   be   kept   at  from   65°  to   70°  F. 


LOCALIZED   OR   PARTIAL  PERITONITIS.  921 

(18.3°— 21.1'^  C).  The  diet  demands  careful  attention.  Pancreatized 
milk  in  accurate  dosage  (5iv-vj — 128.0-192.0 — every  two  hours)  should 
be  administered,  and  if  the  stomach  will  not  bear  the  introduction  of 
nourishment,  recourse  should  be  had  to  rectal  alimentation.  Other 
liquid  food-stuffs,  as  meat-juices  and  egg-white  (diluted),  may  also  be 
allowed.  In  asthenic  cases  alimentation  must  be  generous,  although 
solid  articles  of  food  are  to  be  avoided. 

Medicinal. — Formerly  the  opium  method  of  treatment,  first  insti- 
tuted by  the  late  Alonzo  Clarke,  was  the  one  followed  by  the  bulk 
of  the  profession.  His  plan  Avas  to  administer  |-  gr.  (0.0324)  of  mor- 
phin  or  its  equivalent  (gr.  ij — 0.129)  of  opium,  and  repeat  the  dose 
every  two  hours  until  the  respirations  were  lowered  to  ten  or  twelve  per 
minute.  The  pupils  were  then  observed  to  be  contracted,  the  pulse 
from  76  to  80,  the  pain  relieved,  and  peristalsis  arrested.  This  latter 
effect  was  obtained,  even  though  in  the  case  of  some  patients  larger 
doses  of  opium  than  here  indicated  were  necessary ;  in  others  smaller 
doses  sufficed.  The  bowels  were  absolutely  let  alone.  It  is  explained 
that  in  favorable  cases  the  bowels  moved  spontaneously  at  the  end  of 
one  week,  and  that  the  patient  then  entered  upon  convalescence.  This 
method  of  treatment  is  at  present  adhered  to  only  by  the  ultra-conserv- 
ative element  of  the  profession.  Among  those  authors  who  recommend 
opium  as  the  most  efficient  measure  in  the  treatment  of  this  disease 
many  still  advise  against  the  immoderate  dosage  previously  so  generally 
administered,  but  employ  just  enough  to  keep  the  patient  well  under 
the  influence  of  the  drug. 

The  leading  mode  of  treatment  to-day  consists  in  the  use  of  saline 
purgatives,  exhibited  in  divided  doses  in  concentrated  solution  (oj— ij — 
4.0-8.0 — every  two  or  three  hours)  until  the  irritating  intestinal  contents, 
should  any  be  present,  are  removed,  and  additionally  several  copious 
serous  discharges  occur  daily.  Purgatives  do  good  when  given  in  this 
manner  principally  by  causing  a  rapid  exosmosis  of  serum  from  the  blood- 
vessels of  the  intestines,  by  removing  the  collateral  edema,  and  by  indi- 
rectly relieving  the  congestion  of  the  peritoneum,  thus  promoting  a 
rapid  absorption  through  the  latter  membrane.  By  increasing  the  peri- 
staltic movement  they  also  diminish  the  danger  of  peritoneal  adhesions. 
The  remedies  to  be  selected  will  depend  upon  two  primary  considera- 
tions :  first,  the  etiology  of  the  individual  case  (whether  a  communica- 
tion has  or  has  not  been  established  between  the  peritoneal  cavity  and 
the  bowel),  or  an  intra-peritoneal  abscess  or  abscess-cavity  in  one  of  the 
abdominal  viscera  ;  ancl  secoyidly,  the  type  of  the  case,  whether  sthenic 
or  asthenic.  If  perforation  is  known  to  have  taken  place  or  the  occur- 
rence of  this  accident  is  strongly  suspected,  a  prompt  laparotomy,  fol- 
lowed by  the  free  use  of  salines,  is  the  proper  treatment.  After  the 
primce  vice  have  been  looked  after  by  the  surgeon,  salines,  for  the  reasons 
before  stated,  are  to  be  used  with  a  free  hand.  For  a  like  reason  they 
are  most  serviceable  in  peritonitis  due  to  extension  of  the  inflammation, 
and  also  in  the  puerperal  form.  If  the  patient  be  robust,  with  a  full, 
tense  pulse,  we  may  begin  the  treatment  by  the  use  of  mercury,  the 
best  preparation  being  calomel,  exhibited  in  fractional  doses  (gr.  ss — 
0.0324 — every  hour)  until  its  purgative  action  is  obtained  ;  this  is  to  be 
followed  by  the  salines.      The  object  of  the  calomel  treatment  is  to  de- 


922  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

fibrinate  the  exudations  as  well  as  the  blood  of  the  patient.  Certain 
observers  advocate  the  use  of  small  doses  of  calomel,  and  seek  to  avoid 
any  purgative  action  of  the  remedy.  Indications  demanding  the  opium 
treatment  do  not  often  present  themselves.  When,  however,  the  vital 
forces  are  profoundly  depressed,  as  shown  by  the  symptoms  of  collapse, 
and  there  is  not  even  a  reasonable  suspicion  of  perforation,  then  opium 
should  be  tried,  but  not  in  the  heroic  doses  formerly  advocated.  Enough 
only  should  be  given  to  obtain  the  physiologic  effect  of  the  drug  in  a 
moderate  degree.  Again,  if  the  evidences  of  perforation  into  the  gen- 
eral peritoneal  cavity  are  complete  and  competent  surgical  skill  is  not 
at  hand,  large  doses  of  morphin  are  imperative,  Avith  a  view  to  relieving 
pain,  keeping  the  patient  at  absolute  rest,  and  sustaining  the  heart 
against  the  exhausting  effect  of  shock.  The  bowels  should  now  be 
relieved  by  simple  large  enemata.  The  value  of  serum-therapy  in  this 
disease  is  us  yet  uncertain  (Fowler). 

Local  Treatment. — At  the  onset,  if  the  patient  be  strong,  from  twenty 
to  thirty  leeches  are  to  be  applied  to  the  abdomen.  The  ice-bag  or  ice- 
poultices  are  often  of  distinct  service  in  the  earlier  stages.  Later,  in 
localized  peritonitis,  blisters  may  be  useful,  although  objectionable  in 
the  event  of  surgical  intervention  becoming  necessary.  In  cases  in 
Avhich  meteoric  distention  is  not  great  I  have  also  made  repeated  trial 
of  an  ointment  containing  ung.  ichthyol  (.^j — 32.0);  ung.  belladonnfe 
(sss — 16.0);  ung.  hydrarg.  (.5ij — 04.0);  this  is  applied  to  the  entire 
abdomen  thrice  daily. 

In  order  to  relieve  the  tympany  turpentine  stupes  are  serviceable. 
I  have  also  had  favorable  results  from  the  insertion  of  the  long  rectal 
tube  (soft  esophageal)  well  up  in  the  colon.  Large  high  enemata  should 
be  used ;  and  turpentine  combined  as  follows  may  prove  efficacious  : 

I^.    Turpentine,  3ij(8.0); 

Ox-gall,  3ij(8.0); 

Milk  of  asafetida,  .liv  (128.0); 

Warm  water,  ivj  (192.0). 

Puncturing  the  abdomen  with  a  hypodermic  needle  in  order  to  re- 
lieve tympany,  as  recommended  by  Loomis,  may  also  be  resorted  to, 
though  I  have  had  no  personal  experience  with  this  measure. 

Pain. — No  matter  what  general  plan  of  treatment  is  pursued,  the 
pain  must  be  relieved  by  opium  in  some  form.  Thirst  is  to  be  relieved 
by  chipped  ice,  over  which  a  little  brandy  may  be  sprinkled.  The 
vomitinf/  is  best  treated  by  carbonated  water  exhibited  in  small  quan- 
tities, or  by  iced  champagne  similarly  administered.  One-drop  doses 
of  creosote  are  also  of  value.  For  the  systemic  collapse,  as  well  as  for 
combating  thirst  and  vomiting,  I  can  Avarmly  recommend  saline  infu- 
sion, to  be  repeated  if  needful. 


CHRONIC  PERITONITIS.  923 


CHRONIC  PERITONITIS. 

Definition. — Chronic  inflammation  of  the  peritoneum. 

Pathology  and  etiology. — The  anatomic  characters  presented 
by  different  cases  are  greatly  varied,  though  for  convenience  of  study 
they  may  be  considered  under  two  divisions  (as  in  the  acute  form) :  1. 
Local ;  2.  Greneral.  The  latter  may  be  (a)  Adhesive,  when  the  peritoneal 
layers  are  inseparable  and  indistinguishable,  with  an  obvious  thicken- 
ing, and  the  intestinal  coils  are  everywhere  seen  to  be  grown  together. 
The  cause  is  usually  a  previous  acute  attack,  and,  doubtless  with  great 
relative  frequency,  the  condition  is  produced  by  the  acute  progressive 
form  (Mikulicz),  which  is  localized  at  the  start.  Rheumatism  is  also  an 
occasional  factor,  and  a  mild  variety  of  adhesive  peritonitis,  confined,  as 
a  rule,  to  small  circumscribed  areas,  may  be  engendered  by  the  trocar 
used  for  tapping  in  ascites. 

(h)  Proliferative  Peritonitis. — "•  The  essential  anatomic  feature  is  great 
thickening  of  the  peritoneal  layers,  usually  without  much  adhesion" 
(Osier).  It  has  been  found  to  be  associated  with  cirrhosis  of  the  stom- 
ach, liver,  and  other  abdominal  organs.  The  amount  of  liquid  effusion, 
varying  in  composition  from  serum  to  pus,  is  usually  moderate,  and  it 
may,  owing  to  adhesions,  be  loculated.  The  omentum  is  sometimes 
rolled  up  in  the  form  of  a  massive  cord,  with  its  long  axis  in  the  trans- 
verse direction.  In  an  autopsied  case  of  chronic  peritonitis  apparently 
secondary  to  hepatic  cirrhosis  I  observed  in  the  thickened  membrane 
numerous  small  hard  nodules  that  were  at  the  time  regarded  as  being 
tuberculous  in  nature.  It  is  to  be  pointed  out,  however,  that  a  number 
of  cases  of  pseudo-tuberculosis  have  been  recently  reported.  In  several 
of  these  an  operative  incision  was  followed  by  recovery,  and  this  was  put 
down  as  a  cure  of  tuberculous  peritonitis  till  the  microscope  showed  the 
nodules  to  be  fibrous.  Among  etiologic  factors  chronic  alcoholism  stands 
first.  In  one  case  that  I  saw,  acute  followed  by  chronic  rheumatism 
seemed  to  be  the  only  assignable  cause.  The  condition  is  sometimes 
secondary  to  chronic  nephritis,  to  syphilis,  or  a  general  fibroid  process. 

(c)  Cancerous  Peritonitis. — Quite  often  in  connection  Avith  cancerous 
growths  in  the  peritoneum  a  well-marked  peritonitis  is  evident.  There 
may  be  a  liquid  exudation,  which  is  apt  to  be  bloody  and  chylous. 

{d)  Chronic  Tuberculous  Peritonitis. — This  is  the  most  important  vari- 
ety. The  inflammatory  lesions  are  quite  pronounced,  as  a  rule,  and  lead 
to  marked  thickening  of  the  lavers — chano-es  that  are  to  the  naked  eve 
identical  in  appearance  with  those  noted  under  the  preceding  forms,  but 
which  on  histologic  examination  show  the  presence  of  tubercles  and 
caseous  degeneration.  The  amount  of  liquid  effusion  varies  w^ithin  wide 
limits,  and  is  usually  blood-stained.  The  frequent  association  of  hepatic 
cirrhosis  Avith  tuberculous  peritonitis  should  be  remarked.  From  tuber- 
culous peritonitis,  tuberculosis  of  the  peritoneum  is  also  to  be  distin- 
guished clinically ;  the  latter  may  be  acute  or  chronic,  and  the  lesions 
consist  in  the  deposit  of  various  sized  tubercles  Avithout  much  collateral 
inflammation.  Acute  and  chronic  tuberculosis  of  the  peritoneum  have 
received  due  consideration  in  their  appropriate  place  (p.  309). 

(e)  "  Chronic  Hemorrhagic  Peritonitis." — This  term  should  be  limited 
in  its  application  to  that  form  first  described  by  A'irchoAv,  in  which  the 


924  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

f^eritoneum  is  at  intervals  partly  covered  by  a  membrane  of  new  con- 
nective tissue  that  alternates,  as  it  were,  with  layers  of  hemorrhagic 
extravasation.  A  similar  condition  results  from  the  frequent  use  of 
the  trocar  for  ascites. 

Chronic  Localized  Peritonitis. — This  is  of  frequent  occurrence,  and  is 
confined  most  commonly  to  the  serous  covering  of  the  spleen,  liver,  and 
certain  portions  of  the  bowel,  particularly  of  the  appendix.  The  condi- 
tion results  in  the  formation  of  firm  adhesions,  with  matting  of  the  in- 
testinal coils  and  fibrous  bands.  It  is  usually  the  sequel  of  localized 
acute  peritonitis  occurring  in  connection  with  inflammatory  diseases  of 
the  different  abdominal  organs. 

Symptoms  of  the  General  Forms. — Whether  chronic  peritonitis 
follows  the  acute  form  or  not,  it  always  develops  insidiously.  Most  cases 
remain  quite  obscure,  and  not  a  few  are  totally  devoid  of  clinical  mani- 
festations. The  patient  may  complain  of  disorders  of  the  alimentary 
tract,  and  especially  of  constipation.  On  the  other  hand,  diarrhea  is 
observed  in  tuberculous  peritonitis  from  associated  intestinal  ulceration. 
Rarely  pressure,  from  the  traction  force  of  the  adhesions,  on  the  common 
duct  or  portal  vein  gives  rise  to  oh&iYwci'wc  jaundice,  or  ascites,  as  the  case 
may  be.  I  saw  an  instance  recently  in  Avhich  compression  of  the  veins 
leading  to  the  lower  extremities  caused  unilateral  edema.  Subjective 
abdominal  sensations,  as  uneasiness,  oppression,  heat,  and  pain  (often 
colicky  in  character),  are  experienced.  Sometimes  pain  is  entirely 
absent. 

General  symptoms  appear,  though  they  are  quite  vague  as  a  rule. 
An  irregular  fever,  hectic  in  type,  is  occasionally  observed.  Later,  in- 
creasing general  weakness,  emaciation,  and  general  nervous  disturbance 
become  rather  prominent  clinical  features.  Some  of  these  phenomena, 
however,  may  be  due  to  associated  affections.  When  the  peritonitis  is 
tuberculous  we  frequently  see  clinical  evidence  of  the  causal  disease  in 
other  parts  of  the  economy  {vide  Tuberculous  Peritonitis,  p.  309). 

Physical  Signs. — Inspection  usually  shows  the  belly  to  be  slightly, 
though  unequally,  enlarged.  As  in  acute  peritonitis,  so  here,  we  find 
the  belly  flat,  or  even  concave  occasionally,  with  great  tension  of  its 
walls.  Fluctuation  is  sometimes  obtainable  over  limited  areas  only, 
since  the  fluid  is  not  free,  but  encapsulated.  The  coiled-up  and  shrunken 
om.entum  may  be  palpable  as  a  sausage-shaped  mass,  and  thick  bands 
of  adhesion  may  also  not  rarely  be  felt,  in  different  places,  as  hard,  un- 
even masses  simulating  neoplasmata.  The percussio7i-dulness  varies  con- 
siderably Avith  the  amount  of  effusion,  its  arrangement,  the  degree  of 
peritoneal  thickening,  as  well  as  with  the  character  and  locality  of  the 
fibrous  bands.  It  follows  that  in  some  cases  irregular  areas  of  tym- 
panitic percussion-resonance  and  of  dulness  are  to  be  found  side  by  side 
scattered  over  the  abdomen.  Obviously,  too,  changing  the  patient's 
posture  would  not  give  movable  dulness,  owing  to  sacculation  of  the 
fluid.  A  marked  sense  of  resistance  is  experienced  on  percussion  over 
the  dull  area.  Friction-fremitus  can  sometimes  be  elicited,  and  less  fre- 
(\\\Q\\\\y  fricf ion-sounds  also  during  fiu'ced  breathing. 

Symptoms  of  Chronic  Local  Peritonitis. — This  condition  is 
often  entirely  latent.  When  not  so,  the  most  characteristic  indication 
is  constant  pain,  distinctly  colicky  in  nature  and  often   quite  intense. 


CHRONIC  PERITONITIS.  925 

The  physical  signs  are  negative,  as  a  rule.  Very  rarely  a  resistant,  ill- 
defined  mass,  corresponding  with  the  seat  of  greatest  pain,  can  be  felt. 
A  fibrous  band  may  be  so  arranged  as  to  form  a  snare  through  Avhich  a 
knuckle  of  bowel  may  pass,  with  resulting  strangulation.  Fitz's  analy- 
sis of  295  cases  showed  63  to  be  caused  in  this  way. 

Diagnosis. — That  form  of  chronic  peritonitis  (serous  or  granular) 
most  frequently  seen  in  females  at  the  commencement  of  puberty  is  hard 
to  discriminate  from  tuberculous  peritonitis,  since  the  latter  may  be 
more  or  less  latent.  Tuberculous  peritonitis  is  attended  with  fever, 
more  pain  and  tenderness,  and  there  is  a  more  rapid  accumulation  of 
the  exudate.  Again,  the  general  features,  debility  and  loss  of  flesh, 
progress  more  rapidly  than  in  granular  peritonitis.  The  detection  of 
conclusive  evidence  of  the  disease  in  persons  closely  related,  or  on  phys- 
ical examination  of  associated  pulmonary  or  pleural  lesions,  would  ren- 
der the  diagnosis  of  tuberculous  peritonitis  almost  certain.  In  obscure 
cases  the  guinea-pig  should  be  inoculated  with  the  exudate  (see  Pleu- 
risy, p.  541). 

Course  and  Prognosis. — The  milder  varieties  of  simple  chronic 
peritonitis  may,  though  rarely,  reach  a  favorable  issue.  In  cases  belong- 
ing to  this  category  the  disease  takes  a  chronic  course,  and  leads 
gradually  to  a  condition  of  extreme  debility,  even  if  it  does  not,  as  is 
usually  the  case,  materially  shorten  life.  Tuberculous  peritonitis  has, 
until  recently,  been  regarded  as  being  almost  uniformly  fatal  at  the  end 
of  several  months.  Cures  that  must  be  attributed  to  the  surgeon's  Avork, 
hoAvever,  are  at  present  by  no  means  uncommon.  Rarely  spontaneous 
cures  also  occur,  particularly  among  children,  in  whom  the  disease  is 
less  serious  than  in  adults. 

Treatment. — The  patient  should  be  enabled  to  enjoy  the  benefits  of 
good  sanitary  surroundings.  Close  attention  is  to  be  paid  to  the  diet, 
the  coarser  vegetables  and  sweets  being  prohibited,  since  they  increase 
the  pain  by  exciting  the  production  of  gas.  A  change  of  air  has  im- 
proved the  condition  in  several  instances  occurring  in  my  own  practice. 
The  usual  constipation  may  be  relieved  by  simple  enemata  or  by  the 
use  internally  of  the  fluid  extract  of  cascara  sagrada.  Tonics  and  alter- 
atives, the  latter  with  a  view  to  promoting  the  absorption  of  the  exudate, 
may  also  be  employed,  and  I  would  recommend  especially  for  this  pur- 
pose the  double  iodids,  as  in  the  formula  given  in  the  discussion  of 
Pleurisy  (vide  p.  556).  In  the  early  stages  some  degree  of  relief,  or 
even  a  curative  effect,  may  be  secured  by  local  means,  as  the  application 
of  equal  parts  of  belladonna  and  iodin  ointments  until  mild  counter- 
irritation  is  produced.  Ichthyol  ointment  is  also  serviceable.  After 
all,  however,  little  is  to  be  gained  from  therapeutic  measures,  and  it  is 
to  surgery  that  we  must  look  for  fresh  triumphs  in  the  treatment  of 
this  truly  distressing  complaint.  Cases  of  chronic  localized  peritonitis 
with  adhesions  have  been  operated  upon  successfully  by  W.  E.  Ashton, 
H.  A.  Kelly,  and  others.  Instances  of  chronic  generalized  peritonitis, 
whether  tuberculous  or  not,  in  which  the  fluid  efiusion  reaccumulates 
rapidly  after  repeated  tappings,  also  furnish  adequate  indications  for 
operative  procedures. 


926  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ASCITES. 

{Hydrops  Periioncei :  Dnqjsij  of  the  Peritoneum.) 

Definition. — An  accumulation  of  serum  in  the  peritoneal  cavity, 
resulting  from  stasis  (obstruction)  in  the  branches  of  the  portal  vein. 

Pathology. — The  quantity  of  liquid  contained  in  the  peritoneal 
cavitv  is  (juite  variable,  though  it  often  amounts  to  several  gallons.  It 
is  clear  and  transparent,  or  slightly  opalescent,  especially  on  standing, 
and  the  specific  gravity  ranges  from  1010  to  1014.  In  color  it  often 
has  a  faint  lemon-yellow  tint;  it  may,  however,  be  either  distinctly 
yellow,  brownish  (in'cirrhosis).  bile-stained  (as  Avhen  jaundice  is  present), 
or  slightly  blood-stained.  In  reaction  it  is  usually  alkaline;  very  rarely 
it  is  either  acid  or  neutral. 

The  ascitic  fluid  usually  contains  much  albumin,  resembling  in  this 
respect  blood-serum,  as  would  be  expected  from  its  source.  The  per- 
centage of  albumin  may  be  approximately  ascertained  by  noting  the 
specific  gravity  of  the  fluid  by  the  urinometer.  Thus,  in  true  ascites 
the  specific  gravity  ranges  from  1010  to  1014,  and  the  variation  in  the 
percentage  of  albumin  is  from  1  to  2.  In  eff'usions  due  to  pe?'itonitis 
the  percentage  of  albumin  ranges  higher  (2.5-6  per  cent.);  hence 
the  specific  gravity  ranges  correspondingly  higher  (1015-1024).  The 
standing  specimen  may  show  to  the  unaided  eye  a  minute  coagulum 
of  fibrin.  In  the  lowest  layer  of  the  fluid  the  microscope  discloses  leu- 
kocytes, red  blood-corpuscles  (in  abundance  Avhen  ascites  is  due  to  gen- 
eral venous  stasis),  fat-cells,  endothelium,  and  cholesterin-crvstals.  In 
ascites  the  microscopic  appearances  of  the  peritoneum  are  usually  normal, 
while  in  instances  of  peritonitis  the  membrane,  including  the  subperito- 
neal fibrous  tissue,  is  opaque  and  slightly  thickened. 

In  the  so-called  chylom  ascites  the  fluid  resembles  milk ;  it  contains 
fat-droplets,  a  few  lymphocytes,  and  sugar  (Hodlmoser  ').  This  condition 
may  be  associated  with  a  collection  of  milky  fluid  in  the  left  pleural  sac, 
■when  there  is  thrombosis  of  the  subclavian  vein  at  the  point  at  -which 
the  thoracic  duct  enters.  The  terra  ascites  wUposus  is  applied  to  a 
milkv  fluid,  in  which  the  origin  of  the  fat  is  the  debris  of  degenerated 
epithelial  cells,  with  few  fat-droplets  and  no  sugar  (Quincke  and  Sena- 
tor), to  the  exclusion  of  other  morphologic  elements. 

In  long-standing  cases  the  abdominal  and  the  thoracic  organs  become 
atrophied  from  pressure  exerted  by  the  dropsical  fluid. 

Btiology. — Among  the  chief  causal  factors  are  those  that  hinder 
or  arrest  the  return  of  venous  blood  from  the  peritoneal  membrane, 
as  the  following :  (a)  Pressure  upon  the  branches  of  the  portal  vein 
within  the  liver,  due  to  contraction  of  surrounding  tissues,  as  in  hepatic 
cirrhosis  (including  malarial  atrophy — De  Brun).  syphilis  of  the  liver, 
and  cancerous  infiltration,  {b)  Numerous  conditions  in  the  course  of 
which  pressure  may  be  made  upon  the  portal  vein  external  to  the  liver, 
as  enlargement  of' the  glands  in  the  fissure,  carcinoma,  hydatids,  or 
abscesses  connected  with  the  liver.  Tumors  of  any  adjacent  organs 
{e.g.  pancreas)  may  produce  it.  (c)  Thrombosis  of  the  portal  vein,  {d) 
1  Wiener  Min.  Woc.h.,  11  Jahrg.,  No.  49. 


ASCITES.  927 

Pressure  upon  the  inferior  vena  cava  after  it  receives  the  hepatic  trunk 
(Roberts),  or  upon  the  latter  itself,  or  the  lymphatics,  (e)  The  portal 
circulation  is  also  impeded  in  chronic  pulmonary  aiFections  (cirrhosis 
and  emphysema)  and  heart-diseases  (e.  g.  ascites  due  to  "  pericarditic 
pseudocirrhosis  of  the  liver  " — Pick).  (/)  A  new  growth  in  the  peri- 
toneum may  compress  the  smaller  veins  lying  in  the  membrane  or  the 
root  of  the  mesentery,  [g)  Diminished  resistance  of  the  Avails  of  the 
portal  vessels,  due  to  chronic  affections  that  diminish  the  albuminous 
constituents  of  the  blood  and  impair  the  nutrition  of  the  peritoneum, 
as  Bright's  disease,  carcinoma,  syphilis,  chronic  malaria.  (A)  Chylous 
ascites  is  caused  either  by  a  leakage  of  the  lacteals  (due  to  ulceration, 
injuries,  or  the  presence  of  filarise)  or  by  the  obstruction  of  the  thoracic 
duct  (due  to  thrombosis,  cicatrices,  compression).  Cases  of  lactescent 
ascites  in  Avhich  the  fluid  is  milky  (not  chylous)  have  recently  been 
reported.  The  nature  of  the  fluid  is  as  yet  unknown.  (^)  Adipose 
ascites  has  for  its  direct  cause  fatty  cellular  degeneration,  such  as  is 
found  in  carcinoma,  tuberculous  and  other  forms  of  chronic  peritonitis. 

Leyden  has  recently  (1897)  described  an  ameboid  organism. 

Symptoms. — Slight  peritoneal  dropsy  gives  rise  neither  to  symp- 
toms nor  to  abnormal  physical  signs.  When  the  sac  contains  1  quart 
(1  liter)  of  fluid  or  over,  however,  the  first  subjective  symptoms  that  are 
due  to  the  mechanical  efi'ect  of  the  fluid  appear.  They  are  a  sense  of 
weight  and  fulness,  with  slight  uneasiness.  As  the  proportion  of  trans- 
uded serum  becomes  gradually  increased  these  symptoms  become  more 
pronounced.  There  may  in  addition  be  a  dragging  pain  in  the  loins, 
g astro-intestinal  disturbance  (meteorism,  constipation),  and  dyspnea 
(owing  to  the  resistance  opposed  to  the  descent  of  the  diaphragm, 
resulting  in  compression  of  the  lungs).  The  latter  symptom  is  much 
increased  upon  exertion  or  on  assuming  the  recumbent  posture.  Since 
the  heart  is  displaced  upward,  an  embarrassment  of  its  action  (rapidity 
and  irregularity)  Avould  be  expected.  Syncope  is  not  infrequent  for 
similar  reasons.  Frequent  micturitioyi  from  pressure  upon  the  bladder 
is  common,  and  the  kidneys,  owing  to  compression  of  the  renal  vessels, 
secrete  an  albuminous  urine,  Avhich  is  greatly  lessened  in  amount.    . 

Physical  Signs. — After  the  serum  has  collected  in  considerable  amount 
the  physical  signs  afford  characteristic  evidence  of  the  condition.  From 
inspection  Ave  learn  many  valuable  points:  (a)  The  belly  is  uniformly 
prominent  (the  degree  depending  upon  the  amount  of  serum  present), 
giving  a  rounded  form.  Changing  the  posture  of  the  patient  shifts  the 
point  of  greatest  pouching,  (b)  The  skin  is  seen  to  be  tense,  smooth, 
and  shining,  and  sometimes  shows  line^e  albicantes  ;  the  umbilicus  com- 
monly bulges  forAvard  ;  less  frequently  it  is  obliterated,  and  the  surface- 
veins  are  often  enlarged.  (<?)  The  thorax  appears  small,  except  at  the 
base,  Avhere  it  is  distended,  and  the  ensiform  cartilage  is  sometimes 
abruptly  curled  up.  {d)  The  respirations  are  hurried  and  are  of  the 
thoracic  type,  the  abdominal  movements  being  slight  or  entirely  Avant- 
ing.  As  soon  as  the  belly-walls  become  moderately  tense  fluctuation  is 
elicited  by  placing  the  palm  of  the  left  hand  vertically  upon  one  side  of 
the  abdomen,  and  then,  with  the  finger-tips  of  the  right  hand,  tapping 
lightly  the  opposite  side ;  impulses  thus  sent  through  tbe  fluid  Avill  be 
distinctly  felt  by  the  hand  in  contact  Avith  the  abdomen.  When  the 
dropsical  fluid  is  small  in  quantity  the  patient  should  assume  the  erect 


928  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

posture  during  the  examination.  In  palpating  the  solid  organs  (liver, 
spleen,  abdominal  tumors)  when  ascites  is  present,  the  tips  of  the  fingers 
only  are  placed  upon  the  skin,  and  then  are  suddenly  "dipped,''  dis- 
placing the  fluid,  thus  touching  the  solid  organ  or  new  growth.  J'er- 
cussion  gives  dulness,  even  to  flatness,  over  all  of  that  portion  of  the 
abdominal  cavity  occupied  by  the  fluid.  The  upper  level  of  dulness  is 
not  represented  by  straight  transverse  lines,  but  presents  a  con- 
cavity that  is  pointed  to  the  head.  The  dulness  is  extremely 
movable,  shifting  as  the  patient's  position  is  changed.  When  the 
decubitus  is  supine  the  most  dependent  portions  of  the  abdomen 
give  dulness.  Again,  if  the  patient  be  made  to  lie  on  either  side,  the 
opposite  or  uppermost  flank  will  be  found  clear,  the  ascitic  fluid  always 
gravitating  to  the  bottom  of  the  sac.  Tyson  has  observed  that  the 
flanks  are  tympanitic  with  considerable  frequency  in  ascites,  and  my 
own  experience  has  been  similar,  tympany  over  the  head  of  the  colon 
being  almost  constant,  except  in  pronounced  cases.  Moreover,  to  obtain 
reliable  results,  if  the  layer  of  fluid  be  thin,  the  pleximeter  finger  is 
pressed  lightly  upon  the  surfiice,  and  the  gentlest  percussion  only  is 
allowable.  In  the  cardiac  region  there  is  often  percussion-resonance  as 
high  as  the  fourth  rib,  and  occasionally  a  murmur  may  be  heard  at  the 
base. 

Diagnosis. — In  order  to  arrive  at  a  positive  diagnosis  a  clear  his- 
tory of  one  or  the  other  of  the  known  causative  conditions  is  requisite, 
joined  with  distinct  evidence  of  the  presence  of  fluid — viz.  fluctuation 
and  movable  dulness.  For  the  early  diagnosis  of  ascites  the  patient 
should  be  placed  in  the  knee-elbow  position,  when  dulness  can  be  readily 
elicited  in  the  umbilical  region. 

The  diagnosis  of  chylous  ascites  and  ascites  adiposus  rests  upon  inse- 
cure ground  unless  aspiration  be  resorted  to.  although  the  presence  of 
the  causative  conditions  in  the  case  may  afford  a  basis  for  suspicions. 

Differential  Diagnosis. — Ascites  is  most  apt  to  be  mistaken  for  an 
ovarian  cz/xt.  The  accompanying  table  presents  the  chief  differenti- 
ating points : 

Ascites.  Ovarian  Cyst. 

Clinical  Histori/. 

General  health  is  bad  prior  to  the  ap-  General  health  is  good  before  the  devel- 

pearance  of  the  enlargement.  opment   of  the  tumor  ;    failure  after- 
ward. 

History  of  disease  of  liver,  lungs,  heart,  Frequent  history  of  dysmenorrhea,  neg- 

kidneys,  or  other  organ.  ative  as  to  organic  affections. 

Swelling  begins  below  and  gradually  ex-  Swelling  is  unilateral  at  first,  gradually 

tends  higher  ;    more  noticeable  when  becoming  more  central. 

sitting  than  in  the  standing  posture. 

Physical  Signs. 

Enlargement  is  symmetric,  the  abdomen  Enlargement  is  asymmetric  or  irregular, 

being   rounded    and    most    prominent  unless  the  tumor  be  vei-y  large,  when 

about   the    umbilicus  :   in    the    supine  it  may  fill   the   entire  abdomen.     The 

posture  the  abdomen  flattens,  with  lat-  greatest   circumference    is    below    the 

0!ral   bulging  ;    the  umbilicus  is  often  umbilicus,  which  never  ])ulges. 
poucheil  and  thin. 

Fluctuation  is  general  from  side  to  side  Fluctuation  is  circumscribed,  correspond- 

and  in  a  vertical  direction.  ing  to  the  limits  of  the  tumor. 


ASCITES. 


929 


Ascites. 


Ovarian  Cyst. 


Physical  Signs. 


No  aortic  pulsation  felt. 

Vaginal  examination  often  shows  the 
uterus  to  be  movable.  A  pouch  may 
project  into  the  vagina,  but  no  cyst  is 
detectable. 

When  standing,  the  upper  line  of  dul- 
ness  is  concave. 

In  the  supine  position  the  flanks  are 
especially  dull,  with  tympany  in  front. 

Dulness  is  movable  according  as  the  po- 
sition is  altered. 


Aortic  pulsation  is  sometimes  evident. 
Vaginal  examination  shows  the  uterus  to 

be  displaced.     A  cyst  may  be  felt  and 

outlined  in  the  pelvis. 

When  standing,  the  upper  line  of  dulness 

is  uniform  or  convex. 
In  the  supine  position  dulness  is  still  in 

front  and  the  flanks  are  resonant. 
The   area   of  dulness   is   not  varied  by 

change  of  posture. 


Character  of  the   Fluid 

Ascitic  fluid  has  a  specific  gravity  of 
1010-1014,  and  is  usually  clear.  It  is 
of  a  pale  straw-color. 


Ovarian  fluid  has  a  specific  gravity  of 
1018-1054.  It  is  of  a  thick,  turbid 
character,  and  the  color  is  variable. 


It  should  be  recollected  that  large  cysts  may  spring  from  other  ab- 
dominal organs  than  the  ovaries,  as  the  2)ancreas  and  liver  ;  the  elimi- 
nation of  these  latter  conditions,  however,  does  not,  as  a  rule,  offer 
marked  difficulty.  Ascites  must  be  distinguished  in  practice  from  the 
exudation  due  to  chronic  peritonitis^  and  the  points  of  differentiation 
have  been  arranged  thus  ; 


Ascites. 

A  previous  history  of  organic  disease  of 
the  liver,  heart,  kidneys,  or  other  organ 
is  obtainable. 

No  pain  is  experienced. 

The  abdomen  is  symmetrically  enlarged. 

Fluctuation  is  general  in  the  transverse 
or  vertical  directions. 

Palpation  detects  no  hard  masses  of  ir- 
regular prominence. 

Dulness  is  always  movable  upon  altering 
the  position  of  the  patient. 

The  fluid  consists  of  serum  with  few  mor- 
phologic elements.  It  is  limpid,  with 
a  specific  gravity  of  1010-1014,  and  is 
pale  straw-yellow  in  color,  often  with 
a  greenish  tinge. 

Over-filling  of  the  bladder  has  also  been  confounded  with  ascites,  and 
this  organ  has  been  tapped  under  the  mistaken  notion  that  the  condition 
was  one  of  dropsy  of  the  peritoneum.  If,  however,  the  precaution  be 
taken  to  catheterize  the  patient  before  tapping  for  supposed  ascites,  the 
error  cannot,  as  it  should  not,  occur. 

Prognosis. — The  duration  of  ascites  may  be  for  many  months  or 
even  years.  In  most  instances  the  prognosis  is  unfavorable,  though 
modified  by  the  character  of  the  causal  condition  in  individual  cases. 
The  immediate  cause  of  death  may  be  either  syncope,  asphyxia,  pul- 
monary atelectasis  from  compression  of  the  bases  of  the  lungs  by  the 
diaphragm,  or  it  may  be  the  causal  disease. 

Treatment. — Dietetic. — The  diet   should  be  largely  nitrogenous, 

59 


Chronic  Peritonitis. 

There  is  a  previous  history  of  acute  peri- 
tonitis, tuberculosis,  or  inflammatory 
diseases  of  the  female  pelvic  organs ; 
sometimes  a  history  of  injury. 

Pain  is  a  prominent  symptom. 

Abdomen  is  irregularly  prominent,  and 
rarely  flat. 

Fluctuation  is  often  limited  to  circum- 
scribed areas  due  to  loculation  of  fluid. 

Palpation  often  detects  resistant,  uneven 
prominences, 

Dulness  often  not  changeable  on  varying 
the  position,  owing  to  adhesions. 

The  fluid  is  either  sero-fibrinous,  sero- 
purulent,  or  milky  in  nature.  It  is 
often  viscid,  and  its  specific  gravity  is 
1018-1024.     The  color  varies! 


930  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

light,  nutritious,  and  given  at  stated  periods  with  a  vieAv  to  maintaining 
the  normal  proportion  of  albuminous  material  in  the  blood. 

Medicinal. — By  means  of  therapeutic  measures  we  should  aim  to 
accomplish  two  things :  First,  the  improvement  or  cure  of  the  original 
disease ;  and  secondly,  to  relieve  the  chief  symptoms  by  removing  the 
ascitic  fluid  on  which  they  depend.  Though  the  causative  affection  is 
usually  chronic  and  incurable,  every  effort  should  be  made  to  remove  or 
mitigate  its  pernicious  activity  in  accordance  with  the  principles  laid 
down  in  appropriate  portions  of  this  work.  Of  medicines  used  to  re- 
move the  transudation,  hydragogue  cathartics  are  most  potent  for  good, 
and  particularly  when  the  ascites  is  due  to  cardiac  or  renal  disease. 
Calomel  and  jalap  in  combination,  or  salines  in  full  doses,  administered 
after  the  Matthew  Hay  method,  should  be  tried.  Diuretics  are  also 
recommended,  and  English  authors  greatly  praise  copaiba  and  its  resin 
as  being  among  the  best.  The  bitartrate  and  other  salts  of  potash, 
either  alone  or  in  combination  with  juniper  and  digitalis,  are  of  signal 
value.  Sabrazles  and  Dion  have  recently  recommended  ui'ea  as  an 
effective  diuretic  in  ascites  due  to  benign  forms  of  atrophic  cirrhosis. 
Equally  important  with  the  exhibition  of  the  above  remedies  is  the  use 
of  tonics,  including  hematinics,  to  promote  the  general  nutrition  of 
the  patient.  I  have  reported  one  instance,  occurring  at  the  Philadel- 
phia Hospital,  in  which  a  cure  was  effected  perhaps  solely  as  the  result 
of  measures  intended  to  assist  the  nutritive  processes.  In  ascites  due  to 
cirrhosis  of  the  liver  recourse  should  be  had  to  paracentesis  abdominis, 
not  as  a  last  resort  only,  but  "  as  a  systematic  method  of  treatment " 
(Roberts).  A  single  tapping  is  rarely  sufficient,  and  a  repetition  of  the 
measure  from  time  to  time,  until  the  collateral  circulation  is  established, 
is  to  be  advised  and  encouraged.  In  cases  in  which  the  transuded  serum 
has  rapidly  re-formed  after  its  removal  by  tapping.  Southoy's  tubes,  by 
means  of  which  permanent  drainage  is  secured,  have  been  used  with 
good  results.  Drummond  affirms  that  ascites  due  to  liver-cirrhosis  can 
be  cured,  and  has  proposed  an  operation  whereby  adhesions  between  the 
abdominal  contents  and  its  parietes  are  secured,  in  which  new  blood- 
vessels are  formed,  thus  establishing  an  efficient  collateral  circulation. 


NEW  GROWTHS  IN  THE  PERITONEUM. 

The  most  frequent  and  important  of  the  new  growths  of  the  perito- 
neum are  (a)  carcinoma  and  (6)  tuberculous  deposit  and  tuberculous 
peritonitis,  the  latter  two  having  been  already  considered. 

CARCINOMA    OF   THE   PERITONEUM. 

There  occur  the  usual  varieties — scirrhous,  encephaloid,  and  colloid 
— the  latter  most  frecjuently  involving  the  omentum.  Primary  carci- 
noma of  the  peritoneum  is  rare.  Primary  endothelioma,  however,  is 
occasionally  met  Avith.  It  resembles  true  carcinoma  in  macroscopic  as 
well  as  in  microscopic  appearances,  though  it  is  in  reality  to  be  ranked 


CAECINOMA    OF  THE  PERITONEUM.  931 

with  the  sarcomata  on  account  of  its  origin.  Carcinoma  of  the  perito- 
neum is  almost  always  secondary  to  carcinoma  of  the  stomach,  liver, 
or  pelvic  organs.  The  peritoneum  may  either  be  the  seat  of  numerous 
small  round  miliary  tumors,  or,  less  commonly,  of  larger  and  distinctly 
nodular  masses,  the  most  extensive  development  being  presented  by  the 
colloid  variety.  Cancerous  peritonitis  is  commonly  found  to  be  an  asso- 
ciated condition,  and  the  retro-peritoneal  lymph-glands  not  infrequently 
show  cancerous  development. 

Ktiology. — More  cases  occur  in  the  female  sex  than  in  the  male. 
Age  has  also  a  potent  influence,  most  cases  appearing  late  in  life. 

Symptoms. — When  jyrimary,  carcinoma  of  the  peritoneum  is  ob- 
scure during  the  early  part  of  its  course.  Local  fain  and  discomfort  are 
complained  of,  and  clinical  evidences  of  the  cancerous  cachexia  develop 
early,  but  these  symptoms  are  not  at  first  striking  enough  to  be  entirely 
characteristic.  Later,  however,  the  nodules  can  often  be  plainly  felt 
(unless  the  liquid  effusion  be  too  marked),  and  the  ascites,  loss  of  flesh, 
weakness,  and  anemia  are  now  sufficiently  developed  for  diagnosis.  In 
the  colloid  variety  ascites  is  often  absent,  the  abdominal  cavity  being  the 
seat  of  a  large,  semi-solid,  non-fluctuating  mass. 

The  secondary  form  usually  follows  carcinoma  of  the  stomach  or  the 
ovaries,  and  the  cachexia  will  have  been  developed  before  the  peritoneum 
is  secondarily  involved  in  consequence  of  the  presence  of  the  primary 
growth.  Hence,  any  symptoms  referable  to  the  general  abdominal  cav- 
ity are  strongly  suspicious.  Among  other  constitutional  symptoms, 
apart  from  those  already  mentioned,  is  fever  (rarely  absent),  which  may 
be  due  in  small  measure  to  the  anemia,  though  in  a  greater  measure  to 
the  associated  peritonitis. 

Physical  Signs. — The  abdomen  protrudes  if  effusion  be  present  or  if 
the  carcinoma  be  of  the  colloid  form,  though  this  cannot  be  set  down 
as  a  uniform  rule.  Even  when  the  tumor  is  large,  dropsy  of  the  peri- 
toneum sometimes  makes  its  detection  impossible.  On  practising  palpa- 
tion after  tapping,  however,  the  nodules  can  be  easily  made  out,  either 
extending  from  side  to  side  or  being  more  or  less  localized  and  not 
adherent  to  underlying  structures. 

Differential  Diagnosis. — It  will  be  remembered  that  an  oblong 
tumor  lying  in  a  transverse  position  below  the  stomach  is  met  with  in 
certain  forms  of  chronic  peritonitis.  This  offers  the  same  physical  signs 
that  are  presented  by  cases  of  peritoneal  carcinoma,  unless  the  tumor- 
masses  in  the  latter  affection  be  of  considerable  size.  Carcinoma,  how- 
ever, is  most  apt  to  occur  in  persons  past  middle  life,  while  nodular 
tuberculous  peritonitis  appears  almost  exclusively  in  children  and  young 
adults.  Evidences  of  tul3erculous  disease  elsewhere,  past  or  present, 
and  particularly  suppuration  about  the  umbilicus,  would  point  to  tuber- 
culous peritonitis.  Moreover,  in  all  forms  of  abdominal  carcinoma  the 
inguinal  glands  are  apt  to  be  indurated  and  enlarged.  Proliferative 
peritonitis  usually  gives  a  history  of  chronic  alcoholism.  The  differen- 
tiation of  hydatid  cysts  of  the  peritoneum  from  carcinoma  depends  upon 
the  history  of  the  case,  the  presence  of  hydatid  fremitus,  the  finding 
of  the  booklets  in  the  fluid,  the  less  rapid  growth  of  the  tumor,  and 
the  lessened  amount  of  pain,  fever,  and  cachexia  in  the  latter  disease. 
Carcinoma  of  the  intestine  may  simulate  somewhat  the  disease  under 


932  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

consideration,  but  the  signs  of  increasing  stenosis,  as  evidenced  by 
the  colicky  pain,  the  discharge  of  blood  and  pus  with  the  stools,  and 
the  ribbon-like  character  of  the  feces,  will  serve  to  separate  the  condi- 
tions. Retro-peritoneal  tumors  (sarcomata)  are  discriminated  with  the 
greatest  diflBculty.  As  pointed  out  by  J.  D.  Steele,  in  tumors  behind 
the  peritoneum  the  signs  of  intestinal  obstruction,  coupled  Avith  neu 
ralgic  pains  or  edema  of  the  lower  extremities  from  pressure  upon 
their  nervous  and  venous  supply,  are  important  discriminating  features. 
Tumors  of  the  peritoneum,  however,  whether  of  the  omentum  or  mesen- 
tery, are  movable,  while  those  behind  the  peritoneum  are  generally 
fixed.  In  retro-peritoneal  sarcoma,  however,  "  the  tumor  may  fluctuate 
and  may  move  with  respiration,  or  bo  movable  by  palpation.  '  Omental 
tumors  lie  in  front  of  the  intestines  (as  can  be  shown  by  inflation  of  the 
bowel) ;  mesenteric  new  growths  sometimes  have  a  coil  of  intestine  in 
front  of  them.  On  the  other  hand,  retro-peritoneal  tumors  are  always 
crossed  by  loops  of  intestine  (colon).  Peritoneal  tumors  (particularly 
the  omental)  follow  the  movements  of  respiration,  while  the  retro-peri- 
toneal are,  as  a  rule,  immobile.  The  latter  always  cross  to  some  extent 
the  central  long  axis  of  the  body,  while  the  former  may  be  confined  to 
one  or  the  other  side.  Finally,  the  only  sure  method  of  determining 
the  character  of  tumors  behind  the  peritoneum  is  by  an  exploratory 
celiotomy. 

The  prognosis  is  always  unfavorable. 

Treatment  can  accomplish  nothing  beyond  a  more  or  less  com- 
plete relief  from   the  distressing  symptoms. 

Other  Tumors  of  the  Peritoneum. — Primary  sarcoma  has  been 
referred  to  above  (p.  930).  It  produces  larger  or  smaller  areas  of 
thickening  of  the  peritoneum.  Secondary  sarcoma,  the  commoner 
variety,  assumes  the  form  of  large  nodular  masses  or  of  numerous 
miliary  groAvths.  The  symptomatology  has  been  given  under  Carcinoma 
of  the  Peritoneum. 

Fibromata  and  lipoinata — the  former  as  fibroid  nodules  varying  in 
size  from  a  millet-seed  to  a  split  pea.  the  latter  as  localized  overgrowths 
of  fatty  tissue  showing  great  variation  in  their  size — are  among  peritoneal 
and  retro-peritoneal  neoplasms.  The  lipomata.  hoAvever,  are  the  more 
frequent.  Mr.  Anderson  points  out  that  fibromata  may  merge,  on  the 
one  hand,  into  the  lipomata  {fibro-Upomata) ;  on  the  other,  into  the 
myomata  {fibro-myomata).  It  is  probable  that  lipomata  usually  spring 
from  the  retro-peritoneal  tissue  in  the  neighborhood  of  the  kidneys  and 
iliac  fossa.  Less  commonly,  hoAvever.  they  ''originate  in  the  subperi- 
toneal tissues  of  the  mesenteric  or  omental  folds,  Avhere  general  fatty 
overgrowth  in  varying  degree  is  frequently  observed  "'  (Allchin). 

Peritoneal  lipomata  may  be  associated  Avith  extreme  obesity,  but  this 
is  by  no  means  invariably  the  case.  The  diagnosis  is  rarely  made, 
particularly  in  the  female.  OAving  to  the  close  resemblance  of  these 
groAvths  to  OA-arian  cysts  and  other  tumors  found  in  connection  with  the 
female  genitalia.  They  have  been  mistaken  also  for  ascites,  which  is 
not  rarely  a  symptom  of  fibromatous  and  lipomatous  neoplasms.  The 
prognosis  is  unfavorable,  although,  if  early  recognized,  the  tumors  may 
be  successfullv  removed. 


PART  VII. 

DISEASES  OF  THE  URINARY  SYSTEM. 


I.   DISEASES  OF  THE  KIDNEY. 


MOBILITY  OF  THE   KIDNEY. 

[Movable  Kidney;  Dislocated  Kidney;  Floating  Kidney;   Wandering  Kidney ; 

Ben  Mohilis ;  Nephroptosis.) 

Definition. — A  distinction  is  made  between  two  common  varieties 
of  mobile  kidney,  according  to  the  degree  of  displacement,  as  follows : 
(1)  Movable  kidney.,  the  upper  end  of  which  can  be  felt  during  deep 
inspiration,  and  which  can  be  pushed  down  in  the  retro-j^eritoneal  space 
to  the  level  of  the  umbilicus ;  (2)  Floating  Mdney,  which  is  freely  mov- 
able below  or  beyond  this  point — i.  e.  possessing  a  larger  arc  of  mobility. 
In  the  so-called  'paljpable  kidney  the  lower  edge  of  the  organ  can  barely 
be  felt  on  deep  pressure. 

Ktiology. — xA-lthough  an  anomalous  position  of  the  kidney  is  usu- 
ally acquired,  it  may  be  congenital ;  in  such  cases  the  condition  may  be 
due  to  relaxation  of  the  perinephric  (peritoneal)  tissues,  the  kidney  thus 
having  a  mesonephron  and  floating  freely  about  in  the  abdominal  cavity. 
An  abnormally  long  renal  artery  may  also  predispose  to  the  develop- 
ment of  a  movable  kidney. 

Emaciation  with  a  marked  wasting  of  the  fatty  capsule  in  which  the 
kidney  is  imbedded  is  a  frequent  underlying  cause  of  movable  kidney. 
Women  are  oftener  affected  than  men,  and  relaxations  from  multiple 
pregnancies,  tight-lacing  and  girdling,  and  traumatism  (falls,  heavy 
lifting,  and  the  like)  have  frequently  caused  displacement  and  mobility 
of  the  kidney.  Suckling^  observed  that  a  number  of  girls  who  served 
beer,  and  were  therefore  obliged  to  stoop  and  immediately  stand  up- 
right with  considerable  frequency,  were  likely  to  have  movable  kidney. 
Heavy  tumors  of  the  organ,  the  pressure  of  adjacent  tumors  (as  of  the 
liver),  and  the  traction  of  hernias  may  likewise  cause  the  condition. 

In  enteroptosis,  or  Glenard's  disease,  in  which  there  is  a  downward 
displacement  of  all  the  viscera,  mobility  of  the  kidney  is  often  asso- 
ciated. Although  either  kidney,  or  even  both  kidneys,  may  be  abnor- 
mally mobile,  the  right  one  is  usually  affected,  probably  owing  to  its 
anatomic  position  and  to  its  relation  with  the  liver  above.  Sometimes  a 
floating  kidney  becomes  fixed  by  peritoneal  adhesions  in  an  abnormal 
position,  as  in  the  right  iliac  fossa ;  an  instance  of  this  occurred  in 
a  seaman,  under  my  care,  admitted  to  the  Medico-Chirurgical  Hospital 
^  Edinburgh  Med.  Journ.,  Sept.,  1898. 

933 


934  DISEASES  OF  THE   URINARY  SYSTEM. 

of  Philadelpliia.  In  this  case  the  dislocation  of  the  kidney  ^Yas  appa- 
rently caused  while  on  shipboard  by  a  prolonged  and  intense  straining 
at  stool  after  taking  a  large  dose  of  castor  oil. 

Symptoms. — Movable  kidney  may  exist  without  any  symptoms 
whatever.  It  may  be  discovered  accidentally  by  physical  examination, 
and  not  infrequently  it  is  found  postmortem  in  a  similar  manner,  no 
history  of  trouble  having  been  elicited  during  life. 

The  symptoms  of  movable  kidney  are  local,  reflex,  and  general,  the 
local  and  reflex  symptoms  being  the  most  prominent  in  the  average  case. 
The  reflex  symptoms,  though  usually  abdominal,  may  become  general. 
The  local  symptoms  are  most  marked  in  extreme  mobility  of  the  kidney 
(floating  kidney),  while  in  moderate  mobility  the  reflex  symptoms  usually 
predominate  over  the  local. 

Most  frequently  there  is  a  troublesome  dragging  pain,  or  a  sense  of 
weight  or  pressure  in  the  loins  or  abdomen,  especially  after  long  walking 
or  standing  or  hard  labor ;  this  may,  at  times,  be  referred  to  the  sacral 
region.  Sometimes  the  pain  may  be  quite  sharp  and  colicky  in  nature. 
Pain  in  the  kidney  itself  is  seldom  complained  of,  and  then  only  in  those 
comparatively  rare  conditions  in  which  congestion  is  produced  by  pres- 
sure or  traction  upon  the  renal  veins,  obstruction  of  the  ureter,  or  the 
like.  The  patient  himself  sometimes  recognizes  the  kidney  as  a  tumor, 
tender  and  distressing,  as  in  a  case  under  my  own  care. 

Reflex  gastro-intestinal  disturbances  are  common.  Indigestion  is 
usually  complained  of,  and  occasionally  nausea  and  vomiting  are  noted. 
Dilatation  of  th&  stomach  may  possibly  be  caused  by  a  dislocated  kidney 
pressing  upon  the  duodenum,  but  the  association  of  the  two  conditions 
is  probably  coincident  rather  than  causative.  Pressure-jaundice  is  also 
an  unusual  concomitant  of  the  floating  kidney.  Cardiac  palpitation, 
constipation,  flatulence,  and  edema  of  the  lower  extremities  (from  pres- 
sure on  the  inferior  vena  cava)  may  attend,  and  disturbances  of  the 
pelvic  viscera  have  also  been  noted  occasionally  (dysmenorrhea,  abortion, 
and  irritable  bladder).  Improvement  is  usually  considerable  in  preg- 
nancy. Some  cases  of  dis})laccd  kidney  are  characterized  by  sudden 
and  severe  attacks  of  nephralgic  or  gastralgic  pains,  chills,  fever,  ver- 
tigo, nausea  and  vomiting,  and  general  collapse.  These  attacks  are 
often  periodic,  occurring  sometimes  at  the  menstrual  period,  and  are 
known  as  '•'' DietVs  crises"  or  ^"incarceration  symj^toms."  They  may 
be  excited,  also,  by  a  too  free  indulgence  in  eating  and  drinking,  as  in 
a  case  reported  by  Osier.  It  is  most  probable,  as  Dietl  himself  sug- 
gested, that  these  cases  are  due  to  a  twisting  or  bending  of  the  renal 
vessels  or  of  the  ureter,  or,  perhaps,  to  circumscribed  inflammation  of 
the  mobile  kidney.  An  acute  hydronephrosis  may  thus  develop,  with 
diminished  diuresis.  The  urine  is  concentrated,  and  may  contain  uric 
acid  or  oxalates  in  excess.  After  three  or  four  days,  as  the  attack 
subsides,  micturition  becomes  free,  the  swollen  and  sensitive  kidney 
becoming  movable  once  more.  When  produced  by  movable  kidney 
these  attacks  of  transitional  hydronephrosis  may  occur  intermittently 
{vide  Hydronephrosis). 

Floating  kidney  associated  with  Gldnard's  disease  (enteroptosis, 
splanchnoptosis),  in  Avhich  the  transverse  colon,  pancreas,  stomach, 
intestines,  and  other  viscera  are  prolapsed,  owing  to  looseness  and 
weakness  of  the  visceral  attachments,  gives  rise  to  symptoms  similar  to 


MOBILITY  OF  THE  KIDNEY.  935 

those  stated  above,  only  with  the  addition  of  greater  discomfort  and 
nutritive  and  nervous  disturbances.      Sometimes  there  is  albuminuria. 

The  general  symptoms  of  movable  kidney  are  those  of  "'  nervousness  " 
neurasthenia,  or  hysteria.  Mental  anxiety,  leading  to  melancholia,  some- 
times follows  the  discovery  by  the  patient  of  a  movable  abdominal  tumor, 
which  is  persistently  believed  to  be  a  "  cancer."  Cephalalgia,  backache, 
mental  irritability,  paresthesias,  neuralgias,  nervous  dyspepsia,  and  vari- 
ous hysteric  manifestations  may  arise  and  prove  a  perpetual  annoyance. 
In  those  less  frequent  instances  in  which  men  are  aifected  with  mobile 
kidney  hypochondriasis  may  develop. 

The  physical  signs  of  movable  or  floating  kidney  are  highly  import- 
ant and  diagnostic.  Palpation,  especially  bimanual,  as  by  Israel's 
method.  The  patient  lying  in  a  semi-recumbent  position,  counter- 
pressure  (the  left  hand  being  placed  over  the  lumbar  region,  the 
right  next  the  skin  in  front,  manipulating  the  abdomen  from  above 
downward)  may  detect  a  firm,  movable  tumor  of  renal  size  and 
shape  in  either  flank  (usually  the  right)  just  below  the  ribs  (movable 
kidney),  or  in  the  inguinal  or  umbilical  regions  (floating  kidney). 
Or,  the  patient  may  stand  and,  grasping  the  back  of  a  chair,  may  lean 
slightly  forward,  while  the  examiner,  at  the  patient's  side,  presses  with 
one  hand  over  the  loin,  and  with  the  other  feels  over  the  abdomen  be- 
low the  ribs.  Though  comparatively  easy  to  outline,  the  tumor  is  never- 
theless hard  to  grasp ;  it  is  often,  however,  readily  pushed  into  place. 
Deep  breathing  may  affect  a  palpable  or  movable  kidney,  but  has  no 
eff'ect  upon  one  that  freely  wanders  about  the  abdomen  (floating  kidney.) 
Pulsation  of  the  renal  artery  may  be  felt  in  the  last-named  cases. 

Inspection  and  p>ereussion  of  the  lumbar  region  in  movable  kidney  are 
uncertain,  and  therefore  unreliable.  Visible  depression  here  is  rarer 
than  a  visible  tumor  anteriorly ;  the  latter,  however,  is  not  common, 
although  it  is  occasionally  noted  in  cases  of  marked  wandering  of  the 
kidney,  as  to  the  inguinal  region.  I  have  noted  increased  tympany 
over  the  aff'ected  side  in  several  cases  as  compared  with  the  same  area 
on  the  opposite  side. 

A  diagnosis  is  possible  only  after  a  careful  and  thorough  physical 
examination.  When  this  is  made,  an  abnormally  mobile  kidney  is 
usually  discovered  without  difficulty.  The  size  and  shape  of  the  organ, 
its  right-sided  position,  and  its  mobility,  associated  with  a  train  of  local, 
reflex,  or  general  nervous  disturbances,  especially  in  a  thin,  emaciated 
woman,  are  quite  distinctive.  A  knee-elbow  posture  is  sometimes  more 
favorable  than  the  recumbent  position  for  determining  a  movable  kidney. 

Floating  kidney  is  of  course  more  easily  diagnosticated  than  the 
movable  type,  and  partly  because  of  the  fact  that  in  instances  of  the 
latter,  tumors  of  the  gall-bladder  especially,  and  wandering  spleen  must 
first  be  excluded.  The  absence  of  a  well-defined  splenic  notch,  the 
presence  of  pulsation  of  the  renal  artery,  a  tympanitic  note  over  the 
usually  intervening  colon,  and  an  unchanged  area  of  splenic  dulness  will 
assist  in  the  diagnosis ;  in  addition  there  is  the  fact  that  wandering 
spleen  is  a  comparatively  rare  aff'ection. 

Differential  Diagnosis. — Tumors  of  the  gall-bladder,  as  Henry  Morris 
has  shown,  are  frequently  mistaken  for  movable  kidney  ;  occasionally  the 
opposite  error  is  made  ;  sometimes  both  conditions  may  exist.  They 
are  both  common  to  women  ;  the  right  kidney  is  more  often  movable 
than  the  left ;  they  both  may  present  as  tumors  in  the  right  hypochon- 


936  DISEASES  OF  THE   URINARY  SYSTEM. 

driac  and  umbilical  regions  ;  they  are  more  or  less  movable,  firm,  smooth, 
slightly  tender,  round  or  oval  in  shape,  with  variable  percussion-signs, 
and  dyspeptic  symptoms  ;  and  either  ma}^  give  rise  to  paroxysms  of  severe 
colic,  or  to  jaundice.  Jaundice,  however,  is  probably  rare  in  movable 
kidney,  while  emaciation  and  general  nervous  disorders  are  more  com- 
mon ;  the  floating  tumor  is  also  less  easily  palpated  than  the  cholecystic, 
and  may  vary  in  size  (hydronephrosis),  the  diminution  being  accompanied 
by  a  marked  increase  in  the  flow  of  urine.  If  the  gall-bladder  be  filled 
with  calculi,  the  consistence  is  firmer  than  that  of  the  kidney,  and  fre- 
mitus may  be  felt.  Moreover,  the  movements  of  the  gall-bladder  are 
usually  lateral  within  a  short  arc  of  a  circle,  the  center  of  which  is  a 
point  beneath  the  edge  of  the  right  lobe  of  the  liver ;  while  those  of 
floating  or  movable  kidney  may  be  either  vertical,  oblique,  or  lateral  in 
arcs  of  a  much  larger  radius.  Again,  tumors  of  the  gall-bladder  descend 
with  inspiration,  as  is  not  the  case  with  wandering  kidney. 

In  some  .cases  it  may  be  necessary  to  distinguish  between  the  attacks 
of  pain  known  as  "  Dietl's  crises  "  and  renal,  hepatic,  or  intestinal  colic, 
acute  intestinal  obstruction,  alfections  of  the  genital  organs,  and  appen- 
dicitis; the  symptoms  peculiar  to  these  conditions  must  be  considered 
in  forming  a  diagnosis. 

Tumors  of  the  ovaries  and  bowel  are  rarely  confounded  with  wander- 
ing kidney. 

Prognosis. — In  uncomplicated  cases  life  is  never  endangered,  and 
a  cure  may  be  eff'ected  in  a  large  majority  of  cases  in  which  suitable  com- 
bined medical  and  surgical  treatment  is  pursued.  The  general  nervous 
symptoms  are  usually  very  obstinate,  but  after  relief  is  afforded  from  the 
local  and  reflex  symptoms,  Avhether  by  tentative  or  operative  means,  they 
subside  or  cease  altogether. 

Treatment. — Since  emaciation  and  loss  of  perirenal  fat  is  a  fre- 
quent cause  of  wandering  kidney,  it  is  often  advisable  to  resort  to  meas- 
ures that  will  tend  to  increase  the  weight  and  fat  of  the  body.  The 
"rest-cure,"  Avith  its  forced  feeding,  may  be  all  that  is  necessary  in 
highly  nervous  subjects  having  but  a  slightly  movable  kidney.  In  all 
cases  more  or  less  prolonged  intervals  of  rest  (lying  down)  throughout 
the  day  aid  markedly  in  ameliorating  the  symptoms.  Other  hygienic 
measures,  as  the  avoidance  of  over-exertion,  extreme  bodily  movements, 
straining — as  at  stool — and  so  forth,  should  also  be  enjoined. 

For  several  years,  and  until  recently,  the  operation  for  anchoring  the 
mobile  kidney  has  been  advised  as  appropriate  in  nearly  all  cases.  This 
is  now  perhaps  wisely  deprecated  ;  and  a  reversion  to  the  careful, 
patient,  and  constant  use  of  suitable  abdominal  pads  and  binders  in  cer- 
tain cases  is  meeting  with  much  success  in  aflbrding  comfort  and  sup- 
port, besides  a  marked  reduction  in  the  reflex,  abdominal,  and  general 
nervous  symptoms.  In  severe  cases  of  renal  dit^placements,  in  which 
recurring  attacks  of  hydronephrosis,  strangulation-crises,  profound  ner- 
vous and  mental  disturbances,  or  other  grave  renal  complications  occur, 
some  such  surgical  procedure  as  nephrorrhaphy  may  be  necessary.  This 
often  proves  an  effectual  cure,  although  occasionally  the  anchorage  may  be 
torn  loose  by  a  sudden  or  severe  physical  effort.  Total  extirpation  of  the 
kidney  (nephrectomy)  is  justifiable  only  in  the  gravest  cases  and  after 
other  means  have  failed.  The  hypodermic  injection  of  morphin  and  atroj)in 
and  the  external  application  of  heat  are  indicated  in  the  crises  of  Dietl. 


PASSIVE  HYPEREMIA   OF  THE  KIDNEY.  937 

CIRCULATORY  DISORDERS  OF  THE  KIDNEYS. 

ACTIVE   HYPEREMIA. 
(^Acute  or  Active  Congestion.) 

Definition. — An  acute,  temporary  engorgement  of  the  vessels  of 
the  kidneys,  with  little  or  no  exudation. 

Pathology. — The  kidney  is  swollen,  deep-red  in  color,  and  en- 
gorged with  blood,  which  flows  freely  on  section.  Microscopically,  in 
severe  congestion  there  may  be  seen  cloudy  swelling  of  the  cortical 
epithelium. 

;^tiology. — Acute  renal  congestion  is  due  mainly  to  the  action  of 
irritants  present  in  the  circulation,  as  in  the  acute  infectious  (especially 
the  eruptive)  fevers.  The  stimulating  diuretics  and  certain  poisonous 
drugs,  as  copaiba,  squills,  cantharides,  potassium  chlorate,  and  car- 
bolic acid,  also  sudden  contraction  of  the  peripheral  blood-vessels  by 
exposure  to  cold  while  the  body  is  overheated,  act  as  causes.  Post- 
operative acute  hyperemia  is  frequently  met  with,  particularly  after  ab- 
dominal sections.  When  prolonged  the  congestion  passes  into  an  acute 
nephritis.  It  may  be  caused  in  one  kidney  as  a  result  of  the  nephrectomy 
of  its  fellow.  Certain  ill-defined  centric  and  peripheral  nervous  in- 
fluences and  neuroses  are  held  by  some  to  cause  an  active  hyperemia  of 
the  kidneys  through  a  vasomotor  paralysis  of  the  renal  arteries. 

Sj^mptoms. — There  may  be  a  dull  pain  in  the  lumbar  region,  with 
a  slight  elevation  of  the  temperature  and  pulse-rate.  The  urine  either 
is  scanty,  or,  as  in  cantharides-poisoning,  it  may  be  altogether  sup- 
pressed. It  is  dark,  the  specific  gravity  is  increased,  and  it  contains 
some  free  blood,  a  trace  of  albumin,  and  a  few  hyaline  tube-casts. 

Diagnosis. — The  absence  of  a  marked  quantity  of  albumin,  of  the 
numerous  and  various  casts,  of  dropsy,  and  of  uremic  symptoms  distin- 
guishes active  hyperemia  from  amite  nephritis. 

The  prognosis  is  quite  favorable  upon  the  removal  of  the  cause.  It 
must  be  borne  in  mind  that  a  frequent  repetition  of  the  attacks  may 
lead  to  a  nephritis. 

Treatment. — Absolute  rest  and  a  liquid  diet  should  be  ordered. 
Cupping  over  the  loins  or  the  use  of  hot  fomentations  should  be  prac- 
tised. The  free  use  of  water  and  other  diluents  or  mucilaginous  drinks 
should  be  encouraged.  Saline  laxatives  to  freely  open  the  bowels,  and 
the  use  of  hot  air  or  a  hot  pack  to  promote  sweating,  are  important  aids 
in  relieving  the  congested  kidneys. 

PASSIVE   HYPEREMIA. 
{Chronic  or  Passive  Congestion.) 

Definition. — A  chronic  venous  engorgement  of  the  renal  vessels, 
generally  secondary  to  diseases  of  certain  other  viscera. 

Pathology. — There  is  in  the  later  stages  a  characteristic  condition 
of  the  kidneys  called  "  cyanotic  induration."  Earlier  in  the  case  the 
organs  are  enlarged,  firm,  and  of  a  dark,  bluish-red  color.  The  capsule 
is  usually  non-adherent.  On  section  the  medullary  substance  is  seen  to 
be  darker  red  than  the  cortex  and  coarsely  fibrous  in  appearance.    Micro- 


938  DISEASES  OF  THE   URINARY  SYSTEM. 

scopic  examination  shows  the  capillaries  (both  glomerular  and  medullary) 
somewhat  dilated  and  the  walls  thickened.  The  epithelium  may  either 
be  unchanged  or  a  little  cloudy  and  swollen,  or,  later,  even  fatty  ;  the 
interstitial  tissue  may  be  slightly  increased,  especially  beneath  the  cap- 
sule of  the  kidney. 

Htiology. — Most  commonly  the  renal  congestion  is  a  part  of  a  gen- 
eral venous  engorgement  due  to  chronic  cardiac,  pulmonary,  or  hepatic 
disease.  It  is  found  in  mitral  valvular  disease  with  ruptured  compen- 
sation of  the  heart ;  in  pulmonary  emphysema,  fibroid  phthisis,  and 
chronic  adhesive  pleurisy  ;  and  in  cirrhosis  of  the  liver.  The  "  cardiac 
kidnej  "  is  the  commonest  variety.  Less  frequent  causes  of  congested 
kidneys  are  tumors,  the  pregnant  uterus,  and  ascites,  all  of  which  bring 
about  the  condition  through  pressure  upon  the  renal  veins.  Only  rarely 
may  passive  renal  congestion  be  due  to  thrombosis  of  the  ascending  vena 
cava  or  of  the  renal  veins. 

Symptoms. — These  are  accompanied  by  those  due  to  the  primary 
diseases  that  are  manifested  in  the  general  venous  congestion,  as  edema 
of  the  lower  extremities.  There  may  be  a  sensation  of  Aveight  in  the 
loins.  The  urine  is  diminished  in  ({uantity,  of  a  higher  specific  grav- 
ity, and  darker  in  color  ;  it  contains  a  little  albumin,  some  blood-cor- 
puscles, and  a  few  hyaline  casts  and  epithelial  cells,  depending  upon  the 
chronicity  and  intensity  of  the  congestion.  Urates  may  be  deposited 
in  the  standing  urine. 

Diagfnosis. — From  nephritis  passive  renal  congestion  may  be  differ- 
entiated by  the  comparative  absence  of  albumin,  casts,  general  dropsy, 
and  uremia,  and  by  the  undiminished  quantity  of  urea. 

Prognosis. — This  depends  upon  the  primary  cause.  Chronic  con- 
gestion may  pass  into  chronic  nephritis. 

Treatment. — Rest  and  a  light  and  easily  assimilable  diet,  together 
with  cardiac  tonics  and  diuretics,  are  indicated.  The  infusion  of  dig- 
italis serves  a  good  purpose  by  increasing  the  quantity  of  urine  and 
clearing  it  of  albumin.     Basham's  mixture  is  a  useful  adjuvant. 

EMBOLIC   INFARCTIONS. 

Anemic  and  hemorrhagic  infarctions  of  the  kidney  are  of  pathologic 
rather  than  of  clinical  significance.  Cicatrices  may  result  from  these 
infarctions,  giving  rise  to  the  "embolic  contracted  kidney."  Very 
rarely  the  sudden  appearance  of  a  slight  amount  of  blood  in  the  urine, 
associated  Avith  cardiac  disease  and  possibly  with  a  sudden  severe  pain 
over  the  loin,  may  point  to  hemorrhagic  infiirction. 


SPECIAL  PATHOLOGIC  STATES  OF  THE  URINE. 

HEMATURIA. 

Definition. — The  presence  of  blood  in  the  urine. 

Ktiology. — (1)  Local  or  renal  causes  of  hematuria  include  conges- 
tion (including  that  due  to  torsion  of  tlie  renal  vessels  in  certain  cases 
of  floating  kidney),  acute  inflammation  of  the  kidneys,  and  acute  ex- 
acerbations of  chronic  nephritis,  embolic  hemorrhagic  infarction,  renal 


HEMATURIA.  939 

calculi  and  pyelitis,  tuberculosis,  malignant  renal  disease,  diffuse 
myxangiomatous  condition  of  the  pelvic  submucous  tissue  (Myles), 
hydatids,  traumatism,  and  parasites  (the  filaria  sanguinis  hominis  and 
distoma  hcematobium  (Bilharz). 

(2)  Affections  of  the  Urinary  Tract. — In  the  ureter^  calculi  or  lacera- 
tions due  to  traumatism,  as  in  protracted  and  complicated  abdominal 
sections ;  in  the  bladder,  calculi,  malignant  tumors,  acute  cystitis,  ulce- 
ration and  rupture  of  varicose  veins  at  the  vesical  neck ;  and  in  the 
urethra,  gonorrhea,  calculi,  parasites,  and  traumatism, — may  all  cause 
hematuria. 

(3)  Greneral  Diseases. — Acute  specific  fevers  and  certain  blood-dys- 
crasifB  (purpura,  gout,  scurvy,  hemophilia,  malaria,  and  leukemia)  may 
produce  hematuria.  Malarial  hematuria  in  mild  form  is  not  an  uncommon 
feature  of  paludism  in  the  Middle  States  of  this  country,  and  may  occur 
after  the  manner  of  intermittent  malarial  paroxysms.  That  due  to  the 
renal  congestion  of  chronic  heart-,  lung-,  or  liver-disease  is  not  a  marked 
condition,  and  has  not  been  of  frequent  occurrence  in  my  experience. 

Senator  describes  an  interesting  and  unusual  form  of  hematuria  that 
is  sometimes  seen  in  young  persons  whose  health  may  be  quite  fair, 
the  blood  often  appearing  paroxysmally  and  "without  apparent  cause 
("renal  hemophilia").  Hematuria  may  be  also  a  manifestation  of 
vicarious  menstruation ;  and  of  mountain-sickness  (Dieulafoy). 

Endemic  hematuria,  so  called,  is  that  variety  found  in  some  of  the 
tropical  regions  where  the  distoma  haematobium  (a  trematode  worm) 
abounds. 

Diagnosis. — This  has  for  its  object  the  discovery  (1)  of  blood  in 
the  urine,  and  (2)  of  the  source  of  the  hemorrhage.  Bloody  urine 
varies  in  color  according  to  the  quantity  of  blood  present,  to  its  condi- 
tion (coagulability),  disposition,  and  the  length  of  time  present  in  the 
urine.  A  light  reddish  tinge  may  indicate  a  slight  quantity  of  blood. 
A  dark  coagulum  may  be  at  the  bottom  as  a  sediment,  with  small  clots 
floating  above  in  a  deep-red,  turbid  layer,  above  Avhich,  again,  the  urine 
may  show  but  the  slightest  tint  of  red.  Or  the  urine  may  have  a  smoky- 
red  or  chocolate-hued  appearance.  Microscopically,  the  blood-corpuscles 
are  readily  discovered,  establishing  the  diagnosis  from  hemoglobinuria, 
in  which  condition  they  are  absent.  When  red  corpuscles  are  associated 
with  tube-casts,  renal  hemorrhage  may  be  positively  diagnosed.  In 
ammoniacal  urine  or  in  urine  of  low  specific  gravity  the  corpuscles  are 
very  pale  and  shadowy  (dissolved  hemoglobin).  After  remaining  in 
ordinarily  acid  and  diluted  urine  they  lose  their  disk-like  shape  and  swell 
into  spheres  of  a  smaller  diameter.  Urine  containing  blood  always 
shows  the  presence  of  albumin.  According  to  Newman,'  a  ratio  of  albu- 
min to  hemoglobin  in  excess  of  1  to  1.6  indicates  not  only  an  independent 
albuminuria,  but  also  a  renal  affection  as  the  cause  of  the  hematuria. 

Chemically,  the  blood-pigment  may  be  detected  by  Heller's  test, 
which  consists  in  adding  liquor  potassae,  boiling  the  urine,  and  observ- 
ing the  flakes  of  precipitating  phosphates,  which  become  reddish-yellow 
or  broAvn  from  the  added  hemochromogen.  The  guaiacum  test  is  also 
used.  The  spectroscope  is  sometimes  employed  to  discover  the  bands 
produced  by  the  blood  coloring-matter. 

The  source  of  the  blood  in  hematuria  is  of  great  diagnostic  and 
-  Lancet,  July  9,  1898. 


940  DISEASES  OF  THE   URINARY  SYSTEM. 

therapeutic  importance.  In  renal  hemorrhage  the  blood  is  thoroughly 
mixed  with  the  urine,  giving  a  uniformly  red  or  brown  color,  as  in 
hemorrhagic  nephritis.  Blood-casts  and  leukocytes  may  also  be  found. 
The  disease  causing  hematuria  may  be  traced  sometimes  by  a  study  of  the 
urine ;  thus,  in  cases  of  valvular  cardiac  disease  the  sudden  appearance 
of  hematuria  would  indicate  infarction  of  the  kidney.  The  discovery 
of  a  few  red  blood-corpuscles  in  a  concentrated  urine  would  point  to 
renal  congestion.  In  profuse  renal  hemorrhages  clots  representing  moulds 
of  the  renal  pelves  and  of  the  ureters  may  be  discharged.  Hemorrhage 
due  to  calculus  is  usually  small  in  amount  and  appears  at  more  or  less 
prolonged  intervals.     Tubercular  hemorrhages  may  occur  very  seldom. 

Blood  from  the  ureters  is  usually  moulded  in  clots  in  the  shay*  of 
curved  cylinders,  and  appears  like  small  dark  worms  in  the  urine. 
Casts  from  the  ureters  are  often  secondary  to  hemorrhages ;  in  such 
cases  the  hematuria  may  alternate  with  the  passage  of  clear  urine,  owing 
to  temporary  hemorrhages  or  to  the  blocking  of  the  ureter  on  the  dis- 
eased side.     (See  also  Fibrinuria.) 

Vesical  hemorrhages  may  be  quite  copious.  The  blood  and  urine  are 
not  intimately  mixed,  and  large  clots  settle  on  standing.  The  first  por- 
tions of  urine  discharged  may  not  be  bloody,  while  the  last  portion  may 
consist  of  pure  blood. 

Finally,  urethral  blood  is  discharged  before  the  urine,  and  either 
comes  away  freely  or  may  be  "milked  out"  independently  of  urination. 

The  endoscope  has  been  used  successfully  to  determine  the  source  of 
the  hemorrhage.  It  is  especially  useful  in  women.  It  is  also  possible 
with  this  instrument  to  determine  which  kidney  is  affected. 

Prognosis. — This  varies  with  the  primary  source  of  the  hematuria. 

The  treatment  consists  primarily  in  rest  in  bed.  The  application 
of  dry  cold  to  the  loins  is  useful,  and  the  hypodermic  injection  of  ergotin 
is  to  be  recommended  for  trial.  Internally,  such  hemostatics  as  the  ex- 
tract of  hamaraelis  virginica,  the  extract  of  hydrastis  canadensis,  gallic 
acid,  lead  acetate,  calcium  chloride,  ergot,  and  opium  may  be  used. 
Cantharides  tincture  in  2-  to  5-drop  doses  has  been  tried  with  good 
results  in  hematuria  due  to  renal  congestion. 

HEMOGLOBINURIA. 

Definition. — The  presence  of  blood-pigments,  especially  methemo- 
globin.  in   the   urine. 

Htiology. — The  direct  cause  of  hemoglobinuria  is  a  condition  of 
the  blood  in  which,  as  a  result  of  the  dissolution  of  the  red  corpuscles, 
the  hemoglobin  is  set  free  and  is  excreted  by  the  kidneys. 

(1)  The  causes  of  the  hemolysis  are  principally  toxic,  and  include  the 
following :  {a)  Poisons  (carbolic  and  pyrogallic  acids,  potassium  chlo- 
rate, naphtol,  phosphorus,  arseniuretted  hydrogen,  and  carbon  dioxid). 
(b)  The  ingestion  of  poisonous  fungi  or  of  tainted  edible  mushrooms 
[Helvella  esculenta).  (c)  The  poisons  of  certain  infectious  diseases 
(scarlatina,  typhus  and  typhoid  fevers,  yellow  fever,  syphilis,  scurvy, 
purpura),  (d)  Extensive  burns,  the  absorption  of  hemorrhagic  effusions, 
and  the  transfusion  of  animal  blood,  (e)  Rarely  it  may  be  due  to  ex- 
posure to  cold  and  to  violent  physical  exertion,  (f)  Finally,  there  is 
the  so-called  epidemic  hemoglobinuria  (Winckel's  disease)  that  occurs  in 
the  new-born. 


HEMOGLOBINURIA.  941 

(2)  Paroxysmal  hemoglobinuria,  a  rare  and  interesting  variety,  may 
occur  without  any  apparent  cause  in  persons  enjoying  otherwise  good 
health.  It  appears  thus  distinctly  as  an  independent  disease.  Some 
of  these  cases,  however,  have  been  attributed  to  a  peculiar  susceptibility 
to  cold  (generally  or  locally  applied)  and  to  marked  exertion ;  especially 
is  this  the  case  in  adult  white  males.  It  is  held  by  some  to  be  a 
manifestation  of  Raynaud's  disease,  uricemia,  and  by  others  to  be  the 
result  of  syphilis. 

(3)  It  appears  as  a  symptom  of  malaria  (which  acts  like  the  other  infec- 
tious diseases)  in  the  southern  part  of  this  country,  where  the  pernicious 
varieties  of  malarial  toxemia  are  most  common.  This  is  termed  malig- 
nant malarial  hemoglobinuria  or  hemoglohiyiuric  fever.  In  Africa  it  is 
called  hlack-tvater  fever. 

Symptoms. — These  are  generally  the  symptoms  of  the  condition 
that  accompanies  hemoglobinuria.  In  paroxysmal  hemoglobinuria  the 
attacks  are  usually  sudden,  brief  in  duration,  and  sometimes  intermit- 
tent, especially  when  of  malarial  origin.  An  anemic  condition  seems  to 
be  essential  to  the  production  of  malarial  hemoglobinuria.  Jaundice 
may  be  an  associated  symptom.  The  hemoglobinuria  seldom  lasts  for 
more  than  two  days,  though  very  grave  cases  take  on  the  aspect  of  a 
pernicious  malarial  attack.  There  may  be  lumbar  pains,  chills  and  fever, 
and  gastric  disturbances.  Urticaria  and  purpura  have  also  been  noted, 
as  has  anemia  in  cases  in  which  frequent  attacks  have  taken  place. 

Diagnosis. — This  is  made  by  an  examination  of  the  urine.  Macro- 
scopically,  it  is  of  a  red-brown  color,  slightly  turbid,  with  a  reddish- 
brown  or  brownish-black  sediment.  The  reaction  is  usually  acid,  and 
the  specific  gravity  slightly  lowered.  The  microscopic  features  that 
distinguish  hemoglobinuria  from  hematuria  are  variable.  In  the  former 
condition  few  or  no  red  corpuscles  are  present,  and  the  few  that  may  be 
seen  are  usually  colorless  ("  shadows  ")  or  fragmentary.  Small  flakes  or 
granules  of  disintegrated  hemoglobin  are  found,  and  are  brownish-black 
in  color.  There  may  be  also  brown-tinged  casts  and  epithelium. 
Chemically,  the  urine  is  found  to  contain  albumin,  for  the  discovery 
of  which  Heller's  and  the  guaiac  tests  for  blood-pigment  may  be 
tried.  The  former  has  been  described  in  the  preceding  discussion 
of  Hematuria.  The  guaiac  test  consists  in  overlaying  with  urine  a 
mixture  of  the  tincture  of  guaiac  and  hydrogen  peroxid  or  the  oil  of 
turpentine  (equal  parts).  When  the  blood-coloring  matter  is  present, 
an  indigo-blue  ring  is  formed  above  a  white  resinous  deposit.  When 
shaken  a  lighter  blue  color  develops  throughout  the  contents.  By 
means  of  the  spectroscope  the  three  absorption-bands  of  methemoglobin 
may  be  seen  (red,  green,  and  yellow).  The  blood-serum  in  hemo- 
globinuria may  be  somewhat  red-tinged  on  account  of  the  dissolved 
hemoglobin.  The  hemoglobinuria  is  further  marked  by  the  aplasticity 
of  the  red  corpuscles,  by  their  pallor,  by  poikilocytosis,  and  by  the 
presence  of  the  irregular  flakes  of  hemoglobin. 

The  prognosis  of  hemoglobinuria  depends  upon  the  cause.  It  is 
favorable  in  the  ordinary  paroxysmal  form.  Malignant  malarial  hemo- 
globinuria, however,  is  often  fatal. 

Treatment. — Hemoglobinuria  is  rather  intractable.  During  the 
paroxysms  external  warmth  is  needed,  along  with  hot  drinks  to  encour- 
age perspiration.     In  malarial  cases  quinin,  and  in  syphilitic  the  iodids, 


942  DISEASES  OF  THE   URINARY  SYSTEM. 

should  be  administered  ;  although   by  some  it  is  believed  that  quinin 
may  aggravate  the  syndrome  in  particular  cases. 

ALBUMINURIA. 

Definition. — The  presence  of  albumin  in  the  urine. 

Pathology  and  Ktiology. — The  immediate  cause  is  the  escape  of 
the  normal  blood-constituents,  serum-albumin  and  serum-globulin,  from 
the  vessels  into  the  renal  tubules.  This  transudation  of  albumin  indi- 
cates either  a  transient  and  slight  or  a  permanent  and  grave  nutritional 
disturbance  of  either  the  epithelium  lining  the  glomeruli  or  of  that  of 
the  contained  tufts  of  capillaries,  or,  possibly,  of  the  meinhrana  propria 
or  the  epithelium  of  the  uriniferous  tubules.  These  changes  induce  and 
offer  an  abnormal  perviousness  to  the  albumin  of  the  blood. 

The  principal  causes  of  albuminuria  are — (1)  Those  associated  Avith 
definite  lesions  of  the  kidney  ;  nephritis,  acute  and  chronic  ;  renal  con- 
gestions, active  and  passive  (the  latter  being  secondary  to  chronic  liver-, 
heart-,  and  lung-disease,  pregnancy,  or  tumors) ;  and  certain  toxemias 
Among  the  last-named  are  included  scarlet  fever  (scarlatinal  nephritis) 
and  gout.  Other  causes  are — amyloid  and  fatty  degeneration  of  the 
kidney,  suppurative  nephritis,  and  renal  tumors  (cystic  kidney). 

Albuminuria  occurs  also  in  conditions  in  which  (2)  the  renal  lesions 
are  either  slight  or  undemonstrable :  (a)  Thus,  it  is  present  in  blood- 
changes,  as  in  chronic  lead-,  mercury-,  and  arsenic-poisoning,  scurvy, 
purpura,  syphilis,  leukemia,  or  extreme  anemia,  and  in  cases  in  which 
urobilin  or  bile-pigment  and  sugar  (glucose)  circulate  in  the  blood. 
Again,  slight  albuminuria  may  be  present  in  pregnancy  {kidney  of 
pregnancy).,  in  saccharin  diabetes,  and  after  etherization.  In  certain 
affections  of  the  nervous  system  albumin  is  found  in  small  quantity,  as 
after  an  epileptic  paroxysm,  in  tetanus,  injuries  to  the  head,  apoplexy, 
and  exophthalmic  goiter. 

(h)  The  so-called  accidental  or  spurious  albuminuria  is  due  to  the 
presence  of  pus  or  blood ;  in  such  cases  the  condition  is  not  a  true 
renal  albuminuria,  since  it  is  commonly  associated  with  cystitis,  pyelitis, 
urethritis,  or  is  the  result  of  hemorrhage  from  the  pelvis  of  the  kidney, 
from  the  ureters,  bladder,  or  urethra. 

(<?)  Febrile  albuminuria  is  of  rather  frequent  occurrence  in  diseases 
accompanied  by  pyrexia,  especially  Avhen  long  continued.  Among  these 
are  typhoid  fever,  small-pox,  yellow  fever,  diphtheria,  and  even  influenza, 
follicular  tonsillitis,  and  pneumonitis.  The  renal  changes  in  these  cases 
are,  I  believe,  merely  a  transitory  cloudy  swelling  in  the  glomeruli, 
which,  together  w'ith  the  albuminuria,  rarely  lasts  longer  than  the  fever. 

{d)  Other  forms  of  albuminuria  have  been  styled  physiologic  ore  func- 
tional., transient,  dietetic,  intermittent,  and  cyclic:  in  these  no  definite 
lesions  of  the  kidney  are  found,  and  are  denied  by  some  to  exist.  Re- 
cent observers  are  inclined  to  believe  that  trivial,  non-progressive  renal 
changes  occur  in  these  cases.  Slight  albuminuria  certainly  does  occur 
in  some  cases  after  a  heavy  meal  rich  in  albumin,  after  marked  and  pro- 
longed muscular  exertion,  intense  emotion,  and  cold  bathing. 

'{e)  Cyclic  albuminuria  has  come  to  be  of  greater  interest  and  import- 
ance in  later  years,  particularly  as  it  bears  upon  the  prognosis  and  upon 
life-insurance  risks.     In  this  variety  there  is  a  periodic  appearance  and 


ALBUMINURIA.  943 

absence  of  albumin  in  the  urine.  The  albuminuric  paroxysms  are  very 
variable,  recurring  usually  after  meals  or  on  exertion,  but  generally 
being  absent  during  rest  at  night  or  early  in  the  morning.  The  albu- 
min is  present  in  but  small  quantity,  and  only  rarely  are  casts  (hyaline) 
found.  The  urinary  features  are  otherwise  normal,  and  the  accompany- 
ing signs  and  symptoms  common  to  nephritis  are  absent.  Cyclic  albu- 
minuria is  most  common  in  adolescent  anemic  males,  of  poor  nutrition 
(gastrointestinal  autointoxication  ?),  dyspeptic,  neuralgic,  often  neurotic, 
and  even  hysteric.  Under  careful  management  these  cases  ordinarily 
recover.  There  is,  however,  a  class  of  cases  in  which  the  albuminuria 
is  persistent,  though  but  a  mere  trace  of  albumin  may  be  detected,  and 
neither  can  tube-casts  be  found  nor  are  symptoms  complained  of.  How- 
ever, an  insidious  degeneration  of  kidney-structure  may  manifest  itself 
many  years  later,  an  urgent  condition  sometimes  developing.  Accord- 
ing to  Ranault,  albuminuria  may  rarely  be  even  hereditary/.  Slight 
senile  albuminuria  in  the  very  old,  without  any  particular  evidence  of 
renal  disease,  is  not  uncommon. 

Diagnosis. — This  rests  upon  the  discovery  of  albumin  by  means  of 
any  one  or  more  of  the  reliable  tests  shortly  to  be  described.  Since 
albuminuria  is  no  more  synonymous  with  nephritis  than  is  glycosuria 
or  polyuria  with  diabetes  mellitus,  it  becomes  important  and  necessary, 
both  for  prognostic  and  therapeutic  reasons,  to  dififerentiate  between  the 
so-called  functional  albuminuria,  the  cyclic  variety,  and  those  associated 
with  coarse  and  definite  anatomic  lesions  of  the  kidney. 

Differential  Diagnosis. — Inquiry  and  careful  inference  concerning  the 
etiology  of  a  given  case  must  be  made.  Renal  albuminuria  is  persistent 
and  of  considerable  quantity,  except  in  chronic  interstitial  nephritis. 
Tube-casts  are  usually  present.  Functional  albuminuria  is  slight  and 
inconstant.  Tube-casts  are  either  absent  or  exceedingly  few  in  num- 
ber in  the  latter.  Again,  in  the  former  variety  general  symptoms,  as 
dropsy,  cardiac  hypertrophy,  anemia,  and  uremic  prodromes,  are  pres- 
ent. It  is  true  that  slight  edema  is  sometimes  found  in  cyclic  albumi- 
nuria, but  this  is  probably  due  to  the  marked  anemia  that  is  so  often 
seen.  When  the  quantity  of  albumin  is  disproportionately  large  in 
spurious  albuminuria,  a  suspicion  of  coexisting  renal  albuminuria  should 
be  aroused  (Striimpell). 

Tests  for  Albwniyi. — Two  samples  of  urine,  one  of  the  morning  before 
any  food  is  taken,  and  one  of  the  evening  before  the  patient  retires, 
should  be  examined.  Care  should  be  taken  that  there  be  no  contamina- 
tion of  the  urine  with  the  menstrual,  leukorrheal,  or  urethral  discharges. 
The  smallest  quantity  can  be  detected  only  by  its  coagulum  rendering 
the  urine  turbid ;  hence  any  turbidity  present  before  the  given  test  is 
made  should  be  removed  by  filtration,  unless  this  turbidity  be  due  to 
urates,  when  a  little  warming  of  the  tube  will  render  the  urine  clear. 

(1)  Boili7ig  Test. — This  is  the  commonest  and  I  think  the  most  reli- 
able practical  test  for  albumin.  The  tube  is  filled  about  two-thirds  full 
of  urine.  If  alkaline  or  neutral  in  reaction,  a  drop  of  acetic  or  nitric 
acid  is  added ;  an  excess  of  acid  must  be  carefully  avoided,  lest  the 
albumin  (if  present)  be  converted  into  a  non-coagulable  form.  The  tube, 
held  aslant,  is  then  applied  to  the  flame,  and  slowly  revolved  with  the 
fingers,  so  that  the  upper  portion  of  the  column  of  urine  is  brought  to 
the  boiling-point.     A  comparison  of  this  with  the  lower  portion  of  the 


944  DISEASES  OF  THE   URINARY  SYSTEM. 

urine  is  made.  Any  turbidity  is  due  to  albumin  or  phosphates.  If 
albumin,  adding  a  few  drops  of  nitric  acid  will  increase  and  thicken  the 
coagulum ;  if  phosphate,  the  opaqueness  will  be  cleared  at  once. 

(2)  Heller's  Nitric-acid  Test. — This  is  easily  performed,  and  is  both 
delicite  and  satisfactory.  About  1  c.cm.  of  nitric  acid  is  poured  into  a 
tube,  and  some  urine  is  allowed  to  flow  slowly  from  a  pipet  and  settle 
upon  the  acid.  The  presence  of  albumin  is  indicated  by  a  white  ring  at 
the  point  of  contact  of  the  two  liquids.  Uric  acid,  urates,  and  certain 
urinary  coloring-matters  form  a  pink  or  deep-red  ring  or  zone ;  this 
forms,  as  a  rule,  above  the  juncture  of  the  acid  and  urine.  Hemialbu- 
mose  also  gives  a  white  zone,  but  does  not  respond  to  the  boiling  test  as 
does  serum-albumin. 

(3)  JoIiKSim  s  Picric-aeid  Test. — To  filtered  urine  in  a  test-tube  are 
slowly  added  a  few  drops  of  a  saturated  watery  solution  of  picric  acid. 
Immediate  turbidity  indicates  albumin.  Some  authorities  prefer  that  a 
dram  or  two  (4.0-8.0)  of  the  yellow  fluid  be  placed  gently  on  the  surface 
of  the  urine,  when,  if  albumin  is  present,  a  white  zone  at  once  is  appa- 
rent, together  with  a  haziness  that  spreads  downward  with  the  diffusion 
of  the  liquids.  Heating  emphasizes  the  evidence  of  the  test,  which  is 
extremely  sensitive. 

(4)  Roberts'  nitric -magnesium  test  is  also  very  delicate.  It  consists 
in  using  the  following  mixture,  just  as  in  Heller's  test:  one  volume  of 
concentrated  nitric  acid,  added  to  five  volumes  of  a  saturated  solution 
of  magnesium  sulphate. 

(5)  Trichloracetic-acid  Test. — This  will  discover  minute  traces  of 
albumin,  but  has  the  disadvantage  that  it  responds  to  nucleo-albumin 
as  well  as  to  serum-albumin.  A  few  crystals  may  be  dropped  into  the 
urine,  or  a  saturated  solution  may  be  used  after  the  "■  contact  method," 
when,  if  albumin  be  present,  a  white  coagulum  forms.  This  and  the 
Geisler  test-papers  (A  ierordt)  constitute  portable  and  handy  tests. 

(6)  The  acetic-acid  and  potassinin-ferrocyanid  test  is  also  valuable 
and  minutely  sensitive.  The  urine  is  first  made  decidedly  acid  Avith 
acetic  acid.  A  few  drops  of  a  freshly  prepared  solution  of  potassium 
ferrocyanid  are  then  added,  and  if  either  albumin  or  hemialbumose  be 
present,  it  will  be  precipitated. 

(7)  Quantitative  Test — Eshaclis  Albuminometer. — This  consists  in 
using  a  graduated  test-tube,  into  which  definite  amounts  of  urine  and  a 
reagent  composed  of  10  parts  of  picric  acid,  20  of  citric  acid,  and  enough 
water  to  make  1000  parts  are  carefully  mixed  by  reversing  several  times 
the  stoppered  tube.  After  allowing  this  to  stand  about  twenty-four 
hours,  the  height  of  the  precipitated  albumin  is  read  off  on  an  etched 
scale,  which  will  indicate  approximately  the  parts  per  thousand.  Not 
less  than  0.5  parts  per  thousand  can  be  estimated  correctly,  however. 
Should  there  be  a  hematuria,  if  the  percentage  of  albumin  by  Esbach's 
method,  divided  into  the  number  of  red  cells  per  cubic  centimeter  of 
urine,  is  less  than  30,000,  it  suggests  a  purely  hematuric  albuminuria; 
if  greater,  it  suggests  an  independent  albuminuria  (Goldberg). 

Prognosis.— Etiologic  considerations  bear  heavily  in  this  matter. 
Functional  abuminuria  is  of  favorable  import,  as  a  rule.  The  febrile, 
hemic,  cyclic,  and  paroxysmal  varieties'  usually  clear  u])  with  convales- 
cence and  with  advancing  years  (in  the  latter  case).  The  persistence 
of  albumin  in   these  cases,  however,  even  in  slight  amounts  or  at  vari- 


INDICANURIA.  945 

able  periods,  should  cause  suspicion,  since  there  must  be  some  glome- 
rular renal  change  to  account  for  the  disorder,  the  tendency  of  which  is 
to  progress  steadily  and  insidiously.  Especially  is  this  true  when  there 
is  associated  a  gradually  increasing  arterial  tension.  The  presence  of 
tube-casts  is  conclusive  of  structural  change  in  the  kidneys,  marked  by 
degenerations  and  by  exudative  and  productive  inflammation,  either 
acute  or  chronic. 

*  ALBUMOSURIA. 

True  peptone  (Kiihne)  has  never  been  demonstrated  in  the  urine.  The 
so-called  peptones  discovered  by  Devoto's  and  other  methods  are  really 
albumoses.  These  albumoses  (proto-,  deutero,  hemi-)  are  found  in  acute 
suppurations  or  when  resolution  of  inflammatory  eff"usions  is  going  on, 
as  in  lobar  pneumonia.  They  may  be  found  also  in  acute  rheumatism, 
scorbutus,  myxedema  (Fitz),  primary  multiple  sarcoma  of  bone,^  and 
in  certain  forms  of  metallic  and  ptomain  or  bacterial  poisoning. 
Albumosuria  may  be  suspected  when,  after  negative  results  with  the 
boiling  and  nitric-acid  tests,  cold  acetic  acid  produces  a  cloudiness. 
This  suspicion  may  be  confirmed  by  the  biuret  test,  as  follows :  Any 
albumin  that  is  present  must  first  be  coagulated  and  removed.  Then, 
after  placing  some  Fehling's  solution  in  a  test-tube,  an  equal  quantity  of 
urine  is  alloAved  to  come  in  contact  with  it,  when,  if  albumoses  be  in  the 
latter,  a  rose-pink  zone  or  halo  appears  at  or  near  the  point  of  contact. 

Hemialhumose  is  formed  in  the  urine  in  osteomalacia,  in  chronic 
suppurations,  and  in  sarcomatous  disease  of  the  spinal  cord,  though  the 
clinical  or  diagnostic  significance  of  the  substance  has  not  been  fully 
determined  as  yet. 

INDICANURIA. 

Definition. — The  presence  of  a  pathologic  quantity  of  indican  in 
the  urine. 

Indican  occurs  in  the  urine  in  health  in  very  small  quantities  as  a 
colorless  compound,  and  is,  chemically  speaking,  indoxyl-potassium 
sulphate. 

Pathology  and  Btiology. — Indican  is  increased  abnormally  in 
the  urine  by  any  disorder  whereby  large  quantities  of  albuminous  mat- 
ters are  decomposed.  Thus,  it  occurs  in  intestinal  obstruction,  especi- 
ally when  the  caliber  of  the  small  bowel  is  diminished  from  any  cause 
so  as  to  produce  a  stagnation  of  the  contents  and  a  consequent  decom- 
position from  bacterial  action,  especially  the  action  of  large  numbers 
of  the  common  colon-bacillus.  Under  such  circumstances  indol  and 
phenol  are  formed.  The  former,  being  absorbed  and  oxidized  into  in- 
doxyl,  finally  appears  in  the  urine  in  combination  with  potassium  sul- 
phate. Acute  peritonitis,  obstinate  and  chronic  constipation,  wasting 
diseases,  and  cachectic  conditions  in  which  there  is  a  considerable  de- 
struction of  albuminoids  (as  in  Addison's  disease,  neoplasmata.  cholera 
Asiatica,  and  empyema)  usually  have  an  associated  indicanuria.  An 
increase  of  the  aromatic  sulphates  in  general,  or  an  increase  in  pro- 
portion to  the  fixed  sulphates,  is  especially  significant  of  intestinal  pu- 
trefactive processes.  Since  the  pancreatic  secretion  peptonizes  the  pro- 
1  De  Holstein  :  Sem.  Med.,  March  5,  1899. 
60 


946  DISEASES  OF  THE   URINARY  SYSTEM. 

teids  from  which  arise  leucin  and  tyrosin.  and  these  in  turn  are  decom- 
posed into  skatol,  indol,  and  phenol,  it  is  stated  (Piseuti)  that  any  ob- 
struction preventing  the  flow  of  the  pancreatic  juice  into  the  bowel 
would  be  reflected  in  a  diminished  quantity  of  indican  in  the  urine.  On 
the  other  hand,  any  epigastric  tumor  suspected  of  pressing  upon  the 
small  intestines  would  be  accompanied  with  indicanuria. 

Diagnosis. — This  depends  upon  the  demonstration  of  indican  by 
adding  strong  oxidizing  agents,  which  decompose  this  product  and  set  the 
indigo  or  pigment  free.  At  times  suflicient  oxidation  of  the  indican  has 
taken  place  in  the  urine  before  any  chemical  test  is  applied,  so  that  a 
bluish  tinge  is  given  thereto.  This  may  be  seen  in  urine  that  has 
been  standinor  for  some  time,  the  sediment  ^ivincr  a  bluish  reflection,  or 
there  may  be  a  blue-turbid  film  on  the  surface.  In  the  urine  of  indican- 
uria, moreover,  where  putrefaction  is  marked,  a  pronounced  blue-black 
color  may  be  present. 

Tests. — Jaffe's  well-known  test  consists  in  mixing  equal  volumes  of 
urine  and  hydrochloric  acid,  and  then  adding,  drop  by  drop,  a  concen- 
trated solution  of  chlorinated  lime,  shaking  the  tube  after  each  ad- 
dition.    A  strong  indigo-blue  color  appears  if  there  is  much  indican. 

A  good  modified  test  is  the  use  of  fuming  nitro-hydrochloric  acid 
and  urine  (equal  parts)  and  a  saturated  solution  of  chlorinated  potash, 
used  as  in  the  above  method.  A  blue-black  cloud  or  ring  appears  below 
the  surface.  If  a  few  drops  of  chloroform  are  then  added  and  the  mix- 
ture is  agitated  slightly,  a  blue  color  settles  at  the  bottom,  owing  to  the 
chloroform  carrying  with  it  the  oxidized  indican. 

PYURIA. 

Definition. — The  presence  of  pus  in  the  urine. 

Ktiology. — Pyuria  is  due  to  (1)  suppurative  inflammation  along  some 
portion  of  the  genito-urinary  tract,  or  (2)  to  the  rupture  of  adjacent  ab- 
scesses into  the  tract. 

Pyelitis  and  Pyelo-nephritis. — Pus  from  the  pelvis  of  the  kidney  may 
be  due  to  calculous,  tuberculous,  or  other  irritation.  It  is  associated  at 
times  with  the  "  railed  "  or  transitional  epithelium  usually  seen  early  in 
the  case.  In  pyelo-nephritis  casts  may  indicate  renal  involvement, 
although  it  should  be  borne  in  mind  that  in  abscess  of  the  kidney  pus 
may  be  discharged  continuously  without  the  appearance  of  any  casts  in 
the  urine  whatsoever.  One  such  case  came  to  necropsy  under  the  ob- 
servation of  H.  S.  Anders,  in  which  small  uratic  calculi  were  dis- 
charged now  and  then  for  several  vears.  Later,  several  larger  stones 
were  removed  from  the  bladder  by  Willard  by  suprapubic  cystotomy,  in 
the  hope  that  by  drainage  and  irrigation  of  the  bladder  the  marked 
pyuria  might  subside  or  cease.  The  abdominal  opening  healed  in  a  few- 
months,  and.  whilst  bladder-symptoms  were  absent  after  removal  of  the 
calculi,  pyuria  persisted.  Death  having  occurred  suddenly  from  coro- 
nary-artery disease  and  interstitial  myocarditis,  it  was  found  postmortem 
that  a  large  abscess  occupied  the  lower  third  of  the  left  kidney,  which 
was  filled  with  small,  dark,  and  irregularly-shaped  calculi.  A  thick 
pyogenic  membrane  surrounded  the  purulent  and  calculous  contents. 
!No  casts   were  found  at  any  time  during  life,  though  repeated  exami- 


CHYL  TJRIA.  947 

nations  were  made,  and,  remarkable  as  it  seems,  renal  symptoms  were 
altogether  absent. 

The  pyuria  is  sometimes  intermittent,  one  ureter  becoming  tempor- 
arily occluded  (on  the  side  of  the  disease),  the  clear,  normal  urine  from 
the  healthy  kidney  passing  until  the  ureteral  obstruction  is  relieved,  when 
pus  again  appears.  Purulent  urine  from  the  kidney  is  usually  acid  in 
reaction,  except  when  the  pyelo-nephritis  is  secondary  to  cystitis,  when 
it  is  more  apt  to  be  alkaline  and  to  contain  a  decided  quantity  of  mucus. 
Cystitis. — Pyuria  in  this  affection  is  fetid  in  most  cases.  Bladder- 
symptoms  are  marked.  The  urine  is  alkaline,  and  a  stringy,  tenacious 
muco-pus  comes  with  the  last  portions.  Triple  phosphates  are  often  found. 
The  pus  and  urine  are  not  so  intimately  mixed  as  in  pyelonephritis. 

Urethritis. — The  pus  is  in  small  quantities,  is  passed  in  advance  of 
the  urine,  and  can  be  "milked  out"  from  the  male  urethra.  There  is 
usually  a  history  of  gonorrheal  infection,  and  the  gonococcus  may  be 
demonstrated  in  most  cases. 

Rupture  of  contiguous  abscesses  into  the  urinary  tract  is  accompanied 
usually  with  a  sudden  discharge  of  a  large  quantity  of  pus  in  the  urine, 
preceded  by  symptoms  of  abscess  elsewhere,  as  in  the  pelvis  or  right 
iliac  fossa  (suppurative  appendicitis)  or  perinephric  abscess.  The 
pyuria  disappears  as  abruptly  as  it  came  on,  or  lasts  but  a  few  days, 
lessening  gradually  until  there  is  a  complete  cessation.  The  strongylus 
gigas  in  the  pelvis  of  the  kidney  causes  pyuria  as  well  as  hematuria. 

Diagnosis. — Pus  gives  a  greenish-yellow  or  yelloAvish-white  tinge 
to  the  urine  and  sediment,  the  latter  very  often  becoming  very  tenacious 
or  jelly-like  from  the  presence  of  mucus.  It  may  resemble  a  phosphatic 
precipitate,  as  in  cystitis ;  the  latter,  however,  is  white,  lighter,  more  gran- 
ular, and  not  so  thick  or  tenacious.  Microscopically,  a  positive  diagnosis 
is  made  by  the  discovery  of  pus-corpuscles  (or  leukocytes)  with  their 
granular  protoplasm,  Avhich  has  the  faculty  of  clearing  up  and  showing 
one  or  more  nuclei  upon  the  addition  of  acetic  acid.  The  corpuscles  are 
either  more  or  less  swollen  and  clear,  or  opaque,  granular,  or  even 
nucleated,  according  to  their  number,  the  length  of  time  in  the  urine, 
and  the  degree  of  alkalinity  or  acidity  of  the  latter.  The  greater  the 
change  in  the  urine,  the  more  marked  the  change  in  the  corpuscles.  A 
few  phosphatic  crystals  may  be  seen,  and  epithelium  more  or  less  cha- 
racteristic of  the  seat  of  suppuration  is  present. 

Chemically,  there  is  slight  albuminuria,  a  marked  amount  of  albumin 
usually  indicating  renal  disease.  Nephritis  may  be  diagnosed  in  con- 
nection with  pyuria  by  the  discovery  of  casts.  On  the  addition  of 
liquor  potass?e  to  urine  containing  pus  the  latter  is  converted  into  a 
clear  gelatinoid  substance ;  mucus,  on  the  other  hand,  becomes  thin  and 
flocculent.  Mucus  may  also  be  distinguished  from  pus  by  its  failure  to 
react  to  cold  nitric  acid,  whilst  the  albumin  of  purulent  fluid  coagulates. 

CHYLURIA. 

Definition. — The  presence  of  chyle  in  the  urine. 

Ktiology. — This  interesting  condition  may  be  either  jjarasitic  or 
non-parasitic  in  origin.  The  former  type  is  more  common  in  the  tropics, 
and  is  caused  by  an  engorgement  and  rupture  of  the  bladder  or  renal 
lymph-vessels,  due  to  obstruction  of  the  larger  branches  of  the  thoracic 


948  DISEASES  OF  THE   URINARY  SYSTEM. 

duct  or  in  the  duct  itself,  by  the  filaria  sanguinis  hominis  {vide  Filaria- 
sis).  The  latter  form,  the  pathology  of  which  is  not  definitely  known,  is 
occasionally  found  in  temperate  regions.  It  is  held  to  follow  injuries  to 
the  lymphatic  ducts,  and  may  be  associated  with  pregnancy. 

Diagnosis. — The  urine  is  increased  in  quantity,  and  has  a  milky 
turbidity  [galacturia)  due  to  the  emulsified  fat.  After  standing  for  a  time 
a  light  coagulum  settles  to  the  bottom  and  a  creamy  pellicle  of  fat  rises 
to  the  surface.  The  sediment  contains  also  the  fibrin  of  the  chyle.  Some- 
times as  much  as  2  or  3  per  cent,  of  fat  is  present  {Jipuria) ;  this  may 
be  tested  by  agitating  a  portion  of  the  urine  with  ether,  whereupon 
the  turbidity  disappears.  Owing  to  the  serum-albumin  in  the  chyle,  the 
various  tests  for  that  substance  would  show  traces  of  its  presence  in 
chyluria.  Hematuria  may  be  associated  with  chyluria,  especially  in 
parasitic  cases,  in  which  case  the  blood  comes  from  ruptured  veins  and 
tinges  the  urine  accordingly.  Microscopically,  chyle-containing  urine 
resembles  milk  in  its  millions  of  fine  granules  and  fat-droplets. 

Prognosis. — Chyluria  is  intermittent  in  its  appearance,  correspond- 
ing to  the  times  of  rupture  of  the  vesical  lymphatics,  and  may  last  for 
years.  The  prognosis  of  non-parasitic  chyluria  is  good  as  to  life,  but 
unfavorable  as  to  cure. 

CHOLURIA. 

Definition. — The  presence  of  bile-pigment  in  the  urine. 

Ktiology. — Choluria  may  be  caused  by  any  disease,  local  or  genera,!, 
in  which  jaundice  is  a  symptom. 

Diagnosis. — Bile-stained  urine  has  a  color  varying  from  a  green- 
ish-yellow to  a  brownish-green  or  brown-black,  resembling  porter.  When 
shaken  its  foam  assumes  a  characteristic  yellow  or  greenish-yellow  color. 
White  filter-paper  dipped  in  the  urine  is  stained  yelloAv. 

Tests. — The  chloroform  test  consists  in  adding  this  substance  to  the 
urine  and  allowing  it  to  settle  to  the  bottom  of  the  tube.  If  bile  or 
pigment  be  present,  the  gravitated  chloroform  will  be  colored  yellow. 

Gmelins  test  is  most  commonly  employed,  though  it  is  not  the  most 
delicate.  A  few  drops  of  urine  and  nitric  acid  are  allowed  to  run 
together  on  a  white  porcelain  plate;  if  bile-pigment  (bilirubin)  be  con- 
tained in  the  urine,  a  play  of  colors  ensues,  the  green  predominating,  fol- 
lowed by  the  blue,  violet,  and  red,  each  shade  representing  a  new  form 
of  pigment.  The  first  color  noticed  (green)  corresponds  to  the  biliver- 
din  or  normal  bile-pigment  of  herbaceous  animals.  This  oxidation  of 
bilirubin  into  biliverdin  is  better  accomplished  by  nitric  acid  containing 
a  little  nitrous  acid.  Hence,  the  test  may  be  improved  by  adding  enough 
fuming  nitric  to  ordinary  nitric  acid  to  form  a  yellow  trace  of  the  nitrous 
acid.  This  may  be  placed  in  a  test-tube  or  wine-glass,  and  some  of  the 
urine  added  gently  from  a  pipet.  Bile-pigment  will  be  indicated  by 
successive  rino;s  of  grreen,  blue,  violet,  and  red  from  above  downward ; 
this  occurs,  however,  only  when  the  bile-pigment  is  present  in  consider- 
able quantities. 

Rosenhacli  s  test  is  a  modification  of  Gmelin's,  and  is  more  distinct. 
The  urine  is  first  filtered,  and  a  drop  or  two  of  the  nitric-nitrous  acid  is 
then  poured  upon  the  filter-paper,  Avhen  the  characteristic  colored  rings 
will  appear  if  bile  be  present.  According  to  Penzoldt,  the  Gmelin- 
Rosenbach  test  is  made  more  distinct  by  acidulating  the  filtrate  with 


UROBILINURIA— GLYCOSURIA.  949 

acetic  acid  and  pouring  a  thin  layer  into  a  white  shallow  dish.  The 
acetic  acid  assumes  a  greenish-yellow,  and  later  a  green,  or  even  a  blue- 
green,  shade  if  bile  be  in  the  urine.  This  reaction  is  quickened  or  in- 
tensified by  the  application  of  heat  to  the  liquids. 

In  the  Mar eehal- Rosin  test  a  mixture  of  one  part  of  the  tincture  of 
iodin  and  ten  parts  of  alcohol  is  spread  in  a  deep  layer  over  the  suspected 
urine  in  a  test-tube  or  glass.  A  grass-green  ring  forms  at  the  point  of 
contact  in  choluria. 

Bile-acids. — These  are  principally  the  glycocholic  and  taurocholic 
acids.  Traces  are  found  in  normal  urine,  and  their  clinical  significance 
or  diagnostic  importance,  as  far  as  is  known,  is  practically  nil. 

When  testing  for  bile-acids  the  Stranburger  modification  of  Petten- 
kofer's  method  may  be  used,  as  follows :  "  After  isolation  cane-sugar  is 
added  to  the  extract,  which  is  then  filtered.  A  drop  or  two  of  strong 
sulphuric  acid  is  spread  on  the  dried  filter ;  a  violet  or  purple  color 
appears  "  (Musser). 

Other  constituents  of  the  urine  in  choluria  of  long  standing  are 
slight  quantities  of  albumin  and  icteric  or  yellow  bile-stained  hyaline 
or  finely-granular  casts. 

A  point  in  differential  diagnosis  should  be  noted  in  connection  with 
the  fact  that  certain  drugs,  as  rhubarb  and  santonin,  when  given  intern- 
ally, may  produce  a  discoloration  of  the  urine  similar  to  that  caused  by 
the  presence  of  bile.  On  agitation,  however,  there  will  be  no  yellow 
foam  and  no  reaction  to  the  tests  for  bile,  while  the  addition  of  liquor 
potassse  causes  a  red  color. 

UROBILINURIA. 

Definition. — The  presence  of  pathologic  quantities  of  urobilin  in 
the  urine.  Urobilin  is  the  principal  coloring-matter  of  the  urine,  and 
hence  is  present  in  normal  urine  in  small  quantity.  It  is  derived  from 
hematoidin  or  bilirubin  as  a  product  of  the  reduction  of  these  substances 
in  the  tissues  and  blood-vessels. 

When  present  in  large  quantities  urobilin  gives  to  the  urine  a  red- 
brown  color.  This  is  seen  in  fevers,  varying  in  depth  of  shade  accord- 
ing to  the  degree  of  pyrexia ;  also  in  diseases  of  the  liver,  after  hemor- 
rhagic efi"usions  (due  to  resorption),  in  the  hemorrhagic  diathesis,  in 
purpura,   and  in  progressive  pernicious  anemia. 

When  deposited  in  the  tissues  it  gives  rise  to  a  form  of  jaundice — 
in  which  there  is  a  brownish  discoloration  of  the  skin — called  urobilin- 
icterus. 

Diagnosis. — The  presence  of  urobilin  is  best  detected  by  a  spectro- 
scopic examination.  A  marked  absorption-band  between  Frauenhofer's 
lines  (f  and  b),  fading  off  from  the  green  into  the  blue,  is  characteristic. 
Chemically,  the  addition  of  a  few  drops  of  a  watery  solution  of  zinc 
chlorid  to  the  urine  will  cause  the  peculiar  red-green  fluorescence  of 
urobilin  to  appear. 

GLYCOSURIA. 

Definition. — The  presence  of  sugar  (glucose)  in  the  urine.  Nor- 
mally, a  trace  of  sugar  is  present  in  the  blood  (glykemia),  but  it  may 
be  doubted  whether  any  is  excreted  in  the  urine  in  health,  except  after 


950  DISEASES  OF  THE   URINARY  SYSTEM. 

the  ingestion  of  an  excess  of  food  rich  in  saccharine  or  starchy  sub- 
stances.    Uric  acid  may  give  the  same  reactions  as  glucose  in  the  urine. 

Htiology. — The  causes  of  glycosuria  may  be  enumerated  as  follows : 
(1)  Diabetes  mellitus — the  most  common.  (2)  Certain  diseases,  like 
gout  {intermittent  glycosiwia),  cholera,  typhoid,  typhus,  and  scarlet 
fevers,  whooping-cough,  diphtheria,  malaria  {paroxysmal  glycosuria), 
tetanus,  phthisis,  hepatic  cirrhosis,  and  organic  nervous  diseases,  espe- 
cially those  affecting  the  medulla  and  involving  the  floor  of  the  fourth 
ventricle.  Glycosuria  may  also  result  from  psychic  causes,  as  excessive 
mental  exertion,  extreme  emotional  activity  (grief,  Avorry,  and  shock), 
from  injuries,  as  cerebral  concussion  and  hemorrhage,  and  fracture  of  the 
skull,  from  apoplexy,  cerebro-spinal  meningitis,  and  after  epileptic  parox- 
ysms. (3)  Pregnancy.  (4)  Certain  toxic  agents  cause  a  transient  gly- 
cosuria, among  these  being  carbon  monoxid,  morphin,  atropiu,^ 
hydrocyanic  acid,  amyl  nitrite,  curare,  chloral,  alcohol,  mercury,  arsenic, 
turpentine,  copaiba  (Bettman),  phloridzin,  and  various  coal-tar  deriva- 
tives, as  salicylic  acid  and  salol.  This  source  of  glycosuria  has  been 
experimentally  demonstrated  in  dogs  by  Paul  Gibier  of  the  New  York 
Pasteur  Institute.  (5)  Obesity  and  thyroidismus  may  cause  a  temporary 
glycosuria  (lipogenic),  (6)  Pancreatic  disease  (chronic  interstitial  pan- 
creatitis and,  less  commonly,  pancreatic  calculi,  carcinoma,  and  cysts). 
(7)  Glycosuria  may  occur  in  exophthalmic  goiter,  and,  according  to  Ly- 
man, may  be  present  for  a  short  time  in  (8)  diabetes  insipidus.  (9) 
Heredity  probably  plays  a  part  in  predisposing  to  glycosuria  in  certain 
cases,  particularly  in  the  permanent  aifection.  (10)  Dietetic  or  alimen- 
tary glycosuria  may  at  times  be  noted,  as  in  beer-drinkers. 

Diagnosis. — The  daily  quantity  of  the  urine  of  typical  glycosuria — 
i.  e.  when  masking  saccharine  diabetes — is  greatly  increased  (60  fluid- 
ounces — 2  liters — and  over  j^er  diem) ;  it  is  of  high  specific  gravity  (1025 
and  over),  of  a  clear,  pale-yellow  color,  a  "ripe-fruit"  odor,  a  sweetish 
taste,  and  an  acid  reaction  that  is  intensified  on  standing,  owing  to  the 
fermentation  of  the  sugar.  Albuminuria  is  not  infrequently  associated 
with  glycosuria,  and  the  albumin  should  be  removed  before  testing  de- 
cisively for  sugar.  Again,  since  urine  of  high  color,  heavy  density, 
and  marked  acidity  often  contains  uric  acid,  and  since  this  substance, 
as  already  pointed  out,  responds  to  the  sugar  tests,  care  must  be  exercised 
lest  a  false  conclusion  be  drawn. 

Tests. — The  most  important  of  these  depend  mainly  upon  the  pe- 
culiar property  of  glucose  in  reducing  the  blue  oxid  of  copper  to  the 
orange  or  i-ed  suboxid.  It  must  be  remembered  that  other  metallic  sub- 
stances are  similarly  decomposed. 

(1)  Fehling's  Test. — Two  solutions  are  used,  equal  parts  being  mixed 
to  form  the  Fehling's  solution,  as  follows  : 

Solution  I.  contains  34.64  gm.  of  cupric  sulphate,  dissolved  in 
enough  water  to  make  500  c.cm.  Solution  II. :  173  gm.  of  Eochelle 
salt  are  dissolved  in  480  c.cm.  of  sodium  hydroxid  (sp.  gr.  1.14);  this 
is  then  diluted  with  Avater  up  to  500  c.c. 

Application :  Dilute  1  c.c.  of  Fehling's  solution  (about  10  drops 
of  each  of  the  above  solutions)  Avith  about  1  dram  (4  c.c.)  of  Avater  in 
a  test-tube,  and  heat  to  the  boiling-point.  If  the  clear  blue  color  re- 
mains, the  solution  is  ready  for  use  ;  should  it  change  color,  hoAvever, 
1  F.  Raphael:  DmUche  Med.  Woch.,  July  13,  1899. 


GLYCOSURIA.  951 

the  solution  is  unfit  for  use  and  should  be  discarded.  The  suspected 
urine  is  added,  drop  by  drop,  heating  occasionally,  when,  if  glucose  be 
present,  the  blue  color  'will  be  discharged  by  a  yellow  turbidity,  which 
increases  until  finally  a  deep-yellow  or  orange  red  precipitate  falls. 
Bluish-white  flakes  and  a  greenish  discoloration  of  the  mixture  simply 
indicate  cupric  hydroxid,  and  not  glucose.  This  test  serves  for  the 
detection  of  .001  per  cent,   of  glucose  (Wormley). 

(2)  Trommers  Test. — To  about  5  c.c.  of  urine  in  the  tube  add 
one-third  or  one-half  its  volume  of  potassium  or  sodium  hydroxid, 
and  then,  drop  by  drop,  add  a  10  per  cent,  solution  of  cupric  sul- 
phate. If  a  bluish-white  precipitate  falls,  either  filter  or  agitate  the 
liquid  until  it  assumes  a  slight  and  uniform  turbidity  ;  then  heat,  and, 
if  sugar  be  present,  a  yellow  or  red  deposit  of  cuprous  oxid  falls:  .01 
per  cent,  of  glucose  may  be  detected  in  this  way. 

Besides  uric  acid,  there  are  certain  other  substances  which  when 
present  in  urine  make  the  copper  tests  fallacious  by  reducing  the 
cupric  to  cuprous  oxid.  Among  these  are  mucin,  lactose,  pyrocatechin, 
hydrochinon,  bile-pigments,  glycosuric  acid,  the  products  of  elimina- 
tion after  the  ingestion  of  chloral  (urochloric  acid),  and  benzoic  and 
salicylic  acids. 

(3)  Bottgers  Bismuth  Test. — This  may  be  performed  as  a  counter  to 
the  copper  tests.  Albumin,  however,  interferes  with  the  test  on  account 
of  the  contained  sulphur,  which  forms  a  black  bismuth  sulphid  :  hence, 
if  present,  it  must  first  be  removed.  This  may  be  done  by  acidulating 
the  urine  with  acetic  or  nitric  acid,  boiling,  and  then  filtering.  Bott- 
ger's  test  is  then  made  by  adding  to  the  non-albuminous  urine  or  to  the 
filtrate  from  one-half  to  an  equal  quantity  of  liquor  potassje  and  a  few 
grains  of  bismuth  subnitrate.  Boil  for  several  minutes,  and  if  glucose 
be  present  black  metallic  bismuth  will  be  precipitated. 

(4)  Nylander  s  reagent  may  be  employed.  This  consists  of  2  parts 
of  basic  bismuth  nitrate  and  4  parts  of  sodium  tartrate  to  100  parts  of 
an  8  per  cent,  solution  of  caustic  soda.  One  part  of  the  reagent  is 
boiled  with  10  parts  of  the  urine  for  a  few  minutes,  when  a  change  from 
the  original  to  a  brown  or  black  color  will  indicate  the  presence  of  glu- 
cose. This  test  is  quite  distinct,  but  has  the  fallacy  that  is  common  to 
all  the  bismuth  tests,  of  forming  a  black  precipitate  with  the  sulphur 
compounds. 

(5)  Fermentation  Test. — Though  not  always  convenient  to  apply,  this 
is,  nevertheless,  a  most  reliable  test.  It  depends  upon  the  action  of 
yeast  in  breaking  up  glucose  into  alcohol  and  carbonic-acid  gas  (carbon 
dioxid).  It  is  performed  easily  by  adding  a  small  piece  of  compressed 
yeast  to  the  urine  in  a  test-tube,  inverting  the  latter  in  a  dish  of  the 
same,  and  standing;  aside  for  twelve  to  twenty-four  hours,  the  temper- 
ature being  kept  at  about  80°  to  100°  F.  (26.6°-37.T°  C).  The  evo- 
lution of  gas  resulting  from  the  fermentation  of  the  sugar  takes  place, 
with  a  consequent  reduction  of  the  specific  gravity  of  the  urine.  The 
yeast  may  be  tested  simultaneously  for  its  purity  and  strength  by  pla- 
cing one  portion  in  a  test-tube  containing  about  two-thirds  mercury  and 
filling  with  normal  urine,  and  a  similar  portion  in  a  second  tube  with 
mercury  and  a  thin,  watery  solution  of  sugar  or  glucose ;  the  fermenta- 
tion test  of  the  suspected  urine  may  be  made  at  the  same  time,  and  all 
three   tubes    inverted  over   a  dish  of   mercury.      Obviously,   the    first 


952  DISEASES  OF  THE   URINARY  SYSTEM. 

tube  should  not  show  the  presence  of  carbon  dioxid  if  the  yeast  was 
free  from  sugar  ;  but  the  second  tube  should  show  this  gas  to  be  present 
or  the  yeast  was  inert. 

Other  tests,  such  as  Moore  s  liquor-potassce-and-hoiling  test.,  Johnson  s 
picric-acid  test,  and  the  phenyl-hydrazin  test,  are  more  intricate  and  in 
no  way  more  reliable. 

The  quantitative  estimation  of  sugar  may  be  made  with  Fehling's 
solution  in  two  parts,  as  recommended  above  for  the  qualitative  test. 
This  method  is  based  upon  the  ftict  that  the  cupric  oxid  of  1  c.c.  of 
Fehling's  solution  will  be  reduced  by  not  less  than  0.005  gm.  of  glucose. 
Place  1  c.c.  of  the  solution  in  a  test-tube  and  dilute  with  4  c.c.  of 
water  (5  c.c.  dil.  sol.).  Heat  to  the  boiling-point,  and  add  1  c.c.  of 
urine,  and  heat  the  liquid  again.  If  reduction  has  taken  place,  0.005 
gm. — 0.5  per  cent,  or  more — glucose  is  present ;  if  no  reduction  has 
occurred,  less  than  0.5  per  cent,  is  present.  If  2  c.c.  urine  are  used 
before  the  color  of  the  Fehling  solution  is  discharged,  there  will  be 
0.25  per  cent,  glucose.  If  I  c.c.  is  used,  1  per  cent,  is  present.  If 
^Ig.  c.c.  urine  is  all  that  is  required  (about  2  drops),  then  5.0  per  cent,  of 
glucose  is  present. 

Roberts'  differential-density  method  depends  upon  a  loss  in  the 
specific  gravity  of  the  urine,  due  to  the  fermentation  of  glucose.  Ac- 
cording to  Roberts,  each  degree  in  specific  gravity  lost  is  equivalent  to 
1  grain  of  glucose  in  1  imperial  fluidounce  (437.5  gr.)  of  urine,  or  one 
degree  represents  0.23  per  cent,  glucose.     (See  works  on  Urinalysis.) 

Qircumpolarization. — Finally,  sugar  may  be  determined  by  the  sac- 
charimeter  or  polariscope.  Glucose  polarizes  light  to  the  right.  The 
percentage  may  be  calculated  by  reading  the  vernier  scale  indicating  the 
degree  of  reflection,  and  multiplying  the  number  read  by  the  factor  of 
the  apparatus  used,  after  making  any  required  corrections. 

ACETONUBIA,    DIACETONURIA,    AND    OXYBUTYRIA. 

Acetonuria,  diacetonuria,  and  oxybutyria  are  so  closely  allied  with 
glycosuria,  and  especially  with  diabetic  coma  (acetonemia),  that  they 
may  be  considered  together.  In  the  first-named  condition  the  urine 
contains  acetone;  in  the  second,  diacetic  or  aceto-acetic  acid;  and  in 
the  last,  oxybutyric  acid.  Diacetic  and  oxybutyric  acids  are  products 
of  the  decomposition  of  acetone,  and  hence  the  importance  previously 
ascribed  to  the  latter,  when  detected  in  the  urine  of  diabetics,  has  given 
place  to  the  two  former,  the  oxidation  of  which  yield  acetone. 

Acetonuria  may  exist  to  a  minute  degree  in  health,  the  acetone 
being  a  product  of  the  normal  metamorphosis  of  albumin.  It  may  be 
present  also  in — (1)  diabetes;  (2)  carcinoma;  (3)  febrile  conditions;  (4) 
inanition ;  (5)  psychoses ;  and  (6)  auto-intoxication,  especially  with 
fatty  acids  in  the  stomacli.  Urine  that  contains  acetone  in  pathologic 
(juantities  has  a  fruity  (apple-like)  odor  or  one  resembling  that  of  chlo- 
roform. 

Tests. — (1)  Gerhardt's  original  test  consisted  in  the  addition  of  a  few 
drops  of  the  tincture  of  the  chlorid  of  iron,  which  produced  a  Burgundy- 
red  color  with  acetone,  or  rather  with  the  aceto-acetic  acid. 

(2)  Nitro-jjrussid  Test. — To  a  fluidounce  (32.0)  of  the  urine  add  a 


LITHURIA.  953 

dram  or  two  (4.0—8.0)  of  a  solution  of  sodium  nitro-prussid  (gr.  v  to  3j 
— 0.324  to  32.0)  and  a  few  drops  of  strong  aqua  ammonise.  On  stand- 
ing a  rose-violet  color  appears.  According  to  Legal,  proportionately 
smaller  quantities  of.  urine  and  the  reagent  may  be  used,  and  strong 
liquor  potassae.  A  bright-red  color  develops,  and  fades  rapidly,  but 
upon  adding  acetic  acid  this  changes  to  purple  or  violet-red  (Vierordt). 
This  is  a  better  test. 

(3)  Perhaps  the  most  accurate  and,  at  the  same  time,  satisfactory 
test  for  acetone  is  the  following  :  Distil  the  urine  with  a  little  phosphoric 
acid,  and  add  to  the  distillate  a  few  drops  of  sodium  hydroxid  and  of 
Lugol's  solution.  If  acetone  be  present,  yellow  crystals  of  iodoform 
will  form,  with  the  characteristic  odor. 

Diacetonuria  and  oxybutyria  never  occur  normally.  They  are 
often  associated  with  acetonuria  in  diabetes,  and  sometimes  in  fever,  or 
occur  as  an  independent  disease  (V.  Jaksch).  Moreover,  it  is  believed 
that  diacetic  and  oxybutyric  acids  are  the  causes  of  diabetic  coma,  and 
not  acetone,  as  was  held  formerly.  Stadelmann  affirms  that  of  like 
value  with  the  recognition  of  oxybutyric  acid  in  diabetes  is  the  deter- 
mination of  a  marked  and  increasing  amount  of  ammonia  in  the  urine 
(1  gram — gr.  xv — and  more  per  diem),  as  indicating  the  imminence  of 
diabetic  coma.  Diacetonuria  is  found  to  occur  in  certain  acute  diseases 
of  children,  accompanied  with  convulsions. 

Tests. — The  presence  of  diacetic  acid  is  demonstrated  by  the  chlorid- 
of-iron  reaction,  as  in  the  case  of  acetone,  except  that  the  urine  is  boiled 
previously.  This  is  done  to  avoid  fallacy,  since  in  unboiled  urine  acetic, 
formic,  and  oxybutyric  acids  may  strike  a  Burgundy -red  also ;  in  urine 
that  has  been  previously  boiled  these  do  not  react,  while  the  diacetic 
acid  does,  if  present.  Diacetic  acid  is  usually  present  simultaneously 
with  acetone.  If  a  portion  of  the  urine  is  mixed  with  sulphuric  acid 
and  extracted  with  ether,  diacetic  acid  may  be  inferred  to  be  present  if 
the  extract  shows  a  chlorid-of-iron  reaction  that  fades  within  twenty- 
four  hours  (V.  Jaksch). 

LITHURIA. 

Definition. — A  persistent  excess  of  uric  (lithic)  acid  and  urates 
(lithates)  in  the  urine. 

Normal  urine  contains  about  0.4  part  of  uric  acid  to  1000  parts  of 
urine  (about  gr.  x — 0.648 — per  diem),  or  it  exists  in  the  proportion  of 
about  1  to  45  of  urea,  the  principal  solid  constituent. 

etiology. — The  causes  of  lithuria,  as  seen  in  certain  conditions  in 
which  this  metabolic  change  occurs,  may  be  put  down  to  be  chiefly  as 
follows  :  (1)  Lithemia  (uricemia  ;  uric-  or  lithic-acid  or  gouty  diathesis) ; 
(2)  gout  and  rheumatism ;  (3)  fever ;  (4)  leukemia  and  pernicious  an- 
emia ;  (5)  pulmonary  affections  in  which  the  interchange  of  gases  is  in- 
terfered with  ;  (6)  a  highly  nitrogenous  diet.  Certain  other  conditions 
of  the  urine  may  diminish  its  power  of  dissolving  the  uric  acid  shortly 
after  voidance,  and  may  cause  a  deposit  that  should  not  be  mistaken  for 
an  excess.  Such  are — (a)  temporary  increase  in  the  quantity  of  uric 
acid  from  an  over-indulgence  in  nitrogenous  food ;  (b)  temporary  high 
acidity  ;  (e)  deficiency  in  mineral  salts. 


954  DISEASES  OF  THE   URINARY  SYSTEM. 

Diagnosis. — The  urine  has  a  high  specific  gravity,  a  deep  red-yel- 
low color,  and  a  marked  acid  reaction,  although,  rarely,  uric  acid  is 
formed  in  neutral  or  alkaline  urine  (Yierordt).  Albumin  may  be 
present  in  small  amount  at  the  same  time.  On  standing  the  uric 
acid  is  deposited  in  yellowish-red  or  "  Cayenne  pepper  "  grains,  com- 
posed of  microscopic  uric-acid  crystals.  Chemically  pure  uric  acid  is 
colorless,  but  that  deposited  from  urine  has  always  this  yellowish-red 
appearance  both  to  the  naked  eye  and  under  the  microscope.  Exami- 
nation with  the  latter  shows  a  great  variety  of  rhombic  prisms — "■  whet- 
stone-shaped," '"crosses,"  "lozenges,"  and  other  many-shaped  and  sized 
crystals — single  and  in  agglomerations. 

Test. — The  murexid  reaction  may  be  obtained  by  evaporating  a  little 
urine  in  a  watch-glass  or  porcelain  dish,  adding  a  few  drops  of  strong 
nitric  acid,  and  heating  to  dryness  again  :  this  is  allowed  to  cool,  and 
a  drop  of  liquor  ammonite  added,  when  a  beautiful  purple  shade  of 
murexid  will  appear  if  uric  acid  be  present. 

Urates. — These  are  increased  in  pathologic  conditions  that  give  rise 
to  uric  acid  in  excess,  and  are  usually  present  with  the  latter  in  some 
quantity.  It  is  not  rare,  however,  in  healthy  individuals  for  a  deposit 
of  urates  to  occur  in  concentrated  urine  exposed  to  a  cool  atmosphere. 
Urates  appear  also  in  the  scanty  urine  due  to  the  profuse  perspiration 
and  diarrhea  of  renal  congestion,  in  fever,  from  renal  calculi,  and  after 
a  meal  rich  in  albuminous  elements. 

Urates  occur  principally  as  acid  sodium  urate,  calcium  urate,  and 
ammonium  urate.  They  appear  macroscopically  as  a  flesh-colored  or 
"brick-dust"  (lateritious)  sediment;  this  is  usually  abundant  and  very 
finely  granular  in  appearance,  while  the  urine  above  is  cloudy.  It  is 
quite  characteristic  that  upon  heating  such  urine  it  becomes  clear, 
the  urates  being  completely  dissolved.  Microscopically,  the  sodium  and 
calcium  salts  of  uric  acid  occur  as  needle-  or  dumb-bell-like  crystals  or 
as  fine,  dark,  amorphous  granules.  Ammonium  urate  is  found  in  alka- 
line urine,  often  with  triple  phosphates  when  some  putrescence  has  en- 
sued. It  is  seen  in  dark-brown  or  green  spiculated  spherules ;  these  are 
sometimes  called  ''hedge-hog"  or  "thorn-apple"  crystals.  On  the 
addition  of  a  drop  of  hydrochloric  acid  under  the  cover-glass  uric-acid 
crystals  may  be  seen  to  develop. 

OXALURIA. 

Definition. — A  persistent  excess  of  calcium  oxalate  in  the  urine. 
A  few  crystals  may  occur  in  normal  urine  that  has  been  standing  for  a 
long  time. 

Transient  oxaluria  may  follow  the  ingestion  of  sub-acid  fruits,  as 
pears,  or  of  vegetables  containing  oxalates,  as  rhubarb,  tomatoes,  sorrel, 
asparagus,  and  cauliflower. 

Pathology. — Oxaluria  has  been  described  by  some  English  phys- 
icians as  an  independent  disease  or  special  diathesis  in  which  marked 
dyspepsia  and  hypochondriasis  or  neurasthenia  are  associated.  The 
condition  is  better  explained,  probably,  as  one  of  a  disturbed  metabolism 
— particularly  of  the  fats  and  carbohydrates — in  which  the  oxaluria  and 
the  nervous  symptoms  are  manifestations  analogous  to  the  lithuria  and  the 


PHOSPHATUEIA.  955 

irregular  gouty  symptoms  of  lithemia.  Oxalates  and  lithates  are  not  in- 
frequently found  together  in  the  urine  of  those  subject  to  the  gouty  habit. 
Oxaluria  is  also  present  in  wasting  diseases,  as  in  tuberculosis  and  diabetes 
mellitus,  and  in  the  cancerous  cachexia ;  it  may  appear  in  catarrhal  jaun- 
dice, spermatorrhea,  also  with  the  "  mulberry  calculi,"  and  in  general  pa- 
resis of  the  insane.      Slight  albuminuria  is  not  infrequently  associated. 

Diagnosis. — Oxalate-of-lime  crystals  appear  in  the  urine  in  two 
forms — most  commonly  as  minute,  regular,  highly-refracting  octahedra, 
or,  more  rarely,  as  hour-glass-  and  dumb-bell-shaped  crystals. 

The  octahedral  crystals  have  two  crossed  axes,  giving  a  star  or  enve- 
lope-like appearance.  Oxalates  sometimes  give  a  glittering  and  scintil- 
lating effect  to  floating  mucus  in  urine  that  has  undergone  fermentation. 

The  prognosis  is  usually  favorable. 

In  the  treatment  of  oxaluria  the  nitro-hydrochloric  acid  in  2-drop 
doses  is  a  useful  agent. 

PHOSPHATUEIA. 

Definition. — A  persistent  excess  of  phosphates  in  the  urine. 

Phosphoric-acid  salts  may  be  precipitated  in  normal  urine  that  has 
become  temporarily  alkaline.  These  acid  sodium  and  potassium  phos- 
phates in  normal  acid  urine  are  derived  from  the  alkaline  phosphates 
(neutral  sodium  and  potassium  phosphates)  of  the  blood.  In  normal 
urine  1.2  parts  of  alkaline  phosphates  per  1000  and  0.8  part  of  earthy 
phosphates  are  appreciable. 

Etiology  and  Pathology. — Conditions  that  produce  an  alkaline 
fermentation  of  the  urine  cause  a  deposit  either  of  amorphous  earthy 
phosphates  or  of  crystalline  phosphates.  They  are  also  found  in  the  de- 
composing urine  of  chronic  cystitis,  of  phosphatic  vesical  calculi,  of 
paralysis,  and  in  undue  retention  of  urine.  In  this  alkalinity,  due  to 
the  ammoniacal  fermentation  of  urea,  ammonium  carbonate  reacts  with 
the  phosphates  of  magnesium  to  form  the  triple  ammonio-magnesia  phos- 
phatic crystals,  the  commonest  variety  of  phosphaturia.  Here  the  phos- 
phates are  deposited  before  or  immediately  after  the  urine  is  passed, 
giving  a  milky  appearance  to  the  last  portion.  Deposits  of  phosphates, 
and  especially  of  triple  phosphates,  by  no  means,  however,  indicate  an 
actual  phosphaturia.  This  must  be  determined  by  chemical  analvsis. 
Amorphous  carbonate  of  lime  in  small  quantity  may  be  present  also  if 
ihe  urine  is  strongly  alkaline  and  ammoniacal  (Beale).  The  calcium 
phosphates  are  generally  more  abundant  than  the  magnesian,  and  may 
be  found  in  cases  of  nervous  or  atonic  dyspepsia,  neurasthenia,  melan- 
■cholia,  and  other  debilitated  conditions.  Whether  or  not  a  marked  pre- 
cipitate of  phosphates  means  any  detriment  to  nervous  tissue  alone  has 
Hot  been  determined  precisely  as  yet.  Obviously,  however,  a  certain 
portion  of  phosphates  is  supplied  by  the  food,  and  the  rest  by  the  body 
owing  to  defective  assimilation  and  metabolism. 

A  quantitative  estimation  of  the  daily  output  of  phosphates  shows  a 
"decided  increase  in  Avasting  diseases,  as  tuberculosis,  leukemia,  chronic 
articular  rheumatism,  and  acute  yellow  atrophy  of  the  liver.  The  phos- 
phoric acid  is  not  increased,  however.  The  so-called  "  phosphatic  dia- 
betes "  is  characterized  by  polyuria,  excessive  phosphaturia,  thirst,  ema- 
ciation, and  nervous  disturbances  (Tessier). 


956  DISEASES  OF  THE   URINARY  SYSTEM. 

Diagnosis. — Phosphatic  urine  has  usually  a  stale,  ammoniacal 
odor,  a  whitish  turbidity,  and  a  copious  light-colored  granular  sediment 
falls  on  standing.  Microscopically,  the  calcium  phosphate  crystals  ap- 
pear singly  as  "  knife-blade,"  "  arrow-head,"  or  "  slender  wedge-shape," 
or  in  stellate  clusters.  Acetic  acid  dissolves  them.  The  ammonio-mag- 
nesian  phosphate  crystals  are  transparent  rhombic  or  triangular  prisms, 
large  and  small — "  coffin-lid-shaped."  These  also  are  soluble  in  acetic 
acid  ;  oxalate-of-lime  crystals  are  not  so. 

On  heating  phosphatic  urine  an  increased  cloudiness  is  produced  that 
simulates  albumin,  but  on  acidifying,  as  with  a  drop  of  nitric  acid,  this 
is  cleared  up  at  once. 

LEUCINURIA   AND    TYROSINURIA. 

Definition. — The  presence  of  leucin  and  tyrosin  in  the  urine. 
These  are  strictly  pathologic  substances,  and  are  usually  found  together. 
They  are  products  of  the  decomposition  of  albumin,  intermediary  to 
the  formation  of  urea,  and  are  most  apt  to  be  found  in  the  urine,  along 
with  biliary  matters,  in  certain  hepatic  conditions. 

Htiology. — The  principal  causes  of  leucinuria  and  tyrosinuria  are 
acute  yellow  ati'ophy  of  the  liver,  acute  phosphorus-poisoning  (in  both 
of  which  fatty  degeneration  of  the  liver  is  pathologically  conspicuous), 
specific  infectious  diseases,  as  typhoid  fever,  small-pox,  and  yellow  fever, 
and  pernicious  anemia.  Leucin  and  tyrosin  have  also  been  found  (Kirk- 
bride)  in  the  urine  of  a  patient  with  erysipelas,  during  two  days  of  the 
decline. 

Diagnosis. — Of  the  two  substances,  leucin  is  the  more  soluble,  and 
hence  is  rarely  found  in  the  urinary  sediment.  Tyrosin,  on  the  other 
hand,  may  be  discovered  sometimes  as  a  fine  greenish-yellow  deposit. 
Bile-pigment  may  be  found  not  infrequently  in  urine  containing  leucin 
and  tyrosin.  A  trace  of  albumin  also  may  be  present,  while  the  urea 
is,  as  a  rule,  markedly  diminished.  Leucin  and  tyrosin  may  be  de- 
tected by  evaporating  a  few  drops  of  urine  on  a  glass  slide  and  examin- 
ing microscopically.  Leucin  appears  in  the  form  of  slightly  glistening, 
greenish-yellow  spheres  that  may  show  radiating  lines  and  concentric 
rings.  Tyrosin  is  recognized  by  the  slender  tufts  of  fine,  needle-like 
crystals  arranged  in  star-  or  cross-like  fashion. 

If  the  residuum  after  evaporation  be  heated  with  a  drop  of  nitric  acid, 
slowly  evaporated  to  dryness,  and  then  touched  with  a  drop  of  sodium 
hydroxid,   the  leucin,  if  present,   will  assume  a  yellowish-brown  hue. 

Tyrosin  becomes  red  in  color  Avhen  boiled  with  Millon's  reagent  of 
mercurous  nitrate,  or  it  is  demonstrated  by  a  violet  color  when  carefully 
warmed  with  a  little  sulphuric  acid,  and  then  treated  with  a  drop  of  the 
solution  of  phenic  chlorid. 

CYSTINURIA. 

Definition. — The  presence  of  an  excess  of  cystin  in  the  urine. 
Cystin  in  minute  quantity  may  be  found  sometimes  in  normal  urine.  It 
contains  sulphur.  The  causes  of  cystinuria  have  not  been  well  made  out, 
though  hereditanj  influences  seem  to  have  an  important  bearing  on  the 
etiology  ;  in  what  manner  they  act,  however,  is  not  known.  On  account 
of  the  insolubility  of  cystin  any  marked  quantity  would  be  deposited  in 


UBEA  IN   UBIXE.  957 

the  urine.  Cystin  calculi  sometimes  result,  though  cystinuria  may  ex- 
ist without  the  presence  of  a  cystin  calculus. 

Brieger  points  out  a  probable  significance  in  the  discovery  of  the' 
associated  presence  of  ptomains  with  cystinuria.  Thus,  in  certain  infec- 
tious diseases,  as  intestinal  mycosis,  a  ptomain-cystinic  product  is  sup- 
posed to  be  formed,  then  to  be  absorbed,  and  finally  decomposed  in  the 
urine,  thus  setting  free  the  cystin.  Cystitis  may  be  caused  by  the  action 
of  the  ptomains. 

Diagnosis. — The  sediment  is  light,  and  not  very  unlike  that  of  the 
amorphous  urates.  It  is  not  dissolved  by  heat,  however,  though  soluble 
in  ammonia.  Under  the  microscope  cystin  occurs  in  the  form  of  thin, 
transparent,  hexagonal  crystals.  Care  should  be  exercised  in  forming  a 
diagnosis  of  cystinuria  that  a  contamination  with  iodoform  be  excluded, 
since  the  microscopic  appearance  of  that  substance  is  similar  to  that  of 
cystin.  On  account  of  the  sulphur  contained  in  cystin,  a  test  may  be 
employed  by  which  hydrogen  sulphid  is  liberated,  as  by  boiling  the  sus- 
pected urine  with  a  solution  of  lead  oxid  and  sodium  hydroxid,  black 
lead  sulphid  resulting  from  the  reaction  if  cystin  be  present. 

VARIOUS    OTHER    CONDITIONS. 

Urea. — This  occurs  in  solution  in  the  normal  urine  as  a  product  of 
the  perfect  decomposition  of  the  nitrogenous  elements  of  food  and  tis- 
sues. In  1000  parts  of  urine  about  20  parts  are  constituted  of  urea  (2 
per  cent.,  equivalent  to  about  gr.  450 — 30.0 — daily).  The  quantity  of 
urea  is  increased  in  the  urine  after  the  ingestion  of  a  considerable  quan- 
tity of  proteid  food  ;  sometimes  after  exertion :  in  acute  inflammation 
and  in  fevers — either  relatively  or  absolutely,  as  in  pneumonitis ;  in 
diabetes  and  other  morbid  conditions  in  which  metabolism  is  accom- 
panied by  an  increase  in  the  tissue-waste.  In  febrile  states  its  excretion 
increases  or  diminishes  with  the  exacerbations  and  remissions  of  tem- 
perature respectively. 

Urea  is  pathologically  diminished  in  quantity  in  all  forms  of  nephri- 
tis, and  markedly  so  in  uremia  ;  in  organic  liver-diseases,  as  acute  yellow 
atrophy ;  in  cachectic  and  anemic  states ;  and  in  dropsy,  inanition,  and 
allied  conditions. 

The  quantitative  estimation  of  urea  may  be  made  according  to  one  or 
more  of  several  methods  :  Fowler's  hypochlorite  test  (with  Labarraque's 
solution)  is  perhaps  the  most  practical  for  ordinary  clinical  purposes  ;  the 
hypobromite  and  Liebig's  methods,  both  requiring  special  apparatus, 
are  better  adapted  for  the  laboratory.^  Eowler's  method  is  based  upon 
the  loss  of  specific  gravity  upon  the  liberation  of  the  nitrogen  of  the 
urea.  The  mean  specific  gravity  of  a  mixture  of  1  part  of  urine  and  7 
parts  of  the  solution  of  sodium  hypochlorite  is  taken  while  quiescent, 
and  is  then  subtracted  from  the  specific  gravity  of  the  mixture  taken 
after  agitation  several  times  during  about  two  hours.  The  difference 
which  is  due  to  the  liberation  of  the  nitrogen  (as  is  shown  by  the  effer- 
vescence), multiplied  by  the  factor  0.77,  gives  the  approximate  percent- 
age of  urea  in  the  urine.  This  test,  however,  has  a  considerable  range 
of  error. 

^  See  works  on  Urinalysis. 


958  DISEASES  OF  THE   URINARY  SYSTEM. 

Urine  evaporated  to  a  syrupy  consistence  and  then  treated  with  nitric 
acid  shows  crystalline  quadratic  plates  of  urea  nitrate. 

Chlorids. — About  10  parts  of  the  chlorids  of  sodium  and  potassium  in 
1000  parts  of  urine  are  excreted  daily.  They  are  increased  in  the 
urine  after  muscular  exertion,  during  the  resorption  of  mechanical  or 
inflammatory  transudations  and  exudations,  and  in  intermittent  fevers, 
owing  to  the  destruction   of  the  red  corpuscles. 

Pathologic  diminution  in  the  quantity  of  chlorids  occurs  in  fevers,  in 
the  nephritides,  in  cachectic  conditions,  and  especially  in  such  diseases 
as  pneumonitis,  pleuritis,  and  rheumatism.  In  the  last-named  class  the 
chlorids  diminish  as  exudation  continues,  and  may  even  totally  disap- 
pear from  the  urine  in  extensive  pneumonic  consolidations,  to  reappear 
again  with  the  resorption  of  the  exudate. 

Test. — The  chlorids  may  be  detected,  after  first  removing  any  albu- 
min that  may  be  present,  by  acidulating  with  a  few  drops  of  nitric  acid 
(to  keep  the  phosphates  in  solution),  and  by  then  adding,  drop  by  drop, 
a  strong  solution  of  argentic  nitrate.  According  to  the  abundance  of 
the  resultant  white,  curdy  precipitate  of  argentic  chlorid  a  rough  esti- 
mate may  be  made  of  the  total  quantity  of  chlorids  in  the  urine. 

Lipuria  is  a  term  applied  to  the  presence  of  fat  in  the  urine.  It  may 
result  from  the  steady  use  of  cod-liver  oil  or  of  fatty  food,  or  it  may  be 
found  in  pyonephrosis  (Ebstein) ;  in  phosphorus-poisoning ;  in  pro- 
longed suppuration;  in  the  lipemia  of  diabetes  mellitus;  in  the  "large 
white  kidney"  with  fatty  degeneration  of  chronic  Bright's  disease;  in 
beer-drinkers ;  and  in  chyluria.  Fatty  urine  becomes  clear  upon  agitat- 
ing after  the  addition  of  ether. 

Lipaciduria,  or  urine  containing  volatile  fatty  acids  (acetic,  butyric, 
and  propionic),  is  as  yet  without  diagnostic  significance. 

Melanuria,  or  urine  containing  the  pigment  melanin,  is  found  in  cases 
of  melanotic  sarcoma.  The  urine  is  dark,  either  just  after  being  voided 
or  after  some  exposure  and  oxidation. 

Hematoporphyrinuria  (Urospectrin). — This  term  implies  the  presence 
of  hematoporphyrin  (iron-free  heniatin)  in  the  urine.  It  occurs  after 
long-continued  use  (even  in  small  doses — Miiller)  of  certain  coal-tar 
products,  particularly  sulfonal  andtrional.  In  addition  to  the  gastric  and 
nervous  si/ nipto7ns  in  poisoning  from  these  substances  is  a  cherry-colored 
or  dark  blue-red  urine,  the  abnormal  appearance  of  the  latter  being  due  to 
the  j)resence  of  hematoporphyrin  resulting  from  the  destruction  of  the 
red  blood-corpuscles.  The  condition  has  proved  fatal  in  several  cases 
where  albuminuria  showed  the  kidneys  to  have  been  diseased.  The 
urine  is  ahvays  quite  acid.  According  to  Garrod,  hematoporphyrin 
is  a  scanty  though  constant  ingredient  of  normal  urine.  He  extracts 
it  by  adding  100  c.cm.  of  urine  to  20  c.cm.  of  a  10  per  cent,  solution 
of  sodium  hydroxid.  This  precipitates  the  phosphates,  which  are 
washed  with  water  and  redissolved  with  rectified  spirits.  After  acidula- 
tion  Avith  hydrochloric  acid  the  solution  shows  spectroscopically  bands 
of  acid  hematoporphyrin.  The  treatment  consists  in  the  prompt  with- 
draAval  of  these  drugs  and  the  free  administration  of  alkalies. 

Pneumatinuria,  or  gas-formation  in  the  bladder,  rarely  occurs.  Heyse ' 
records  a  case  of  myelitis  in  which  this  condition  was  present. 

'  Zeit.f.  klin.  Med.,  1894,  xxiv.  p.  130,  quoted  in  The  American  Year-Book  of  Medicine 
and  Surgery  for  1896. 


THE  NEPHRITIDES.  959 

Fibrinuria. — In  certain  conditions  of  the  genito-urinary  tract,  partic- 
ularly pyelitis  and  ureteritis,  fibrinous  (and  mucous)  casts  are  found  in 
the  urine.  Fibrinuria  may  follow  nephro-lithiasis,  as  in  a  case  recorded 
by  V.  Jaksch. 

Bacteriuria. — There  are  probably  few  specimens  of  urine  that  do  not 
contain  bacteria.  Engel  has  found  a  great  variety  of  organisms  in  the 
nephritides,  one  of  which  (a  micrococcus  of  characteristic  groAvth  and 
properties)  w^as  present  in  17  out  of  31  cases,  hence  regarded  by  him  as 
the  specific  cause  of  some  of  the  cases  in  this  category  of  diseases.  This 
organism  was  found  in  mild  types  of  nephritis,  and  Engel  believes  it  to 
be  responsible  for  many  instances  of  the  sort  beginning  as  mild  forms 
of  ^'•bacterial  alhuminuria.''  Warburg^  reported  a  case  of  chill  and 
fever  with  turbid  urine  due  to  large  numbers  of  the  Bacillus  lactis  aero- 
genes. 

Lactosuria.^Lactose  is  found  in  the  urine  of  some  puerperse. 

Inosituria. — Inosite  occurs  in  the  urine  in  diabetes  insipidus. 

Alkaptonuria. — Alkaptone  is  an  obscure  substance  (so  called  by 
Bredeker)  that  is  sometimes  found  in  the  urine  of  phthisical  cases,  or 
at  times  in  that  of  patients  without  any  apparent  local  or  general  dis- 
ease. Alkaptonuria  seems  to  be  congenital  in  a  few  cases.  On  expos- 
ure the  urine  darkens  in  color ;  also  upon  the  addition  of  liquor  potas- 
sae.     It  gives  the  sugar-reaction  with  Fehling's  solution  (Osier). 

Urine  as  afi"ected  by  the  administration  of  various  drugs — as  carbolic 
acid,  salol,  antipyrin,  and  potassium  iodid — responds  to  certain  chemical 
tests,  for  the  study  of  which  the  reader  is  referred  to  works  on  urinal- 
ysis and  clinical  diagnosis. 

Oholesterinuria  has  been  found  in  cases  of  pyonephrosis,  hydro- 
nephrosis, renal  hydatids,  epilepsy,  and  severe  dyspepsia. 


THE  NEPHRITIDES. 

Before  considering  the  several  varieties  of  nephritis,  and  especially 
the  clinical  history  peculiar  to  each  variety,  it  may  be  well  to  first  de- 
scribe certain  general  manifestations  of  renal  diseases  that  are  more  or 
less  common  to  all.  Reference  to  these  symptoms  under  the  different 
forms  of  nephritis  will,  it  is  hoped,  thus  make  possible  a  clearer  appre- 
hension of  their  significance  and  clinical  importance,  as  well  as  render 
unnecessary  any  further  elaboration. 

One  of  these  pathologic  conditions  has  already  been  described — viz. 
(1)  Albuminuria.  It  remains,  then,  to  speak  of  (2)  the  MorpJiologic 
constituents  of  the  urine  in  nephritis,  (3)  Edema  [anasarca,  dropsy),  and 
(4)  Uremia. 

THE  MORPHOLOGIC  CONSTITUENTS  OF   THE  URINE   IN   RENAL  DISEASE  : 
CASTS,  EPITHELIUM,  ETC. 

1.  Tube-casts. — These  are  undoubtedly  the  most  important  morpho- 
logic elements  in  the  urine  of  a  nephritic.     Albuminuria  is  coincident- 
1  Munchener   Med.  Wochen.,  July  18,  1899. 


960  DISEASES  OF  THE    URINARY  SYSTEM. 

ally  present,  and  the  occurrence  together  of  these  two  pathologic  con- 
stituents furnishes  indisputable  evidence  of  renal  disease.  According 
to  the  nature  and  quantity  of  the  casts  also  may  be  determined  the  cha- 
racter and  variety  of  the  affection  of  the  kidneys  in  most  instances. 
Casts,  as  their  name  implies,  are  simply  cylindric  bodies  moulded  in 
the  renal  tubules,  and  composed  essentially  of  the  coagulable  substances 
in  the  serum  exuded  from  the  blood-vessels.  The  coagula  of  the  tubules 
are  mostly  albuminous.  Other  morphologic  elements  may  be  mixed 
Avith  casts,  such  as  epithelium,  red  blood-cells,  pus-cells,  and  the  granu- 
lar matter  and  fat-droplets  due  to  degeneration  of  the  renal  epithelium. 

Singly,  the  casts  are  invisible  to  the  naked  eye,  but  in  acute  nephritis 
they  may  be  so  abundant  as  to  form  a  cloudy  sediment  near  tlie  bottom 
of  the  urine-containing  glass. 

[a)  Microscopically,  the  unmixed  or  hyaline  cast — the  commonest — 
appears  either  long  or  short  and  narrow  or  broad,  of  a  clear,  transparent, 
homogeneous  substance,  delicate  in  outline,  and  often  showing  ends  with 
a  cheesy — or  wax-like — fracture.  They  may  be  straight  or  slightly 
curved  and  tortuous,  with  fine  short  transverse  lines  here  and  there  at 
the  borders  of  the  cast.  Rarely,  a  cast  may  be  found  equal  to  a  milli- 
meter in  length.  The  so-called  narrow  easts  are  about  equal  in  width 
to  the  diameter  of  a  leukocyte,  while  the  medium  or  broad  casts  are 
from  three  to  four  times  this  size.  They  will  take  either  the  carmin 
or  gentian-violet  stain.  Hyaline  casts  are  usually  associated  with  other 
varieties  of  casts  in  nephritis,  though  in  fevers,  congestion  of  the  kid- 
neys, chronic  interstitial  nefjhritis,  and  in  amyloid  kidney  they  may 
occur  unassociated  with  other  forms  of  casts  (Vierordt). 

(h)  Granular  casts  are  nothing  more  than  hyaline  casts  with  fine  or 
coarse  granules  superadded.  The  granules  represent  minute,  opaque 
particles  of  urates,  albumin,  fat,  cellular  debris,  and  even  bacteria 
(bacterial  casts).  It  should  be  remembered,  however,  that  granular 
casts  may  be  simulated  by  casts  of  coagulated  albumin  covered  with 
particles  of  hcmatoidin,  especially  in  acute  nephritis.  The  hematoidin 
can  be  recognized,  however,  by  the  brown-yellow  coloration. 

(c)  Epithelial  casts  are  hyaline  casts  more  or  less  covered  with  renal 
epithelium,  indicating  an  acute  destjuamative  nephritis.  The  epithelial 
cells  may  shoAv  evidence  of  granular  or  fatty  change. 

(d)  Blood-casts  consist  of  soft  hyaline  casts  having  red  blood-cells 
imbedded  in  them.  These  are  present  in  renal  hemorrhage  and  in  acute 
hemorrhagic  nephritis. 

((•)  Wa.ri/  casts  are  similar  in  appearance  to  hyaline  casts,  though 
better  defined,  broader  as  a  ^rule,  and  of  an  opaque,  slightly  yellowish 
tint.  They  often  show  broken  ends.  They  do  not  necessarily  indicate 
amyloid  disease  of  the  kidney,  as  Avas  formerly  held.  They  may.  how- 
ever, sometimes  show  the  amyloid  reaction  with  iodin  and  potassium 
iodid,   and  are   always   suggestive  of  serious  renal   disease. 

(/)  Fatty  casts  are  such  as  have  left  upon  and  in  them  fat-droplets 
or  granules,  which,  if  abundant,  are  indicative  of  fatty  degeneration  of 
the  kidney.  Cells  showing  gi-anulation  from  fatty  change  ma}'  be  seen 
simultaneously. 

*       Rolled  casts  or  pseudo-casts  (made  by  sliding  a  cover-glass  over  a 
specimen  of  urine)  of  urates,  epithelial  cells,  blood-corpuscles,  and  d(?bris 


BBOPSY  OF  RENAL   DISEASE.  961 

should  not  be  mistaken  by  beginners  for  genuine  tube-casts.  The  same 
may  be  said  of  cylindroids,  mucous  cylinders,  and  foreign  substances. 
Nephritis  may  exist  when  the  casts  are  always  to  be  found,  varying  in 
numbers  only,  while  albuminuria  may  be  inconstant  or  intermittent. 

2.  Epithelium. — Renal  cells  are  found  in  the  urine  of  those  forms  of 
nephritis  that  are  characterized  by  a  catarrhal  or  desquamative  and 
exudative  process  in  the  tubules.  Epithelial  cells  from  the  kidney  are 
polygonal  or  spheric  in  contour,  with  an  indistinct  cell-wall ;  they 
have  a  large  oval  nucleus,  and  are  either  abundantly  granular  or  show  a 
fatty  change.      These  cells  are  about  the  size  of  the  white  corpuscle. 

3.  Leukocytes. — Only  when  attached  to  casts  can  it  be  positively 
affirmed  that  leukocytes  are  of  renal  origin  (Striimpell).  The  pus-cells 
are  frequently  seen  to  be  Avithout  nuclei  in  marked  or  chronic  pyuria. 

4.  Red  Blood-corpuscles  {vide  Hematuria,  p.  934). — In  acute  hem- 
orrhagic nephritis  and  in  severe  renal  congestion  free  red  blood-cor- 
puscles are  generally  to  be  found. 

5.  Fat-globules  and  granular,  fatty-degenerated  cells  are  seen  espe- 
cially in  the  subacute  and  chronic  forms  of  nephritis  with  fatty  degen- 
eration of  the  proliferated  epithelium,  or  in  the  fatty  stage  of  large 
white  kidney. 

DROPSY   OF   RENAL   DISEASE. 

Since,  as  in  other  conditions,  renal  dropsy  or  edema  is  an  abnormal 
accumulation  of  watery  fluid  transuded  from  the  blood-vessels  into  the 
cellular  tissues  and  lymph-spaces,  the  question  arises,  "  What  is  the 
rationale  of  its  development  in  nephritis  ?  "  On  the  ground  that  the 
renal  secretion  consists  principally  of  water,  and  that  in  most  forms  of 
nephritis  the  urine  is  diminished,  it  was  formerly  held  that  the  dropsy 
was  due  to  the  saturation  of  the  tissues  with  the  water  that  was  not 
excreted  by  the  kidneys.  This  theory  is  not  fully  tenable,  however,  for 
there  are  some  cases  of  edema  unaccompanied  by  any  diminution  in 
the  daily  quantity  of  urine ;  on  the  other  hand,  certain  instances  of 
renal  disease  in  which  there  is  a  state  of  almost  anuria  show  no  evidence 
of  dropsy  whatever.  The  failure  of  any  one  theory  to  explain  the  eti- 
ology and  pathology  of  edema  has  justified  the  proposal  of  another  and  un- 
doubtedly a  more  plausible  one  by  Landerer — viz.,  that  the  relaxation  of 
the  tissues  (which  may  be  caused  by  the  increased  transudation  of  stasis, 
or  by  hyponutrition  from  hydremia),  and  their  consequent  loss  of  elas- 
ticity, prevent  that  forcing  of  the  lymph  into  circulation  that  exists  in 
the  normal  state,  and  as  a  result  a  watery  infiltration  of  the  tissues  is 
permitted.  The  loss  of  elasticity  or  power  of  resistance  in  edematous 
tissues  is  quite  apparent  under  the  skin,  and  affords  a  positive  means 
of  diagnosis  in  the  pitting  produced  by  the  pressing  finger. 

The  dropsy  of  the  nephritides  may  be  either  slight  or  marked,  local 
or  general  (anasarca),  and  sudden  or  slow  in  onset.  It  is  purely  renal 
in  origin  perhaps  only  in  acute  Bright's  disease  or  in  the  earlier  stages 
of  chronic  Bright's  disease.  In  all  forms  of  chronic  nephritis  the  dropsy 
may  be  due,  in  part,  to  the  venous  stasis  of  cardiac  incompetency.  In 
chronic  interstitial  nephritis,  especially,  edema  is  slight,  and  usually  is 
the  result  of  weakness  and  dilatation  of  the  heart,  increasing  pari  passu* 
with  the  latter. 

61 


962  DISEASES  OF  THE    URINARY  SYSTEM. 

I  desire  to  mention  here  those  rare  cases  of  dropsy  that  simulate 
Bright's  disease  in  which  no  satisfactory  causative  lesion  is  apparent  or 
discoverable,  and  also  those  cases,  rarer  still  perhaps,  that  have  a  peculiar 
family  or  congenital  origin. 

Physical  Signs. — The  recognition  of  edema  is  made  possible  by  both 
inspection  and  palpation.  Renal  dropsy  is  manifested  first  by  puffiness 
of  the  skin  of  the  face,  and  especially  of  the  eyelids.  At  other  places 
wliere  there  is  loose  subcutaneous  cellular  tissue,  and  in  particular  where 
the  parts  are  dependent,  dropsy  is  most  apt  to  be  seen  early,  as  under 
the  malleoli  of  the  ankles,  the  dorsum  of  the  foot,  and  the  scrotum. 
Later,  the  limbs  and  the  lower  part  of  the  back  become  swollen,  and 
even  the  whole  body  is  involved  in  severe  cases.  The  skin  has  a  pecu- 
liar waxy  pallor  and  a  glossy  appearance.  When  evident  vascular  or 
cardiac  changes  exist,  so  as  to  permit  of  increased  dropsy  from  engorge- 
ment, as  in  cirrhotic  kidney,  a  cyanotic  or  muddy  color  of  the  skin  may 
prevail. 

Pathologic  Features. — Dropsy  is  most  constant  and  most  persistently 
decided  in  the  large  white  kidney  of  subacute  or  chronic  nephritis  ;  it  is 
most  uncommon  and  irregular  in  chronic  interstitial  nephritis  (contracted 
kidney).  The  familiar  pitting  on  pressure  over  edematous  tissues  is  a 
true  indication  of  fluid  under  the  skin.  There  is  also  a  doughy  or  putty- 
like consistence.  In  very  marked  cases  of  dropsy  the  deeper  parts,  such 
as  the  muscles,  become  affected.  The  serous  cavities  also  in  general 
anasarca  show  evidences  of  eff'usion,  and  thus  give  rise  to  hydro-thorax, 
hydro-peritoneum,  and  hydro-pericardium.  Less  frequently  there  may 
be  edema  of  the  larynx,  uvula,  conjunctiva,  and  other  mucous  membranes. 
Edema  of  the  brain,  either  local  or  general,  may  be  the  cause  of  grave 
uremic  symptoms  in  chronic  nephritis,  or  of  unilateral  convulsions  or 
paralysis  and  apoplectic  seizures.  The  dropsical  li(|uid  is  chemically 
similar  to  a  diluted  blood-serum.  A  minute  quantity  of  albumin  and 
urea  is  present. 

UREMIA. 

Definition. — Uremia  is  the  term  applied  to  a  group  of  manifestations, 
mainly  nervous  and  either  acute  or  chronic,  resulting  from  a  toxemia  due 
to  the  retention  in  the  body  of  certain  products  of  urinary  or  renal  origin. 

Although  most  common  in  Bright's  disease,  uremia  may  arise  also  in 
other  diseases,  as  in  gout  (gouty  kidney),  scarlet  fever  (scarlatinal  nephri- 
tis), typhus  fever,  yellow  fever,  and  cholera,  in  which  the  kidneys  and 
blood  may  be  seriously  aff"ected.  Kidneys  which,  on  account  of  marked 
structural  changes,  fail  to  eliminate  the  normal  (juantity  of  solid  constit- 
uents are  directly  or  indirectly  responsible  for  an  association  of  the 
morbid  conditions  known  as  uremia. 

Our  present  knowledge  of  the  pathology  and  etiology  of  uremia, 
as  of  renal  edema,  is  based  solely  upon  theoretic  views.  The  theory 
that  attributes  uremic  symptoms  to  the  retention  of  the  excretory  prod- 
ucts appears  to  have  the  strongest  proofs  to  support  it;  but  the  positive 
nature  of  these  substances,  or  which  is  the  most  toxic,  or  whether  several 
are  concerned  in  the  causation  or  not,  remains  to  be  determined.  Since 
the  urea  and  uric  acid  have  been  found  in  increased  quantities  in  the 


UREMIA.  963 

blood  of  uremic  patients,  and  since  these  products  are  diminished  in  the 
urine  of  nephritis,  they  also  were  at  first  supposed  to  be  the  cause.  Am- 
monium carbonate,  it  was  alleged  by  Frerichs,  operated  in  the  same  man- 
ner after  it  accumulated  in  the  blood  in  sufficient  quantity  as  a  result  of 
the  decomposition  of  the  urea  by  a  ferment. 

Not  only  some  of  the  solid  urinary  constituents  accumulate  in  the 
blood  in  uremia,  but  the  water  also  is  only  partly  eliminated,  and  its 
presence  in  the  blood  renders  the  latter  hydremic  and  of  lower  specific 
gravity.  Notwithstanding  the  fact  that  most  cases  of  uremia  may  be 
traced  to  a  marked  simultaneous  diminution  in  the  quantity* of  urine 
passed,  there  remain  still  certain  instances  of  renal  disease  in  which 
uremic  symptoms  appear  without  any  such  perceptible  diminution. 
Even  more  frequent  perhaps  are  those  perplexing  cases  of  anuria  now 
and  then  reported  in  which  no  uremic  symptoms  appear.  In  the  latter 
instances  it  is  probable  that  the  elimination  of  products  normally  ex- 
creted by  the  kidneys  may  be  accomplished  through  other  channels,  as 
by  the  skin  and  bowels ;  in  the  former  it  is  still  likely  that  the  solid 
urinary  constituents  are  retained,  even  with  an  undiminished  quantity 
of  water  excreted. 

.Traube's  theory  of  the  cause  of  uremia,  particularly  of  the  nervous  or 
cerebral  manifestations,  was  that  it  is  an  acute  edema  of  the  brain — local 
or  general — with  cerebral  anemia.  This  would  seem  to  explain  certain 
cases  of  nephritis,  as  already  mentioned,  in  which  a  fair  amount  of  urine 
and  solid  constituents  are  passed  ;  also  cases  of  anuria  due  to  urethral  ob- 
struction in  which  no  uremic  symptoms  appear  ;  and  certain  cerebral 
disturbances.  But  with  our  present  knowledge  of  the  chemico-pathology 
and  of  the  clinical  cause  of  the  uremia  of  nephritis  in  all  its  forms  there 
is,  I  think,  no  doubt  that  most  cases  are  caused  by  the  toxemia  produced 
by  the  retention  of  the  mass  of  excrementitious  substances  due  to  an 
abatement  of  the  renal  functions. 

Delafield,  however,  attributes  the  sudden  violent  motor  symptoms  of 
acute  uremia  to  a  contraction  of  the  arteries  from  some  unknown  cause 
other  than  blood-contamination. 

The  symptoms  of  uremia  may  be  either  acute  or  chronic  in  onset, 
severity,  and  course.  In  acute  uremia  the  severest  nervous  symptoms 
come  on  suddenly ;  they  last  but  a  comparatively  short  time,  and  termi- 
nate fatally,  with  convulsions  and  coma,  dyspnea,  feeble  cardiac  action  and 
pulse,  fever,  and  pulmonary  edema.  These  acute  symptoms,  however,  are 
not  infrequently  preceded  by  mild  uremic  prodromes,  as  headache,  som- 
nolence, nausea,  malaise,  slight  dyspnea,  and  uneasiness. 

Chronic  uremia  is  characterized  by  the  absence  of  the  marked  symp- 
toms referred  to  above,  the  milder  manifestations  alone  appearing  and 
lasting  over  a  considerable  length  of  time.  Here  the  general  prostration, 
the  feeble  cardiac  and  arterial  states,  the  occasional  stupor  and  delirium, 
transient  dimness  of  vision,  anorexia  and  nausea,  irregularly  hurried 
breathings,  and  muscular  twitchings,  indicate  the  grave  condition  of  the 
patient.  To  gain  a  more  thorough  knowledge  of  this  interesting  and 
serious  complication  of  renal  disease  a  divisional  study  of  the  symptom- 
atology is  necessary. 

Cerebral  Symptoms. — These  vary  from  a  slight  headache,  tremors,  and 


964  DISEASES  OF  THE   URFNARY  SYSTEM. 

the  restlessness  of  anxiety  to  the  most  violent  maniacal  delirium  and  con- 
vulsions ;  from  somnolence,  low  muttering,  and  mental  stupor  to  profound 
coma ;  and  from  slight  visual  disturbances  to  complete  amaurosis.  The 
onset  of  a  noisy  delirium,  and  less  commonly  of  a  marked  mania,  is  often 
abrupt,  and  may  be  the  first  manifestation  of  Bright's  disease  in  an  indi- 
vidual. Delusional  insanity  {folie  Brightique)  is  seen  in  a?  few  cases. 
Bischoif  has  observed  only  two  cases  of  purely  uremic  psychoses  among 
3000  cases  of  insanity,  and  believes  that  a  neuropathic  tendency,  chronic 
alcoholism,  and  pregnancy  are  the  most  important  predisposing  causes. 
Melancholia  and  the  delusion  of  persecution,  with  suicidal  and  homicidal 
tendencies,  may  thus  occur.  The  most  characteristic  symptom  of  uremia, 
however,  is  the  convulsion  (uremic  eclampsia).  Uremic  convulsions  are 
epileptiform  in  type,  although  they  may  be  either  unilateral  or  local — of 
the  Jacksonian  form  of  epilepsy.  They  are  supposed  to  be  due  to  a  local 
or  general  edema  of  the  brain,  and  are  probably  allied  to  the  apoplexia 
serosa  of  early  writers  (Osier).  The  convulsions  of  uremia  may  come 
on  suddenly  or  may  be  preceded  by  headache,  vertigo,  dropsy,  nausea, 
and  vomiting.  As  in  the  epileptiform  convulsion,  after  the  early 
tonic  rigidity  there  may  follow  at  short  intervals  the  clonic  spasm,  with 
cyanosis,  fever,  and  contracted  arteries,  and  the  intervening  periods*  of 
unconsciousness,  shallow  or  noisy  respiration,  and  slow,  hard  pulse. 
Coma  may  come  on  gradually  as  well  as  during  the  convulsive  attacks. 
It  may  be  preceded  by  headache,  apathy,  and  insomnia,  and  continue 
progressively  to  deepen  for  a  long  time.  A  typhoid  state  not  infre- 
quently accompanies  uremic  coma.  The  temperature  is  usually  low- 
ered, and  moderate  dilatation  or  contraction  of  the  pupils  may  be 
evidenced. 

Uremic  Amaurosis. — Blindness  may  follow  uremic  convulsions,  or, 
rarely,  it  may  come  on  without  motor  disturbances.  It  is  of  purely 
centric  origin  (the  cortex  of  the  occipital  lobe),  and  its  duration  is  short, 
lasting  but  a  few  days  in  most  instances.  Uremic  deafness,  which  is 
probably  also  of  centric  origin,  is  a  less  common  manifestation.  Other 
nervous  phenomena,  as  hemiplegia,  monoplegia  (from  cerebral  or  spinal 
congestion  or  edema),  contractures,  aphasia,  pruritus,  paresthesise,  and 
cramps  in  the  calf-muscles  are  not  so  frequent  in  occurrence. 

Circulatory  Disturbances. — The  pulse  is  moderately  slow,  tense,  and 
full  in  uremia,  but  with  the  onset  of  acute  and  severe  symptoms,  as  con- 
vulsions, it  usually  becomes  accelerated,  small,  and  feeble.  The  heart's 
action  is  labored  and  feeble. 

Respiratory  Symptoms. — Renal  dyspnea,  which  is  sometimes  called 
"  uremic  "  or  "  renal  asthma,"  is  a  marked,  rather  constant,  and  often  an 
early  symptom  of  uremia.  The  respirations  are  deep  and  often  stertorous 
in  coma,  or  they  may  be  irregular,  accelerated,  and  shallow,  sometimes 
assuming  the  Cheyne-Stokes  type.  Dyspneic  attacks  are  especially  apt  to 
occur  at  night.  In  chronic  uremia  slight  dyspnea  may  be  continuous  for  a 
long  time.  Again,  alternating  paroxysmal  exacerbations  may  arise.  The 
uremic  dyspnea  is  probably  due  in  most  cases  to  the  toxemia  affecting  the 
respiratory  nervous  centers.  It  may,  however,  be  the  result  of  cardiac 
weakness  or  of  dropsy  or  pulmonary  edema. 

Gastro-intestinal  Symptoms. — Uremic  stomatitis  is  generally  seen. 
The  breath  is  foul,  the  tongue,  lips,  and  gums  are  red,  swollen,  and  pain- 


UREMIA.  965 

ful,  and  the  saliva  is  increased.  Uremic  vomiting  is  also  usually  of  cen- 
tric origin,  though  it  may  be  provoked  by  the  irritation  of  the  gastric 
mucosa,  caused  by  the  vicarious  elimination  of  the  urea  and  the  decom- 
position of  the  latter  into  irritating  ammonium  carbonate.  The  vomiting 
may  come  on  suddenly  and  be  persistent.  Uncontrollable  hiccough  and 
sometimes  uremic  diarrhea  may  be  associated.  The  irritant  action  of  the 
ammonium  carbonate  on  the  intestinal  mucous  membrane  may  produce  a 
catarrhal  or  diphtheritic  inflammation,  and  ulceration  even  (Grawitz). 
Uremic  diarrhea  may  also  exist  apart  from  any  marked  gastric  disturb- 
ances. 

General  Symptoms. — The  skin  of  the  face  is  usually  pale  in  uremic 
coma.  Urea  may  be  excreted  by  the  sweat-glands,  and  may  be  seen  as 
minute  glistening  crystals  in  some  of  the  cutaneous  furrows  after  the 
evaporation  of  a  free  sweat.  The  skin  is  often  harsh  and  dry,  as  in 
chronic  interstitial  nephritis.  Uremic  pruritus  is  probably  the  result  of 
the  peripheral  irritation  of  the  cutaneous  nerves  by  crystals  of  urea.  The 
temperature  is  generally  lowered,  but  uremic  fever  frequently  accompanies 
the  convulsions  or  they  may  be  preceded  by  "uremic  chills."  In  some 
cases  the  temperature  rises  to  105°-107°  F.  (40.5°-41.6°  C.)  just  before 
death,  whilst  in  other  cases,  characterized  by  a  profound  and  lasting  coma 
that  deepens  into  collapse,  the  temperature  may  be  so  low  as  91°  or  93°  F. 
(32.7°-33.8°  C). 

There  is  not  infrequently  an  ammoniacal  odor  about  a  uremic  patient. 
The  urine  is  diminished  in  quantity,  is  generally  highly  albuminous,  and 
deficient  in  urea.  A  previous  dropsy  is  sometimes  markedly  reduced 
upon  the  appearance  of  acute  uremic  symptoms. 

Duration  and  Prognosis. — Acute  uremia  is  manifested  by  coma 
and  convulsions,  seldom  lasting  more  than  a  few  days.  Chronic  uremia, 
in  which  milder  nervous  symptoms,  nausea  and  vomiting,  and  dyspnea 
are  more  prominent,  may  persist,  however,  for  many  weeks.  While  a 
grave  condition,  uremia,  even  in  its  most  acute  and  violent  forms,  is  not 
at  once  necessarily  fatal,  for  under  proper  treatment — as  by  venesection, 
for  instance,  follow^ed  by  judicious  hygienic  measures — life  may  be  con- 
siderably prolonged.  Sooner  or  later,  however,  barring  a  possible  death 
from  some  intercurrent  affection,  a  fatal  result  is  inevitable. 

Diagnosis. — Uremia  may  be  recognized  by  the  history,  the  marked 
arterial  tension,  and  the  accentuated  Second  sound  of  the  heart ;  also  by 
the  albuminuria  (the  urine  has  to  be  withdrawn),  the  temperature,  and 
the  odor  of  the  breath.  The  presence  of  dropsy  in  some  cases  is  a  valu- 
able indication  of  the  nephritic  origin  of  uremic  manifestations. 

Differential  Diagnosis. — Uremic  unconsciousness  coming  on  suddenly, 
as  in  chronic  interstitial  nephritis,  may  simulate  alcoholism,  cerebral 
hemorrhage  {apoplexy),  cerebral  tumor,  or  meningitis.  The  points  of 
dissimilarity  between  the  first  two  conditions  and  uremia  are  here  tabu- 
lated (Herri  ck) : 

Cerebral  Hemorrhage.  Alcoholic  Narcosis.  Uremia. 

Pupils  unequal  or  dilated.     Pupils   contracted    or    di-  Pupils   generally   dilated ; 

lated  ;  eyes  injected.  albuminuric  retinitis. 

Stertorous,    puffy    breath-     No  stertorous  breathing.  Sharp,  hissing  stertor. 

ing,  and  flapping  cheek. 

No  odor.                                    Odor  of  alcohol.  No  odor,  unless  urinous. 


966 


DISEASES  OF  THE   URINARY  SYSTEM. 


Cerebral  Hemorrhage. 

Paralysis  ;  hemiplegia. 
Unconsciousness  absolute. 


Alcoholic  Narcosis. 

Xo  paralysis,  usually. 
]May  be  aroused. 


Pulse  slow  and  strong  or     Pulse  frequent  and  feeble. 


irregular  ;  arteries  often 
atheromatous. 

Coma  sudden  and  deep. 
Convulsions  late  ;  may  be 

unilateral. 
Urine  generally  negative. 
Apoplectic     habit ;     heart 

may  show  hypertrophy. 


Coma  gradual. 
No  convulsions. 

Urine  generally  negative. 
Red  face  and  nose,  heart 

often  weak,  dilated,  my- 

ocarditic. 


Uremia, 

No  paralysis. 

May  or  may  not  b e 
aroused. 

Pulse  at  first  strong,  later 
weak  and  rapid  :  tension 
strong;  arterio-scle- 
rosis. 

Coma  gradual  or  sudden. 

Preceded  by  general  con- 
vulsions, headache,  etc. 

Urine  albuminous. 

Edema  and  pallor  ;  heart 
bypertrophied. 


In  meningitis  the  mode  of  onset,  the  rigidity  of  the  neck,  incoherence  or 
mikl  delirium,  photophobia,  and  pronounced  fever  point  to  the  distinction. 

Uremic  coma  must  also  be  differentiated  from  opium-poisoning  and 
diabetic  coma.  Chronic  uremia  must  not  be  confounded  with  the  asthenic 
?>t2iteoi  typhoid  fever  dirvdi  acute  miliary  tub  ere  ulo  sis.  In  opium-poisoning 
the  pupils  are  contracted  and  do  not  respond  to  light.  Again,  in  opium- 
poisoning  the  respirations  are  slow,  deep,  and  full,  and  the  patient  may 
answer  rationally  when  aroused.  In  uremic  coma,  it  will  be  remembered, 
consciousness  is  abolished.  In  diabetic  coma  the  history  must  be  learned, 
the  harsh,  dry  skin  and  emaciation  noted,  and  especially  are  the  ethereal 
odor  and  the  Burgundy-red  reaction  of  the  urine  (acetone)  with  the  tincture 
of  the  chlorid  of  iron  to  be  observed  ;  sugar  is  also  present. 

The  prognosis  is  grave,  but  guarded ;  it  is  even  favorable  in  many 
cases,  so  far  as  immediate  results  are  concerned. 

Treatment. — This  will  be  detailed  in  the  discussion  of  the  various 
forms  of  nephritis.  Suffice  it  to  say  that  the  supreme  indication  is  the 
prompt  elimination  of  the  poisons  in  the  blood.  When  diaphoresis  and 
catharsis  fail  either  in  promptness  or  efficiency,  venesection  should  be  em- 
ployed ;  the  latter  measure  is  also  probably  the  most  reliable  in  urgent 
cases  of  uremic  convulsions  or  coma.  The  counter-injection  (intra- 
venous) of  normal  salt  solution  may  be  indicated  in  cases  of  profound 
weakness  threatening  collapse. 

Bozzoli  recommends  the  subcutaneous  injection  of  sterilized  serum 
because  of  the  gratifying  results  secured  in  a  number  of  cases  of  uremia. 


AMYLOID  KIDNEY. 

Definition. — Amyloid  (waxy  or  la rdaceous)  degeneration  of  the  kid- 
neys ;   it  is  usually  coexistent  with  a  similar  degeneration  of  other  viscera. 

Pathology. — Macroscopically,  the  amyloid  kidney  appears  pale, 
greenish  or  yellowish-white,  firm,  and  uniformly  enlarged,  and  the  surface 
is  smooth,  glistening,  and  often  mottled,  owing  to  the  prominence  of  the 
stellate  veins.  On  section  a  homogeneous,  anemic,  or  ''bacon-like" 
surface  presents  itself,  particularly  in  the  cortical  region.  The  cortex 
is  wider  than  normal ;   the  pyramids  may  be  red  in  color   and  slightly 


AMYLOID  KIDNEY.  967 

infiltrated  ;  and  the  glomeruli  may  show  an  infiltration  by  the  glistening, 
translucent  amyloid  (albuminoid)  material.  On  the  application  of  Lugol's 
solution  of  iodin  to  the  amyloid  areas  a  mahogany-red  color  is  produced. 
Brushing  over  the  amyloid  substance  with  a  solution  of  iodin,  and  then 
with  dilute  sulphuric  acid,  gives  a  blue  or  violet  tint.  Similarly  used, 
a  1  per  cent,  solution  of  methyl-violet  strikes  a  red  color.  The  capsule 
of  the  kidney  is  thickened,  though  not  always  adherent. 

Microscopically,  the  amyloid  change  is  generally  found  in  the  early 
stages  to  affect  the  walls  of  the  capillaries  of  the  Malpighian  tufts.  The 
walls  are  swollen  with  the  homogeneous  material  and  the  vessel-lumen  is 
diminished  or  obliterated.  The  straight  uriniferous  tubules  are  also  in- 
filtrated later  perhaps,  the  deposit  occurring  primarily  in  the  membranse 
proprige.  A  diffuse  nephritis  is  nearly  always  an  associated  condition. 
The  tubules  generally  contain  hyaline  casts.  Fatty  degeneration  of 
the  epithelium,  glomerulites  or  waxy  glomeruli,  and  a  thickening  of 
Bowman's  capsule  are  common  in  markedly  amyloid  kidneys.  In  ad- 
vanced cases  most  of  the  secretory  structure  becomes  atrophied.  Amy- 
loid infiltration  of  the  smaller  granular  kidney  is  less  common  than  of 
the  large  white  kidney,  with  intense  parenchymatous  changes. 

Hypertrophy  of  the  heart  is  not  always  present  in  amyloid  disease  of 
the  kidneys.  Amyloid  infiltration  of  other  organs,  however,  as  of  the 
liver  and  spleen,  is  usually  associated  with  waxy  kidneys. 

Ktiologfy. — The  causes  of  amyloid  kidney  are  those  of  the  amyloid 
change  affecting  (either  simultaneously  or  nearly  so)  other  organs,  as  the 
spleen,  liver,  and  intestines. 

Commonly,  amyloid  disease  is  marked  also  in  the  other  solid  organs 
named  above  ;  it  is  secondary  to  wasting  diseases,  cachexise,  and  the  like. 
Perhaps  the  most  frequent  cause  of  the  waxy  kidney  is  tuberculosis,  espe- 
cially of  the  lungs  ("chronic  ulcerative  phthisis"):  tuberculosis  of  the 
intestines  also  is  often  associated  and  aggravates  the  amyloid  infiltration. 
Next  in  order  are  the  prolonged  suppurations,  particularly  of  the  bones, 
as  in  osteitis  of  the  vertebrae  and  hips  (usually  tuberculous).  Chronic 
empyema,  intestinal  ulcers,  vesico-vaginal  fistulse,  and  other  purulent 
affections,  chronic  in  nature  also,   have  the  same  etiologic  effect. 

Amyloid  kidney  is  often  present  in  syphilis,  especially  in  the  tertiary 
stage,  when  ulceration  of  the  mucous  surfaces  and  of  the  bones  is  present. 
Rarely,  gout,  malaria,  leukemia,  cancer,  and  chronic  valvular  endocar- 
ditis with  insufficiency  seem  to  produce  amyloid  disease. 

Symptoms. — These  vary  greatly  according  to  the  extent  to  which 
the  amyloid  degeneration  has  encroached  upon  the  normal  kidney-struc- 
ture, and  may  be  overshadowed  partially  or  completely  by  those  of  the 
dominant  causal  affection. 

The  urine  is  pale  yellow,  clear,  and  variable  in  quantity,  and  the 
amount  passed  in  twenty-four  hours  is  sometimes  normal  or  may  be 
slightly  diminished.  More  frequently,  perhaps,  it  is  increased,  and  espe- 
cially in  marked  or  advanced  cases.  The  specific  gravity  is  apt  to  be 
low  (1015—1005),  and  there  is  seldom  any  sediment. 

Serum-albumin  and  globulin  may  both  be  present  in  the  urine;  but  a 
highly  significant  condition,  and  one  that  is  seemingly  diagnostic,  is  the 
high  proportion  of  globulin  as  compared  with  the  serum-albumin  (Sal- 
kowski.  Senator).      Tube-casts  may  be  found,  but  their  presence  may  be 


968  DISEASES  OF  THE   URINARY  SYSTEM. 

only  temporary;  they  are  usually  wide  hyaline  or  fatty  and  granular, 
and  are  few  in  number  (Fig.  66).  The  amyloid  reaction  may  be  elicited 
with  the  hyaline  casts ;  symptoms  referable  to  the  kidney  are  often 
absent  in  comparison  with  those  of  the  nephritides.  Dropsy  is  not  in- 
variably present,  and  when  present  is  but  moderate  in  degree  and  gen- 
erally in  the  legs  only.  It  is  proportionately  prominent  with  the  in- 
crease in  the  anemia,  circulatory  depression,  and  wasting  of  flesh  and 
strength.  The  latter  manifestations,  constituting  a  cachectic  appearance, 
are  quite  commonly  observed  in  amyloid  kidney. 

The  associated  enlargement  and  the  firm,  sharp  outlines  of  the  liver 
and  spleen  are  of  diagnostic  significance.  Marked  diarrhea  may  be  due 
to  coexisting  amyloid  infiltration  of  the  intestines  or  to  tuberculous  intes- 
tinal ulcers,  and  is  often  seen  in  advanced  cases. 

Diagnosis. — This  can  seldom  be  made  upon  the  urinary  manifesta- 
tions alone.  Important  and  often  necessary  adjuncts  are  the  histories  of 
causation  and  of  the  associated  symptoms  and  physical  signs.  Thus, 
there  will  be  evidenced  in  most  cases  tuberculosis,  chronic  bone-suppura- 
tions, or  syphilis,  while  coexisting  hepatic  and  splenic  enlargements,  wast- 
ing, and  cachexia  are  usually  present.  In  any  of  the  diseased  conditions 
mentioned  amyloid  kidney  may  be  diagnosticated  with  reasonable  cer- 
tainty upon  the  development  of  an  increased  quantity  of  pale  clear  urine 
of  low  specific  gravity  and  containing  a  large  amount  of  albumin,  or  even 
with  slight  albuminuria. 

From  parenchymatous  nephritis  amyloid  kidney  is  to  be  diff"erentiated 
by  the  history,  by  the  more  marked  and  generally  distributed  dropsy, 
and  by  the  albuminuric  retinitis  that  characterize  the  former.  In  chronic 
interstitial  nephritis  there  are  less  marked  albuminuria  and  dropsy,  and 
there  are  present  arterio-sclerosis,  cardiac  hypertrophy,  and  a  pronounced 
tendency  toward  uremic  symptoms. 

Prognosis. — This  varies  with  the  cause.  Incipient  bone-disease  or 
tuberculosis,  with  only  slight  evidences  of  amyloid  change  in  the  kidneys, 
may  be  controlled.  As  a  rule,  however,  the  structural  alterations  are  so 
far  advanced,  and  the  constitutional  powers  of  resistance  so  much  ener- 
vated, before  the  amyloid  infiltration  can  be  distinctly  apprehended  that 
in  the  majority  of  instances  the  prognosis  is  entirely  unfavorable.  In 
decided  cases  death  ensues  in  from  several  weeks  to  as  many  months. 

Treatment. — This  also  depends  upon  the  causal  aff"ection.  Hygienic 
and  dietetic  measures  are  always  useful,  however,  with  a  view  to  improving 
the  general  nutrition.  The  iodid  of  iron  has  been  recommended  as  an 
alterative,  and  easily  assimilable  and  palatable  fats  and  tonics  may  also 
be  tried.  Tuberculous  cases  require  creasote  or  allied  preparations  ;  syph- 
ilitics  require  mercurials  and  iodids ;  while  malarial  subjects  do  best 
under  the  systematic  use  of  arsenic,  iron,  and   quinin. 


NEPHROLITHIASIS. 

(Renal  Calculi;  Pi/ditis  Calculosa  :  Renal  Colic;   Gravel.) 

Definition. — A  condition  characterized  by  the  formation  of  fine  or 
coarse  concretions  in  the  kidney-substance  or  in  the  renal  pelvis  by  the 
precipitation  of  certain  of  the  solid  urinary  constituents. 


NEPHROLITHIASIS.  969 

Varieties. — According  to  their  size,  renal  concretions  are  variously 
termed — (1)  Renal  sand,  of  which  the  particles  are  fine  and  pulverized ; 
(2)  Renal  gravel,  consisting  of  coarse  grains  or  even  of  pea-sized  concre- 
tions ;  (3)  Renal  stone,  or  calculus,  when  larger  masses  than  the  preceding 
exist,  either  more  or  less  rounded  or  as  stony  casts  or  moulds  of  the  pelvis 
of  the  kidney,  its  iufundibula,  and  calyces  (dendritic  or  coral  calculi). 

According  to  their  composition,  the  chemical  varieties  of  renal  concre- 
tions are — (1)  Uric-acid  calculi,  the  most  frequent  in  occurrence.  Urates 
are  often  associated  in  the  calculus  with  uric  acid,  thus  producing  strati- 
fication. These  concretions  may  occur  as  sand,  gravel,  or  large  stones : 
they  are  usually  quite  hard,  reddish-brown  or  black  in  color,  and  have  a 
smooth  though  irregularly-shaped  surface.  The  fracture  is  crj'stalline, 
and  in  the  larger  calculi  often  shows  the  alternating  layers  of  uric  acid 
and  ammonium  urate.     Pure  uratic  stones  may  occur  in  children. 

(2)  Calcium- oxalate  concretions  occur  more  rarely  in  the  kidney.  They 
constitute  the  so-called  "mulberry  calculi,"  from  a  fancied  resemblance 
to  the  mulberry,  oAving  to  their  dark-brown  or  black  color  and  very  irreg- 
ular and  nodulated  or  prickly  appearance.  They  are  also  quite  dense ; 
lamination,  however,  is  not  common,  although  they  are  sometimes  formed 
about  a  uric-acid  nucleus. 

(3)  Phosphatic  calculi  of  the  kidney  are  still  less  common  than  the 
oxalate,  but  they  ai-e  more  common  in  the  bladder.  They  may  consist  of 
calcic  phosphate  or  ammonio-magnesic  phosphate,  and  may  possibly  be 
associated  with  calcic  carbonate.  Phosphatic  salts  are  most  often  depos- 
ited secondarily  about  uric-acid  or  oxalate  calculi  in  the  alkaline  urine  of 
a  cystitis  set  up  by  the  irritation  of  the  true  renal  stones.  Phosphatic 
calculi  are  grayish-white  in  color  and  are  comparatively  soft. 

(4)  Renal  stones  composed  of  cystin,  xantJiin,  carbonate  of  lime,  fatty 
or  saponaceous  matters  (urostealith),  indigo,  and  fibrin,  though  of  extreme 
rarity,  have  been  occasionally  reported.  Cystin  calculi  have  a  pale-yellow 
color  and  a  waxy  luster. 

Pathology. — The  anatomic  changes  of  the  kidney  vary  with  the 
degree  and  persistence  of  the  irritation,  the  size  of  the  calculi,  and  their 
passage  or  retention.  Sometimes  numerous  granular  and  pea-sized  con- 
cretions are  found  in  the  renal  pelvis,  with  desquamated  epithelium  and  a 
turbid  urine.  Interesting  cases  are  those  in  which  a  dendritic  stone 
occupies  a  great  portion  of  the  atrophied  kidney-substance,  as  well  as 
the  entire  pelvis  of  the  organ.  In  one  of  my  own  patients  the  left  kidney 
was,  apparently,  nearly  twice  the  normal  size,  owing  to  the  presence  of  a 
larg^  coral-calculus  (uric  acid  and  urates),  connected  by  an  isthmus  with 
a  rounded  stone  in  the  inferior  portion  quite  as  large  as  a  large  walnut. 
The  pelvis  of  the  right  kidney  also  contained  a  dendritic  calculus. 

Secondary  Lesions. — Perhaps  the  most  usual  result  of  renal  concre- 
tions is  a  pyelitis  :  this  may  be  simple  catarrhal,  diphtheritic,  or  purulent, 
with  or  without  hemorrhages,  depending  upon  the  intensity  of  the  mechan- 
ical irritation.  A  pyelo-nephritis  may  follow  in  severe  cases,  as  may  even 
a  general  suppuration  (pyonephrosis)  or  perinephric  abscess  and  perfora- 
tions. Renal  pus-cavities  are  sometimes  found  postmortem  containing 
numerous  small  stones.  Hydronephrosis  is  another  important  pathologic 
sequel,  in  which  the  cause  is  to  be  attributed  to  the  blocking  of  the 
ureter  by  an  erstwhile  passing  stone  or  by  the  closing  of  the  aperture  of 


970  DISEASES  OF  THE   URINARY  SYSTEM. 

a  ureter  from  within  the  pelvis.  Pressure-necrosis  and  perforation  may 
thus  be  induced.  Owing  to  the  prolonged  pressure  of  a  dendritic  calculus, 
there  is  commonly  a  distinct  and  marked  atrophy  of  the  renal  parenchyma, 
resulting  in  chronic  diffuse  nephritis  with  little  or  no  exudation. 

Ktiologfy. — The  definite  causation  and  the  exact  manner  of  formation 
of  renal  concretions  are  still  unestablished.  We  may  infer  not  a  little, 
however,  with  some  good  reason,  since  the  predisposing  causes  are  rather 
distinct.  Thus,  in  children  and  in  advanced  life  (before  15  and  after 
50  years  of  age — Purdy)  the  occurrence  of  calculi  is  most  common,  the 
uratic  variety  being  most  freouent  in  the  former  and  the  uric  acid  in  the 
latter.  Men  are  subject  to  nephrolithiasis  more  often  than  are  women. 
The  uric-  or  lithic-acid  state  (lithemia),  gout,  and  the  various  influences 
that  induce  these  conditions,  as  an  excessive  meat  (proteid)  diet  or  a 
sedentary  life,  seem  to  predispose  to  stone.  Heredity,  I  believe,  plays 
a  prominent  part  in  many  cases. 

Broadly  speaking,  any  habit  of  the  system  that  encourages  the  pre- 
cipitation of  insoluble  abnormal  ingredients  or  of  normal  ingredients  in 
excess,  owing  to  chemical  changes  in  the  urine,  tends  to  the  formation 
of  calculi.  It  should  be  stated,  however,  that  the  primary  causes  of  cal- 
culus-formation is  the  presence  of  some  substance  in  the  urinary  tract 
that  affords  a  nucleus  about  which  the  successive  layers  of  crystals  may 
deposit  and  adhere,  such  as  bits  of  mucus,  colloid  material,  epithelial 
shreds,  parasitic  ova,  bacteria,  blood-clots,   and  tube-casts. 

It  is  generally  believed  that  the  retjuisite  conditions  for  the  formation 
of  a  uric-acid  renal  calculus  are — a  highly-acid  urine,  an  excess  of  uric 
acid,  a  low  percentage  of  salines,  and  deficiency  of  the  normal  urinary 
coloring-matters. 

Symptoms. — These  may  be  slight,  progressive,  and  chronic,  or  they 
may  be  intensely  acute  and  comparatively  short  in  duration,  though  sub- 
ject to  repetition — /.  e.  renal  colic.  It  is  not  unusual  for  patients  to 
pass  uric-acid  sand  and  gravel  for  years  without  much  complaint.  A 
sudden  blocking  of  a  ureter,  however,  or  a  slowly-passing  stone  of  dis- 
tending dimensions  produces  great  agony  at  times.  A  smooth,  snugly- 
fitting  dendritic  calculus  in  the  pelvis  may  not  cause  any  symptoms  for 
years  until  the  destruction  of  tissue  by  its  weight  and  mechanical  irritation 
ensues  ;  there  is  then  a  progressive  failure  of  health,  a  constantly  increas- 
ing pain  in  the  back,  occasional  hematuria,  tenderness^  on  pressure  over 
the  diseased  kidney,  both  anteriorly  (deep)  and  posteriorly,  and  finally 
uremia  and  death. 

The  characteristic  symptoms  of  stone  in  the  kidney  appear  as  an  attack 
of  renal  colic.  This  happens  when  a  calculus  in  its  passage  down  the 
ureter  acts  as  a  mechanical  irritant,  or  when  it  is  caught  and  stopped  in 
the  passage.  The  large  ""gravel"  or  pea-sized  and  more  or  less  rough 
stones  usually  cause  the  attack,  which  comes  on,  as  a  rule,  quite  suddenly, 
although  it  may  be  preceded  by  a  chill  and  some  general  uneasiness  or 
by  slight  pain  in  the  region  of  the  kidney.  It  may  be  excited  by  a  sud- 
den muscular  effort.  The  pain  is  tearing  in  character,  and  rapidly 
reaches  an  agonizing  maximum  of  severity,  starting  from  the  lumbar  re- 
gion and  extending  down  along  the  ureter  into  the  groin,  and  often  into 
the  testicle  and  inner  side  of  the  thigli.  The  paroxysm  may  appear  in 
the  form  of  a  diffuse  abdominal  and  lumbar  pain  in  some  instances.    There 


NEPHROLITHIASIS.  971 

is  local  tenderness  on  pressure,  and  nausea  and  repeated  vomitings  are 
frequent.  The  patient  is  often  collapsed,  and  perspiration,  a  rapid,  small, 
and  feeble  pulse,  trembling,  anxiety,  bodily  twistings  about,  convulsions 
even,  and  syncope  may  ensue.  There  may  be  moderate  fever.  The  urine 
is  scanty  or  may  be  suppressed  for  a  time,  and  is  often  bloody.  Frequent 
and  painful  attempts  at  urination  are  made,'  with  the  passage  of  but  a  few 
drops  at  a  time,  owing  perhaps,  in  part  at  least,  to  a  reflex  spasm  of  the 
vesical  sphincter  (vesical  tenesmus).  The  presence  of  pus  and  of  pelvic 
epithelium  in  the  urine  indicates  a  pyelitis.  When  a  large  quantity  of 
clear  urine  is  passed,  as  sometimes  happens,  it  may  be  looked  upon  as 
having  come  from  a  healthy  kidney. 

The  paroxysyn  of  renal  colic  ends  when  the  impacted  stone  passes  out 
of  the  ureter.  This  may  occur  within  a  few  hours  or  it  may  take  several 
days ;  in  instances  of  the  latter  type  the  attacks  of  renal  colic  may  be 
intermittent. 

Recovery  is  not  always  complete  immediately  upon  the  evacuation  of 
the  stone.  The  previously  retracted  testicle  may  be  painful  and  swollen 
for  a  little  while,  and  there  are  apt  to  be  aching  and  soreness  over  the 
aifected  kidney  and  ureter. 

In  certain  severe  cases  of  mechanical  irritation  the  symptoms  of  pye- 
litis, pyelo-nephritis  with  abscess,  or  hydronephrosis  may  be  superadded. 
Anuria  and  uremia  result  from  simultaneous  obstructive  suppression  of 
the  urine  upon  both  sides. 

Nephrolithiasis  as  a  chronic  affection  may  exist  for  many  years,  with 
recurring  paroxysms  of  renal  colic.  I  observed  a  case  for  five  years 
that  had  extended  over  a  period  of  thirty  years,  until  it  finally  came  to 
necropsy.  Between  the  attacks  of  colic  the  patient  may  be  entirely 
comfortable,  save  perhaps  an  occasional  burning  in  the  urethra  on  mic- 
turition, owing  to  a  highly-concentrated,  acid  urine  or  to  the  passage 
of  minute  uric-acid  granules.  There  are  apt  to  be  pain  and  tenderness 
over  a  kidney  containing  a  large  imbedded  stone.  A  smoky-hued 
urine,  due  to  slight  hematuria,  is  also  sometimes  present  in  long-stand- 
ing cases  of  renal  calculus,  particularly  after  exertion. 

A  renal  intermittent  fever,  simulating  malarial  paroxysms,  may  occur 
in  nephrolithiasis,  and  is  analogous  to  the  hepatic  intermittent  fever  of 
cholelithiasis. 

Pyelitis — simple  or  purulent — with  late  involvement  of  the  kidney- 
parenchyma  (pyelo-nephritis)  is  a  frequent  concomitant  of  chronic  nephro- 
lithiasis. The  presence  of  pus  in  the  urine  is  constant,  with  an  absence 
of  renal  epithelium  in  cases  of  an  abscess-cavity  of  the  kidney.  In  ordi- 
nary pyelitis  the  pyuria  is  often  intermittent. 

The  general  health  of  patients  with  nephrolithiasis  is,  as  a  rule,  re- 
markably good.  Anorexia  is  not  only  seldom  present,  but  such  persons 
are  habitually  free  and  good  livers.  Persistent  headaches  with  nausea, 
however,  should  warn  one  of  uremia.  Splenic  and  hepatic  enlargement 
may  be  found  with  prolonged  suppurative  pyelo-nephritis,  indicating 
amyloid  disease. 

Diagnosis. — This  resolves  itself  into  a  study  of  the  diagnostic  cha- 
racters of  (o)  the  attacks  of  renal  colic,  {h)  of  the  underlying  systemic 
condition  in  general,  and  (c)  the  renal  condition  in  particular  that  renders 
these  attacks  possible.     The  latter  can  be  discovered  only  by  a  careful 


972  DISEASES  OF  THE   URINARY  SYSTEM. 

and  continuous  study  of  the  clinical  history  and  urinary  manifestations  as 
outlined  in  previous  paragraphs. 

Nephrolithiasis  may  be  positively  diagnosed  in  a  case  in  which,  after 
sudden,  agonizing,  colicky  pain,  referred  to  either  lumbar  region  and 
radiating  down  the  ureteral  course  to  the  testicle,  a  concretion  is  found  to 
have  passed  with  the  urine.  It  is  therefore  necessary  in  a  suspected  case 
of  renal  colic  to  pour  the  urine  through  a  fine  sieve  as  soon  as  passed. 
The  more  recent  improvements  in  the  operative  technic  for  producing 
the  Roentgen  rays  enable  us  to  detect  renal  calculi  with  considerable 
accuracy  as  to  their  number,  size,  and  relative  position. 

Differential  Diagnosis. — Renal  colic  must  not  be  taken  for  biliary  or 
intestinal  colic.  The  antecedent  history  is  of  great  value  in  arriving  at  a 
diagnosis.  In  biliary  colic  there  may  be  jaundice,  and  pain  referred  to 
the  upper  rather  than  to  the  lower  abdominal  zone,  both  of  which  symp- 
toms are  absent  in  renal  colic ;  while  in  the  latter  the  disturbance  of  mic- 
turition and  the  character  of  the  urine,  especially  the  hematuria,  are 
characteristic. 

In  intestinal  colic  the  griping  pain  is  usually  most  intense  in  the  um- 
bilical region,  is  often  relieved  by  pressure,  and  is  associated  with  tym- 
panites and  constipation ;  it  has  usually  a  dietetic  origin,  while  the  renal 
and  urinary  symptoms  are  absent.  The  exclusion  of  lumbodynia  and 
lumho-ahdominal  neuralgia  is  not  so  difficult.  The  differentiation  of  the 
varieties  of  calculi  from  the  symptoms  is  not  positive.  It  has  been  sug- 
gested, however,  that  the  oxalate  stones  usually  cause  the  sharpest  pains 
and  the  hematuria.  Right-sided  ureteral  pain  felt  over  the  lower  ab- 
dominal region  may  be  confounded  at  first  with  appendiceal  colic.  Mus- 
ser  has  found  the  pain  of  renal  colic  to  be  more  paroxysmal  and  less 
uniform  in  location  than  in  the  latter  however.  Early  roial  tuberculosis 
{vide)  with  its  hematuria  and  pyuria  must  be  differentiated  from  renal 
calculus  also. 

Prognosis. — This  should  always  be  guarded,  owing  to  the  possible 
dangers  and  complications  that  frequently  attend  nephrolithiasis  in  all 
of  its  forms.  Thus  the  passage  of  gravel  without  marked  symptoms 
tends  to  persist  or  recur — in  both  events  an  unfavorable  tendency,  since 
subsequent  formations  are  apt  to  be  larger  and  cause  serious  symptoms. 
An  attack  of  renal  colic  may  itself  be  fatal.  Large  latent  calculi  (den- 
dritic), of  long  standing,  are  nearly  always  incurable,  and  in  most  in- 
stances lead  to  such  grave  complications  as  pyelo-nephritis,  pyo-  and 
hydronephrosis,  perinephric  abscess,  and  uremia. 

Treatment. — Paroxysms  of  renal  colic  call  for  prompt  relief.  This 
is  best  afforded  by  hypodermic  injections  of  morphin  and  atropin, 
coupled  with  hot  baths  or  fomentations  applied  to  the  loins.  The  free 
use  of  hot  drinks,  as  lemonade,  soda,  or  plain  water,  is  also  helpful  in 
promoting  the  passage  of  the  stone.  Drinking  large  quantities  of  gly- 
cerin mixed  with  water  has  proven  of  service  in  some  cases.  Cases  of 
excessive  suffering  require  the  inhalation  of  chloroform. 

The  treatment  of  the  nephrolithiasis  without  or  between  attacks  of 
renal  colic  is  most  important.  First  to  be  considered  are  the  hygienic 
and  dietetic  measures,  for  in  mild  and  uncomplicated  cases  much  can  be 
done  to  prevent  the  aggravation  of  the  disorder,  and  at  least  the  forma- 
tion of  larger  concretions  may  be  delayed.  When  the  tendency  is  to 
uric-acid  gravel  (the  commonest  variety),  the  patient  should  live  a  reg- 


NEPHROLITHIASIS.  973 

ular,  calm,  steady,  and  temperate  life.  Exercise  should  be  so  managed 
that  it  may  be  taken  rather  moderately  in  the  open  air,  and  with  a  view 
to  preventing  additional  weight  in  persons  of  fair  nutrition  and  to  pro- 
moting a  reduction  of  weight  in  the  obese.  In  short,  the  exercise  should 
be  sufficient  to  thoroughly  use  up  all  nitrogenous  food,  so  that  the  formation 
and  elimination  of  urea  may  be  increased  to  normal  and  the  quantity  of 
uric  acid  diminished.  Hence  I  would  strongly  advise  a  clinical  study  of 
the  percentage  of  urea  in  the  urine  (vide  p.  957). 

Over-indulgence  in  food,  particularly  in  red  meats  (liver,  sweetbread, 
and  similar  nuclear  food),  should  be  prohibited,  owing  to  the  ready  for- 
mation of  uric  acid  from  the  latter.  Alcohol  should  be  taken  seldom, 
or,  better,  not  at  all.  On  the  other  hand,  since  the  urine  is  apt  to  be 
scanty  and  highly  acid,  the  patient  should  be  encouraged  to  drink  freely 
of  plain  and  alkaline  waters,  artificial  and  natural.  The  value  of 
various  pure  spring-waters  as  diluents  is  undoubted,  the  Buffalo, 
Londonderry,  and  Otterburn  Lithia,  the  Saratoga,  Bedford,  and  Poland 
waters,  all  being  distinguished  for  their  purity.  More  marked  and  more 
generally  useful  for  their  alkalinity  are  the  Carlsbad,  Vichy,  and  carbon- 
ated waters.  In  cases  characterized  by  occasional  hematuria  the  Bock- 
bridge  alum-water  may  be  tried.  Plain  soda-water  and  lemonade  may  be 
used  as  adjuvants. 

The  medicinal  treatment  of  nephrolithiasis  is  aimed  to  secure  a  sol- 
vent and  disintegrating  action  upon  the  stones  ;  it  is  symptomatic.  It  is 
extremely  doubtful  whether  stones  once  formed  in  the  pelvis  of  the  kid- 
ney and  remaining  there  are  ever  dissolved,  though  certain  drugs  would 
seem  to  have  had  an  eroding  effect  in  some  instances,  and  they  are 
to  be  recommended  as  useful  in  preventing  the  formation  of  new  deposits. 
Lithium  citrate  or  carbonate  in  5-grain  (0.324)  doses  in  tablet  form, 
three  or  four  times  daily,  has  been  generally  employed  for  the  purpose. 
Sodium  phosphate  and  the  vegetable  salts  of  potash,  as  the  citrate,  acetate, 
and  tartrate,  are  useful.  Much  water,  especially  the  carbonated,  should 
be  drunk,  along  with  doses  of  the  above,  in  order  to  facilitate  the  solvent 
action,  and  in  this  way  relieve,  in  a  measure,  the  local  distress  and  pain. 
Becently  piperazin,  lycetol,  and  urotropin  have  been  brought  forward 
as  uric-acid-calculus  solvents  by  some  clinicians,  and  that  they  have 
such  action  as  is  claimed  has  been  proved  beyond  a  doubt  in  certain 
cases.  Whilst  they  deserve  a  further  trial  in  nephrolithiasis,  it  is  too 
,  much,  however,  to  expect  to  look  for  positive  and  successful  results  in 
every  case. 

Recently,  Van  Noorden  and  Strause  have  recommended  calcium  car- 
bonate (gr.  x-xv — 0.648-0.972 — or  more  thrice  daily).  The  theory  is 
that  the  calcium  unites  with  the  acid  phosphates  in  the  intestines,  and 
thus  reduces  the  deuterophosphates  in  the  urine,  leaving  the  protophos- 
phates  to  dissolve  the  uric  acid.     They  report  excellent  clinical  results. 

The  reaction  of  the  urine  must  be  tested  at  stated  intervals  and  kept 
faintly  acid.  Should  the  urine  become  alkaline,  the  alkaline  treatment 
must  be  suspended  for  a  while,  or  a  secondary  deposit  of  phosphates  about 
the  uric-acid  stone  may  be  induced.  Nagging  lumbar  pains  may  be  re- 
lieved by  occasional  doses  of  such  analgesics  as  phenacetin,  belladonna, 
hyoscyamus,  codein,  and  indirectly  by  the  sweet  spirits  of  niter,  buchu. 


974  DISEASES  OF  THE   URINARY  SYSTEM. 

and  uvta  ursi.  Renal  hemorrhage  may  be  controlled  effectually  by  the 
use  of  the  fluid  extract  of  ergot,  or  by  alum  in  10-  or  15-grain  (0.648  or 
0.972)  doses,  or  by  gallic  acid  in  20-  or  30-grain  (1.29-1.94)  doses. 

Efforts  to  acidify  the  urine  are  indicated  "when  the  calculus  happens 
to  be  composed  of  pliosphates  or  of  calcium  carbonate.  This  is  more 
difficult  of  accomplishment  than  when  it  is  necessary  to  reduce  the  acidity. 
Saccharin  in  2-  or  3-grain  (0.129-0.194),  and  benzoic  and  boric  acids  in 
5-  to  15-grain  (0.324-0.972)  doses,  in  capsules,  seem  to  be  most  useful  for 
this  purpose.  It  is  claimed  for  calcium  carbonate,  again,  that  it  dimin- 
ishes the  phosphates  Avithout  making  the  urine  alkaline. 

The  question  of  surgical  interference  must  be  decided  in  not  a  few 
cases ;  thus,  it  may  be  briefly  stated  that  in  protracted  and  obstinate 
cases  of  calculous  renal  disorder,  with  persistent  local  pain,  a  gradually 
decreasing  capacity  for  Avork.  and  evidences  of  severe  pyelitis,  pyelo- 
nephritis, or,  worse,  of  perinephric  abscess,  the  surgeon  must  operate.  In 
the  simplest  cases  a  nephrotomy  or  nephro-lithotomy  may  be  performed 
and  the  stone  removed.  Where  the  renal  structure  is  much  damaged  it 
may  be  necessary  to  do  a  nephrectomy.  To  avoid  the  increased  perils  of 
the  latter  operation,  hoAvever,  it  Avere  better  that  a  nephrotomy  Avere  done 
as  early  as  consistent  Avith  the  diagnosis  of  incarcerated  pelvic  stone  and 
the  condition  of  the  patient. 


ACUTE  NEPHRITIS. 

{Acute  Brighfs  Disease;  Acute  Diffuse  Nephritis ;  Acute  Parench/matous  Nephritis ; 
Exudative.  Catarrhal,  Tubal,  Desquamative,  and  Glomei-ulo-nephriiis  of  Acute 
Course. ) 

Definition. — An  acute  inflammation  of  the  kidneys,  more  or  less 
diffuse  in  nature.  It  may  be  either  of  a  mild,  severe,  or  grave  cha- 
racter. Delafield  describes  three  varieties  of  acute  renal  inflammation 
under  the  common  synonym  of  acute  Bright's  disease,  as  folloAvs  :  (1)  acute 
degeneration  of  the  kidneys,  (2)  acute  exudative  nephritis,  and  (3)  acute 
productive  nephritis.  This  division  is  of  etiologic  and  pathologic  import- 
ance and  interest,  rather  than  of  clinical  necessity  or  practical  value. 

Pathology. — The  anatomic  changes  in,  and  the  appearances  of,  the 
kidneys  vary  considerably  in  different  cases  according  to  the  degree  of 
involvement.  Fi'om  the  very  mild  to  the  gravest  cases  of  nephritis  there 
is  an  intermediate  series  of  continuously  more  marked  pathologic  changes 
in  the  renal  tissues.  These  depend  greatly  on  the  amount  of  poisonous 
material  circulating  in  the  kidneys  and  eliminated  by  them,  as  Avell  as 
upon  the  intensity  and  duration  of  its  noxious  action. 

In  the  mildest  cases  the  macroscopic  appearances  of  the  kidneys  may 
present  nothing  distinctly  abnormal.  As  a  rule.  hoAvever,  the  organs  are 
slightlv  enlarired,  sAvollen.  and  somcAvhat  softened.  These  conditions  are 
more  evident  Avhen  the  interstitial  exudation  is  abundant  and  when  in- 
flammatory edema  is  evident.  The  kidneys  may  be  reddened  and  con- 
gested and  appear  bloody  on  section,  or  they  may  be  pale  and  mottled. 
In  examples  of  the  former,  hemorrhages  may  be  formed  beneath  the  cap- 


ACUTE  NEPHRITIS.  975 

sule  {acute  hemorrhagic  nephritis),  though  it  is  more  common  to  see  red 
patches  of  hyperemia  alternating  with  opaque,  whitish  portions  on  both 
the  outer  and  cut-surfaces  of  the  kidneys.  The  cortex  especially  is 
swollen,  turbid,  and  pale,  or  slightly  congested  in  the  mildest  cases,  and 
is  deeply  mottled  (red  and  pale  glomeruli)  or  hyperemic  in  severe  in- 
stances. The  pyramids  usually  show  an  intense  redness.  The  surfaces 
are  smooth  and  the  capsule  non-adherent. 

Microscopically,  alterations  may  be  discovered  that  are  not  visible  to 
the  naked  eye  in  the  very  mild  cases  referred  to  above.  There  is  simply 
a  cloudy  swelling  or  a  granular  (parenchymatous)  degeneration  of  the 
epithelium  of  the  Malpighian  tufts.  Bowman's  capsule,  and  of  the  cortical 
uriniferous  tubules.  This  is  not  true  acute  nephritis,  however,  in  the 
absence  of  exudative  changes  in  the  interstitial  tissue.  The  acute  paren- 
chymatous degeneration  may  be  almost  exclusively  limited  to  the  glome- 
ruli, as  in  some  cases  of  scarlatina,  and  hence  the  ievm  glomerulo-nephri- 
tis.  The  cells  are  swollen,  opaque,  and  irregular  in  shape,  while  the 
cell-contents  are  granular  (albuminoid  or  fatty).  A  further  advance  in 
the  process  is  seen  in  cellular  coagulation-necrosis  or  disintegration,  des- 
quamation of  the  cells,  and  hyaline  degeneration  of  masses  of  them  in  the 
tubules.  Acute  degenerative  changes  are  frequently  found  in  the  acute 
infectious  diseases  or  when  inorganic  poisons  have  been  introduced  into 
the  body.  In  phosphorus-poisoning  actual  fatty  degeneration  of  the 
epithelium  may  be  found,  this  either  proceeding  from  the  cloudy  swell- 
ing or  developing  independently.  A  rapid  necrosis  of  cells  is  also  met 
with  in  severe  cases. 

True  acute  nephritis  is  not  only  characterized  by  changes  of  the  renal 
epithelium  (the  parenchyma),  but  the  inflammatory  exudate  (serum,  leu- 
kocytes, and  erythrocytes)  is  found  between  the  tubules.  The  kidneys 
show  difierent  stages  of  the  process  in  different  portions.  In  some  places 
there  is  only  a  slight  cellular  infiltration  of  the  intertubular  tissues ;  in 
others,  besides  the  desquamation  of  necrotic  epithelial  cells  and  the  pres- 
ence of  hyaline  casts  in  the  tubules,  the  interstitial  tissue  is  swollen  by 
the  coagulated  sero-fibrinous  exudate,  abundant  leukocytes,  and  some  red 
blood-corpuscles.  It  should  be  stated  that  the  inflammatory  exudate  col- 
lects also  in  the  Malpighian  bodies  and  tubules.  The  epithelium  lining 
the  latter,  especially  the  convoluted  portion,  is  often  flattened,  and  the 
tubules  themselves  may  be  dilated  and  choked  with  degenerated  cells,  or, 
more  frequently  in  the  straight  tubules,  with  hyaline  casts.  The  white 
blood-cells  that  are  found  infiltrating  the  stroma  of  the  kidney  are  not 
usually  equally  difi"used,  but  are  collected  in  foci  in  the  cortex. 

The  glomerular  epithelium  of  the  capsule,  and  especially  that  covering 
the  outside  of  the  capillaries  of  the  tufts,  is  swollen  and  opaque,  and  the 
outlines  of  the  individual  capillaries  are  lost.  In  most  cases  of  diffuse 
exudative  nephritis  new  epithelium  appears,  and  a  restoration  of  the 
glomerular  function  takes  place.  In  the  productive  variety  of  acute 
diffuse  nephritis,  however,  according  to  Delafield,  the  lesions  consisting 
of  a  cellular  growth  in  the  capsules  and  of  connective  tissue  around 
thickened  arteries — are  more  permanent  in  character  from  the  first,  and 
hence  the  increased  gravity  of  the  disease.  In  the  more  intensely  acute 
cases  the  new  tissue  between  the  tubules  is  lai'gely  cellular ;  in  those  of 
a  subacute  type  it  is  relatively  dense  and  fibrous. 


976  DISEASES  OF  THE   URINARY  SYSTEM. 

Anasarca  and  pleural,  pericardial,  and  peritoneal  dropsy  are  also  found 
in  those  dying  of  acute  Bright's  disease.  Cerebral  edema,  meningitis, 
and  lobar  pneumonia  ai'e  to  be  mentioned  as  complicating  conditions  that 
are  sometimes  seen  postmortem. 

Htiology. — Acute  nephritis  may  occur  at  any  time  of  life,  though  it 
more  often  makes  its  appearance  before  than  after  middle  life.  Males  are 
more  susceptible  than  females,  and  particularly  when  engaged  in  occupa- 
tions requiring  exposure  to  cold  and  wet.  The  habitual  use  of  alcoholics 
also  is  generally  a  predisposing  cause  of  acute  Bright's  disease. 

The  principal  exciting  causes  of  acute  diifuse  nephritis  are  the  follow- 
ing :  (1)  Those  acting  on  the  skin,  as  cold  and  dampness,  extensive  burns, 
and  chronic  skin-diseases.  In  many  cases  it  is  difficult  to  estimate  whether 
the  influence  of  alcoholic  intemperance  predominates  or  the  exposure  in- 
cident to  it.  Thus,  acute  intoxication  from  beer-drinking  itself  may 
cause  an  attack  of  acute  nephritis,  but  it  is  likely  that  in  most  instances 
the  direct  exciting  cause  is  cold  acting  upon  the  individual  in  his  ex- 
posed and  maudlin  condition.  The  disease  may  also  be  attributed  at 
times  to  exposure  to  cold  and  wet  irrespective  of  alcoholic  indulgence.  It 
may  be  presumed  with  reason  that  in  such  cases  there  is  some  inherent 
or  acquired  weakness  or  a  susceptibility  of  the  kidneys,  rendering  them 
the  weak  links  in  the  visceral  or  systemic  chain. 

(2)  Biologic  Toxic  Agents. — These  embrace  the  poisons  of  the  acute 
infectious  diseases,  though  in  the  majority  of  cases  scarlet  fever  is  the 
primary  affection.  Nephritis  may  supervene  during  the  height  of  scarla- 
tina, but  more  often  it  occurs  in  the  second  or  third  week  of  convales- 
cence. Other  infectious  fevers  may  also  cause  acute  nephritis  (small- 
pox, typhus,  typhoid,  relapsing  fever,  epidemic  influenza,  cholera,  diph- 
theria, yellow  fever,  measles,  chicken-pox,  erysipelas,  septico-pyemia, 
acute  lobar  pneumonia,  cerebro-spinal  meningitis,  dysentery,  acute  artic- 
ular rheumatism,  and  tuberculosis :  syphilis  is  rarely  a  cause).  Acute 
infectious  nephritis  may  also  occur  as  a  primary  disorder,  and  the  brunt 
of  the  affection  may  fall  either  upon  the  kidney,  rather  than  upon  any 
other  part,  or  upon  the  organisui  as  a  whole,  as  in  the  fevers.  Manna- 
berg,  among  others,  has  described  such  cases,  and  demonstrated  strep- 
tococci in  the  urine. 

(3)  Chemical  Toxic  Agents. — Among  the  principal  irritants  of  this 
class  are  turpentine,  cantharides,  carbolic  and  salicylic  acids,  iodoform, 
the  mineral  acids,  potassium  chlorate,  and  such  inorganic  poisons  as  phos- 
phorus, lead,  arsenic,  and  mercury.  The  excessive  ingestion  of  highly- 
acid,  spiced,  or  adulterated  foods  (as  from  salicylic  acid  and  lead  chromate) 
may  in  certain   individuals  cause  acute  renal   inflammation. 

(4)  Pregnane//. — Here  the  nephritis  (gravidarum)  comes  on  in  prim- 
iparge,  usually  in  the  last  months  of  pregnancy.  It  is  probably  caused  by 
renal  engorgement  due  to  mechanical  pressure,  as  well  as  to  nutritive  dis- 
turbances in  the  kidney,  owing  to  the  altered  blood-condition. 

(5)  Finally,  latent  and  insidious  chronic  ne/>]tritis  may  be  the  cause 
of  ail  onset  of  a  manifest  acute  nephritis. 

Symptoms. — The  onset  varies  with  the  cause  of  the  nephritis, 
though  generally  it  is  rather  sudden.  Chilliness,  nausea  and  vomiting, 
pain  in  the  back,  and,  within  twenty-four  hours,  dropsy,  are  seen  in  some 
cases.      Children  may  be  seized  with  convulsions  (uremic),  and  adults  are 


ACUTE  NEPHRITIS.  977 

not  less  liable  to  them  in  severe  attacks.  Fever  may  be  present,  although 
it  is  neither  constant  nor  high.  The  characteristic  symptom  is  the  early 
appearance  of  edematous  puffiness  of  the  eyelids  and  face,  with  pallor  of 
the  skin.  Soon  (and  sometimes  at  first,  even)  a  swelling  is  noticed  about 
the  ankles  and  legs,  and  in  marked  cases  the  whole  body  becomes  drop- 
sical, so  that  pitting  on  pressure  may  be  observed  pretty  much  all  over 
the  bodily  surface.  In  such  instances  the  scrotum  and  penis  or  the 
labia  may  become  enormously  distended,  the  skin  having  almost  a  trans- 
lucent appearance. 

Local  symptoms,  as  pain  and  tenderness  in  the  lumbar  region,  are 
often  wanting  and  are  never  marked.  There  may  be  a  desire  to  mictu- 
rate often,  accompanied  by  slight  burning  and  vesical  tenesmus,  due  to 
the  concentrated  urine.  In  very  severe  dropsy  the  tense,  dry  skin,  as 
of  the  limbs,  may  be  sensitive  or  even  painful  to  the  pressing  finger. 
Movements  of  the  body  are  often  difiicult,  painful,  and  distressing  in 
marked  anasarca.  Intense  headache  and  backache  may  precede  the  on- 
set of  uremia. 

In  mild  cases  the  renal  condition  may  be  overlooked  unless  a  urinary 
examination  is  made.  Prostration  may  be  unnoticed,  and  the  patient 
feel  nothing  more  than  a  general  malaise. 

The  characteristics  of  the  urine  in  acute  nephritis  are  all-important. 
The  total  quantity  passed  in  twenty-four  hours  is  diminished,  and  may  be 
very  scanty,  sometimes  amounting  to  not  more  than  from  5  to  25  ounces 
(150-740  c.c).  Suppression  occurs  in  some  cases  of  toxic  origin,  when 
an  acute  degeneration  or  necrosis  of  the  renal  epithelium  takes  place,  and 
in  the  most  severe  exudative  inflammations.  The  specific  gravity  is  in- 
creased to  1025  or  more  early  in  the  case  ;  later  it  may  be  as  low  as  1010 
or  1015.  The  color  is  darker  than  normally,  and  is  usually  smoky-red 
or  reddish-browm,  according  to  the  amount  of  blood  passed.  If  the  ab- 
normal morphologic  constituents  are  present  in  great  quantity,  a  more  or 
less  abundant  flocculent  sediment  appears  on  standing. 

Microscopically,  some  red  blood-corpuscles  and  renal  epithelium  are 
found,  along  with  the  characteristic  blood,  epithelial  and  granular  tube- 
casts  (Fig.  61).  Chemically  the  urine  is  acid,  and  on  boiling  a  thick, 
curdy  precipitate  of  albumin  forms.  The  percentage  of  the  latter  by 
weight  varies  from  ^  to  1  per  cent.  The  urea  and  gross  solids  are 
diminished. 

Other  symptoms  may  develop  during  the  course  of  acute  Bright's  dis- 
ease. If  great  general  edema  is  present,  physical  signs  of  hydrothorax, 
ascites,  and  hydropericardium  may  be  elicited.  The  first-mentioned  con- 
dition is  bilateral  and  causes  dyspnea ;  the  second  increases  the  dyspnea 
by  pressing  the  diaphragm  upward ;  and  the  last  impairs  the  heart's 
action.  Strlimpell  describes  a  form  of  pneumonia — a  '"stiif  inflamma- 
tory edema  " — midway  between  lobar  pneumonia  and  broncho-pneumo- 
nia, that  sometimes  develops  in  severe  cases  of  acute  nephritis.  Edema 
of  the  conjunctivae,  soft  palate,  and  larynx  may  also  occur.  Recently, 
Lapinsky  reported  a  fatal  case  of  acute  parenchymatous  nephritis  in 
which  severe  bilateral  sciatic  neuritis  was  associated. 

The  pulse  is  often  hard  and  tense,  and,  though  slow  at  first,  it  may 
become  accelerated  later.  Cardiac  hypertrophy  of  a  slight  degree  may 
be  detected.     The  aortic  second  sound  is  accentuated.     Epistaxis  is  an 

62 


978  DISEASES  OF  THE   URINARY  SYSTEM. 

occasional  symptom,  and  subconjunctival  hemorrhages  are  sometimes  seen 
as  a  result  of  uremic  convulsions  that  may  not  have  been  witnessed.  A 
very  constant  symptom  is  the  dry,  anemic  skin.  Uremic  manifestations 
may  ensue  at  any  time  during  the  course  of  the  disease.  They  appear 
early  in  the  most  severe  cases,  with  intense  headache  and  backache,  vom- 
iting, and  convulsions. 

The  clinical  course  in  other  cases  differs  somewhat  from  the  above,  which 
may  be  considered  as  the  common  form  resulting  from  exposure.  Acute 
nephritis  occurring  as  a  complication  of  the  infectious  fevers,  except 
scarlatina,  may  be  characterized  by  the  very  slight  degree,  or  even  by 
the  absence,  of  dropsy.  Albuminuria,  hematuria,  anemia,  and  uremia 
supervene  in  the  graver  affections.  In  scarlatinal  nephritis,  however, 
anasarca  is  common,  and  slight  edema  at  least  is  quite  constant.  During 
the  period  of  convalescence  tube-casts  (granular  or  fatty  granular)  may 
be  found  in  the  urine  (Fig.  62).  In  mild  affections  simply  a  little  albu- 
min and  a  fcAv  hyaline  casts  reveal  the  parenchymatous  degeneration. 
In  cases  of  degenerative  nephritis  due  to  mineral  poisoning  the  subsidence 
of  the  acute  toxic  symptoms  may  be  followed  by  the  ti/phoid  condition. 
In  the  so-called  nephro-typhoid  condition,  where  typhoid  fever  begins 
with  pronounced  symptoms  of  acute  nephritis,  hematuria  may  be  marked. 
The  nephritis  of  pregnancy  is  usually  gradual  in  its  onset.  The  albumin 
increases  in  amount  from  month  to  month,  and  reaches  a  high  percentage 
during  the  eighth  and  ninth  months.  Some  hyaline  or  faintly  granular 
casts  are  found  (Fig.  64),  and  erythrocytes  rarely  appear  in  the  urine. 
Danger  of  eclampsia  is  constant  until  the  child  is  delivered ;  but  recov- 
ery is  rapid  after  the  birth  of  the  child  as  a  rule. 

That  variety  of  acute  {productive)  nephritis  in  which  there  is  a  ten- 
dency to  the  formation  of  patches  or  wedges  of  fibrous  tissue  is  charac- 
terized by  higher  fever,  by  cerebral  and  circulatory  disturbances  of  a 
typhoid  nature,  and  by  anemia,  dropsy,  and  a  highly-albuminous  urine, 
even  though  blood  may  be  absent  and  casts  may  be  few.  The  dropsy  is 
most  apparent  in  the  legs.  Dyspnea,  vomiting,  diarrhea,  and  a  progres- 
sive and  rapid  loss  of  flesh  and  strength  ensue  until  convulsions  or  coma, 
sometimes  preceded  by  acute  maniacal  excitement,  end  in  death.  Milder 
cases,  lasting  from  two  to  four  weeks,  apparently  get  well,  albumin  and 
casts  persisting,  however,  until,  after  an  interval  of  weeks  or  months, 
another  and  similar  attack  occurs.  In  short,  the  first  acute  attack  is 
liable  to  clironic  repetition  until  a  fatal  one  takes  place. 

Diagfnosis. — The  condition  cannot  be  overlooked  when  the  urine  is 
carefully  examined  both  chemically  and  microscopically.  The  dreaded 
eclampsia  gravidarum  can,  however,  be  recognized  only  by  repeated 
urinarv  examination,  especially  during  the  last  months  of  pregnancy. 
Acute  Bright's  disease  sliould  be  suspected,  and  the  urine  examined  in 
everv  case  showing  pallor  of  the  skin  and  puffy  eyelids,  whether  general 
prostration  of  the  health  is  apparent  or  not.  The  characteristic  symp- 
toms of  acute  exudative  nephritis,  as  commonly  seen  when  the  condition 
is  due  to  cold  or  occurs  in  scarlet  fever,  are  the  following :  headache, 
restlessness,  muscular  twitching,  nausea  and  vomiting,  a  tense  pulse, 
moderate  fever,  dropsy,  and  anemia.  Tube-casts  and  albuminuria  are 
constant.  It  should  be  borne  in  mind  that  slight  albuminuria  occurring 
in  the  course  of  pregnancy  or  during  any  of  the  fevers,  without  casts,  is 


Fig.  61.  Fig.  62. 


Fig.  63.  Fig.  64. 


Fig.  65.  TFiG-  66. 

Fig.  61.— a.  G.,  aged  fifteen,  male,  suffering  from  acute  nephritis.     Trine  showing  granuhir 
casts  (Queen  obj.  J;  eye-piece  ij.).  ,..,.,  ,      ^ 

Fig.  62.- C.  a.,  ased  nine,  male.    Scarlatinal  nephritis,  third  week  of  convalescence.    I  rme 
showing  granular  casts  (Queen  obj.  i;  eye-piece  ij.).  ^  ,       ■,     „ 

Fig.  63.— J.  D.,  aged  flftv-four,  male,  suffering  from  cancer  of  the  common  duct  and  head  ot 
the  pancreas.    Urine  showing  bile-stained  casts  ^  Queen  obj.  J ;  eye-piece  iv.). 

Fig.  64.— B.  J.,  aged  twenty-two,  female,  suffering  from  puerperal  eclampsia.    1  rme  showing 
large,  fl'nelv  granular  casts  (Queen  obj.  J:  eye-piece  ij.). 

Fig.  6,5.— S.  a.,  aged  fifty-eight,  male.    Urine  showing  granular  and  ftitty  casts;  post-mortem 
showed  chronic  parenchyniatous  nephritis  (Queen  obj.  J;  eye-piece  iv.).  ,     ,   ,  .^ 

Pjg    66  — C    C  ,  aged  fortv-two,  female,  suffering  from  septicopyemia  with  amyloid  kidney. 
Urine  showing  epithelial  and  (so-called)  amyloid  casts  (Queen  obj.  J;  eye-piece  ij.). 

[L.  Napoleon  Boston.] 


ACUTE  NEPHRITIS.  979 

not  a  true  nephritis,  although  the  ]att,er  maj  be  a  more  or  less  remote 
consequence  of  the  glandular  degeneration  of  the  renal  epithelium  asso- 
ciated with  the  febrile  albuminuria.  In  addition  to  the  presence  of  albu- 
min and  hyaline  and  cell-casts,  however,  a  diminished  quantity  of  sooty- 
looking  urine  and  the  discovery  of  red  and  white  blood-corpuscles  will 
render  the  diagnosis  positive.  The  history  of  the  case  and  the  causal 
factors  are  also  to  be  taken  into  consideration. 

Prognosis. — The  duration  of  ordinary  exudative  nephritis  follow- 
ing exposure  to  cold  and  wet  varies  from  a  few  days  to  three,  four,  or 
six  weeks.  The  albuminuria  steadily  decreases,  and  with  the  casts 
finally  disappears,  while  the  daily  quantity  of  lighter  urine  increases, 
as  does  the  daily  excretion  of  urea.  The  prognosis  depends  much  upon 
the  primary  disease  or  causative  condition,  and  also  upon  the  intensity 
and  character  of  the  renal  inflammation.  Scarlatinal  nephritis  is  less 
likely  to  be  recovered  from  than  nephritis  due  to  exposure  to  cold  after 
alcoholic  excesses.  The  acute  parenchymatous  degeneration  that  accom- 
panies typhoid  fever,  diphtheria,  and  other  infectious  fevers,  as  well  as 
pregnancy,  is  usually  a  mild  affection  and  recovery  takes  place  easily. 
But  in  acute  yellow  atrophy,  yellow  fever,  cholera,  and  in  severe  phos- 
phorus- or  mercurial  poisoning  death  may  occur  from  the  intense  and 
widespread  necrosis  of  renal  epithelium.  In  favorable  cases  of  ordinary 
exudative  nephritis  the  dropsy  and  albuminuria  gradually  diminish, 
while  the  color  of  the  skin  and  the  quantity  of  urine  and  urea  increase, 
so  that  in  the  course  of  from  three  to  four  or  six  weeks  recovery  is 
established.  After  the  disappearance  of  the  dropsy  the  albumin  may 
persist  for  some  time,  and  then  slowly  disappear ;  but  rarely,  in  unfavor- 
able cases,  even  when  dropsy  has  disappeared,  albuminuria  may  continue 
and  the  affection  become  a  chronic  parenchymatous  nephritis. 

Serious  and  often  dangerous  symptoms  of  acute  nephritis  are — severe 
general  edema,  dropsical  effusions  into  the  serous  sacs  (as  hydrothorax), 
uremia  (especially  Avhen  beginning  with  cerebral  manifestations,  as  coma 
or  convulsions),  and  finally  inflammation  of  the  internal  organs,  as  pleu- 
ritis,  pneumonitis,  pericarditis,  peritonitis,  and  meningitis.  In  the  ab- 
sence of  uremia  recovery  in  cases  of  marked  general  dropsy  is  quite 
common.  Suppression  of  urine,  however,  lasting  more  than  twenty-four 
or  forty-eight  hours,  is  usually  a  fatal  symptom.  The  prognosis  is  un- 
favorable also  in  cases  in  which  the  nephritis  has  a  productive  character. 
Life  may,  on  the  other  hand,  be  prolonged  for  several  years. 

Treatment. — I  shall  not  include  here  the  management  of  the  pri- 
mary affection  of  which  the  nephritis  may  be  either  a  complication  or 
consequence. 

Since  the  renal  function  is  diminished  by  the  congestion  and  inflam- 
mation, the  first  object  in  the  treatment  is  to  relieve  these  conditions 
and  thus  restore  the  excretory  function.  The  single  or  combined  use 
of  diaphoretics  and  cathartics  is  practised,  therefore,  not  that  the  skin 
and  bowels  should  be  made  to  perform  the  work  normally  done  by  the 
kidneys,  but  in  order  to  restore  the  functional  equilibrium  by  the  anti- 
phlogistic effect  produced. 

Absolute  rest  in  a  warm  bed  and  in  a  warm  room  is  of  primary  im- 
portance. Woollen  underwear  and  blankets  should  be  provided,  so  as 
to  promote  a  constant  free  action  of  the  sweat-glands.      These  hygienic 


980  DISEASES  OF  THE   URINARY   SYSTEM. 

measures  should  be   carried  out  both  in  the  mild  and  in  the  severer 
cases. 

Bland  liquid  foods  only  should  be  allowed  in  the  diet,  and  the  patient 
should  be  encouraged  to  drink  freely  of  water  (plain,  distilled,  or  car- 
bonated), lemonade,  skimmed  milk,  or  buttermilk  ;  these  are  especially 
valuable  Avhen  hot.  Later,  thin  meat-broths  may  be  allowed,  although 
a  strict  milk  diet  is  better. 

Local  bloodletting,  as  by  leeches  or  cupping  over  the  loins,  I  seldom 
employ  ;  in  rare  cases,  however,  when  much  pain  is  complained  of,  it 
may  be  useful,  although  hot  fomentations  may  be  more  so.  Diminution 
of  the  edema  and  the  elimination  of  urea  and  other  urinary  constituents 
that  may  be  retained  in  acute  nephritis  are  best  obtained  by  ex- 
citing a  profuse  perspiration.  The  hot-air  or  hot-water  bath  and 
the  hot  wet-pack  may  be  used  to  accomplish  these  results,  and 
in  most  cases  the  last-named  method  suffices.  It  is  easily  applied  by 
wringing  a  blanket  out  of  hot  water,  wrapping  the  patient  in  it,  and 
then  with  a  dry  blanket,  and  finally  a  rubber-cloth  cover,  surrounding 
all.  This  furnishes  a  steam-bath  in  which  the  patient  may  remain  until 
copious  sweating  has  lasted  an  hour  or  so,  according  to  the  condition. 
Children  suffering  from  scarlatinal  nephritis  may  be  treated  thus,  or 
([uite  readily  also  by  immersion  in  hot  water,  for  twenty,  thirty,  or  forty 
minutes ;  the  skin  should  then  be  lightly  dried,  and  the  child  wrapped 
in  warm  sheets  or  blankets  and  warmly  covered  in  bed.  Hot  vapor  or 
air  may  be  generated  alongside  the  bed,  and  transferred  under  the  raised 
or  cradled  bed-clothes  by  means  of  a  tin  funnel  and  pipe.  The  sweating 
will  be  aided  by  the  drinking  of  hot  lemonade  or  soda-water  or  of  water 
containing  spirit  of  Mindererus.  Should  the  skin  fail  to  respond  to 
these  measures,  as  in  uremia,  perspiration  may  be  started  by  a  hypo- 
dermic injection  of  pilocarpin  (gr.  ^  to  ^ — 0.008  to  0.0108),  after  which 
it  will  continue  to  pour  out  on  the  application  of  heat.  The  heart  and 
pulse  should  be  watched  after  the  injection  of  pilocarpin,  as  serious  col- 
lapse sometimes  attends  its  use.  The  sweatings  should  be  repeated  until 
the  dropsy  disappears  and  as  often  as  the  patient's  strength  will  permit. 
A  useful  adjunct  to  the  above  is  the  administration  of  hydragogues,  as 
the  saline  cathartics,  elaterium,  and  compound  jalap  powder.  Elaterium 
extract  (gr.  ^\ — 0.0108-0.0162)  is  prompt  in  action,  and  magnesium 
or  sodium  sulphate  (3j — 4.0),  given  in  hot  concentrated  solution  every 
hour,  or  a  calomel  purge,  may  be  recommended.  It  may  be  necessary 
to  aid  in  relieving  the  tension  and  distress  of  extreme  edema  by  multi- 
ple punctures  or  by  the  use  of  a  small  trocar  and  canula,  with  a  drain- 
age-tube (Southey)  attached  to  the  latter  after  the  trocar  is  withdrawn. 
Aspiration  must  be  performed  if  either  hydro-thorax,  hydro-pericardium, 
or  ascites  assumes  serious  proportions.  Half-ounce  (16.0)  doses  of  the 
spirit  of  Mindererus  (liq.  ammon.  acetat.)  in  Avater  may  be  added  to  the 
diaphoretic  treatment ;  this,  combined  with  aconite,  aids  in  controlling 
the  fever  that  may  be  present  and  in  preventing  the  vaso-constriction 
that  is  often  premonitory  of  uremic  symptoms. 

Uremic  convulsions  that  do  not  soon  yield  to  prompt  diaphoresis  and 
catharsis  should  be  treated  by  venesection.  As  much  as  a  pint  or  two 
(.5-1  liter)  of  blood  may  be  withdrawn  and  life  saved  thereby.  Some- 
times chloroform-inhalations  are  needed  to  subdue  the  very  violent  con- 


CHRONIC  NEPHRITIS.  981 

vulsive  seizures,  as  in  eclampsia.  Their  return  may  be  prevented  by 
rectal  injections  of  potassium  bromid  and  chloral,  consisting  of  1  dram 
(4.0)  of  the  former  and  \  dram  (2.0)  of  the  latter. 

Nausea  and  vomiting  may  be  controlled  by  the  use  of  cracked  ice, 
minute  doses  of  cocain,  dilute  hydrocyanic  or  hydrochloric  acid,  bis- 
muth, and  by  the  addition  of  soda-  or  lime-water  to  the  milk. 

Contraction  of  the  arteries  with  increased  tension  and  beginning 
muscular  twitchings  call  for  the  use  of  nitroglycerin,  chloral  hydrate, 
or,  possibly,  morphin. 

Diuretics  other  than  the  simple  diluent  drinks  mentioned  have  very 
little  use  in  the  therapy  of  acute  diffuse  nephritis,  at  least  early  in  the 
disease.  Later,  as  adjuvants  to  the  diuretic  properties  of  water,  potas- 
sium bitartrate  or  acetate,  sodium  benzoate,  and  cardiac  stimulants,  as 
caffein  citrate  and  the  infusion  of  digitalis,  may  be  given,  well  diluted. 

During  convalescence  care  must  be  exercised  that  the  patient  does 
not  catch  cold.  The  diet  must  not  be  increased  to  solids  too  sud- 
denly nor  too  rapidly,  and  particularly  in  the  matter  of  meats.  Light 
watery  vegetables,  fruits,  and  cereals  may  be  gradually  added  to  the 
diet-list,  although  milk  should  be  mainly  used.  Ferruginous  tonics 
are  indicated  for  the  anemia,  and  Basham's  mixture  is  an  admirable 
preparation  at  this  stage. 

A  change  of  locality  to  a  warmer,  drier,  and  more  equable  climate, 
and  careful  habits  of  dress,  diet,  and  exercise,  are  necessary  in  cases  of 
recovery  from  the  very  serious  forms  of  nephritis,  in  which  the  renal 
parenchyma  is  shown  to  have  been  somewhat  damaged  by  the  per- 
sistence of  slight  albuminuria  at  intervals. 


CHRONIC  NEPHRITIS  (EXUDATIVE). 

{^Chronic  Bright' s  Disease:  Chronic  Parenchymatous  Nejjhritis ;  Chronic  Diffuse 
Nephritis  icith  Exudation;  Chronic  Tubal  and  Chronic  Desquamative  Nephri- 
tis; Chronic  Glomerulo-nephritis ;  Large  White  Kidney;  Secondare/  or  Fatty 
and  Contracted  Kidney.) 

Definition. — A  chronic  diffuse  inflammation  of  the  kidneys,  at- 
tended with  epithelial  degeneration,  exudation  from  the  blood-vessels, 
and  permanent  connective-tissue  changes  in  the  stroma.  According  to 
Delafield,  this  is  the  chronic  productive  {or  diffuse)  nephritis  with  exu- 
dation— one  of  two  varieties  of  chronic  Bright's  disease. 

Pathology. — Although  there  are  several  types  of  pathologic  kidney 
in  this  disease,  and  many  individual  cases  in  which  anatomic  differences 
are  noted,  the  changes  of  structure  are  essentially  the  same,  and  the 
variations  depend  upon  the  causation  and  duration  of  the  nephritis. 

The  first  type  of  kidney  to  be  mentioned  is  the  large  ivhite  kidney 
(without  waxy  degeneration).  It  is  either  enlarged  or  normal  in  size, 
and  pale  or  yellowish  in  color.  The  surface  is  smooth,  and  the  capsule 
is  easily  stripped  off.  On  section  the  cortex  is  broader  than  normally, 
yellowish-white  throughout,  or  it  may  present  opaque  yellowish  or  whit- 
ish areas  with  mottlings  of  red.     The  pyramids  are  congested  in  some 


982  DISEASES  OF  THE   URINARY  SYSTEM. 

cases.  Microscopically,  the  following  changes  are  commonly  observed : 
the  renal  epithelium  is  swollen,  hyaline,  granular,  or  fatty,  and  more  or 
less  disintegrated  or  flattened ;  the  glomeruli  are  enlarged  from  the 
growth  of  the  capsule-cells  and  of  the  cells  covering  the  capillaries,  and 
in  some  cases,  owing  to  the  connective-tissue  thickening  of  the  capsule, 
the  tuft  of  capillaries  is  found  to  be  atrophied.  The  interstitial  tissue 
shows  some  thickening  of  the  arterial  walls  and  a  moderate  growth  of 
connective  tissue  in  patches  around  the  glomeruli  and  tubules  ;  the  latter 
contain  hyaline  and  granular  casts. 

The  small  white  kidney,  or  secondary  contracted  kidney,  in  most  in- 
stances is  probably  a  later  stage  of  the  preceding,  in  which  the  degen- 
eration of  epithelium  is  more  advanced  and  the  growth  of  connective 
tissue  and  resultant  cicatricial  contraction  are  prominent  features.  .  The 
kidneys  are  about  normal  in  size  (shrinkage  of  the  large  white  kidney), 
the  surface  is  slightly  granulated,  and  the  capsule  is  proportionately  ad- 
herent. While  this  kidney  is  usually  grayish  or  yellowish  in  color 
{pale,  fP'anular  kidney),  there  may  be  some  mottling  due  to  red  spots. 
The  consistence  is  firmer  than  that  of  the  large  white  kidney.  The  cut- 
surface  shows  yellowish-white  foci  of  the  fatty  degenerated  epithelium 
in  the  somewhat  narrowed  cortex,  and  hence  the  term  that  is  sometimes 
used  of  ''small,  granular,  fatty  kidney."  Under  the  microscope  we 
find  extensive  degeneration  and  disintegration  of  the  epithelium  of  the 
glomeruli  and  convoluted  tubules,  with  atrophy  of  the  parenchyma,  and 
a  corresponding  increase  of  the  interstitial  connective  tissue.  Waxy 
degeneration  may  be  associated. 

Another  variety  is  the  large  red  or  variegated  kidney  of  chronic  hem- 
orrhagic nephritis.  The  organs  are  usually  enlarged,  swollen,  red,  and 
congested-looking  or  mottled,  and  fretiuently  "bumpy"  or  slightly 
bossellated.  The  capsule  is  slightly  adherent  to  the  depressions  between 
the  bosses.  Red  spots,  due  to  small  hemorrhages,  may  be  noticed  on 
both  the  outer  and  cut-surfaces  of  the  kidney.  The  section  shows  also 
congested  portions  and  gray  or  yellow  spots  corresponding  to  the  anemic 
and  fatty  degenerated  portions.  Small  cortical  hemorrhagic  areas  or 
striations,  brownish-red  in  color,  are  distinctive  of  the  kidney.  The 
microscopic  appearances  are  those  of  the  large  white  kidney  plus  those 
of  acute  nephritis.  Or,  there  may  be  inflammatory  edema  and  cellular 
infiltration  of  the  intertubular  tissue,  and  dilated  tufts  of  capillaries  with 
surrounding  cellular  hyperplasia.  This  variety  of  chronic  nephritis  is 
frequently  found  in  inebriates. 

Htiology. — The  disease  may  follow  either  the  acute  diffuse  nephri- 
tis, as  of  scarlet  fever  or  pregnancy,  or  simple  chronic  congestion  and 
chronic  degeneration  of  the  kidneys.  More  often  it  arises  insidiously,  in 
a  subacute  manner  and  without  any  previous  acute  manifestation.  Males 
are  more  frequently  subject  to  this  form  of  chronic  Bright's  disease  than 
females.  Children  aff"ected  with  the  disease  have  usually  had  scarlatinal 
nephritis.  Young  adults  are  more  commonly  affected,  however,  with 
the  usual  variety,  developing  subacutely.  Drinkers  of  beer  and  other 
malt  and  alcoholic  intoxicants  seem  to  be  liable  to  the  disease.  It  is 
not  improbable  that  some  toxic  or  infectious  agency,  acting  slowly  and 
persistently,  may  in  the  insidious  cases  be  the  cause  of  the  nephritis, 
although   manifestations   elsewhere   may  be  absent.      I  have  observed  it 


CHRONIC  NEPHRITIS.  983 

in  certain  individuals  living  in  malarial  regions.  Persons  working  under 
exposure  to  cold  and  wet,  or  those  living  in  humid  and  low,  marshy- 
localities,  are  more  liable  to  this  renal  malady  than  those  who  are  better 
protected  from  climatic  vicissitudes.  Tuberculosis,  syphilis,  and  chronic 
suppuration  may  give  rise  to  this  so-called  "parenchymatous"  form  of. 
chronic  Bright's  disease,  and  it  is  usually  combined  with  amyloid  disease 
(waxy  degeneration). 

Symptoms. — There  may  be  a  persistence,  in  a  lesser  degree,  of  the 
symptoms  of  an  acute  parenchymatous  nephritis,  particularly  the  anemia, 
dropsy,  and  the  albuminuria,  until  the  affection  becomes  chronic.  In 
most  cases,  however,  the  disease  develops  slowly  and  gradually,  in  a 
subacute  manner,  though  the  earlier  symptoms  seldom  indicate  any 
renal  derangement.  There  may  be  simply  a  general  impairment  of 
health  and  strength,  loss  of  appetite,  nausea,  and  attacks  of  indigestion, 
headache,  dulness,  and  perhaps  some  pallor.  Soon  there  is  puffiness 
of  the  eyelids  or  sAvelling  of  the  feet  or  ankles,  or  both,  and  the  com- 
plexion takes  on  a  blanched  appearance.  The  edema  gradually  extends 
up  the  legs,  and  is  often  worse  as  the  day  grows,  while  on  rising  in  the 
morning  it  may  be  found  to  have  disappeared  during  the  night's  rest 
and  recumbency.  The  quantity  of  urine  is  diminished  in  the  majority 
of  cases,  though  in  the  later  stages  it  may  be  nearly  or  quite  normal, 
and  even  slightly  increased  in  long-standing  instances  of  pale  contracted 
kidney  or  when  absorption  of  the  dropsy  is  taking  place.  Superadded 
acute  nephritis  may  cause  a  very  scanty  or  a  suppressed  secretion  of 
urine.  The  specific  gravity  is,  of  course,  increased  in  scanty  urine,  and 
vice  versa.  Albuminuria  is  often  quite  marked.  The  amount  of  albumin 
may  be  from  one-fourth  to  three-fourths  of  the  volume  af  the  urine,  or 
from  1  to  3  per  cent,  by  weight,  so  that  the  daily  loss  of  albumin  may 
be  considerable.  The  urea  is  much  diminished.  The  color  of  the  urine 
is  turbid,  sometimes  smoky-yellow,  and  urates,  casts,  red  and  white 
blood-cells,  epithelial  cells,  granular  debris,  and  fatty  granular  cells 
are  found  in  the  usually  abundant  sediment.  The  tube-casts  are  of 
different  varieties,  but  narrow  or  broad  hyaline,  fatty  granular  (Fig.  65), 
and  epithelial  casts  are  commonly  observed. 

The  edema  is  prominent  and  persistent.  It  gradually  extends  all 
over  the  body,  so  that  pitting  can  be  obtained  on  the  limbs,  chest,  abdo- 
men, and  back.  The  loose  subcutaneous  tissues,  as  of  the  penis,  scrotum, 
and  eyelids,  are  particularly  distended.  In  chronic  hemorrhagic  nephri- 
tis, only,  the  edema  may  be  absent  or  very  slight.  The  j^asty,  pallid 
complexion  and  anasarca  are  most  characteristic  of  chronic  exudative 
nephritis,  especially  with  large  white  kidney.  The  dropsy  may  be  mod- 
erate and  about  stationary  for  several  months ;  then,  despite  all  treat- 
ment, it  becomes  insidiously  worse,  death  ensuing  in  a  month  or  two. 

Dropsy  of  the  serous  sacs,  with  its  attendant  distressing  symptoms, 
may  be  present  in  serious  cases,  and  edema  of  the  larynx  and  lungs 
may  come  on  suddenly  and  cause  death.  Dyspnea  may  be  toxic  and 
nervous,  as  well  as  mechanical  or  cardiac  in  origin.  Cardiac  dyspnea, 
due  to  failure  of  the  heart's  action,  as  seen  in  many  cases,  is  usually 
worse  on  lying  down.  It  may  be  provoked  by  vaso-constriction,  and  is 
then  a  danger-signal  of  uremia.  Catarrhal  bronchitis  may  be  associated 
with  cough  and  expectoration. 


984  DISEASES  OF  THE   URINARY  SYSTEM. 

The  heart  is  often  affected  with  moderate  hypertrophy  of  the  left 
ventricle^  and  later  by  dilatation  and  weakness  of  both  ventricles.  The 
aortic  second  sound  is  accentuated  and  the  pulse-tension  increased. 

Uremic  syynptoms  are  frequently  manifested,  except  the  convulsions 
which  are  common  to  chronic  nephritis  without  exudation.  Headache, 
vertigo,  sleeplessness,  nausea  and  vomiting,  diarrhea,  and  stupor,  coma, 
or  delirium,  may  develop  and  precede  a  fatal  termination. 

Albuminuric  neuro-retinitis,  as  evidenced  by  dimness  of  vision  and 
field-defects,  occurs  in  quite  a  number  of  cases.  The  skin  of  the  legs 
becomes  subject  to  a  red  eczematous  eruption  in  some  cases  of  great 
dropsical  distention.  In  the  absence  of  complicating  inflammations, 
such  as  pericarditis,  endocarditis,  pneumonitis,  and  ulcerative  colitis, 
which  are  rare,  the  temperature  is  practically  normal. 

The  course  of  chronic  exudative  nephritis  may  either  continue 
from  bad  to  Avorse,  until  death  ends  all  in  a  year  or  two,  or  anemia, 
dropsy,  and  albuminuria  may  attack  one  who  for  years  previous  has  had 
apparent  good  health,  after  a  first  attack  the  second  proving  fatal  within 
a  few  months.  Again,  some  patients,  having  a  little  pallor,  slightly 
diminished  urine  of  high  specific  gravity,  with  albumin,  may  complain 
of  nothing  for  years,  until  decided  attacks,  lasting  for  several  months, 
may  occur,  with  intervals  during  which  the  dropsy,  dyspnea,  etc.  may 
be  absent,  although  some  albuminuria  persists. 

The  average  duration  of  the  disease  varies  from  one  and  a  half  to 
three  years.  The  duration  of  chronic  hemorrhagic  nephritis  may  be 
somewhat  longer  (eight  months  to  two  years)  than  that  of  the  large 
white  kidney  (six  to  eighteen  months),  but  it  is  shorter  than  the  second- 
ary, contracted  kidney,  which  lasts  from  one  and  a  half  to  three  or 
even  five  years. 

Diagnosis. — The  diagnosis  of  the  disease  itself  is  not  difficult,  but 
of  the  stage  or  the  variety  of  kidney  it  is  almost  impossible  to  tell  cor- 
rectly in  some  instances.  The  urinary  examination,  coupled  with  the 
symptoms  of  dropsy  and  anemia,  is  sufficiently  diagnostic  of  chronic 
diffuse  nephritis  (with  exudation). 

In  cases  of  large  white  kidney  the  urine  passed  is  less  in  quantity 
and  of  higher  specific  gravity  than  in  the  small,  pale,  and  contracted 
kidney.  Edema  is  usually  greater  in  the  former  also,  Avhile  in  the  latter 
cardio-vascular  changes  are  more  marked,  as  shown  by  the  physical  signs 
and  the  hard  pulse.  The  transition  of  the  disease  from  the  earlier  to 
the  later  stage  may  be  thus  noted.  The  casts  in  the  latter  may  also  be 
narrower  and  more  darkly  granular  than  in  the  large  white  kidney. 
The  existence  of  hemorrhar/ic  kidney  may  be  inferred  from  the  history 
of  alcoholism  and  the  persistent  presence  of  red  blood-corpuscles  and 
blood-casts  in  the  urine. 

Chronic  parenchymatous  is  distinguished  from  chronic  interstitial 
nephritis  by  the  following  points  of  difference: 

Chronic  Parenchymatous  Nephritis.  Chronic  Interstitial  Nephritis. 

Occurs  in  early  or  middle  life.  Occurs  later  in  life. 

There  is  a  previous  history  of  an  acute  A  previous  history  of  gout,  chronic  lead- 
attack  of  scarlet  fever,  or  perhaps  of  poisoning,  syphilis,  excessive  eating 
acute  alcoholism.                                                and    drinkinji    (spirits),    nerve-strain ; 

otherwise  often   negative. 


CHRONIC  NEPHRITIS.  985 

Chronic  Parenchymatous  Nephritis.  Chronic  Interstitial  Nephritis. 
The  onset  is  gradual  or  markedly  mani-  The  onset  is  very  slow,  insidious,  and  in- 
fest.             "  definite. 
Dropsy  is  a  constant  symptom.  Dropsy  is  rare. 
Vascular  changes  and  cerebral  symptoms  Arterio-sclerosis,     cardiac    hypertrophy, 

are  compara,tively  uncommon.  and  cerebral  symptoms  are  common. 

Marked  albuminuria,  with  tube-casts.  Very  slight  albuminuria  and  few_  casts. 

Urine    but   little  increased  in   quantity.  Urine  of  very  low  specific  gravity,  and 

often   diminished;    specific    gravity  "is  excessive  in   quantity. 

increased  or  slightly  diminished. 

Anemia  occurs  earlier  and  is  more  dis-  Anemia    slowly    progressive     and     less 

tinct.  marked. 

Uremic  symptoms  are  generally  less  se-  Uremic  symptoms  are,  generally  severe 

vere — amaurosis,    vomiting,    diarrhea,  — coma  and  convulsions,  great  dyspnea. 

headache. 

Runs  a  shorter  course — from  two  to  six  Has   a  more    chronic   course — seven   to 

or  seven  years.  thirty  years. 

ProgfnosiS. — This  is  invariably  bad  as  to  cure,  thougli  life  may  be 
prolonged  in  certain  cases.  In  severe  cases  death  may  take  place  in  from 
three  months  to  a  year,  either  from  uremia,  dropsy,  cardiac  dilatation,  or 
complications.  Cases  of  a  year's  duration  almost  never  recover,  and, 
a  fortiori.,  those  in  which  advanced  secondary  contraction  of  the  kidney 
may  be  inferred  are  incurable,  and  may  soon  terminate  fatally.  Com- 
plete recoveries  from  the  disease,  particularly  in  children  that  have  had 
scarlet  fever,  may  occur  but  rarely.  The  prognosis  depends  greatly  on 
the  quantity  of  urine  passed  in  the  twenty-four  hours,  the  excretion  of 
urea  and  total  solids,  and  upon  the  amount  and  persistency  of  the  albu- 
min, as  well  as  upon  the  degree  of  car dio- vascular  and  retinal  changes. 

Treatment. — The  indications  for  treatment  are  similar  to  those  in 
acute  nephritis.  The  dropsy  and  uremia  must  be  treated  symptomatically, 
and  the  diet  is  of  importance.  Skimmed  milk  and  buttermilk,  or 
"  zoolak,"  with  dried  bread,  crackers,  and  zwieback,  perhaps,  should 
be  depended  on  as  much  as  possible  when  dropsy  is  pronounced. 
When  dropsy  is  slight,  more  solid  food,  light  meats  and  vegetables,  rice, 
and  other  light  cereals,  and  fruits,  and  out-of-door  life  should  be  recom- 
mended. 

Residence  in  a  warm,  dry  climate  may  aid  in  prolonging  life.  Wool- 
lens should  be  worn  next  to  the  skin,  and  prolonged,  sudden,  and  severe 
exercise  should  be  forbidden. 

The  infusion  of  digitalis,  strophanthus,  spartein,  adonidin,  or  con- 
vallaria,  may  be  needed  in  cardiac  weakness,  or  nitroglycerin  for  con- 
tracted and  tense  arteries  with  a  tendency  to  uremic  twitchings.  Unir- 
ritating  diuretics,  such  as  Trousseau's  diuretic  wine  and  Basham's 
mixture  for  the  anemia,  are  useful.  Strontium  lactate  in  doses  of  from 
15  to  20  grains  (0.972-1.29),  three  times  daily,  I  have  found  useful  in 
some  cases.     Diuretin  has  also  been  tried  lately  with  favorable  results. 


986  DISEASES   OF  THE   URINARY  SYSTEM. 


CHRONIC  NEPHRITIS  (NON-EXUDATIVE). 

{Chronic  Interstitial  Nephritis;  Chronic  Brighfs  Disease;  Primary,  or  Genuine, 
Contracted  Kidney;  Cirrhotic  Kidney:  Red  Granular  Kidney;  Renal  Arterio- 
sclerosis :  Chronic  Productive  {Diffuse)  Nephritis  without  Exudation  [Delajield) ; 
Gouty  Kidney.) 

Definition. — A  chronic  diffuse  inflammation  of  the  kidneys,  attended 
with  a  growth  of  connective  tissue  in  the  stroma,  degeneration  and 
atrophy  of  the  renal  parenchyma,  and  marked  change  in  the  cardio- 
vascular system. 

Pathology. — In  genuine  primary  contraction  of  the  kidneys  there 
is  a  reduction  in  size  and  weight  about  equal  in  both  organs.  They 
may  be  only  one-half  or  one-third  the  size  of  normal  kidneys,  and  the 
two  kidneys  together  may  not  weigh  over  two  ounces.  They  are  often 
found  imbedded  in  thick  adipose  tissue,  the  capsule  being  thick,  opaque, 
and  very  adherent,  so  that  on  stripping  it  off"  it  brings  away  portions  of 
the  renal  cortex.  The  outer  surface  of  the  kidney  is  red,  irregularly 
granular,  or  finely  nodular,  and  occasional  small  cysts  are  sometimes 
present.  The  consistence  is  firm,  dense,  and  resistant  to  the  knife.  Ex- 
amination of  the  cut-surface  shows  a  thin  atrophied  cortex,  and  dark, 
reddish  streaks  alternating  with  pale  portions.  The  pyramids  are  also 
diminished,  and  darker  than  the  cortex.  In  the  gouty  contracted  kidney 
the  pyramids  show  fine  striations  of  sodium  urate  or  of  uric  acid,  or  crys- 
tals representing  uric-acid  infarctions. 

Microscopically,  the  essential  changes  are  an  increased  production  of 
connective  tissue,  especially  in  the  cortical  substance,  and  a  more  or  less 
proportionate  degeneration  and  atrophy  of  the  renal  parenchyma,  the 
destruction  of  which  is  due  to  the  circulation  of  noxious  agents,  but  which 
is  replaced  by  cicatricial  fibrous  tissue  (Weigert). 

The  new  tissue  is  not  uniformly  distributed  in  the  cortex,  but  occurs 
in  irregular  masses  around  the  shrunken  glomeruli  or  between  the  tubules. 
The  distribution  of  connective  tissue  in  the  pyramids  is  more  diffuse. 
Many  of  the  glomeruli  are  quite  small  and  fibrous  in  advanced  cases, 
while  in  the  earlier  cases  the  cells  of  the  tufts  and  capsules  are  swollen 
and  multiplied,  and  a  small-celled  infiltration  is  seen  around  the  glom- 
eruli and  tubules.  Later  this  infiltration  of  cells  becomes  fibrillated  and 
ends  in  thickening.  Glomerular  atrophy  is  due  partly  to  the  changes  in 
and  growth  of  the  capillary  and  intra-capillary  cells,  as  well  as  of  those 
around  the  tufts ;  partly  also  to  capsular  tliickening  and  hyaline  or 
waxy  degeneration ;  and  partly  to  the  thickening  and  occlusion  of 
arterioles. 

The  tubules  show  marked  changes.  Some  are  included  in  masses  of 
connective  tissue,  so  that  there  is  compression-atrophy  and  even  total  oblit- 
eration of  the  lumen.  In  other  instances  the  intertubular  connective 
tissue  constricts  the  tubules  in  certain  places,  so  that  the  lumen  is  else- 
where increased.  This  dilatation  is  especially  prominent  in  the  granules 
seen  on  the  outer  surface  of  the  kidney,  and,  owing  to  the  damming  back 
of  urine  in  some  of  the  tubules  thus  obstructed,  little  cysts  are  visible  to 
the  naked  eye  here  and  there.  The  epithelium  lining  these  tubules  shows 
granular,   fatty,    or  waxy   degeneration,   and   may   be   either    flattened, 


CHRONIC  NEPHRITIS.  987 

cuboid,  or  swollen.  The  tubes  may  contain  granular  or  fatty  debris 
and  tube-casts. 

An  important  change  in  most  cases  is  the  growth  of  fibrous  tissue  in 
the  walls  of  the  arteries,  causing  sclerosis.  This  affects  the  intima  (end- 
arteritis), the  media,  and  adventitia,  all  of  which  are  thickened  by  the 
hyperplasia  of  connective-tissue  elements.  The  arteries  and  capillaries 
are  thus  mostly  occluded  by  the  obliterating  endarteritis  or  by  their  con- 
version into  masses  of  connective  tissue.  Waxy  or  hyaline  degeneration 
is  seen  also  {vide  Arterio-sclerosis).  These  arterio-capillary  changes  may 
in  some  cases  be  the  primary  condition  that  leads  to  granular  and  con- 
tracted kidneys,  and  may  represent  the  renal  eflFects  of  a  general  arterio- 
sclerosis or  fibrosis. 

An  almost  constant  accompaniment  of  chronic,  non-exudative,  produc- 
tive nephritis  is  cardiac  hypertrophy.  The  degree  of  the  latter  depends 
upon  the  extent  of  the  renal,  and  also  of  the  general  arterial,  degener- 
ation and  sclerosis.  The  whole  heart  may  become  so  large  that  the  term 
cor  hovinum  has  been  fittingly  applied  to  it.  In  moderate  enlarge- 
ments the  left  ventricle  only  is  hypertrophied. 

Complicating  lesions  of  chronic  Bright's  disease  that  may  be  men- 
tioned are  cerebral  hemorrhage,  cirrhosis  of  the  liver,  pulmonary  em- 
physema, chronic  endocarditis,  chronic  endarteritis,  pericarditis,  bron- 
chitis, and  gastric  catarrh. 

Ktiology. — The  cause  of  the  very  slow  primary,  diffuse  degenera- 
tion, atrophy,  and  fibroid  contraction  of  the  kidneys  is  sometimes  quite 
obscure,  (a)  In  some  cases  it  would  seem  to  be  "  only  an  anticipation 
of  the  gradual  changes  which  take  place  in  the  organ  in  extreme  old 
age"  (Osier) — the  "senile  kidney."  {b)  Heredity  undoubtedly  plays  a 
part  in  the  causation  of  certain  cases,  even  to  the  third  or  fourth  gene- 
ration, (c)  Age  and  Sex. — The  disease  is  more  common  in  males  than 
in  females,  and  it  usually  begins  near  middle  life  ;  it  is  seldom  manifested 
symptomatically  until  about  fifty  or  sixty  years  of  age,  and  is  therefore 
an  affection  of  advanced  life,  (d)  Individuals  having  a  special  tendency 
to  sclerotic  degeneration  of  the  arteries,  from  whatever  injurious  influ- 
ence, are  more  liable  to  chronic  interstitial  nephritis,  although  the  pro- 
longed irritation  of  deleterious  (especially  chemico-toxic)  agents  may 
give  rise  to  the  disease  in  those  whose  cellular  nutrition  is  usually  not 
defective.  Thus,  the  disease  has  been  attributed  to  the  following  causes  : 
alcoholism,  uric  acid,  and  lead,  giving  rise  to  chronic  poisoning.  Chronic 
syphilis  and  chronic  malaria  probably  are  also  causative  factors,  (g) 
Habitual  overeating  and  drinking,  owing  to  the  imperfect  metabolism 
of  the  substances  ingested,  cause  a  constant  excretion  of  irritating  prod- 
ucts by  the  kidney,  and  no  doubt  frequently  cause  granular  atrophy 
and  sclerosis  of  the  organ.  The  continuous  and  even  moderate  use  of 
alcohol  for  many  years,  especially  of  spirituous  liquors,  is  a  w-idespread 
cause  of  the  disease.  It  is  equally  likely  that  the  excessive  use  of  red 
meats  in  the  diet  leads  to  the  production  of  the  uric  acid  that  induces 
the  renal  disorder  {uricemia  ;  lithemia).,  by  deranging  the  function  of  the 
liver  (Murchison).  (/)  Allied  to  the  above  is  gout,  which  causes 
chronic  Bright's  disease — in  England  perhaps  more  than  in  this 
country,  lithemia  and  nervous  dyspepsia  being  more  common  there. 
((/)  According  to  Striimpell,  severe  acute  articular  rheumatism  is  some- 


988  DISEASES  OF  THE   URINARY  SYSTEM. 

times  followed  by  contracted  kidney,  {h)  Chronic  Bright's  disease  with 
renal  sclerosis  is  favored  in  origin  and  development  by  the  anxieties, 
worries,  and  high  nervous  tension  connected  with  modern  business  ac- 
tivity and  "social  functions,"  the  latter  particularly  acting  their  part 
among  elderly  ladies.  Associated  with  these  are  usually  over-indul- 
gence in  rich  foods  and  wines,  and  sedentary  habits,  {i)  The  cold, 
moist  climate  of  New  England  and  the  Middle  States  would  seem,  ac- 
cording to  Purdy,  to  predispose  to  contracted  kidney.  A  chronic  pro- 
ductive nephritis  without  exudation,  though  not  the  true  "  contracted 
and  red  granular  "  kidney,  may  be  caused  by  hydronephrosis,  chronic 
pyelitis,  and  chronic  congestion  of  the  kidney,  as  from  heart-disease. 

Symptoms. — These  may  be  latent  for  years,  while  the  morbid  pro- 
ductive changes  in  the  kidneys  are  slowly  effected.  The  first  symptoms 
may  not  appear  until  late  in  life,  although  the  kidneys  may  be  in  an 
advanced  stage  of  degeneration.  Or  some  complicating  or  intercurrent 
affection  may  set  in,  as  pneumonia  or  pericarditis,  and  cause  the  de- 
velopment of  grave  or  fatal  renal  symptoms.  More  commonly,  how- 
ever, there  is  an  attack  of  uremia,  with  headache,  stupor,  or  convulsions, 
dyspnea,  nausea  and  vomiting,  and  a  tense  pulse.  This  attack  may  be 
recovered  from.  Then  there  is  an  interval  of  variable  duration,  during 
which  the  health  is  more  or  less  impaired,  and  lassitude,  drowsiness, 
disordered  digestion,  headache,  failing  vision,  dyspnea,  and  frequent 
micturition  are  complained  of.  This  is  followed  by  another  uremic 
attack,  severer  than  the  first,  or  perhaps  fatal ;  if  not  fatal,  the  general 
health  is  still  more  reduced,  and  confinement  to  the  house  or  bed  is 
necessary,  until  the  vital  forces  can  no  longer  compensate  for  the  destruc- 
tion of  the  renal  parenchyma. 

Spasmodic  dyspnea  (uremic ;  cardiac)  is  sometimes  the  first  manifes- 
tation of  contracted  kidney.  The  gradual  onset  of  periods  of  uncon- 
trollable drowsiness  during  the  day  is  often  marked.  An  attack  of 
hemiplegia  may  also  be  the  first  indication  of  renal  disease.  Sometimes 
progressive  loss  of  flesh  and  strength,  with  a  dry,  harsJi,  wrinkled  skin, 
may  be  from  the  beginning  the  only  clinical  features  of  the  affection 
until  death  results  from  sheer  feebleness  and  emaciation.  The  complex- 
ity and  variability  of  the  symptoms  make  it  best  to  describe  them  under 
the  heads  of  the  various  systems : 

Urinary  System. — The  daily  quantity  of  urine  is  usually  increased 
so  much  that  patients  are  troubled  Avith  a  desire  to  urinate  frequently, 
not  only  during  the  day,  but  two  or  three  times  during  the  night.  This 
complaint  may  be  aggravated  by  the  hyperacidity  of  the  urine  and  the 
irritability  of  the  prostate  (especially  in  advanced  age)  that  are  so  often 
associated  with  cases  of  renal  cirrhosis.  The  urine  voided  during  the 
twenty-four  hours  may  measure  several  quarts  (2  to  4  liters)  in  well- 
marked  cases  of  the  disease.  Early  in  the  attack,  when  the  incipient 
degeneration  and  destruction  of  the  parenchymatous  cells  is  taking 
place,  the  quantity  of  urine  may  be  slightly  decreased  ;  but  as  the 
"blood-flow  to  the  parts  that  remain  must,  cceteris  paribus,  be  as  great 
as  it  would  have  been  to  the  whole  of  the  organs  if  they  had  been  in- 
tact," excessive  pressure  is  brought  to  bear  within  the  capillaries  by  the 
compensating  hypertrophy  of  the  heart,  and  the  secretion  of  the  urine, 
especially  of  the  watery  elements,  becomes  more  active.     The  polyuria 


CHBONIO  NEPHRITIS.  989 

may  give  rise  to  a  suspicion  of  diabetes.  The  urine  is  clear  and  pale- 
yellow  in  color,  the  specific  gravity  being  seldom  above  1010  or  1012, 
and  it  may  be  as  low  as  1002  or  1005.  Albumin  is  found  only  in 
traces  or  it  may  be  absent  altogether  [glomerular  atrophy),  especially  in 
urine  voided  in  the  early  morning.  The  urea  is  diminished,  as  in  all 
forms  of  Bright's  disease,  and  there  is  little  or  no  sediment.  A  very 
careful  microscopic  examination  may  reveal  a  few,  usually  narrow,  hya- 
line or  granular  casts,  perhaps  some  leukocytes,  and  rarely  a  few  ery- 
throcytes. In  the  later  stages  of  the  disease  or  upon  the  supervention  of 
an  uremic  exacerbation  or  of  a  complicating  inflammation  the  urine  may 
be  decreased,  the  albumin  increased,  and  numerous  casts  be  discovered 
in  a  more  apparent  urinary  sediment.      Hematuria  is  rare. 

Circulatory  System. — The  physical  signs  of  cardiac  hypertrophy  are 
present.  Symptoms  referable  to  the  heart  are  absent,  unless  dilatation 
and  feebleness,  sudden  arterial  contraction,  cardiac  complications,  or 
endocarditis  occur.  Inspection  and  palpation  of  the  hypertrophied  heart 
show  an  apex-beat  displaced  downward  and  to  the  left,  and  an  increased, 
heaving,  and  rather  circumscribed  apical  impulse.  These  signs  may  be 
less  evident  both  in  cases  of  coexisting  emphysema  and  later  when  dila- 
tation may  eclipse  the  hypertrophy.  The  left  border  of  the  deep  cardiac 
dulness  extends  outside  the  nipple-line  in  the  fifth  or  sixth  interspace. 
The  first  sound  of  the  heart  is  loud  and  may  be  duplicated.  A  dis- 
tinctive auscultatory  sign  is  the  accentuation  of  the  aortic  second  sound, 
indicating  increased  vascular  tension ;  it  may  have  a  metallic  quality. 
In  quite  a  majority  of  the  cases  I  observe,  sooner  or  later,  a  mitral  sys- 
tolic murmur ;  it  is  due  to  relative  insufiiciency. 

The  pulse  is  increased  in  tension,  and  is  hard,  incompressible,  and 
persistent,  the  duration  of  each  pulse-wave  being  increased  {pulsus  tar- 
dus). The  radial  artery  itself — and  this  is  true  of  most  of  the  palpable 
arteries — feels  hard,  thickened,  and  often  tortuous,  on  account  of  the 
arterio-sclerosis.  As  soon  as  compensation  of  the  heart  fails,  symptoms 
of  breathlessness  (especially  on  exertion),  palpitation,  and  the  like,  ap- 
near,  and  sometimes  in  paroxysmal  attacks  ("  cardiac  asthma  ").  The 
resultant  stasis  gives  rise  to  transudation  into  the  lungs  (bronchorrhea ; 
pulmonary  edema),  and  later  to  edema  of  the  extremities. 

Respiratory  System. — Epistaxis  may  be  a  serious  symptom.  Sudden 
edema  of  the  larynx  may  also  occur,  and  is  always  grave.  Transuda- 
tions into  the  pleural  sac  (hydrothorax),  as  well  as  into  the  lungs  {vide 
supra),  may  precede  death.  Dyspnea,  which  is  either  cardiac  or 
uremic,  is  usually  worse  at  night,  and  a  true  orthopnea,  together  with 
Cheyne-Stokes  breathing,  may  be  observed  toAvard  the  end  of  the  pa- 
tient's life  and  in  association  with  uremic  stupor  and  coma. 

Nervous  System. — Symptoms  referable  to  the  nervous  system  are  very 
important,  since  they  are  usually  indicative  of  grave  uremia.  Cephal- 
algia is  frequent,  and  neuralgic  pains  throughout  the  body,  and  insom- 
nia, may  be  complained  of.  Later  great  drowsiness  is  often  a  premo- 
nition of  uremic  coma.  Convulsions  may  be  preceded  by  muscular 
twitchings,  which  should  attract  attention  to  the  imminent  danger  of 
the  former.  Cerebral  apoplexy  with  hemiplegia  may  be  the  first 
symptom  of  contracted  kidney.  It  is  especially  apt  to  occur  in  cases 
of  marked  hardening  and  weakening  of  the  arteries.      There  may  be 


990  DISEASES  OF  THE   URINARY  SYSTEM. 

an  hemorrhagic  pachymeningitis,  as  well  as  a  hemorrhage  into  the 
brain-substance.  The  hemiplegia  may  persist  until  death  ;  or  it  may 
disappear  in  a  short  time,  and  be  followed  by  subsequent  attacks  at  in- 
tervals. Formication.,  numbness,  and  pallor  of  one  or  more  fingers  (the 
so-called  "dead  finger")  I  believe  with  Dieulafoy  to  be  sometimes  the 
earliest  symptoms  of  chronic  Bright's  disease. 

Of  the  special  senses,  nephritic  retinitis  is  often  the  earliest  evidence 
of  chronic  Bright's  disease.  The  patient  may  or  may  not  have  had 
slight  dimness  of  vision  (mistiness)  prior  to  the  ophthalmoscopic  exami- 
nation. The  loss  of  vision  aifects  both  eyes,  and  is  usually  partial  {am- 
hlyopid).  Sudden  and  complete  blindness  may  come  on  in  grave  cases 
— uremic  amaurosis — the  condition  being  due  to  neuro-retinitis.  The 
optic  papilla  is  swollen,  and  surrounded  by  retinal  hemorrhages  or  by 
white  dots  and  streaks  ("  feather-splashes  ").  Tinnitus  aurium,  deafness, 
and  vertigo  are  not  uncommon. 

Digestive  System. — Anorexia,  nausea,  and  annoying  dyspepsia  are 
often  complained  of.  Severe  vomiting  may  usher  in  an  uremic  attack. 
Catarrhal  gastritis  may  exist  for  some  time,  the  tongue  being  coated 
and  the  breath  heavy  and  urinous.      Uremic  diarrhea  may  also  occur. 

The  Skin. — Edema  is  usually  absent  in  renal  sclerosis ;  when  it  does 
occur,  however  (as  in  the  ankles  and  limbs),  it  is  due  to  dilatation  and 
failure  of  the  heart.  The  skin  is  dry,  and  minute  lustrous  scales  of  urea 
may  be  seen  around  some  of  the  pores.  A  certain  degree  of  pallor  is 
noticed,  and  often  tlie  skin  has  a  cyanotic  tinge.  Pruritus  and  trouble- 
some eczema  are  frei^uently  present,  and  muscular  cramps,  occurring 
especially  in  the  calves  of  the  legs  and  at  night,  may  also  be  associated. 
The  general  nutrition  gradually  fails,  so  that  in  advanced  cases  the 
debility  and   emaciation  are  extreme. 

It  is  important  to  bear  in  mind  the  fact  that  uremia  may  come  on  at 
any  time  during  the  course  of  the  disease,  and  that  it  may  be  the  first 
symptomatic  manifestation  ;  also  that  it  may  either  be  sudden  and  severe 
in  its  onset  (acute  uremia)  or  mild,  insidious,  and  gradual  (chronic 
uremia).  Moderate  fever  may  attend  an  uremic  attack,  or  the  tempera- 
ture may  be  normal ;  in  chronic  uremia,  with  prostration,  coma,  delir- 
ium, and  feeble  pulse,  it  may  be  even  subnormal. 

Among  the  complications  that  may  occur  in  the  red,  granular,  and 
contracted  kidney  are  the  following:  pneumonia,  either  lobar  or  lobu- 
lar; pleuritis,  pericarditis,  laryngitis,  bronchitis,  gastritis,  enteritis, 
peritonitis,  meningitis,  endocarditis,  emphysema,  phthisis,  and  hepatic 
cirrhosis. 

Diagnosis. — This  depends  in  great  part  upon  the  physical,  chemi- 
cal, and  histologic  examination  of  the  urine.  Both  the  morning 
and  evening  urine  should  be  examined  repeatedly  for  albumin  and 
casts,  since  one  examination — and  especially  that  of  the  morning 
urine — may  give  negative  results,  owing  both  to  the  scarcity  of  these 
two  pathologic  elements  and  to  the  fact  that  albumin  may  be  altogether 
absent  in  some  instances.  The  mere  discovery  of  a  trace  of  albumin  or 
of  a  few  casts  is  not  always  positive  evidence  of  chronic  Bright's  disease, 
as  both  may  exist  in  other  conditions.  But  the  age,  habits,  and  symp- 
toms of  the  patient  must  be  studied  in  connection  with  frequent  urinary 
examinations;  and  a  persistent  slight  albuminuria,  with  casts,  and  the 


CHRONIC  NEPHRITIS.  991 

passage  daily  of  large  quantities  of  clear,   pale  urine  of  low  specific 
gravity,  aiford  sufficient  grounds  for  making  the  diagnosis. 

Contracted  kidney  should  be  suspected  in  all  cases  in  which,  during 
middle  life,  either  one  or  more  of  the  following  symptoms  and  signs  may 
be  noticed :  frequent  headache,  congestive  disorders,  repeated  epistaxis, 
vertigo,  dimness  of  vision,  intractable  conjunctival  irritation  (Alle- 
man),  impaired  strength,  dyspneic  attacks,  gastro-intestinal  dyspep- 
sia, noises  in  the  ear,  itching  of  the  skin,  cramps  in  the  calves,  mus- 
cular twitchings,  growing  mental  dulness,  increasing  pulse-tension, 
and  rigidity  and  tortuosity  of  the  temporal  and  radial  arteries.  Sud- 
den coma,  convulsions,  amaurosis,  apoplexy,  vomiting,  or  dyspnea  in 
persons  in  the  middle  period  of  life,  with  or  without  a  history  of  poly- 
uria, should  create  the  suspicion  of  chronic  Bright's  disease.  It  will  be 
found  in  such  cases  that  there  has  been  a  diminution  in  the  urinary  flow 
before  the  attack.  Persons  of  lithemic,  gouty,  rheumatic,  or  alcoholic 
habits,  or  in  whom  lead-toxemia  is  discoverable,  with  evidences  of  car- 
diac hypertrophy,  an  accentuated  aortic  second  sound,  and  a  hard  pulse, 
are  often  readily  diagnosed  as  subjects  of  contracted  kidney  when  a  fur- 
ther examination  of  the  urine  is  made. 

The  diagnosis  may  be  very  difficult,  however,  in  cases  in  which  the 
first  examination  of  the  patient  is  made  during  a  sudden  uremic  or  apo- 
plectic attack.  Catheterization  should  be  done  if  necessary,  and  the 
detection  of  albuminuria  will  then  clear  the  diagnosis. 

In  order  to  difierentiate  between  primary  renal  affection  with  second- 
ary cardiac  hypertrophy  and  primary  heart-disease  with  a  secondary  con- 
gested kidney  occurring  late  in  the  case,  the  general  features,  course, 
symptoms,  and  signs  must  be  carefully  and  judiciously  balanced.  Prom- 
inent cardio-vascular  changes  would  indicate  an  arterio-sclerotic  kidney, 
rather  than  the  primary  granular  and  contracted  kidney  of  toxic  origin, 
though  even  here  the  diagnosis  is  often  quite  difficult.  The  symptoms 
of  ordinary  non-inflammatory  senile  kidney  may  not  be  unlike  those  of 
chronic  interstitial  nephritis,  though  not  so  severe ;  and  yet,  from 
excessive  eating  and  drinking  at  times,  uremic  attacks  may  supervene 
to  cloud  the  diagnosis. 

Prognosis. — The  duration  of  chronic  interstitial  nephritis  varies. 
In  uncomplicated  cases  it  may  last  for  five,  ten,  twenty,  or  possibly  thirty 
years.  Complications  or  intercurrent  affections  may,  however,  shorten  the 
duration  very  much,  or  the  existence  of  the  condition  may  be  unknown, 
as  frequently  happens,  when  the  postmortem  examination  shows  the  char- 
acteristic kidneys  in  one  who  during  life  had  no  symptoms  indicating 
renal  disease,  and  whose  death  was  caused  by  some  intercurrent  disease. 
The  gradual  destruction  of  the  renal  parenchyma  and  its  replacement 
by  scar-tissue  cause  irreparable  damage  to  the  organs.  On  the  other 
hand,  the  fact  that  the  process  is  usually  a  slow  one  and  its  duration 
long  is  compatible  with  the  preservation  of  life  for  many  years,  and  with 
comparative  comfort,  even,  in  many  instances.  The  prognosis  in  a  given 
case  depends  very  much  upon  the  general  constitutional  condition,  the 
cardio-vascular  state,  and  the  presence  or  absence  of  uremia  and  inflam- 
matory complications.  Cardiac  dilatation  and  insufficiency  indicate  a 
not  far  distant  end.  Convulsive  and  apoplectic  seizures  are  often  fatal, 
and  hemorrhages,  persistent  vomiting,  and  diarrhea,  retinitis  yiephritica, 


992  DISEASES  OF  THE   URINARY  SYSTEM. 

coma,  and  delirium  render  the  prognosis  as  to  further  systemic  toler- 
ance of  the  degenerated  kidneys  exceedingly  grave. 

Treatment. — An  early  recognition  of  the  disease  and  the  steadfast 
practice  of  careful  hygienic  measures  will  prevent,  to  a  considerable 
degree,  the  advance  of  the  cirrhotic  changes.  Noxious  substances  enter- 
ing into  the  etiology  of  the  aft'ection  must  be  avoided  and  removed  as 
far  as  possible.  The  formation  of  uric  acid  must  be  reduced  by  dietetic 
management,  alcoholics  must  be  interdicted,  and  lead — when  the  cause 
of  the  condition — must  be  kept  from  further  poisoning  the  system  by  a 
change  of  occupation.  By  diminishing  these  irritants  the  heart  and 
blood-vessels  are  also  conserved — a  point  of  vital  importance. 

The  hygienic  treatment  must  embrace  a  regulation  of  all  the  habits 
of  body  and  modes  of  life.  The  patient  must  be  treated,  and  not  his 
malady,  since  that  is  incurable.  A  dietary  that  is  suitable  for  each  in- 
dividual case  must  be  made  out,  and  on  general  principles.  Saundby's 
rule  is  a  good  guide:  "Eat  very  sparingly  of  butcher's  meat;  avoid 
malt  liquors,  spirits,  and  strong  wines."  An  exclusive  milk  diet  may 
be  necessary  for  short  periods  when  gastric  irritation  is  present,  but  in 
such  a  chronic  disease  undue  weakness  would  result  from  a  restriction 
to  milk  alone.  I  would  therefore  recommend  a  light  nourishing 
diet,  including  lean  meat  once  daily  in  favorable  cases.  Vege- 
tables, greens,  fruits,  and  light,  well-cooked  farinaceous  articles  may 
also  be  partaken  of,  and  tea,  coflfee,  and  cocoa  may  be  drunk.  The  use 
of  natural  mineral  waters  aids  in  the  renal  circulation  and  keeps  the 
kidneys  Hushed.  In  general  a  mixed  diet  will  be  of  advantage ;  the 
nitrogenous  and  carbohydrate  elements  (sugars  and  starches)  are  used  in 
limited  amounts,  while  pure  fats  and  fruits  (raw  or  cooked)  are  to  be 
recommended.  Stout  pei'sons  and  those  leading  sedentary  lives  should 
have  less  food  than  those  taking  exercise,  and  gastric  disorder  requires 
the  elimination  of  all  but  soft,  bland  foods,  or  a  liquid  diet  until  diges- 
tion is  restored.  Extremes  of  bodily,  mental,  and  emotional  activity 
should  be  avoided,  and  physical  exercise  should  be  moderate,  regular, 
and  taken  in  the  open  air,  provided  the  latter  be  warm  and  dry.  Men- 
tal labor  should  never  be  excessive,  nor  should  the  patient  be  subjected 
to  the  vicissitudes  of  worry,  anxiety,  or  competitive  tension.  Venereal 
excitement  and  indulgence  of  any  kind  tending  to  unbalance  the  self- 
control  or  disturb  the  equanimity,  cheerfulness,  and  contentment  should 
be  strictly  forbidden  and  guarded  against. 

A  change  of  residence  to  a  warm,  mild,  and  dry  climate  is  often  of 
service  in  prolonging  life.  The  variability  and  humidity  of  temperate 
climates,  particularly  during  the  winter  months,  aggravate  this  disease, 
Avhile  a  sea-voyage  or  a  sojourn  at  some  southern  European  resort  may 
be  very  beneficial  to  one  who  can  aiford  it. 

The  indications  for  medicinal  treatment  are  principally  as  follows : 
The  bowels  should  be  kept  free  by  the  aid  of  laxatives  or  laxative  alka- 
line mineral  waters.  Papoid,  peptenzyme,  and  other  digestants,  with 
bitter  tonics,  are  useful  in  some  cases  in  which  a  furred  tongue  and  indi- 
gestion are  troublesome.  Acids  or  alkalies,  according  to  special  indica- 
tions, may  also  be  used  simultaneously.  An  increased  vascular  tension 
(vaso-constriction),  such  as  to  place  a  serious  strain  upon  the  heart ;  the 
other  extreme,  of  a  very  low  tension  that  induces  dropsy  ;  and  compli- 


PYELITIS.  993 

cations,  usually  uremic  (convulsions,  dyspnea,  headache),  also  call  for 
therapeutic  assistance.  High  tension  is  to  be  met  by  the  cautious  use 
of  nitroglycerin  in  gradually  ascending  doses,  beginning  Avith  1  minim 
(0.066)  three  or  four  times  daily,  until  all  danger  of  rupture  of  the  ves- 
sels seems  to  be  past.  Headache,  vertigo,  and  the  so-called  renal  asth- 
ma (dyspnea)  are  also  often  relieved  by  this  drug. 

Low  tension,  with  signs  of  cardiac  dilatation,  scanty  albuminous 
urine,  and  edema,  requires  heart-tonics  and  stimulants,  in  conjunction 
with  purgatives.  Digitalis  (preferably  in  infusion)  has  good  effects, 
especially  when  combined  with  strychnin  nitrate  or  with  caffein  citrate. 
Calomel  and  the  salines  should  be  given  for  the  dropsy. 

Uremic  symptoms  should  be  treated  as  in  acute  Bright's  disease  by 
causing  profuse  sweating  and  free  catharsis,  and  in  some  cases  by  phle- 
botomy. Inhalation  of  amyl  nitrite  or  chloroform,  or,  what  is  often  a 
useful  and  necessary  measure,  the  hypodermic  injection  of  morphin  (gr. 
|— 0.0108),  may  be  tried  in  convulsions,  severe  headache,  or  dyspnea. 

Contracted  kidney  of  a  probable  malarial  or  syphilitic  origin  may  be 
benefited  somewhat  by  the  use  of  arsenic  and  the  iodids  respectively ; 
but  no  drugs  can  possibly  restore  the  destroyed  renal  parenchyma  or 
transform  connective-tissue  cells  into  secreting  kidney-cells. 


PYELITIS. 

{Pyelonephritis  ;  Pyonephrosis.) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney.  The  com- 
pound terms  above  represent  inflammation  of  the  kidney-structure  as  a 
result  of,  and  combined  with,  pyelitis. 

Pathology. — In  the  mildest  varieties  of  pyelitis  (the  catarrhal)  the 
morbid  changes  consist  simply  of  a  reddened,  swollen,  and  turbid  mucous 
membrane,  covered  with  an  exudation  of  viscid  muco-pus  and  desqua- 
mated epithelium.  Ecchymoses  are  sometimes  seen.  The  urine  in  the 
pelvis  of  the  kidney  is  also  turbid  from  the  admixed  pus-corpuscles  and 
pelvic  epithelium.  In  calculous  pyelitis,  owing  to  prolonged  and  severe 
irritation,  purulent  inflammation  and  ulceration  prevail,  and  the  kidney- 
structure  is  also  involved  by  extension  (pyelonephritis).  Renal  ab- 
scesses are  thus  formed,  and  small  dark  calculi  are  frequently  found 
mingled  with  the  pus  in  quite  a  number  of  small  abscess-cavities ;  or 
perhaps,  as  noted  before  (vide  Nephrolithiasis),  one  large  abscess-cavity 
may  replace  the  destroyed  renal  parenchyma  {pyonephrosis). 

A  diphtheritic  inflammation,  Avith  the  formation  of  a  false  membrane 
and  sloughing  of  the  pelvis,  sometimes  follows  the  severe  infections  of 
the  specific  fevers.  Marked  hemorrhagic  areas  may  be  seen  also.  In 
tuberculous  pyelitis  there  is  usually  an  association  of  nephritis  with 
areas  of  tuberculous  softening  and  ulceration,  and  later  pyonephrosis. 
In  very  chronic  and  sluggish  cases  the  pyelitis  may  be  followed  by  an 
infiltration  of  the  kidney-structure  with  cheesy  or  putty-like  masses  that 
may  become  the  seat  of  calcification. 

Persistent  obstruction  leading  to  pyelitis  is  associated  with  dilatation 

63 


994  DISEASES  OF  THE  URINARY  SYSTEM. 

of  the  pelvis  from  retention  of  urine  or  of  pus  (pyonephrosis).  This  in 
turn,  from  prolonged  pressure,  causes  the  marked  atrophy  of  the  secret- 
ing structure  of  the  kidney  that  is  seen  in  such  cases.  There  is  also  an 
increase  in  the  interstitial  tissue  and  secondary  contraction. 

The  so-called  surgical  kidney  is  found  when  an  acute  bilateral  pye- 
litis, following  a  severe  cystitis,  has  excited  an  acute  suppurative  m- 
flammation  of  the  kidney.  Acute  suppurative  or  interstitial  inflamma- 
tion of  the  kidney  due  to  metastatic  or  miliary  abscesses  is  considered 
under  the  heading  Pyemia  (vide  p.  199). 

Ktiologfy. — Pyelitis  rarely  is  primary  or  independent  in  origin,  as 
after  exposure  to  cold  and  wet.  The  secondary  causes  of  pyelitis  are 
as  follows :  (1)  renal  calculi  (the  most  frequent) ;  (2)  extension  upward 
of  urethritis,  cystitis,  or  ureteritis,  particularly  when  gonorrheal  in 
origin  ;  (3)  retention  of  decomposed  urine  in  the  pelvis  of  the  kidney ; 

(4)  renal     affections,    as    tubercle,    carcinoma,    and   acute    nephritis ; 

(5)  specific  fevers;  (6)  foreign  bodies,  other  than  stone  in  the  pel- 
vis ;  (7)  irritating  diuretics.  To  point  out  briefly  certain  additional 
facts  bearing  upon  the  causation  of  pyelitis  in  the  order  named,  it 
should  be  mentioned  that  calculous  pyelitis  may  result  from  the  irrita- 
tion of  the  constant  presence  and  passage  of  small  stones  ("gravel  "'), 
or  even  of  uric-acid  '"sand."'  as  well  as  from  the  large  dendritic  concre- 
tions that  send  offshoots  into  the  calyces.  Extensions  of  inflammation 
to  the  pelvis  from  lower  portions  of  the  urinary  tract  may  occur  in  pro- 
tracted cases  of  such  affections  as  gonorrheal  urethritis  aud  puerperal 
and  calculous  cystitis.  Obstructive  pyelitis  sometimes  follows  the  im- 
paction of  renal  calculi  or  of  other  foreign  bodies  in  the  ureter  when 
there  is  pre-existing  inflammation  of  the  tract,  or  when,  as  usually  hap- 
pens, there  is  chemical  irritation  from  the  decomposition  of  the  accumu- 
lated urine.  There  may  be  obstruction  in  the  bladder  and  urethra,  as 
from  enlarged  prostatic  tumors,  stricture,  phimosis,  and  paralysis  of  the 
sphincter  vesicae,  or  as  in  paraplegia.  Under  the  consideration  of  tuber- 
culosis and  carcinoma  of  the  kidney  is  included  the  involvement  of  the 
pelvis  by  these  conditions.  Infectious  pyelitis  may  also  result  from 
small-pox,  diphtheria,  typhus  and  typhoid  fevers,  and  scarlatina,  and 
it  depends  upon  the  irritating  effect  of  certain  substances  eliminated  by 
the  kidneys.  It  is  usually  associated  with  more  or  less  nephritis  (pyelo- 
nephritis). Parasites,  such  as  the  echinococcus  (hydatids),  distoma, 
strongylus,  and  filaria,  may  give  rise  to  pyelitis.  Cantharides,  cubebs, 
copaiba,  turpentine,  and  diabetic  urine  even,  may  in  rare  instances  also 
excite  a  pyelitis. 

Symptoms. — These  are  frequently  overshadowed  by  those  of  the 
primary  condition  that  causes  the  pyelitis :  they  are  varied  also  for  the 
same  reason.  The  clinical  manifestations  of  a  simple  catarrhal  pyelitis 
are  slight  pain  and  tenderness  in  the  region  of  the  affected  kidney  or 
kidneys,  mild  fever,  with  a  turbid  urine  of  acid  reaction,  showing  a  few 
pus-cells,  a  little  mucus,  rarely  some  red  blood-corpuscles,  and  a  trace 
of  albumin. 

In  the  severer  varieties,  as  in  calculous  pyelitis,  especially  when 
there  are  attacks  of  renal  colic,  the  urine  frequently  shows  to  the  naked 
eye  the  presence  of  blood  and  a  marked  amount  of  pus,  some  7nucus, 
and  the  transitional  caudate    epithelial   cells   from  the  middle  layers 


PYELITIS.  995 

of  the  mucosa.  The  presence  of  the  latter,  however,  is  not  constant, 
hence  its  absence  does  not  exclude  the  existence  of  a  pyelitis,  since 
some  of  the  most  destructive  forms  of  the  affection,  as  the  acute  or 
chronic  suppurative  or  the  pyelonephritic,  may  be  unaccompanied  by  the 
presence  of  the  pelvic  epithelium  in  the  urine.  This  holds  still  more 
true  in  the  case  of  true  pyonephrosis,  in  which  the  kidney  usually  be- 
comes one  large  abscess. 

In  severe  pyelitis  the  pain  is  often  acute,  coursing  doiv'n  the  ureters. 
The  fever  is  moderate,  and  there  are  present  the  common  symptoms  de- 
scribed under  Nephx*olithiasis  (vide  p.  970). 

The  fever  in  purulent  pyelitis  (pyonephrosis)  and  pyelonephritis 
takes  on  a  hectic  or  typhoid  type.  Paroxysms  of  rigors  or  chills,  fol- 
lowed by  a. rapid  rise  in  temperature  and  ending  in  perspiration,  may 
be  observed ;  or  there  may  be  marked  prostration  and  feebleness  of 
circulation,  delirium,  and  stupor.  The  temperature-curve  runs  an 
irregular  course,  with  marked  remissions,  in  cases  having  a  pyemic 
nature. 

In  obstructive  pyelitis  the  urine  sometimes  flows  freely  and  nor- 
mally for  a  while,  until  the  developing  pain  over  the  inflamed  kidney 
ends  in  relief  by  the  expulsion  of  the  obstacle  and  the  passage  of  puru- 
lent urine.  This  alternation  of  normal  with  pyoid  urine  is  indicative  of 
a  unilateral  pyelitis. 

Ammoniacal  urine  is  met  with  in  cysto-pyelitis.  Albuminuria  is  de- 
cidedly shown  according  to  the  degree  of  pyuria. 

In  chronic  suppurative  pyelitis  or  pyelonephritis  the  pyuria  is  vari- 
able both  in  quantity  and  constancy.  Intermittent  pyuria  may  be  due 
to  the  temporary  blocking  of  the  ureter  by  a  stone  {vide  Obstructive 
Pyelitis).  The  pus  is  seldom  mixed  with  epithelium  in  chronic  purulent 
pyelitis.  The  associated  intermittent  fever  may  be  like  that  of  tubercu- 
lous pyelitis,  and  marked  prostration,  anemia,  and  emaciation  are  con- 
comitants. Evidences  of  amyloid  change  may  be  revealed  in  long-stand- 
ing, chronic  cases. 

The  term  ammoniemia  has  been  applied  to  that  complexus  of  nervous 
symptoms  that  is  supposed  to  arise  from  the  decomposition  and  absorption 
of  urinary  substances.  These  symptoms  may  be  similar  to  the  manifesta- 
tions of  diabetic  coma. 

Distinct  enlargement  and  fluctuation  of  the  diseased  kidney  may 
be  determined  in  some  cases  of  pyonephrosis.  This  may  also  be  inter- 
mittent, being  detectable  while  there  is  obstruction  to  the  flow  of  pus, 
and  vice  versa.  According  to  A.  H.  Smith,  at  the  menstrual  periods 
pyelitis  may  be  subject  to  marked  exacerbations,  simulating  renal 
colic. 

In  chronic  pyelitis  with  atrophy  of  the  kidney  the  onset  of  uremia  may 
terminate  the  case.  Granular  kidney  alone  may  have  been  simulated  by 
the  passage  of  an  increased  quantity  of  urine  of  proportionately  low 
specific  gravity. 

Diagfnosis. — This  embraces  the  discrimination  from  other  affections, 
and  the  possible  detection  of  the  variety — etiologically  considered — of  the 
pyelitis.  It  is  most  important  to  pay  attention  to  the  clinical  history  of 
any  case  with  a  view  to  the  discovery  of  the  cause ;  also  the  urinary  con- 
dition must  be  carefully  studied.     In  the  very  nature  of  this  afiection  it 


996  DISEASES  OF  THE   URINARY  SYSTEM. 

is  often  impossible  to  exclude  other  affections  of  the  urinary  tract,  as 
nephritis^  cystitis,  and  urethritis. 

Epithelium  from  the  pelvis  of  the  kidney  cannot  be  distinguished  from 
transitional  bladder-cells ;  but,  given  the  indications  of  a  pyelitis,  its  cal- 
culous cause  is  at  once  made  clear  upon  the  passage  of  the  characteristic 
uratic  or  oxalatic  concretions.  It  may  happen  that  the  urine  from  one 
kidney  is  prevented  from  flowing  by  the  impaction  of  a  stone  in  the 
ureter.  The  urine  may  now  flow  clear  from  the  other  and  vicariously 
acting  kidney  until,  the  stone  having  given  way,  it  suddenly  increases 
in  quantity  and  changes  in  character,  owing  to  the  return  of  the  mor- 
phologic elements  of  the  pyelitis  (corpuscles,  desquamated  epithelium, 
crystals,  and  debris). 

In  women  catheterization  of  the  ureters  and  renal  pelves,  as  described 
and  practised  by  Pawlik  and  Kelly,  is  a  most  certain  method  of  deter- 
mining in  doubtful  cases  from  which  side  the  purulent  urine  arises.  Pal- 
pation of  the  ureters  through  the  lateral  and  anterior  fornix  of  the  vagina 
will  sometimes  reveal  thickening  and  tenderness  in  c^'sto- pyelitis,  and 
ureteral  distention  sometimes  may  be  felt  in  pyelitis  calculosa. 

Vierordt  mentions  having  seen  in  some  cases  of  pyelo-nephritis  pecu- 
liar hyaline  casts  "split  like  a  pair  of  trousers."  Casts  and  albumin  are 
usually  present  when  the  kidney-structure  is  involved  by  extension  of  the 
pyelitis,  while  marked  pain  in  the  region  of  the  kidney  indicates  predom- 
inant pyelitis,  though  it  does  not  exclude  the  possibility  of  coexisting 
nephritis.  Marked  vesical  irritability  points  to  associated  cystitis,  but 
in  intense  pyelitis  with  much  pus  and  an  acid  urine  vesical  tenesmus  may 
also  be  troublesome.  Tuberculous  can  be  discriminated  from  calculous 
pyelitis  by  finding  tubercle  bacilli  in  the  pus.  The  presence  of  a  fluc- 
tuating tumor  in  the  lumbar  region  is  significant  enough  of  pus ;  but  it 
may  be  difficult  to  determine  whether  it  is  due  to  pyonephrosis  or  peri- 
nephric abscess,  although  pyuria  and  the  previous  history  of  pyelitis,  as 
w^ell  as  the  more  circumscribed  and  less  edematous  character  of  the  swell- 
ing of  the  former,  are  important  distinguishing  points. 

Differential  Diagnosis. — The  hemorrhagic  pi/elitis  of  Senator,  Dela- 
field,  and  others,  described  as  occurring  in  milder  forms,  and  particu- 
larly in  girls  of  neurotic  types,  may  be  distinguished  by  the  intermit- 
tent hematuria  and  the  occasional  lumbar  pain,  lasting  but  a  few  days 
or  a  Aveek,  and  followed  uniformly  by  recovery.  Digestive  disturbances 
may  be  prominent  in  these  cases. 

Difiiculty  is  sometimes  experienced  in  diagnosticating  pyelitis  when 
coexistent  with  cystitis — pyelo-ci/stitis.  These  affections  will  not  be  con- 
founded, however,  when  it  is  recollected  that  their  histories  differ.  There 
is  pain  in  one  lumbar  region  in  the  former,  and  in  the  bladder  in  the  latter. 

According  to  Rosenfeld,  (1)  an  alkaline  reaction  is  not  found 
in  uncomplicated  pyelitis ;  (2)  the  limit  of  albumin  in  the  urine,  even 
with  severest  cystitis,  is  0.1  per  cent,  (maximum,  0.15) ;  (3)  if  the  pus- 
corpuscles  are  crenated,  and,  in  the  absence  of  vesical  tumor,  if  the  red 
corpuscles  of  a  microscopic  hemorrhage  are  chemically  or  morphologically 
decomposed,  pyelitis  exists,  and  especially  if  non-imbricated,  small  epi- 
thelial cells  are  practically  absent.  Stress  is  laid  upon  the  relation  of 
the  albumin-content,  which  is  from  two  to  three  times  greater  with  pye- 
litis than  with  cystitis. 


HYDRONEPHROSIS.  997 

Progfnosis. — Renal  complications  always  make  the  pyelitis  a  serious 
affection.  Catarrhal  cases  recover.  Calculous  pyelitis  tends  toward 
chronicity.  Pyelo-nephritis  and  pyonephrosis  are  apt  to  end  fatally  from 
exhaustion  or  uremia.  Perforation  and  the  discharge  of  pus  into  the  peri- 
toneal cavity,  pleural  sac,  intestine,  and  bronchi  even,  may  precede  death. 
The  gravity  of  all  cases  of  pyelitis  depends  upon  the  causes  and  upon  the 
tendency  to  consecutive  suppuration. 

Treatment. — This  varies  according  to  the  cause :  the  latter  needs 
to  be  removed,  its  effects  counteracted,  and  its  return  avoided.  The 
treatment  of  calculous  pyelitis  is  essentially  the  treatment  of  nephro- 
lithiasis. Primary  inflammation  of  the  lower  portions  of  the  urinary 
tract  must  be  combated ;  causes  of  retention  of  decomposed  urine,  as  an 
urethral  stricture  or  enlarged  prostate,  must  be  diminished ;  infectious 
fevers  must  be  judiciously  handled  and  irritating  diuretics  withheld. 

Local  measures  are  of  value  in  all  forms  of  pyelitis.  Hot-water 
bags,  fomentations,  poultices,  and  dry  cupping  are  often  of  great  service. 
Internally,  the  use  of  diluents  is  to  be  recommended,  especially  the 
alkaline  mineral  waters,  flaxseed  tea,  barley-water,  skimmed  and  butter- 
milk, and  lemonade. 

Potassium  citrate,  uva  ursi,  pichi,  buchu,  and  pareira  bravaare  some- 
times selected  for  their  soothing  properties.  But,  practically,  none 
of  the  remedies  named  nor  any  other  drug  is  of  any  avail  when  suppu- 
ration is  once  established.  Irrigation  by  means  of  Kelly's  ureteral 
catheter  may  be  practised  with  good  results  in  females.  Hypodermo- 
clysis  of  normal  salt-solution  may  be  of  sustaining  value  at  critical 
times  in  cases  of  infectious  pyelonephritis.  In  chronic  pyelitis  salol 
and  the  oils  of  turpentine,  sandalwood,  juniper,  copaiba,  and  erigeron 
have  been  used  for  their  stimulating  and  alterative  effects  upon  the 
mucous  membrane.  Surgical  intervention  is  necessary  in  severe  puru- 
lent pyelitis,  pyelonephritis,  and  pyonephrosis. 


HYDRONEPHROSIS. 


Definition. — An  obstructive  accumulation  of  urinary  fluid  in  the 
pelvis  and  calyces  of  the  kidney ;  it  may  cause  dilatation,  pyelitis,  or 
inflammation   and  atrophy  of  the  renal  structure. 

Patholog'y. — Hydronephrosis  is  usually  unilateral  The  pathologic 
changes  consist  of  a  dilation  of  the  pelvis  of  the  kidney,  associated 
with  a  degree  of  atrophy  of  the  renal  tissue  depending  upon  the  degree 
and  persistence  of  the  pressure.  The  accumulated  fluid  causes  flatten- 
ing and  atrophy  of  the  papillge,  and  gradually  of  the" tubules  and  glom- 
eruli, as  the  dilatation  and  distention  increase,  until  in  extreme  cases 
remnants  only  of  the  renal  structure  remain  in  the  walls  of  the  hydro- 
nephrotic  cyst.  The  mucous  membrane  lining  the  pelvis  and  calyces 
first  becomes  thinned,  and  later  thickened,  by  the  growth  of  connective 
tissue,  thus  forming  the  dense  sac-wall.  There  is  also  a  growth  of  con- 
nective tissue  in  the  renal  parenchyma,  medullary  and  cortical,  a  chronic 
nephritis  with  degeneration  and  atrophy  of  the  renal  cells  being  set  up. 

A  nepJirydrotic  cyst  may  be  very  large,  containing  as  much  as  several 


998  DISEASES  OF  THE   URINARY  SYSTEM. 

gallons  of  liquid.  Sometimes  in  medium-sized  sacs  the  external  appear- 
ance of  the  walls  may  be  lobulated ;  the  interior,  however,  usually  shows 
only  partial  septa  projecting  from  the  wall  into  the  cavity  of  the  sac. 
The  smaller  sacs  partially  enclosed  by  the  membranous  septa  probably 
represent  the  dilated  calyces.  According  to  the  seat  of  obstruction  one 
or  both  ureters  may  also  be  dilated.  If  one  kidney  is  affected,  its  fellow 
is  often  hypertrophied. 

The  fluid  contained  in  the  sac  varies  in  composition,  but  usually  is  a 
clear,  thin,  yellowish,  watery  urine.  The  specific  gravity  is  low,  and 
the  reaction  is  often  slightly  alkaline.  Traces  of  albumin,  urea,  uric 
acid,  and  salts  are  found.  Turbidity  may  be  present,  owing  to  admix- 
ture with  pus,  blood,  or  epithelium,  but  only  in  instances  in  which  pre- 
vious inflammatory  conditions,  as  a  calculous  pyelitis,  or  subsequent 
complications  of  like  nature  have  existed. 

Ktiology. — Ilydi-onephrosis — or,  better,  nephri/di'osis — is  in  most 
instances  secondarily  produced  by  diseases — congenital  or  acquired — 
that  cause  occlusion  of  the  ureter.  Probably  from  20  to  35  per  cent, 
of  cases  are  congenital  (Roberts).  In  these  cases  the  causal  condition 
is  one  of  stricture,  due  to  obstruction  caused  by  a  defective  development 
or  malformation  in  the  urinary  passage  of  one  or  both  sides,  usually  the 
latter.  Thus,  there  may  be  a  valve-like  formation  or  a  very  acute  in- 
sertion of  the  ureter  into  the  kidney.  The  dilation  has  occasionally 
become  so  great  in  the  fetus  as  to  cause  considerable  mechanical  diffi- 
culty during  labor. 

Among  adults,  women  are  more  often  subject  to  hydronephrosis  than 
men,  and  especially  women  who  have  borne  children.  The  condition 
may  be  bilateral,  as  from  a  stricture  low  down  and  due  to  gonorrheal 
urethritis,  but  more  often  it  is  unilateral.  The  causes  of  these  acquired 
cases  are  as  follows :  (1)  Impacted  calculi  in  the  ureter  or  renal  pelvis. 
(2)  Disease  of  the  ureteral  walls,  as  inflammatory  thickening  and  cica- 
tricial stenosis  from  ulcers.  (3)  Flexion  and  twisting  of  the  ureter,  as 
from  movable  kidney.  (4)  Pressure  upon  the  ureter  from  Avithout,  as 
by  tumors  and  constricting  bands  (pelvic  adhesions).  The  gravid  and 
retrodisplaced  uterus,  uterine  and  ovarian  neoplasms,  enlarged  and  pro- 
lapsed spleen,  and  similar  conditions  causing  compression  or  traction 
and  obliteration  of  the  lumen  of  the  ureter,  are  found  in  this  class.  (5) 
Diseases  and  tumors  of  the  bladder  that  involve  the  ureteral  orifices, 
particularly  carcinoma  and  ])apilloma,  or  that  cause  retention,  as  pros- 
tatic enlargement.     (G)  Urethral  stricture. 

Symptoms. — These  depend  somewhat  upon  the  cause  and  extent 
of  the  hydronephrosis.  Marked  bilateral  disease,  when  congenital,  may 
render  the  fetus  jnviable.  The  unilateral  variety  may  be  overlooked 
for  years,  and  no  symptoms  may  point  to  the  trouble  until  a  tumor  can 
be  made  out  by  inspection  and  palpation,  or  until  the  ureter  of  the  re- 
maining kidney  may  become  obstructed  and  symptoms  of  uremia  super- 
vene. The  latter  are  more  apt  to  come  on,  and  earlier  too,  in  double 
hydronephrosis. 

Locally^  the  patient  may  complain  of  frecpient  and  severe  yains  that 
shoot  about  the  affected  loin  and  downward  toward  the  thigh.  Sensa- 
tions of  weight  and  a  dragging  discomfort  are  common.  Anorexia, 
nausea  and  vomiting,  eructations,  and  irregularity  of  bowel-action  are 


HYDBONEPHBOSIS.  999 

associated  sometimes.  In  large  hydronephrotic  cysts  a  continuous  dull, 
aching  pain  only  may  be  felt,  or,  as  is  not  infrequently  the  case,  the 
tumor  may  be  absolutely  painless.  Obstinate  constipation  may  result 
from  compression  of  the  colon,  or  in  moderate  enlargements  diarrhea 
may  occur  from  the  pressure-irritation. 

Usually  a  swelling  is  detected  in  the  region  of  the  affected  kidney. 
It  gradually  increases  in  size,  and  in  marked  enlargements  distinct 
bulging  may  be  visible  in  the  hypochondriac  and  lumbar  regions.  Pal- 
pation reveals  a  rounded,  firm,  yet  somewhat  elastic  and  sometimes  fluc- 
tuating tumor.  There  may  be  slight  tenderness.  Dulness  on  percussion 
is  found  over  the  mass,  except  where  the  colon  overlies  it,  when  tym- 
pany is  elicited  ;  this  is  a  characteristic  sign  of  kidney-tumors.  Mod- 
erate enlargements  generally  do  not  descend  during  inspiration.  There 
may,  however,  be  exceptions  to  this  rule. 

The  inter mitte7it  form  of  hydronephrosis  (Landau)  is  interesting  from 
the  variations  that  occur  in  the  size  of  the  tumors.  A  marked  diminu- 
tion  is  eoiyicident  ivith  a  more  or  less  sudden  increase  in  the  quantity  of 
urine  passed ;  and,  on  the  other  hand,  as  the  tumor  gradually  enlarges 
the  flow  of  urine  decreases.  These  cases  are  in  most  instances  due  to 
movable  kidney.  Colicky  pains  often  usher  in  the  periods  of  greatest 
distention  preceding  the  sudden  increase  in  the  flow  of  clear  urine. 
This  variety  of  the  affection  occurs  most  frequently  in  women  that  have 
borne  children.  The  general  symptoms  scarcely  amount  to  more  than 
a  certain  loss  of  flesh  incident  to  the  associated  worry  and  anxiety. 
The  filling  of  the  nephrydrotic  cyst,  the  distention,  and  the  pain  and 
discharge,  with  subsidence  of  the  tumor,  recur  with  variable  frequency. 
According  to  Osier  :  "  Among  the  circumstances  liable  to  cause  them 
are  sudden  and  violent  exercise,  the  jarring  and  jolting  of  riding  and 
driving,  any  fatigue,  mental  emotions,  and  errors  in  diet."  The  tumor 
may  continue  to  develop  in  size  for  several  days  after  the  pain  has  dis- 
appeared. The  latter  may  last  from  several  hours  to  a  day.  During 
the  intervals,  and  after  the  urine  has  increased  in  quantity,  gradually 
or  quickly,  the  patient  feels  tolerably  comfortable,  and  this  sometimes 
for  weeks  or  months.  For  obvious  reasons  the  tumor  is  rather  mobile 
in  intermittent  hydronephrosis. 

The  occurrence  of  chills,  fever,  and  sweats,  nausea  and  vomiting, 
abdominal  distention,  and  rapid  pulse  usually  indicates  suppuration,  and 
pyonephrosis  may  be  the  consequence.  The  urine  will  then  be  cloudy 
and  reveal  pus,  following  both  discharge  and  aspiration.  A  lowered 
specific  gravity  and  the  presence  of  albumin  will  be  noted  when  a 
chronic  nephritis  has  been  set  up.  Increased  arterial  tension  and  symp- 
toms of  acute  febrile  or  chronic  afebrile  uremia  may  be  added. 

Hydronephrosis  paraplegica  is  a  form  of  the  disease  in  which  para- 
plegia develops  as  a  complication. 

The  course  of  nephrydrosis  is  usually  chronic,  with  variations  and 
exacerbations  depending  upon  the  cause  of  the  affection. 

Diagnosis. — This  is  obviously  very  difficult  in  cases  in  which  the 
accumulation  of  liquid  is  small.  Characteristic  signs  are  the  gradual 
development  of  a  tumor  in  either  flank,  as  described  above,  with  dimi- 
nution in  the  urinary  flow,  followed  by  a  more  or  less  sudden  free  dis- 
charge and  the  subsidence  of  the  tumor,  with  recurrences  (as  in  the  in- 


1000  DISEASES  OF  THE   URINARY  SYSTEM, 

termittent  variety).  When  these  do  not  occur  and  the  tumor  continu- 
ously enlarges,  aspiration  may  be  practised  to  determine  whether  the 
mass  is  solid  or  liquid  ;  the  nature  of  the  latter  may  also  thus  be  ascer- 
tained, whether  urinary  or  not.  Ureteral  catheterization  will  determine 
which  is  the  dry  side. 

The  history  of  the  case  and  the  detection  of  some  causative  occlusion 
will  point  to  the  diagnosis. 

Differential  Diagnosis. — The  nephrydrotic  sac  must  be  distinguished 
by  exclusion  from  an  ovarian  cyst,  cystic  kidney,  and  tumors  of  the  spleen, 
liver,  and  gall-bladder.  Very  large  cysts  may  be  mistaken  for  ascites. 
Assurance  of  the  presence  of  the  colon  over  the  tumor  is  diagnostic, 
and  a  chemical  examination  of  the  fluid  obtained  by  the  use  of  the  ex- 
ploring needle  will  suffice  in  most  cases.  It  should  be  remembered, 
however,  that  a  slight  amount  of  urea  is  sometimes  found  in  ovarian 
cystic  fluid.  The  presence  of  pus-cells  in  abundance  in  the  aspirated 
fluid,  Avith  symptoms  of  suppuration,  is  significant  of  pyonephrosis. 

Prognosis. — This  is  generally  unfavorable,  though  in  unilateral 
hydronephrosis  evidences  of  compensation  on  the  part  of  the  unaff"ected 
kidney  should  render  the  case  guardedly  favorable,  particularly  if  the 
cause  be  a  movable  kidney.  The  bilateral  affection  is  always  grave, 
owing  to  the  danger  of  uremia.  Infection  of  the  cyst  with  pus-organ- 
isms is  usually  a  fatal  complication.  Recovery  may  ensue  in  rare  in- 
stances in  which  a  spontaneous  discharge  of  the  liquid  takes  place.  Rup- 
ture of  the  sac  is  unlikely. 

Treatment. — The  removal  of  the  cause  is  seldom  feasible.  Symp- 
tomatic treatment  only  is  required  in  mild  cases,  though  sometimes  gen- 
tle massage  over  the  sac,  properly  directed  and  cautiously  applied  (to 
avoid  rupture),  may  cause  a  reduction  in  the  size  of  the  tumor.  Most 
often  surgical  measures  only  are  of  use.  These  embrace  puncture  and 
aspiration,  incision  (nephrotomy)  and  drainage,  nephrorrhaphy,  ne- 
phrectomy, and  the  formation  of  a  renal  fistula.  These  procedures,  how- 
ever, are  undertaken  only  when  successive  reaccumulations  of  the  fluid 
follow  those  measures  first  mentioned. 


PERINEPHRIC    ABSCESS. 

( Perinephritis.) 

Definition. — Suppurative  inflammation  of  the  connective  tissue 
surrounding  the  kidney. 

Pathology. — The  suppuration  attacks  the  lax  adipose  tissue  or 
the  fatty  capsule  in  which  the  kidney  is  imbedded  and  the  adjacent 
retroperitoneal  tissue.  The  starting-point  of  suppuration  is  usually  be- 
hind the  kidney.  There  may  be  several  small  abscesses  at  first,  but 
more  often  a  single  large  abscess  is  found.  The  walls  may  be  soft  and 
shreddy,  or  in  more  chronic  cases  thickened  and  fibrous.  A  bulging 
externally  over  the  affected  lumbar  region  is  not  infrequent,  particularly 
in  large  and  extensive  accumulations  of  pus.  The  latter  has  a  tendency 
at  a  given  point  to  burrow  into  the  surrounding  tissues,  and  especially 
downward  toward  the  iliac  fossa,  pointing  in  the  groin  near  Toupart's 


PERINEPHRIC  ABSCESS.  1001 

ligament.  It  may  extend  backward  and  open  upon  the  skin-surface. 
Sometimes  the  pus  perforates  the  diaphragm  and  discharges  through  the 
pleural  cavity  and  lungs,  or  the  colon,  vagina,  bladder,  or  peritoneum 
may  be  perforated.  The  pus  is  occasionally  quite  offensive,  and  may 
be  ichorous  from  an  admixture  of  infiltrated  urine.  Perirenal  abscess 
due  to  calculous  pyonephrosis  may  contain  calculi  that  have  ulcerated 
through  pelvic  or  renal  walls.  Thickening  of  the  adjacent  peri- 
toneum is  often  found.  In  certain  cases  of  perinephritis,  which  usually 
gave  no  symptoms  during  life,  the  postmortem  examination  has  revealed 
fibrous  adhesions  and  a  firm  and  thickened  and  fatty  capsule,  stripped 
with  difficulty  from  the  true  capsule  of  the  kidney. 

etiology. — Perirenal  abscesses,  when  not  traumatic  in  origin,  de- 
velop most  frequently  as  a  result  of  purulent  pyelo-nephritis  or  pyo- 
nephrosis. Hence  they  are  usually  secondary.  Other  primary  condi- 
tions that  may  cause  perirenal  suppuration  are  the  following  :  extension 
of  inflammation  from  the  ureter  or  pelvis  of  the  kidney;  from  a  pelvic 
abscess  ;  from  appendiceal  or  hepatic  abscesses  ;  and  from  spinal  caries 
(psoas  abscess)  and  empyema.  Sometimes  tuberculous  processes  in  the 
kidney  and  suppurating  new  growths,  as  carcinoma  and  cysts  (includ- 
ing the  echinococcus),  are  complicated  by  perirenal  abscess.  More  rarely 
such  severe  infectious  diseases  as  typhus  fever,  small-pox,  and  pyemia 
lead  to  purulent  perinephritis.  Finally,  there  are  cases  for  which  no 
cause  is  discoverable. 

Symptoms. — Subjectively,  there  is  noted  a  dull,  throbbing  pain 
over  the  affected  region  that  is  increased  by  motion ;  sometimes,  when 
the  abscess  is  large  and  presses  on  the  large  nerve-trunks,  the  pains  may 
become  shooting  in  character  and  be  felt  in  the  leg  on  the  same  side. 
Numbness  may  also  be  felt.  Pain  and  tenderness  on  palpation  are  com- 
mon. The  patient  is  prostrated,  weak,  and  often  quite  emaciated,  and 
flexure  of  the  thigh  on  the  affected  side  is  frequent.  The  characteristic 
fever  of  suppuration  is  present  in  the  deeply  remitting  or  intermitting 
type,  with  alternating  chills  and  debilitating  sweats.  Pus  is  found  in 
the  urine  only  Avhen  the  kidney  is  involved.  Sooner  or  later  evidences 
of  a  tumor  are  seen ;  the  areas  can  be  palpated,  and  a  gradual  bulging 
in  the  lumbar  area,  increasing  slowly,  Avith  smoothness  and  glistening 
of  the  skin  and  pitting  (edema),  may  be  observed.  Fluctuation  is  fre- 
quently apparent  in  advanced  cases,  and  in  favorable  cases  signs  of 
"pointing"  appear. 

Diagnosis. — Should  the  abscess  tend  to  burrow  downward,  the 
condition  may  be  somewhat  obscure  on  account  of  the  absence  of  dis- 
tinct local  symptoms.  Indeed,  involvement  of  the  psoas  may  give  rise 
to  symptoms  of  coxitis,  as  pain  referred  to  the  knee-joint.  The  diag- 
nosis is  usually  easy,  and  when  in  doubt  as  to  whether  the  tumor  is  an 
abscess  or  an  hydronephrosis  or  solid  mass,  the  exploring  needle  should 
be  used. 

Differential  Diagnosis. — An  important  point  in  differentiating  peri- 
nephric abscess  from  suppurative  pyelitis  or  pyelo-nephritis  alone  is 
the  fact  that  in  the  latter  the  quantity  of  urine  is  usually  diminished, 
whilst  in  the  former  there  is  less  apt  to  be  any  interference  with  the 
renal  secretion.  Again,  Avhilst  in  the  latter  the  urine  usually  contains 
blood  and  pus,  in  the  former  the  urine  is  free  from  blood,  though  not 
necessarily  from  pus,  and  casts  are  also  absent  here. 


1002  DISEASES  OF  THE   URINARY  SYSTEM. 

Prognosis. — This  is  guardedly  favorable  if  the  abscess  points  ex- 
ternally in  the  lumbar  area.  Of  course  rupture  into  the  peritoneal 
cavity,  bladder,  bowel,  and  groin  is  always  a  serious  occurrence. 

The  treatment  is  essentially  surgical,  and  consists  in  free  incision 
and  drainage. 


CYSTIC  KIDNEY. 

{Renal  Cyst.) 

Pathology. — Congenital  cystic  kidneys  are  in  reality  collections  of 
cysts,  varying  in  size  from  a  pea  to  a  marble,  and  separated  from  each 
other  by  septa  of  compressed  renal  or  fibrous  tissue.  Either  one.  or  fre- 
quently both,  kidneys  may  be  affected  with  what  is  sometimes  termed 
congenital  ci/Htic  degeneration  of  the  kidneys.  There  is  considerable  en- 
largement of  the  organs,  and  during  intra-uterine  life  they  may  attain  a 
size  so  enormous  as  to  render  parturition  extremely  difficult  and  danger- 
ous. The  fetus  is  usually  non-viable,  though  in  mild  cases  the  affection 
may  be  tolerated  for  some  years  after  birth.  The  cystic  fluid  may  be 
either  clear  or  turbid,  a  reddish-yellow  or  a  dark-brown  in  color,  acid 
in  reaction,  and  holds  in  solution  urinary  salts,  blood,  cholesterin,  and 
sometimes  uric  acid  and  urea.  A  single  layer  of  flattened  epithelial 
cells  lines  the  cyst-walls.  The  cysts  themselves  seem  to  be  dilatations 
of  the  renal  tubules  and  of  Bowman's  capsules,  due,  in  some  instances, 
to  an  obliteration  of  the  tubules  of  the  papilhe  or  to  stenosis  of  some 
portion  of  the  urinary  tract. 

The  cystic  kidneys  usually  met  with  in  adult  life  (acquired)  are  of 
several  varieties :  (1)  One  or  perhaps  a  few  cysts  may  be  present,  larger 
usually  than  those  in  the  congenital  cystic  kidney,  which  seem  to  cause 
no  interference  with  the  normal  renal  functions.  Sometimes  a  reddish- 
brown  colloid  material  is  contained  in  these  cysts. 

(2)  Small  and  often  (juite  minute  cysts  frequently  accompany  the 
chronic  nephritic  kidney  that  is  small,  contracted,  and  cirrhotic.  These 
result  from  dilated  tubules  and  capsules  when  the  former  are  narrowed 
by  the  hyperplasia  of  fibrous  tissue. 

(3)  Cystic  kidneys  in  adults  may  have  the  pathologic  characteristics 
of  the  congenital  variety — a  mere  conglomeration  of  cysts  containing  a 
clear  or  colored  serum  or  a  cloudy,  dark,  thick,  and  colloid  liijuid.  This 
condition  is  sometimes  associated  with  similar  cystic  disease  of  the  liver 
and  spleen.  It  may  be  a  late  manifestation  of  mild  congenital  disease. 
The  kidneys  have  been  found  converted  into  cysts  in  cases  in  which  the 
presence  of  calculi  (uric  acid)  in  the  tubules  has  probably  started  the 
the  cystic  degeneration. 

(4)  Solitary  cystic  adenoma  occurs  rarely.  It  is  in  the  form  of  a 
globular  tumor  projecting  from  the  surface  (usually  the  anterior)  of  the 
kidney.  It  may  be  as  large  as  an  orange,  and  may  be  enclosed  in  a  dis- 
tinct capsule.  On  section  the  mass  is  found  to  be  composed  of  various- 
sized  cysts  separated  by  septa  of  fibrous  tissue  lined  with  cuboid  or 
columnar  epithelium.  The  remainder  of  the  kidney  appears  to  be  quite 
health  V. 


NEW  GROWTHS  OF  THE  KIDNEY.  1003 

Ktiology. — Cystic  disease  of  the  kidneys  is  either  congenital  or 
acquired.  The  former  is  jDrobably  commoner  than  the  latter  condition, 
may  even  be  hereditary,  and  may  persist  for  a  "while  in  extra-uterine 
life,  while  the  acquired  variety  may  be  of  unknown  origin  or  secondary 
to  chronic  interstitial  nephritis  or  to  urinary  calculi  in  the  renal 
tubules.  The  direct  cause  of  intra-uterine  renal  cysts  is  not  definitely 
known,  but  they  are  probably  developmental  rather  than  pathologic, 
since  other  defects  of  embryonic  growth  are  frequently  associated  with 
the  disease. 

Symptoms. — These  may  be  absent  in  adults  until  the  sudden  de- 
velopment of  uremia.  Ordinarily,  the  clinical  picture  is  similar  to  that 
of  chronic  interstitial  nephritis.  There  is  an  increase  in  the  quantity 
of  urine,  which  is  of  low  specific  gravity ;  the  normal  solids  are  dimin- 
ished in  quantity  :  and  aceto-soluble  albumin  may  be  present  (Clifford 
Mitchell).^  Slight  albuminuria  maybe  present.  On  'palpation  a  large, 
rounded,  and  sponc/e-Iilce  mass  may  be  felt  in  either  hypochondrium  or  on 
both-  sides.  Cardiac  hypertrophy  and  increased  arterial  tension,  as  in 
chronic  cirrhosis,  are  also  frequently  met  with  in  cystic  degeneration 
of  the  kidneys.  Parker^  reports  a  case  Avhich  was  followed  by  exfolia- 
tive dermatitis. 

The  diagnosis  can  only  be  made  upon  the  presence  of  the  above 
symptoms  and  the  discovery  of  the  clear  physical  signs  of  the  tumor.  It 
should  be  pointed  out  that  a  possible  complication  of  perinephric  abscess, 
due  to  rupture  of  one  or  more  of  the  cysts  (as  has  occurred — Osier), 
would  of  course  render  a  diagnosis  wellnigh  impossible. 

Prognosis. — Bilateral  cystic  disease  of  the  kidney  must  eventually 
prove  fatal,  owing  to  the  sudden  onset  of  uremia  or  cardiac  failure. 
Solitary  cysts  give  a  tolerably  favorable  outlook  under  proper  surgical 
interference. 

Treatment. — The  unilocular  cysts  just  referred  to  above  may  be 
removed,  capsule  and  all,  and  the  kidney  sutured.  Bilateral  disease 
cannot  be  operated  upon  for  obvious  reasons ;  unilateral  cystic  degen- 
eration may  be  treated  by  nephrectomy,  Avith  narrow  chances  of  success. 


NEW  G-ROWTHS  OF  THE  KIDNEY. 

The  most  common  tumors  of  the  kidney  are  those  belonging  to  the 
class  of  adenomata  (benign)  and  those  that  are  either  sarcomatous  or  car- 
cinomatous (malignant). 

Adenomata  may  be  congenital  or  acquired.  They  grow  in  the 
cortex  of  the  kidney  in  the  form  of  small  nodular  masses,  which  in  some 
cases  may  increase  to  a  considerable  size  before  any  symptoms  are  pro- 
duced. A  cystic  growth  may  be  combined  with  adenoma  {cystic  ade- 
7ioma)^  and  lympJiadenoma  is  also  occasionally  seen  as  a  secondary 
growth.  Other  benign  tumors  that  may  affect  the  kidney  are  angioma, 
fibroma,  and  lipoma.  Very  large  vascular  adenomata  may  become 
malignant.  GraAvitz,  Lubarsch,  Kelly,  and  others  have  described  a 
variety  of  tumor  [hypernephroma)  derived  from  aberrant  adrenal  tissue 
misplaced  in  the  kidney. 

^  Philadelphia  Medical  Journal,  Aug.  19,  1899. 

^  American  Journal  of  Mediccd  Sciences,  Sept.,  1899. 


1004  DISEASES  OF  THE   URINARY  SYSTEM. 

Sarcoma  and  carcinoma  may  be  either  primary  or  secondary. 
Sarcoma  is  frequently  congenital  in  origin,  and  may  have  an  admixture 
of  striped  muscular  tissue.  The  presence  of  the  latter  in  the  kidney 
points  to  developmental  disturbances  during  embryonic  life  as  the  cause 
of  a  variety  of  tumor  known  as  rJiabdomyoma.  Alveolar  sarcoma  is 
also  met  with. 

Renal  carcinoma  is  probably  of  less  frequent  occurrence  than  sar- 
coma ;  it  may,  however,  be  found  in  children  as  well  as  in  aged  persons, 
the  t^yo  extremes  of  life.  Carcinoma  of  the  kidney  is  usually  of  the  soft 
medullary  or  encephaloid  variety.  As  a  primary  affection  it  probably 
originates  in  the  renal  tubules.  Both  sexes  are  subject  to  the  disease. 
Secondary  carcinoma  of  the  kidney,  although  probably  more  frequent 
than  the  primary  form,  is  seldom  of  clinical  importance.  Renal  carci- 
noma may  occur  as  a  diffuse  infiltration  or  in  nodular  masses,  one  kid- 
ney usually  being  affected  in  primary  carcinoma.  The  tumor  sometimes 
reaches  an  enormous  size,  and  instances  are  recorded  in  which  nearly 
the  whole  abdomen  has  been  filled,  and  in  Avhich  the  growth  weighed  as 
much  as  31  lbs.  (14  kgms.,  Roberts).  Rhabdomyomata  do  not,  as  a 
rule,  attain  a  very  large  size,  though  sarcomata  may  grow  (juite  large. 
Softening  and  hemorrhage  within  these  malignant  growths  may  occur. 
The  pelvis  of  the  kidney  may  be  invaded,  and  metastatic  areas  may 
form  in  the  liver  or  the  lungs,  though  this  occurs  in  the  case  of  primary 
renal  carcinoma  less  readily  than  from  carcinoma  in  other  organs.  Me- 
tastatic growths  arise  most  likely  through  involvement  of  the  renal  vein. 
The  renal  parenchyma  is  either  partially  or  wholly  destroyed,  the .  pyr- 
amids being  attacked  later  than  the  cortex. 

Symptoms. — Lumbar  pain  on  the  affected  side  is  often  an  early 
symptom,  and  may  persist  throughout  the  course  of  the  disease.  It 
may  be  paroxysmal,  and  be  felt  extending  down  the  thigh,  or  it  may  be 
dull,  dragging,  and  limited  in  character.  Pain  is  not,  however,  a  con- 
stant symptom  in  a  certain  proportion  of  the  cases. 

Hematuria  may  occur  early  or  late,  and  often  appears  before  any 
tumor  is  palpable.  The  blood  may  be  in  a  fluid  state  or  in  clots,  the 
latter  not  seldom  taking  the  form  of  pelvic  or  urethral  casts,  the  passage 
of  which  may  give  rise  to  colicky  pains.  Casts  of  the  ureter  sometimes 
resemble  lumbricoid  worms.  The  hemorrhage  may  be  excessive  and 
cause  marked  Aveakness  and  a  symptomatic  anemia,  superadded  to  the 
cancerous  anemia  that  is  usually  present ;  on  the  other  hand,  it  may  be 
so  slight  as  to  be  discoverable  only  microscopically.  It  recurs  at  irreg- 
ular intervals  of  days  or  weeks.  Large  clots  may  accumulate  in  the 
bladder  and  cause  vesical  irritability.  The  urine  from  the  healthy  kid- 
ney may  be  quite  normal,  and  may  be  secured  for  observation  by  ureteral 
catheterization.  Cancer-cells  or  tissue-fragments  of  the  neoplasm  very 
rarely  appear  in  the  urine,  at  least  so  as  to  be  distinctly  recognizable  as 
such.  Anorexia.,  nausea  and  vomiting,  progressive  loss  of  flesh  and 
strength,  increasing  pallor,  and  the  concomitant  symptoms  of  the  can- 
cerous cachexia  are  seen  to  develop. 

Physical  Signs. — These  may  not  be  sufficient  to  reveal  the  presence 
of  the  tumor  for  some  time  after  the  above  symptoms  have  been  observed. 
The  appearance  of  a  palpable  tumor  in  either  flank  is  a  definite  aid  to 
diagnosis.  It  is  felt  between  the  ribs  and  pelvis  latero-anteriorly,  and 
at  first,  when  small  and  on  the  right  side,  it  may  be  movable.     Both 


NEW  GROWTHS   OF  THE  KIDNEY.  1005 

sarcoma  and  carcinoma  of  the  kidney  may  assume  enormous  sizes.  The 
tumor  feels  dense  and  hard  (except  rapidly-growing  tumors,  as  encepha- 
loid),  either  smooth  or  lobulated,  and,  Avhen  not  too  large,  may  retain 
the  natural  position  and  form  of  the  kidney.  The  growth  extends 
downward  and  inward,  and  in  the  very  large  malignant  renal  tumors  of 
childhood  the  abdomen  shows  considerable  enlargement,  along  wath  an 
abnormal  pulsation  and  a  prominence  of  the  veins.  Usually  the  tumor 
does  not  move  with  respiration.  Percussion  gives  dulness  over  the  mass, 
although  in  small  and  moderately  large  tumoi'S  the  overlying  colon  may 
cause  a  tympanitic  note  to  be  heard.  Neighboring  organs,  as  the  liver 
and  spleen,  may  be  found  by  palpation  and  percussion  to  be  displaced 
by  the  renal  tumor. 

Diagnosis. — The  presence  of  a  tumor,  Avhen  not  too  large  and  dis- 
tinctly occupying  the  lumbar  and  lower  lateral  abdominal  region,  to- 
gether with  hematuria,  pain  of  a  local  nature,  and  progressive  failure  of 
nutrition,  may  be  looked  upon  as  diagnostic  of  a  malignant  type  of 
renal  tumor.  The  relation  of  the  colon  to  the  tumor  and  immovability 
of  the  latter  during  respiration  are  also  diagnostic.  When  the  tumor  is 
very  large  and  adhesions  have  formed,  as  in  cancerous  kidney,  it  may 
be  mistaken  for  other  conditions. 

Differential  Diagnosis. — AiFections  such  as  hydronephrosis,  pyone- 
phrosis, cystic  kidney,  hydatids,  ovarian,  splenic,  and  hepatic  tumors,  and 
(particularly  in  children)  retroperitoneal  sarcoma  must  be  diiferentiated 
from  renal  growths.  Careful  bimanual  palpation  will  aid  in  the  diagno- 
sis, but  the  exclusion  of  other  lumbar  enlargements  must  be  made  by 
close  attention  to  the  history  and  to  the  development  and  course  of  the 
symptoms.  Hematuria  alone,  in  aged  persons,  is  suggestive  of  carcinoma 
when  no  tangible  cause  for  the  presence  of  the  blood  is  at  hand.  Hepatic 
and  splenic  tumors  are  usually  movable  during  deep  breathing,  whilst 
renal  tumors  are  not  so.  In  cases  of  hepatic  growths  also  the  area  of 
dulness  extends  higher,  w^hilst  in  renal  growths  on  the  right  side  a  tym- 
panitic area  generally  lies  between  the  liver  and  the  tumor.  The  cha- 
racteristic notch  and  edge  of  the  spleen,  and  the  absence  of  the  overlying 
colon-tympany,  are  points  that  distinguish  splenic  enlargements  from 
those  of  the  left  kidney.  Pelvic  growths  (ovarian  and  uterine)  enlarge 
from  below  upward,  and  are  readily  detected  by  vaginal  examination. 
In  children  Lobstein's  cancer  (retroperitoneal  sarcoma),  if  very  large,  is 
easily  mistaken  for  a  renal  tumor,  except  that  it  is  usually  more  cen- 
trally situated  and  more  firmly  fixed. 

Prognosis  and  Treatment. — The  termination  in  cases  of  renal  carci- 
noma is  inevitably  fatal,  and  children  succumb  more  quickly  than  adults. 
The  disease  may  last  from  a  few  months  to  sometimes  a  year  or  two. 

If  the  kidney  be  removed  Avhile  the  growth  is  still  small,  the  prog- 
nosis is  fairly  good ;  but  if  large  or  if  metastatic  tumors  have  formed, 
the  prognosis  is  always  bad.  Bloch  warmly  advocates  in  some  cases  the 
removal  of  small  sections  of  kidney-substance,  to  avert  the  necessity  of 
a  nephrectomy  by  proving  the  non-malignancy  of  the  growth.  The  treat- 
ment,  aside  from  early  surgical  measures,  is  entirely  symptomatic  and 
supportive,  and  obviously  it  is  unsuccessful.  Renal  colic,  excessive 
hematuria,  and  a  gradually  lowered  vitality  may  be  met  by  the  use  of 
palliatives,  tonics,  and  by  nutritious  and  easily  digestible  diet.  Kuclein 
may  be  tried  hypodermically  or  by  the  mouth. 


1006  DISEASES  OF  THE   URINARY  SYSTEM. 

II.    DISEASES  OF  THE  BLADDER. 
CYSTITIS. 

Definition. — Inflammation  of  the  mucous  membrane  of  the  bladder. 
It  may  be  either  acute  or  chronic,  the  latter  being  clinically  the  much 
more  frequent  condition. 

ACUTE    CYSTITIS. 

Pathology. — Cystoscopic  examination  performed  according  to  Paw- 
lik's  or  Kelly's  method,  hereafter  to  be  described,  reveals  an  intensely 
hyperemic  condition  of  the  vesical  mucosa,  -which  is  puify,  edematous, 
and  of  a  bright-red  color ;  this  may  be  more  intense  at  points,  especi- 
ally in  the  vicinity  of  the  trigone.  The  membrane  is  bathed  in  a  thick, 
tenacious  muco-pus,  and  here  and  there  may  be  noted  denuded  areas, 
and  the  exfoliated  epithelium  often  hanging  in  shreds  from  the  bladder- 
wall  ;  overlying  these  denuded  patches  hemorrhagic  effusions  may  be 
observed.  In  the  severer  grades  of  the  disease  the  intense  general  hy- 
peremia causes  a  disappearance  of  the  blood-vessels  that  are  to  be  seen 
in  the  normal  condition.  Occasionally  small  patches  of  ulceration,  due 
to  abscess-formation  {phlegmonous  cystitis),  may  be  observed,  and  in 
rare  and  fatal  instances  the  entire  bladder-wall  is  involved  in  a  necrotic 
process. 

Etiology. — Cases  of  acute  cystitis  may  be  grouped  according  to 
their  origin   into  four  main  classes,  as  follows  : 

(1)  Catarrhal. — Like  other  mucosse,  the  vesical  epithelium  is  very  re- 
sponsive to  systemic  circulatory  disturbances.  Thus,  sudden  exposure 
to  extremes  of  cold  or  heat  or  violent  atmospheric  changes,  thereby 
abruptly  suppressing  the  action  of  the  skin,  may  be  potent  influences  in 
the  etiology  of  the  disease.  An  intense  acute  catarrhal  inflammation 
may  follow  retention  of  the  urine  in  the  bladder,  with  or  without  its 
subsequent  decomposition  ;  it  may  also  be  the  result  of  pressure  from 
an  enlarged  prostate  or  other  tumor,  and  may  follow  cystocele,  urethral 
stricture,  or  paresis  of  the  bladder-wall.  In  simple  over-distention  of 
the  bladder,  with  the  accumulation  of  a  gallon  (4  liters)  or  more  of 
urine,  the  so-called  acute  exfoliative  ci/stitis  may  result,  in  which  the 
entire  mucous  membrane  of  the  bladder  may  be  shed,  and  the  patient 
shortly  manifest  all  the  symptoms  of  grave  uremic  intoxication.  The 
prolonged  retention  of  urine  is  folloAved  by  decomposition  of  the  fluid, 
and  this  by  its  irritant  action  always  excites  a  cystitis  that  soon  assumes 
the  chronic  type. 

(2)  Septic. — This  may  result  either  from  the  direct  introduction  of 
pus-producing  germs  into  the  bladder  or  from  tlie  systemic  transmission 
of  these  micro-organisms  to  the  organ.  This  is  known  as  the  bac- 
terial origin  of  cystitis.  Under  the  first  class  may  be  mentioned  the 
passage  of  a  dirty  catheter  or  sound  ;  this  is  a  cause  of  cystitis  in 
puerperal  women,  and  in  men  who  are  the  subjects  of  minor  grades  of 
urethral  stricture,  and  who  have  been  subjected  to  gradual  dilatation  by 
means  of  bougies.  Gonorrheal  ci/stitis  is  also  to  be  included  under  this 
heading.  There  is  a  condition  known  as  febrile  cystitis,  which  consti- 
tutes the  second  class  of  septic  cases.     This  comprises  the  vesical  in- 


ACUTE  CYSTITIS.  1007 

flammation  that  is  present  in  the  various  febrile  conditions,  and  which 
is  probably  a  direct  result  of  the  presence  in  the  urine  of  the  causal 
bacilli  or  their  toxins  (Fitz).  Thus,  in  all  of  the  infectious  diseases 
and  fevers  (typhoid  and  the  other  exanthemata,  rheumatism,  diphtheria, 
tuberculosis)  there  is  noted  a  cystitis  of  varying  degrees  of  severity 
that  can  be  accounted  for  only  by  the  local  irritant  action  of  the  spe- 
cific germ  of  the  associated  disease,  or  its  eliminating  toxins.  The  so- 
called  gouty  cystitis,  which  is  often  present  in  lithemic  individuals,  and 
which  is  due  to  the  irritating  and  concentrated  urine,  may  also  be  here 
included. 

(3)  Toxic. — Certain  drugs  when  introduced  into  the  system  manifest 
an  irritant  action  upon  the  vesical  mucosa,  and  promptly  excite  a  severe 
grade  of  acute  cystitis.  Prominent  among  these  may  be  mentioned 
Cantharides  and  other  irritants  of  the  urinary  tract — cubebs,  copaiba, 
and  sinapis.  Workers  in  coal-tar  dye-stuffs  are  sometimes  affected  with 
acute  cystitis. 

(4)  Traumatic. — Traumatic  inflammation  of  the  bladder  follows  the 
improper  and  careless  use  of  the  catheter,  sound,  or  other  instrument ; 
the  presence  in  the  bladder  of  calculi  or  other  foreign  bodies  ;  and  the 
pressure  of  the  fetus  in  parturition,  or  of  large  masses  of  impacted 
feces. 

(5)  From  Adjacent  Inflammation. — Irritation  with  consecutive  inflamma- 
tion may  result  from  the  extension  of  an  inflammatory  process  from  sur- 
rounding structures  either  by  continuity  or  contiguity  of  tissue.  Thus, 
a  cystitis  may  follow  a  urethritis — gonorrheal  or  otherwise  ;  it  may  re- 
sult from  an  extension  downward  of  a  ureteritis,  or  it  may  be  conse- 
quent upon  a  vaginitis,  a  malignant  neoplasm  of  an  adjacent  viscus,  a 
salpingitis,  pelvic  peritonitis,  or  pelvic  abscess  in  the  immediate  vicinity 
of  the  bladder,  as  in  the  vesico-uterine  pouch. 

Symptoms. — The  symptoms  of  acute  cystitis  are  very  marked. 
Pain,  vesical  irritability,  vesical  and  rectal  tenesmus,  frequency  of  mic^ 
turition,  fever,  and  urinary  changes  are  all  pronounced.  Prominent 
among  these  is  pain,  which  may  be  most  intense  and  is  the  earliest  and 
most  persistent  manifestation  of  the  disease.  Its  seat  is  the  suprapubic 
region,  whence  it  may  radiate  to  the  sacral  region,  the  perineum,  the 
end  of  the  penis,  or  the  upper  portion  of  the  thighs  ;  it  is  most  con- 
stant, but  is  worst  just  before  micturition,  by  which  it  may  be  alleviated. 
It  is  considerably  relieved  by  the  recumbent  posture,  and  is  aggravated 
by  pressure  over  the  bladder.  As  the  inflammatory  process  diminishes 
the  pain  gradually  disappears,  and  the  entire  attack  may  subside  in  a 
few  days  or  a  week. 

With  the  pain,  and  probably  ranking  second  in  severity,  is  the  rec- 
tal and  vesical  tenesvius,  or  strangury.  There  is  an  almost  constant  de- 
sire to  urinate,  the  patient  sitting  upon  the  urinal,  it  may  be,  for  hours. 
The  urine  may  be  opaque  or  highly-colored.  It  is  often  bloody  (in 
very  acute  cases  the  vesical  contents  may  consist  of  a  small  quantity  of 
pure  blood  only),  is  of  a  specific  gravity  varying  from  1005  to  1030  (in 
the  febrile  cases),  and  contains  pus-corpuscles  in  abundance,  mucous  flakes 
in  large  quantities,  shreds  of  disintegrated  and  exfoliated  epithelium  (blad- 
der) ;  also  numerous  micro-organisms  (streptococci,  staphylococci,  gono- 


1008  DISEASES  OF  THE   URINARY  SYSTEM. 

cocci,  proteus  vulgaris,  bacilli  of  tuberculosis,  and  very  commonly  the 
bacillus  coli  communis) ;  fungous  mycelial  threads  and  yeast-cells 
have  even  been  found  in  certain  cases  (mt/cotic  cystitis).  Its  reaction 
may  be  either  acid  or  alkaline ;  if  alkaline,  it  contains  ammonium 
urate,  amorphous  phosphates,  and  triple  phosphates  (crystalline)  as 
a  rule.  More  or  less  albumin  will  be  noted,  and  on  standing  a 
dense  sediment  forms  in  the  bottom  of  the  flask,  composed  of  all 
the  foregoing  substances,  as  shown  by  chemical  and  microscopic 
examination.  The  total  quantity  of  urine  voided  in  the  twenty- 
four  hours  may  be  normal  in  amount  or  even  slightly  in  excess 
of  the  normal.  On  the  other  hand,  if  exfoliation  of  the  mucous 
membrane  takes  place,  there  may  occur  partial  or  even  total  suppression 
of  the  urine.  Feve)\  with  or  without  an  initial  rigor,  persists  through- 
out the  attack,  but  is  not  of  a  severe  type,  save  in  the  septic  and  ma- 
lignant (diphtheritic)  forms  of  the  disease,  when  it  mav  reach  103°-105° 
F.  (39.4°-40.5°  C). 

Abscesses  may  form,  and  betray  tliemselves  by  localized  pain,  ten- 
derness, and,  in  some  cases,  by  a  circumscribed  induration.  These  may 
rupture  into  the  bladder,  followed  by  the  free  escape  of  pus  from  the 
urethra  and  by  relief  (temporary  as  a  rule)  from  urgent  symptoms,  or 
they  may  spread  to  the  peritoneum  and  induce  peritonitis,  Avhich,  if  not 
promptly  treated  by  surgical  measures,  may  prove  fatal  by  gradual 
asthenia. 

In  the  variety  associated  with  extreme  exfoliation  of  the  vesical 
mucosa  grave  uremic  manifestations  follow.  These  include  all  the 
features  of  the  typhoid  state  (dry,  brown  tongue,  mild  delirium,  ner- 
vous and  muscular  twitching ;  headache ;  gastric  disturbances ;  and 
coma).     There   is   also   some    degree   of   malaise   and   anorexia. 

It  must  not  be  forgotten  that  acute  cystitis  may  represent  an  acute 
exacerbation  in  the  chronic  form,  and  at  times  may  assume  a  severe 
type  of  the  disease. 

Diagnosis. — Cystitis  should  be  readily  recognized  from  the  history 
of  the  case  and  the  frequency  of  the  two  almost  pathognomonic  symp- 
toms— suprapubic  pain  and  vesical  tenesmus.  An  examination  of  the 
urine  Avill  reveal  the  characteristic  clinical  features.  Cystitis  may  be 
confounded  with  acute  iiephritis  or  pyelo-nephritis,  but  a  careful  study 
of  the  clinical  manifestations  and,  if  need  be,  the  catheterization  of  the 
ureters  after  vesical  irrigation,  will  reveal  the  true  condition.  The 
presence  of  tube-casts  in  the  urine  would  indicate  renal  involvement. 
The  percentage  of  albumin  is  usually  much  larger  in  nephritis  than  in 
irritability  of  the  bladder.  The  differentiation  between  cystitis  and 
vesical  irritability  will  be  noted  under  the  latter  condition. 

The  prognosis  of  the  milder  grades  of  cystitis  is  good ;  the  septic 
and  malignant  (diphtheritic)  cases  ofter  a  much  graver  outlook.  Exten- 
sion of  tlie  process  upward  toward  the  kidneys  is  always  serious. 

Treatment. — The  treatment  of  acute  cystitis  includes  prophylactic, 
hygienic,  and  medicinal  measures. 

Prophylactic. — Most  important  is  the  prevention  of  the  disease,  and 
this  includes,  in  addition  to  the  usual  care  of  the  body,  the  observance 
of  thorough  asepsis  whenever  it  becomes  obligatory  to  introduce  an 
instrument  (catheter,   sound)  into  the  bladder. 


CHRONIC  CYSTITIS.  1009 

Hygienic. — The  cause  of  the  disease,  if  evident  (calculus,  external 
pressure),  should  be  sought  and  removed.  The  patient  should  at  once 
be  placed  absolutely  at  rest  in  the  recumbent  posture.  The  value  of 
this  injunction  will  be  most  clearly  understood  when  it  is  stated  that  in 
the  erect  position  the  intra-vesical  pressure  is  three  times  that  in  the 
dorsal  position.  The  simple  observance  of  this  laAv  will  do  much  toward 
relieving  the  sufferings  of  the  patient.  The  diet  must  be  regulated,  and 
all  irritating,  highly  seasoned  articles  of  food  must  be  interdicted. 
Alcohol  in  any  form  is  prohibited.  If  it  can  be  enforced,  during  the 
early  stages  of  the  disease  an  absolute  milk  diet  will  be  most  bene- 
ficial. The  patient  should  be  instructed  to  drink  freely  of  water  and 
other  diluent  drinks,  whereby  an  internal  irrigation  of  the  bladder  may 
be  secured  and  much  of  the  irritating  substance  removed.  The  free 
action  of  the  skin  may  be  secured  by  friction  and  warm  bathing. 

Medicinal. — The  drugs  to  be  employed  are  the  saline  laxatives  and  the 
various  mild  diuretics  and  urinary  alterants.  The  reaction  of  the  urine 
will  indicate  the  variety  of  alterant  to  be  employed.  If  it  be  acid, 
alkaline  waters  are  serviceable,  as  the  soda-preparations,  Vichy,  or  the 
potassium  salts.  In  alkaline  conditions  of  the  urine  probably  the  most 
valuable  drugs  are  benzoic  and  boracic  acid  and  salol.  Benzoic  acid  is 
best  administered  in  the  form  of  ammonium  benzoate,  which  may  be 
given  in  10-grain  (0.648)  doses  thrice  daily  in  the  compound  infusion 
of  buchu,  or  in  uva  ursi.  Hot  applications  and  hot  local  bathing  (sitz- 
baths)  Avill  do  much  to  relieve  the  pain  and  tenesmus  ;  if  these  be  severe, 
a  rectal  suppository  of  opium  and  belladonna  or  an  enema  of  chloral 
hydrate  will  generally  give  prompt  relief.  Tincture  of  cannabis  indica, 
administered  internally,  may  answer  if  opium  be  contraindicated.  Under 
such  a  course  as  the  preceding  a  cure  may  be  expected  within  eight  or 
ten  days.  It  is  prudent  to  advise  the  patients  to  wear  flannel  or  silk 
binders  over  the  abdomen,  to  avoid  chilling  of  the  surface  and  subse- 
quent acute  attacks. 

CHRONIC    CYSTITIS. 

Pathology. — The  vesical  mucosa  is  not  so  hyperemic  as  in  the 
acute  variety,  but  is  of  a  peculiar  muddy  or  grayish-blue  (slate)  color, 
dotted  here  and  there  with  patches  of  erosion  or  of  actual  ulceration. 
The  muco-pus  that  bathes  its  surface  is  not  so  apt  to  be  hemorrhagic  as 
in  the  acute  form  of  the  disease,  although  slight  hemorrhages  may  and 
do  occur.  Owing  to  the  slow  course  and  long  duration  of  the  disease 
there  follows  an  immense  thickening  of  the  bladder-wall  from  hyperplasia 
of  its  constituents,  conjoined  with  more  or  less  edema  of  the  tissues. 
The  result  is  a  contraction  of  the  wall  with  a  proportionate  diminution 
in  the  vesical  capacity.  The  mucosa  may  become,  as  it  were,  polypoid 
in  spots,  and  there  may  follow  obliteration  or  partial  obstruction  of  the 
ureteral  orifices,  with  consequent  dilatation  of  the  ureters  and  renal 
pelves  from  a  damming  back  of  the  secretion.  The  urinary  changes 
are  about  as  in  the  acute  form,  save  that  the  reaction  is  always  alkaline 
and  the  amount  of  mucus  and  pus  is  proportionately  greater. 

Htiology. — Chronic  inflammation  of  the  bladder  may  be  the  result 
of  a  neglected  or  oft-repeated  acute  attack.  It  may  occur  from  the 
persistent  action  of  an  exciting  cause,  as  the  presence  of  some  irritating 

64 


1010  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

substance  (calculus)  in  the  bladder,  or  of  some  excitant  external  to  that 
viscus,  as  a  localized  inflammation  or  a  displaced  uterus.  Again,  the  in- 
flammation of  the  bladder  may  be  of  a  chronic  tendency  from  the  begin- 
ning ;  especially  is  this  true  of  the  tuberculous  variety  and  of  that  due 
to  neoplasmata  of  the  organ. 

The  symptoms  and  diagnosis  differ  but  slightly  from  those  of 
acute  cystitis.  It  may,  however,  be  pointed  out  that  the  pain  and  tenes- 
mus are  less  intense.  Oppositely,  the  amount  of  aJhumin  in  the  urine 
is  comparatively  large.  The  same  remark  applies  to  the  quantity  of 
mucus  and  pus  [vide  Pathology) ;  indeed,  the  last-named  ingredient  often 
forms  a  thick  gelatinous  mass  in  the  standing  urine  that  tends  to  adhere 
to  the  receptacle.  Chronic  cystitis  is  accompanied  by  debility  and 
emaciation,   which,   however,   are  of  slow   development. 

The  prognosis  is  always  serious,  and  the  course  of  the  disease  is  at 
the  best  protracted. 

Treatment. — Very  generally,  the  treatment  set  down  for  the  acute 
disease  will  not  answer  in  the  chronic  form.  Undoubtedly,  there  will 
follow  more  or  less  amelioration  of  the  symptoms,  but  the  tendency  is 
toward  a  prolonged  chronicity.  In  such  cases,  after  the  removal  of  the 
ascertainable  causes  so  far  as  practicable,  we  are  compelled  to  resort  to 
local  treatment  of  the  bladder.  This  includes — (1)  Vesical  irrigation; 
(2)  Topical  applications ;  (3)  Permanent  drainage  of  the  bladder. 

Vesical  irrigation  is  secured  by  means  of  an  aseptic  soft-rubber 
catheter  which  is  connected  with  a  graduated  glass  funnel :  a  siphonage 
is  produced  by  the  alternate  elevation  and  depression  of  the  funnel, 
which  contains  the  irrigating  fluid.  The  latter  may  consist  of  plain 
sterilized  (boiled)  water,  sterile  normal  salt-solution  (40-60  gr.  to  the 
pint — 2.59-4.0  per  \  liter),  or  a  weak  solution  of  mercuric  chlorid  (1 : 
50,000-100,000).  The  irrigation  should  be  done  slowly,  and  not  more 
than  twice  or  thrice  daily  in  severe  cases,  and  much  less  frequently  in 
ordinary  cases,  according  to  the  exigencies  of  the  condition. 

Vesical  medication  may  be  secured  by  means  of  the  funnel  after  irri- 
gation, the  medicating  substances  being  dissolved  in  a  pint  of  water  and 
allowed  to  flow  slowly  in  and  out  of  the  bladder.  The  drugs  that  may 
be  used  in  this  manner  are  silver  nitrate  or  zinc  sulphate  (1-5  gr.  to  the 
ounce — 0.0648-0.324  to  32.0)  or  a  saturated  solution  of  boric  acid.  If 
the  salts  of  zinc  or  silver  are  used,  not  more  than  an  ounce  of  the  solu- 
tion should  be  allowed  to  enter  the  bladder,  and  much  less  than  this 
amount  will  generally  suffice.  In  cases  in  which  there  exist  patches  of 
ulceration  the  application  must  be  made  directly  to  these  areas  through 
the  endoscope  or  cystoscope  (Pawlik,  Kelly).  In  women  this  may  be 
readily  done  by  placing  the  patient  in  the  exaggerated  lithotomy  or 
knee-chest  posture,  dilating  the  urethra,  and  introducing  the  cystoscope, 
through  which  a  reflected  light  is  thrown  upon  the  distended  bladder- 
wall.  Stronger  solutions  may  now  be  employed,  as  silver  nitrate,  20- 
30  gr.  (1.29-1.94)  to  the  ounce.  This  application  should  be  followed 
by  a  slight  irrigation  of  the  bladder. 

When  this  local  medication  fails  to  eflfect  a  cure,  permanent  drainage 
of  the  bladder  must  be  secured — in  the  male  by  a  suprapubic  or  perineal 
incision,  and  in  the  female  bv  the  establishment  of  a  vesico-vaginal  fis- 


VESICAL  HEMORRHAGE.  1011 

tula.     This  places  the  bladder  absolutely  at  rest,  and  gives  the  inflamed 
mucosa  a  chance  to  heal  under  proper  medication. 

As  to  internal  remedies,  various  agents  that  possess  a  local  stimulating 
eifect  upon  the  genito-urinary  tract  are  advised  by  most  authors,  but  I 
think  little  is  to  be  gained  from  their  employment  as  compared  with  the 
results  achievable  from  topical  treatment.  Most  efficacious  among  inter- 
nal remedies  are — oil  of  sandabvood,  terebene,  urotropin,  pichi.  buchu 
(fluid  extract),  and  the  oil  of  copaiba.  If  disinfection  of  the  bladder  in 
loco  is  not  practicable,  antiseptics  should  be  given  internally,  combined 
with  those  stated  above.  Salol  and  potassium  chlorate  are  excellent  for 
this  purpose. 


NEOPLASMS  OF  THE  BLADDER. 

Primary  new-growths  of  the  bladder  are  exceedingly  rare,  occur- 
ring, however,  with  greater  frequency  in  males  in  about  the  proportion 
of  3  to  1 ;  they  may  be  either  benign  or  malignant.  On  the  other  hand, 
secondary  neoplasmata,  particularly  carcinomata,  are  relatively  common. 
The  most  frequent  variety  of  new-growth  encountered  is  carcinoma,  par- 
ticularly the  so-called  villous  or  papillomatous  carcinoma,  Williams  ^  find- 
ing in  20  women  aff"ected  with  bladder-tumor,  carcinoma  in  16.     Other 

O  ... 

growths  are  sarcomatous,  fibromatous,  cystic,  and  papillomatous  in  nature. 

The  symptoms  are  the  same  for  all  varieties,  and  include,  first  and 
most  commonly,  hemorrhage  (which  is  both  persistent  and  free),  together 
with  pain,  frequency  of  micturition,  and  occasionally  the  discharge  of 
detached  fragments  of  the  growth.  In  carcinomatous  cases  of  advanced 
standing  cachexia  will  be  marked.  Examination  by  means  of  the  cysto- 
scope  will  reveal  the  nature  of  the  complaint.  In  the  case  of  secondary 
growths  the  primary  tumor  may  often  be  detected. 

The  prognosis,  of  course,  will  depend  upon  the  nature  of  the  growth. 

The  treatment  is  purely  surgical,  and  comprises  enucleation  of  the 
tumor  either  by  means  of  the  snare,  or  after  a  vesical  section. 


VESICAL  HEMORRHAGE. 

(Vesical  Hemorrhoids.) 

Hemorrhage  of  the  bladder  has  been  mentioned  as  a  symptom  of 
various  affections,  both  general  and  local,  among  the  former  being  leu- 
kemia and  malarial  hematuria,  and  among  the  latter  nephrolithiasis  and 
tuberculosis  and  carcinoma  of  the  bladder.  It  is  also  a  prominent  mani- 
festation in  stone  in  the  bladder,  and  not  infrequently  appears  in  preg- 
nancy (late).  Independently  of  the  operation  of  all  of  the  above-men- 
tioned etioloo;ic  factors,  hemorrhaore  has  been  known  to  occur  from  the 
bladder,  and  recent  precise  methods  of  exploring  the  viscus  (endoscopic 

1  Brit.  Med.  Journ.,  1889. 


1012  DISEASES  OF  THE   URINARY  SYSTEM. 

examination)  have  shown  it  to  be  due  to  a  hemorrhoidal  state  of  the  ves- 
sels. The  hemorrhage  may  be  profuse,  and,  rarely,  even  fatal  in  its 
effects. 

The  diagnosis  is  based  in  part  upon  the  absence  of  the  more  obvi- 
ous causes  of  hematuria  and  the  presence  of  free  bleedings,  but  chiefly 
upon  the  result  of  a  careful  cystoscopic  exploration  of  the  bladder. 

The  prognosis,  so  far  as  my  experience  extends,  is  eminently  favor- 
able, though  a  few  fatal  cases  have  been  reported. 

Treatment. — This  is  mainly  local.  The  bladder  may  be  irrigated 
with  an  astringent  solution  (1  per  cent,  tannic  acid,  ^  per  cent,  alum), 
and  this  may  be  alternated  with  an  antiseptic  solution  (3  per  cent,  boric 
acid,  1  per  cent,  salicylic  acid).  I  have  recently  observed  a  case  in 
which  recovery  followed  the  internal  admission  of  the  extract,  hamamelis 
fluid.  (3J-4.0),  t.  i.  d. 


NEUROSES  OF  THE  BLADDER. 

IRRITABILITY   OF   THE    BLADDER. 

Definition. — By  this  term  is  meant  a  condition  of  the  bladder  in 
which  there  exists  an  hyperesthesia  of  the  organ,  especially  of  the  neck — 
that  portion  surrounding  the  urethral  and  ureteral  orifices  {vesical  trigone) 
— without  the  presence  of  any  tangible  cause  therefor.  This  must  be  dis- 
tinguished from  the  irritability  that  is  associated  with  true  organic  dis- 
ease of  the  bladder  itself,  as  in  the  presence  of  calculi,  tumors,  or  fissure 
of  the  neck,  or  Avith  disease  of  the  surrounding  structures. 

Pathology. — There  are  no  pathologic  features  to  be  noted.  A  cysto- 
scopic examination  of  the  bladder  may  reveal  a  slight  increase  in  the  vas- 
cularity of  the  mucous  membrane,  but  the  condition,  in  most  instances  at 
least,  must  be  regarded  as  a  true  neurosis.  The  condition  of  irritable 
bladder  in  women,  which  has  previously  been  held  to  be  a  purely  func- 
tional derangement,  is  now  regarded  by  Dacheux  and  Zuckerkandl  as  a 
localized  hyperemia,  especially  at  the  has  fond,  and  less  often  at  the 
beginning  of  the  urethra.' 

Etiology. — While  in  many  instances  no  well-defined  causal  relations 
can  be  determined,  it  is  very  generally  true  that  the  patients  who  are  the 
subjects  of  vesical  irritability  are  individuals  of  a  neui'otic  temperament, 
very  often  manifesting  strong  hysteric  tendencies.  They  present  the  cha- 
racteristic features  of  this  unfortunate  group.  They  are  generally  illy- 
nourished,  fretful,  irritable,  peevish,  suffering  almost  constantly  from 
vague  neuralgic  attacks  in  different  portions  of  the  body  (cephalalgia,  tic 
douloureux,  lumbo-sacral  pain),  and  in  a  chronic  condition  of  physical 
prostration.  Frequently  they  eventually  develop  a  true  hypochondriasis 
or  melancholia.  In  others  there  may  be  found  a  history  of  extreme  men- 
tal and  physical  tire,  overwork,  business  anxiety,  over-indulgence  in  ven- 
ery,  menstrual  irregularity,  dysmenorrhea,  ovarian  or  uterine  disorders, 
long-continued  gastro-intestinal  disturbance  (dyspepsia),  improper  hy- 
'  TIte  American  Year-Book  of  Medicine  and  Surgery,  1897,  p.  576. 


NEUROSES  OF  THE  BLADDER.  1013 

gienic  surroundings,  improper  regimen,  indulgence  in  late  hoursj  and  a 
general  lack  of  will-power.  It  must,  however,  be  remembered  that  sub- 
jects of  chronic  malarial  intoxication  very  often  manifest  all  the  symp- 
toms of  vesical  irritability,  marked,  it  may  be,  by  a  feature  of  more  or  less 
periodicity.  This  has  been  termed  by  some  malarial  fever  of  the  urethra 
and  bladder.  Lithemic  individuals  also  are  very  prone  to  develop  a  pro- 
nounced vesical  irritability,  the  affection  in  them  probably  resulting  from 
the  local  action  of  the  highly  concentrated  and  irritating  urine.  The  con- 
dition must  commonly,  however,  be  regarded  as  belonging  essentially  to 
the  large  group  of  neuroses. 

In  a  certain  percentage  of  cases  the  bladder-trouble  is  a  reflex  mani- 
festation of  some  disease  of  an  adjacent  organ,  as  the  urethra,  ureter,  va- 
gina, rectum,  anus,  or  the  internal  organs  of  generation.  These  are  not, 
however,  to  be  looked  upon  as  cases  of  true  neurotic  vesical  irritability. 

Symptoms. — The  symptoms  of  irritable  bladder  are  mainly  extreme 
painfulness  and  frequency  of  micturition,  associated  with  marked  vesical 
and  rectal  tenesmus.  The  dysuria  is  not  always  or  altogether  relieved  by 
micturition;  indeed,  the  pain  may  be  just  as  severe,  or  even  worse  after, 
than  before,  the  voiding  of  the  urine.  Especially  is  this  true  when  there 
coexists  a  more  or  less  spasmodic  muscular  action  of  the  bladder-walls, 
the  hypersensitive  mucosa  then  being  squeezed,  and  the  patient  suffering 
at  times  to  such  an  extent  as  to  be  thrown  almost  into  a  state  of  collapse. 
There  is  usually  a  sense  of  weight  or  pressure  in  the  pubic  region,  which 
is  largely  relieved  when  the  patient  assumes  the  recumbent  posture.  Uri- 
nation is  often  performed  spasmodically,  or  there  may  be  a  spasm  of  the 
urethra  and  neck  of  the  bladder  resulting  in  an  utter  inability  to  perform 
the  act.  The  urine  may  be  normal  in  appearance  and  amount.  Very 
often  it  is  increased  in  quantity  (Jiysterie  polyuria),  and  at  times  the  op- 
posite may  be  true  and  more  or  less  suppression  be  noted.  In  lithemic 
cases  the  urinary  characteristics  already  mentioned  under  that  condition 
will  be  present  {vide  p.  401). 

Diagnosis. — Very  frequently  will  simple  vesical  irritability  be  con- 
founded with  true  cystitis.  The  points  of  differentiation,  however,  are  as 
follows  : 

Irritable  Bladder.  Cystitis. 

The   patient  is  of  a  neurotic  tempera-  May  occur  in  any  individual,  irrespective 

ment,  and  generally  gives  no  history  of  temperament.    It  frequently  follows 

of  organic  bladder-disease  nor  of  ope-  catherization,  sounding,  or  other  trau- 

rations  upon  the  bladder.  matism. 

Pain  is  severe,  and  often  worse  after  mic-  The  pain  is   usually  much  relieved   by 

turition.  micturition. 

The  constitutional  symptoms  are  those  of  The    constitutional    symptoms    are    not 

nervous  depression.  marked,  save  in  grave  cases. 

Never  results  fatally.  May  result  fatally. 

The  urine  does  not  present  any  marked  There   are   always  present   marked   and 

alteration  in  its  physical  or  chemical  characteristic  alterations  in  the  physi- 

qualities.  It  may  show  hyperacidity,  cal  and  chemical  qualities  of  the  urine, 
or  extreme  concentration,  or  dilution. 

The  appearance  of  the  mucosa  is  negative  Cystoscopic  exploration  reveals  the  angry 

in  true  neurosis.  and   diseased  mucosa,  and  may  show 

the  cause  (calculus,  tumor). 

The  duration  is  always  protracted.  The  duration  of  acute  attacks  may  be 

short. 


1014  DISEASES  OF  THE   URINARY  SYSTE3I. 

Prognosis. — Good  as  regards  life ;  doubtful  as  regards  the  ultimate 
cure  of  the  patient. 

Treatment. — Since  the  condition  is  largely  one  of  neurotic  origin, 
the  attention  of  the  physician  must  be  directed  mainly  toward  a  bet- 
terment of  the  state  of  the  nervous  system.  Absolute  rest,  physical 
and  mental,  must  be  insisted  upon,  and  the  patient  must  be  subjected  to 
a  course  of  strict  moral  suasion  Avhenever  this  may  be  deemed  necessary. 
Any  cause  of  reflex  irritation  must  be  removed,  and  a  careful  search 
should  be  instituted  for  some  such  condition  as  cervical  stenosis,  uterine 
displacements,  anal  fissure,  hemorrhoids,  stricture  of  the  rectum,  vaginitis, 
urethritis,  tuberculous  infection  of  Skene's  glands  of  the  urethra,  chronic 
gastro-intestinal  catarrh,  and  the  like.  The  habits  of  the  patient  must 
be  inquired  into,  and  late  hours,  the  eating  of  improper  and  unwholesome 
articles  of  food,  masturbation,  or  the  reading  of  sensational  and  trashy 
literature  corrected.  In  many  instances  the  pronounced  neurasthenic 
condition  demands  a  course,  more  or  less  protracted,  of  the  AVeir  Mitchell 
rest-treatment  {vide  Neurasthenia,  p.  1177).  The  urine  should  be  care- 
fully examined  for  lithemic  and  other  pathologic  features,  and  by  an  ap- 
propriate course  of  treatment  it  should  be  rendered  as  bland  and  unirri- 
tating  as  possible.  Large  draughts  of  diluent  drinks  may  be  of  benefit, 
and  if  these  be  combined  Avith  the  prolonged  administration  of  nerve- 
sedatives  and  antispasmodics,  a  marked  amelioration  of  the  patient's  con- 
dition may  be  secured.  In  cases  associated  with  spasmodic  muscular  con- 
traction it  may  become  necessary  to  employ  an  occasional  suppository  of 
opium  and  belladonna,  or  an  enema  of  chloral  hydrate.  Change  of  air 
and  scene,  regulation  of  the  diet,  the  institution  of  a  proper  course  of 
gymnastics,  mental  and  physical,  and  the  observance  of  a  happy  and 
cheerful  atmosphere  will  generally  do  much  to  improve  the  patient's  con- 
dition. The  administration  of  tonics  (strychnin,  iron)  and  the  prevention 
of  constipation  are  very  essential.  Especially  must  it  be  remembered 
that  in  all  these  cases  of  simple  vesical  irritability  physical  exploration 
of  the  bladder  is  absolutely  contraindicated.  The  patient's  mind  must  be 
directed  away  from  the  bladder  in  order  to  secure  good  results. 

NEUROSES    OF   MICTURITION. 

1.  Incontinence  of  Urine  {^Enuresis). — An  inability  to  retain  the 
urine.  This  may  arise  from  a  number  of  causes.  Frequently  it  is  the 
result  of  some  lesion  of  the  spinal  cord  involving  the  sphincteric  cen- 
ter of  the  bladder ;  this  is  known  as  paralytic  incontinence,  and  is  to 
be  recognized  by  a  constant  dribbling,  alternating  with  spurts  of  urine 
when  voluntary  or  involuntary  muscular  action  is  brought  into  play, 
as  in  the  act  of  coughing,  sneezing,  or  bending  forward  of  the  body. 
It  may  be  the  result  of  a  general  bodily  weakness  or  after  prostrating 
diseases  (typhoid,  late  stages  of  pulmonary  tuberculosis).  Again,  it 
may  result  from  some  local  condition  in  the  bladder  or  urethra.  Here 
may  be  mentioned  paralysis  of  the  urethra  from  over-dilatation  or  from 
traumatism,  or  that  due  to  pressure  of  the  fetal  head  in  a  prolonged  labor  ; 
imperfect  vesical  innervation ;  over-distention  of  the  bladder,  producing 
a  paresis  of  its  walls  ;  or  from  some  temporary  obstruction  at  the  urethra 
or  base  of  the  bladder,  such  as  a  tumor  or  a  sharpW  retroflcxcd  uterus. 


NEUBOSES  OF  MICTURITION.,  1015 

It  may  be  a  result  of  over-distention  of  the  bladder,  with  partial  paral- 
ysis of  the  sphincter,  the  bladder  remaining  overfilled,  while  there  is  a 
constant  escape  of  a  few  drops  of  urine  {incontiiience  of  retention).  It 
may  follow  some  local  causes  of  irritation,  as  the  presence  of  vesical  cal- 
culi, pressure  from  an  anteflexed  uterus  upon  the  fundus  of  the  bladder, 
cystitis,  and  parasites.  The  condition  known  as  spasmodic  incontinence 
is  that  due  to  an  over-action  of  the  compressor  muscle  of  the  bladder,  as 
a  consequence  of  Avhich  there  is  a  diminution  of  the  vesical  capacity,  the 
urine  being  forcibly  and  involuntarily  ejected  at  irregular  intervals. 
Finally,  nocturnal  enuresis  is  that  variety  which  is  so  common  in  young, 
delicate,  and  often  neurotic  children :  this  is  usually  noticed  in  the  early 
hours  of  sleep,  and  is  often  the  result  of  some  local  irritation  acting  upon 
a  hypersensitive  organism,  such  as  the  presence  of  ascarides,  an  elongated 
prepuce,  contraction  of  the  urethral  meatus,  or  masturbation.  Nocturnal 
incontinence  may  be  a  manifestation  of  nocturnal  epilepsy  or  of  incipient 
cerebral  or  spinal  disease  (Fitz).  The  constant  escape  of  urine  in  the 
paretic  cases  is  apt  to  result  in  extensive  excoriation  of  the  parts. 

The  treatment  varies  according  to  the  cause.  The  enuresis  of  chil- 
dren, if  left  alone,  will  eventually  cure  itself  as  the  age  and  strength  of 
the  patient  increases,  though  obvious  exciting  causes,  if  present,  should 
be  removed  if  not  impracticable.  Good  hygiene,  systematic  evacuation 
of  the  bladder,  elevation  of  the  hips  on  a  pillow  in  bed,  plenty  of  out- 
of-door  exercise,  a  change  to  the  seashore  or  mountains,  an  abundance 
of  suitable  and  strengthening  food  with  a  minimum  of  water,  and  the 
administration  of  tonics  (iron,  cod-liver  or  olive  oil,  and  strychnin),  will 
generally  effect  a  cure.  The  fluid  extract  of  rhus  aromatica  in  5-  to  15- 
drop  doses,  thrice  daily,  has  been  very  beneficial  in  children.  Excellent 
results  often  follow  the  administration  of  minute  doses  of  atropin  or 
tincture  of  belladonna.  A  favorite  formula  of  my  own  in  cases  possess- 
ing a  hypersensitive  nervous  organization  has  long  been  as  follows  : 


Tr.  belladonnse,               3ss-j 

(     2.0-4.0); 

Sodii  brom.,                    jij 

(     8.0); 

Ac.  hydrobrom.  dil.,       3ijss 

(  10.0); 

Ext.  ergotse  fl.,                3ij 

(     8.0); 
(     4.0); 

Glycerini,                        3j 

Elix.  simplicis,  q.  s.  ad  giv 

(128.0). 

M.  et  Sig.  3j  (4.0)  three  or  four  times  a  day  for  a  child  of 
five  years. 

In  very  delicate  or  feeble  children  suffering  from  enuresis  I  substitute 
a  motor  tonic  and  stimulant  (tr.  nucis  vom.)  for  the  bromids  or  nerve- 
sedatives. 

Spasmodic  action  of  the  vesical  compressor  may  be  relieved  by  the 
cautious  use  of  the  motor  depressants,  while  its  converse,  paresis,  de- 
mands the  exhibition  of  full  doses  of  strychnin  or  tincture  of  nux  vomica. 
The  judicious  and  careful  use  of  the  catheter,  followed  by  the  adminis- 
tration of  strychnin,  will  promptly  effect  a  cure  in  the  incontinence  of 
retention.  Any  local  cause  of  vesical  irritation  must  be  removed.  Gal- 
vanism in  the  paretic  cases,  applied  both  to  the  bladder  and  to  the 
urethra,  may  be  of  service,  and  in  the  female  Sanger  suggests  massage 


1016  DISEASES  OF  THE   URINARY  SYSTEM. 

of  the  urethra.  Should  excoriation  occur,  bland  ointments,  as  of  zinc 
oxid  and  lanolin,  should  be  used. 

2.  Retention. — Nervous  retention  of  the  urine  is  occasionally  encountered 
in  hysteric  and  highly  neurotic  individuals.  Its  most  common  manifesta- 
tion is  an  inability  to  urinate  in  the  presence  of  others.  It  is  also  occa- 
sionally noted  after  childbirth,  when  it  may  be  due  to  nervous  reaction, 
to  edema  and  tortuosity  of  the  urethra,  or  to  a  temporary  inability  of  the 
bladder-walls  to  contract  upon  their  contents,  thereby  permitting  a 
longer  retention  of  the  vesical  contents,  and  even  favoring  over-disten- 
tion  of  the  organ.  If  the  urine  be  allowed  to  remain  for  too  loner  a 
period  in  the  bladder,  fermentative  changes  follow  and  a  secondary  cys- 
titis will  result.  Under  these  circumstances  an  exfoliation  of  a  portion  or 
even  of  the  entire  bladder-epithelium  may  be  noted. 

The  treatment  consists  in  the  administration  of  strychnin  and  other 
nerve-tonics,  in  building  up  the  general  constitution,  and  in  aifording  a 
change  of  air  and  recreation.  In  that  variety  following  childbirth  the 
patient  should  be  urged  to  make  voluntary  efforts  at  micturition,  and 
these  may  be  seconded  by  the  firm  application  of  an  abdominal  binder 
and  compress,  or  of  hot,  moist  flannel  cloths,  kept  up  for  tAventy  minutes 
or  a  half  hour.  The  sound  of  running  water,  as  when  pouring  water 
from  a  pitcher  into  the  basin,  often  causes  a  contraction  of  the  bladder 
and  excites  the  flow  of  urine.  It  may  become  necessary,  the  foregoing 
methods  failing,  to  resort  to  catheterization,  the  usual  antiseptic  precau- 
tions being  observed. 


PART  VIII. 

DISEASES   OF    THE    NERVOUS    SYSTEM. 


The  central  nervous  system  is  generally  divided  into  two  parts — the 
brain  and  the  cord.  The  hrain  consists  of  the  cerebral  hemispheres,  the 
basal  ganglia,  the  pons,  the  cerebellum,  and  the  medulla.  The  cerebral 
hemispheres  are  joined  together  by  the  corpus  callosum  and  the  anterior 
and  posterior  commissures.  They  are  united  to  the  pons  by  the  crura  cere- 
bri, and  the  pons  is  continuous  with  the  medulla,  which  in  turn  is  con- 
tinuous with  the  spinal  cord.  The  surface  of  the.  cerebral  hemispheres 
is  divided  by  sulci  or  fissures  into  various  regions,  known  as  the  frontal, 
parietal,  temporo-sphenoidal,  and  occipital  lobes.  The  superior  longi- 
tudinal fissure  separates  the  two  convolutions  ;  the  fissure  of  Sylvius  is  be- 
tween the  frontal  and  parietal  lobes  above  and  the  temporo-sphenoidal  lobe 
below.  The  fissure  of  Rolando  divides  the  frontal  from  the  parietal  lobe, 
and  the  parieto-occipital  fissure  the  latter  from  the  occipital  lobe.  The 
continuation  of  the  last-named  fissure  upon  the  median  surface  forms  the 
upper  boundary  of  the  cuneus,  the  lower  boundary  of  which  is  the  cal- 
carine  fissure.  The  hippocampal  fissure  separates  the  fascia  dentata 
from  the  hippocampal  gyrus,  and  by  its  extension  inward  produces  an 
elevation  in  the  lateral  ventricle  known  as  the  hippocampus  major. 
Each  lobe  is  subdivided  by  secondary  fissures  into  a  number  of  lobules. 
The  topography  of  the  hemispheres  is  important  because  it  is  now  pos- 
sible to  map  out  Avith  considerable  accuracy  the  regions  in  which  vari- 
ous motor  impulses  originate,  and  with  less  accuracy  the  regions  in 
which  various  sensory  phenomena  are  perceived.  The  accompanying 
diagrams  illustrate,  more  satisfactorily  than  could  any  description, 
the  regions  that  have  been  hitherto  determined.  There  is  some  dis- 
cussion in  regard  to  the  degree  of  individuality  of  these  centers,  but 
the  weight  of  evidence  inclines  to  the  belief  that  they  are  not  sharply 
delimited.  Ordinarily  speaking,  one  side  of  the  brain  innervates  the 
opposite  side  of  the  body  ;  but  certain  parts,  as  the  muscles  of  the 
trunk,  appear  to  receive  impulses  simultaneously  from  both  hemispheres, 
and  other  functions  seem  to  be  accomplished  exclusively  upon  one  side ; 
thus  motor  speech  is  ordinarily  disturbed  only  when  the  lesion  is  in  the 
left  hemisphere. 

The  central  nervous  system  is  composed  practically  of  two  ele- 
ments— the  neuroglia,  or  supporting  substance,  and  the  neurons.  The 
neuroglia  consists  of  round  cells  with  radiating  processes,  lying  in  the 

10X7 


1018 


DISEASES   OF  THE  NERVOUS  SYSTE3I. 


midst  of  a  tangled  netAvork  of  fibers.  Its  function  appears  to  be  ex- 
actly similar  to  that  of  connective  tissue.  The  neuron,  or  nerve-unit, 
consists  of  a  ganglion-cell,  the  protoplasmic  processes  springing  from  it, 
and  the  neuraxon,  or  axis-cylinder.  The  cell-body  consists  of  pro- 
toplasm and  nucleus.  The  latter  contains  a  nucleolus  and  a  small 
amount  of  chromatin ;  the  former  is  composed  of  a  reticulum  of  fibril- 
lar ground-mass,  in  which  are  found,  in  certain  cells,  peculiar  bodies, 
that  take  the  basic  stain,  are  irregularl}-  spindle-shaped,  and  are  often 
arranged  concentrically  to  the  nucleus ;  they  also  extend  a  short  dis- 
tance into  the  protoplasmic  processes.  The  protoplasmic  processes 
branch  irregularly,  and  along  the  sides  of  the  finer  ramifications  are 
placed  short  lateral  offshoots,  the  buds  or  gemmules.  The  axis-cylinder 
is  a  single  process,  of  uniform  thickness,  usuall}^  single,  but  sometimes 


w\    0    T 


Fig.  67.— Diagram  of  the  cortical  centers  and  areas  of  representation  on  the  lateral  aspect  of  the 

hemicerebrum  (Mills). 

branched,  and  giving  off  at  regular  intervals  fine,  long  branches,  the 
collaterals  ;  it  terminates  either  as  a  tuft  of  fine  fibers  surrounding  a 
ganglion-cell,  or  in  a  motor  plate  in  the  muscles,  or  in  a  special  sense- 
corpuscle  in  the  skin.  It  cannot  be  too  frequently  reiterated  that  each 
neuron  constitutes  an  individual  unit  that  is  entirely  independent  of  all 
other  neui'ons  and  has  no  anatomical  connection  with  them  whatever.^ 
A  physiological  communication  must,  of  course,  exist,  that  perhaps  is 
analogous  to  electric  induction  ;  and  it  has  been  suggested,  by  Dercum 
among  others,  that  during  life  the  protoplasmic  processes  move  about 
and  make  contact  ■with  the  surrounding  nervous  structures.  The  func- 
tions of  the  various  elements  of  the  neuron  are  as  yet  imperfectly  un- 
derstood.    The  cell-body  appears  to  exercise  a  trophic  action  over  the 

'  Apatliy,  and  more  recently  Bethe,  have  claimed  that  delicate  neuro-fibrils  pass  from 
one  neuron  to  unotiier.     This  has  not  yet  been  confirmed. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1019 


other  parts,  especially  the  axis-cylinder.  It  probably  also  generates  the 
nervous  impulses.  The  protoplasmic  processes  may  have  nutritive  func- 
tions, or  serve  to  conduct  impulses  to  the  cells  (cellipetal).  The  axis- 
cylinder  conducts  impulses  from  the  cell  (cellifugal),  except  in  the  case 
of  the  peripheral  process  of  the  cells  of  the  spinal  ganglion.^  A  short 
distance  from  the  cell  the  axis-cylinder  is  enveloped  by  the  myelin- 
sheath,  giving  rise  to  the  nerve-fiber,  and  when  aggregated  together 
these  fibers  form  the  white  matter  of  the  nervous  system. 

It  has  been  possible  to  trace  more  or  less  accurately  the  course  of 
many  of  the  groups  or  systems  of  fibers.     These  exist  because  cells 


•  Fig. 


Zones  and  centers  of  the  mesial  aspect  of  the  human  cerebrum  (Mills). 


having  the  same  functions  are  usually  grouped  together,  forming  cen- 
ters or  ganglia,  and  the  fibers  from  these,  taking  the  same  course,  form  a 
bundle.  Three  classes  are  recognized  :  (1)  fibers  wholly  within  one 
hemisphere,  fibril  proprise,  uniting  adjacent  convolutions,  and  long  as- 
sociation-fibers, uniting  different  lobes ;  (2)  fibers  passing  from  one 
hemisphere  to  the  other,  commissural  fibers  ;  (3)  fibers  passing  from  the 
cerebrum  to  the  other  parts  of  the  central  nervous  system,  the  pro- 
jection-fibers, forming  the  corona  radia'ta. 

The  columns  or  tracts  that  have  been  mapped  out  in  the  cord  may  be 
seen  in  the  accompanying  diagram  (Fig.  69).  In  the  antero-lateral  por- 
tion are  found  the  anterior  or  uncrossed  pyramidal  column,  the  antero- 
lateral column  of  Gowers,  the  cerebellar  column,  and  the  crossed  pyram- 
idal column.  In  the  posterior  region  are  the  columns  of  Goll  and  Bur- 
dach.    The  rest  of  the  white  matter  forms  the  so-called  ground-bundles. 

In  the  area  comprising  the  anterior  and  lateral  columns  both  ascend- 
ing and  descending  fibers  are  found. 

^  Lenhossek  lias  suggested  that  this  is  a  modified  protoplasmic  process. 


1020 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


The  columns  fhat  transmit  ascending  impulses  are — 1.  The  direct 
lateral  cerebellar  column.  2.  The  antero-lateral  ascending  column  of 
Gowers.  3.  The  antero-lateral  ground-bundle  or  fundamental  column. 
4.  The  columns  of  GoU  and  Burdach.  Descending  impnlses  are  trans- 
mitted chiefly  by  the  direct  and  crossed  pyramidal  tracts  and  the  antero- 
lateral descendiiQg  tract.  The  direct  lateral  cerebellar  tract  of  Flechsig 
takes  origin  in  the  cells  of  the  column  of  Clarke,  and  first  appears  in  the 
lower  dorsal  region,  and  passes  through  the  restiform  body  to  the  cere- 
bellum. Gowers'  tract,  or  the  antero-lateral  ascending  column,  is  first 
seen  in  the  lumbar  cord,  and  arises  from  some  of  the  cells  of  the  pos- 
terior horn.  It  then  crosses  to  the  other  side  of  the  cord  through 
the  posterior  commissure  and  terminates  in  the  region  of  the  lateral 
nucleus. 


Fig.  69. — Section  of  spinal  cord  (after  Dana),  slmwiiig  complete  subdivision  of  white  columns 
into— 

(DPy,  direct  pyramidal 
tract. 
AFC,  anterior  funda- 
mental column. 


Lateral 
columns. 


f  LFC.  lateral  fundamental  column. 
I  LL,  lateral  limiting  layer. 

C'PyT,  crossed  pyramidal  tract. 

CT,  direct  cerebellar  tract. 

ALT,  antero-lateral  ascending  tract. 


f  Column  of  Goll. 


Posterior  columns.  \  Column  of  Burdach. 

I  RZ,  nm-zone,  or  Lissauer  s 
[     column. 


C  ARZ,  anterior  root-zone. 
I  MRZ,  middle  root-zone. 
I  OZ,  oval  zone. 
I  PRZ,  posterior  root-zone. 


The  direct  and  crossed  pyramidal  columns  constitute  the  great  motor 
path  by  which  fi])ers  descend  from  the  cortex  and  end  in  the  motor  nuclei 
of  the  cranial  and  spinal  nerves — in  the  latter  case  in  the  multipolar  gan- 
glion-cells of  the  anterior  horns.  Their  origin  is  in  the  motor  region  of 
the  cerebral  cortex — i.  e.  the  ascending  frontal  and  parietal  regions,  the 
paracentral  lobule,  and  the  posterior  part  of  the  inferior  frontal  convolu- 
tion; they  then  approach  one  another,  as  do  fibers  from  all  parts  of 
the  cerebral  cortex  (known  collectively  as  the  corona  radiata),  to  enter 
the  internal  capsule.  This  may  be  described  as  a  wedge,  bounded  in 
front  and  to  the  inner  side  by  the  caudate  nucleus  and  the  optic  thalamus, 
and  on  the  outer  side  by  the  lenticular  nucleus. 

All  of  the  fibers  of  the  corona  radiata  do  not  pass  through  the  internal 
capsule,  some  being  lost  in  the  gray  matter  of  the  basal  ganglia,  while 


Fig.  70.— X,  Peripheral  sensory  tract ;  6,  6i,  h",  b^,  cells  in  the  short  fibers,  tnrough  the  intercalation 
of  which  sensory  impulses  are  conducted  to  the  brain :  c,  continuation  of  the  paths  for  sensory 
impulses  leading  to  the  cortex. 


Fig.  71. — 1,  Motor  centers  for  the  lower  extremities  ;  li,  motor  centers  for  the  upper  extremities  ; 
2,  motor  centers  for  the  nerves  of  the  face ;  3,  4,  5,  lateral  pyramidal  tract  (red) :  6,  7,  8.  anterior 
pyramidal  tract  (green) ;  py.  pyramids  (redi;  col  (red  and  green),  collateral  fibers  leading  to  gray 
substance.  The  Roman  numerals  iIII,  IV,  etc.)  indicate  the  nuclei,  and  correspond  with'the 
numbers  of  the  cerebral  nerves  ;  the  letters  {g,  h,  etc.)  represent  the  points  of  decussation  and  the 
names  of  the  individual  nerves. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1021 

others  take  origin  in  tlie  ganglia.  The  angle  of  the  internal  capsule  is 
known  as  the  genu  or  knee,  the  part  anterior  to  it  as  the  anterior  limb, 
and  the  posterior  portion  as  the  posterior  limb.  Through  the  anterior 
limb  pass  the  fibers  from  the  frontal  region  :  in  the  region  of  the  genu 
are  the  fibers  for  the  muscles  of  the  face  and  tongue  ;  and  in  the  pos- 
terior limb,  the  motor  fibers  to  the  extremities,  also  the  sensory  or  teg- 
mental fibers,  and  at  its  posterior  end  the  fibers  of  the  optic  radiation. 

The  crusta  consists  of  fibers  that  pass  through  the  pons  and  enter  the 
medulla,  constituting  its  p^a-amidal  tracts. 

The  tegmental  fibers  are  continuous  through  the  longitudinal  fibers  of 
the  pons  with  those  derived  from  i\\Q  formatio  reticularis  of  the  medulla. 
This  is  formed  by  fibers  from  the  superior  cerebellar  peduncles,  the  olivary 
body,  and  the  posterior  and  lateral  columns  of  the  cord,  which  are  rein- 
forced in  their  upward  course  by  fibers  derived  from  the  quadrigeminal 
and  geniculate  bodies. 

Tracing  the  pyramidal  fibers  through  the  medulla,  they  will  be  found 
to  divide  into  two  unequal  portions  at  its  lower  part.  The  larger  decussates 
at  this  point  (the  region  of  the  fia'st  and  second  cervical  nerves),  constitut- 
ing the  decussation  of  the  pyramids ;  it  then  crosses  to  the  posterior  part 
of  the  lateral  column  of  the  opposite  side,  in  which  it  runs  as  the  crossed 
pyramidal  tract. 

In  their  course  these  fibers  give  ofi"  collaterals  at  right  angles  to  them- 
selves. These  pass  into  the  gray  matter,  and  terminate  in  arborizations 
about  the  root-cells  of  the  anterior  horn  of  the  same  side.  The  main  axes 
end  in  the  same  manner.  As  these  main  fibers  "with  their  collaterals  pass 
into  the  gray  matter  at  various  levels  of  the  cord,  the  tract  becomes  more 
and  more  attenuated,  and  terminates  finally  in  the  lumbar  enlargement  of 
the  cord  in  the  neighborhood  of  the  third  or  fourth  sacral  nerve.  The 
smaller  division  of  the  medullary  pyramids  passes  directly  into  the  anterior 
region  of  the  cord  without  decussating,  and  is  known  as  the  direct  pyramidal 
tract,  or  the  column  of  Tlirck.  In  its  course  it  gives  off  collaterals  at  right 
angles.  These  pass  through  the  anterior  commissure  at  diflterent  levels  of 
the  cord,  and  end  in  relation  with  cells  of  the  anterior  horn  of  the  oppo- 
site side.     The  main  fibers  terminate  precisely  in  the  same  manner. 

Thus  it  will  be  observed  that  the  fibers  of  the  column  of  Tiirck  de- 
cussate in  the  anterior  commissure  of  the  cord ;  like  the  tract  previously 
described,  it  becomes  gradually  smaller  from  above  downward,  and  ends 
in  the  lower  part  of  the  dorsal  cord.  The  axis-cylinders  of  the  multi- 
polar ganglion-cells  of  the  anterior  horns  pass  out  through  the  anterior 
roots  of  the  same  side  and  terminate  in  end-plates  of  muscles.  Dejerine, 
Oppenheim,  Monakow,  and  other  neurologists  believe  that  each  motor 
cortex  sends  fibers  to  both  sides  of  the  body,  and  that  the  decussation 
of  the  pyramids  is  not  a  complete  one,  a  small  number  of  the  fibers 
running  in  the  lateral  pyramidal  tract  on  the  same  side  as  the  lesion. 
This  is  borne  out  clinically  by  the  slight  paresis  and  the  plus  knee-jerk 
on  the  same  side,  neither  of  which,  however,  approaches  in  degree  the 
palsy  and  increased  knee-jerk  on  the  side  opposite  to  the  lesion. 

Pathologic  confirmation  of  this  view  has  been  obtained  by  several 
observers,  who  have  found  degeneration  in  both  latero-pyramidal  col- 
umns in  cases  of  a  unilateral  lesion  in  the  motor  cortex. 

Motor-fibers  from    the  nuclei  of   cranial   nerves    after    decussating 


1022 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


join  with  motor  fibers  of  the  internal  capsule.  The  exact  course  of 
these  fibers,  however,  has  not  been  demonstrated  anatomically.  Since 
many  of  the  muscles  supplied  by  the  cranial  nerves  functionate  bilater- 
ally— e.  g.  the  eye-muscles  and  the  muscles  of  mastication — the  suppo- 
sition is  that  in  addition  to  fibers  from  its  own  nucleus  each  motor  cranial 
nerve  receives  fibers  from  the  corresponding  nucleus  of  the  opposite 

side.  It  was  Broadbent  who  first 
pointed  out  that  parts  that  func- 
tionate bilaterally  are  supplied 
from  both  sides  of  the    brain. 

The  course  of  the  fibers  of  the 
posterior  column  is  as  follows : 

The  ganglion-cells  on  the 
posterior  roots  give  rise  to  two 
fibers,  fused  for  a  short  distance 
from  the  cell,  but  soon  bifurca- 
ting. The  longer  of  the  two,  the 
centrifugal  fiber,  extends  to  the 
surface  and  terminates  in  pointed 
or  bulbous  endings  in  the  epi- 
dermis, or  in  special  sensory 
nerve-endings  in  tactile  cells, 
tactile  corpuscles,  or  end-bulbs. 
The  centripetal  fibers  or  axons 
penetrate  the  cord,  and  divide  in 
the  white  matter  into  ascending 
and  descending  fibers.  The  for- 
mer may  be  either  long  or  short. 
The  short  fibers  are  vertical  at 
first,  but  finally  bend  into  the 
gray  matter,  and  end  in  relation 
with  certain  cells  of  the  anterior 
cornua.  forming  perhaps  a  part 
of  the  reflex  arc.  Their  collat- 
erals end  in  a  similar  manner. 
The  long  fibers  extend  up  the 
cord  to  the  medulla,  ending  in  the  usual  manner  in  the  gray  nuclei 
of  the  columns  of  Goll  and  Burdach  :  these  are  known  as  the  nucleus 
yraciUs  and  nucleus  cuneatus,  respectively.  They  also  give  off  col- 
laterals in  their  course.  The  descending  fibers,  on  the  other  hand, 
are  all  short,  and  probably  constitute  the  so-called  comma  tract  of 
Schultze. 

Since  fibers  continue  to  enter  the  cord  at  diff'erent  levels,  those  that 
have  entered  below  are  pushed  more  and  more  toward  the  median  line. 
It  will  thus  be  seen  that  the  column  of  Goll  is  made  up  almost  entirely 
of  long  fibers,  and  that  the  column  of  Burdach  also  contains  long  fibers, 
although  it  is  probable  that  the  short  ones  predominate.  The  long 
fibers  are  concerned  in  muscular  coordination  and  equilibrium.  It  is 
likely  that  the  fibers  of  pain  and  temperature  sense,  although  entering 
by  the  posterior  roots,  do  not  pass  up  through  the  posterior  columns,  but 
rather  through  the  gray  substance  of  the  spinal  cord. 


. Lumbar 


Sacral 


Fig.  72.— Diagram  showing  the  groupings  and  plex- 
uses of  the  spinal  nerves  (redrawn  after  Baker). 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1023 


Since  the  post-natal  growth  of  the  vertebrae  is  more  rapid  than  that 
of  the  cord,  it  follows  that  the  spinal  nerves  assume  a  more  and  more 
oblique  position,  until  finally  the  spinal  segments,  each  of  which  con- 
sists of  an  anterior  and  posterior  nerve-bundle  with  a  transverse  plane 
of  white  substance,  lie  considerably  above  the  vertebrae  after  which  they 
are  named  (see  Fig.  67).  The  folloAving  table  (Starr,  modified  by  Mills 
and  Dana  from  the  experimental  and  clinical  studies  of  Thorburn  and 
others)  shows  the  localization  of  function  (not  organs)  in  the  difi'erent 
segments  of  the  cord : 

Localization  of  the  Funetio7is  of  the  Segments  of  the  S-pinal  Cord. 


Segment. 
First  cervical. 


Second  and  third 
cervical. 


Fourth  cervical. 


Fifth  cervical. 


Sixth  cervical. 


Seventh  cervical. 


Eighth  cervical. 


First  dorsal. 


Second  dorsal. 


Muscles. 
Rectus  laterales. 
Rectus  capitis. 
Anticus  and  posticus. 
Sterno-hyoid. 
Sterno-thyroid. 
Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Omo-hyoid. 
Diaphragm. 

Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  iufra-spi- 
natus. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Brachialis  anticus. 

Supinator  longus. 

Supinator  brevis. 

Deep  muscles  of  shoul- 
der-blade. 

Rhomboid. 

Teres  minor. 

Peetoralis  (clavicular 
part). 

Serratus  magnus. 

Deltoid. 

Biceps. 

Brachialis  anticus. 

Subscapular. 

Peetoralis  (clavicular 
part). 

Serratus  magnus. 

Triceps. 

Pronators. 

Rhomboid. 

Latissimus  dorsi. 

Triceps  (long  hpad). 

Extensors  of  wrist  and 
fingers. 

Pronators  of  wrist. 

Flexors  of  wrist. 

Subscapular. 

Peetoralis  (costal  part). 

Serratus  magnus. 

Latissimus  dorsi. 

Teres  major. 

Triceps  (longhead). 
Flexors    of    wrist    and 

fingers. 
Intrinsic  hand-muscles. 

Extensors  of  thumb. 
Intrinsic  hand-muscles. 
Thenar  and  hypothenar 
muscles. 


Reflex  and  Centers. 


Hypochondrium  (?).  Sud- 
den inspiration  pro- 
duced by  sudden  pres- 
sure beneath  the  lower 
border  of  the  ribs. 

Pupillary  (fourth  cervi- 
cal to  second  dorsal). 
Dilatation  of  the  pupil 
produced  by  irritation 
of  the  neck. 


Scapular  (fifth  cervical 
to  first  dorsal).  Irrita- 
tion of  skin  over  the 
scapula  produces  con- 
traction of  the  scap- 
ular muscles. 

Supinator  longus.  Tap- 
ping the  tendon  of  the 
supinator  longus  pro- 
duces flexion  of  fore- 


Triceps  (fifth  to  sixth 
cervical).  Tapping  el- 
bow tendon  produces 
extension  of  forearm. 

Posterior  wrist  (sixth  to 
eighth  cervical).  Tap- 
ping tendons  causes 
extension  of  the  hand. 


Anterior  ivrist  (seventh  to 
eighth  cervical).  Tap- 
ping anterior  tendons 
causes  flexion  of  wrist. 

Palmar  (seventh  cervical 
to  first  dorsal).  Strok- 
ing the  palm  causes 
closure  of  the  fingers. 


Sensation. 


Back  of  head  to  vertex 
and  neck.  (Occipitalis 
major,  occipitalis  mi- 
nor, auricularis  mag- 
nus, superficialis  colli, 
and  supraclavicular.) 

Neck. 

Shoulder,  anterior  sur- 
face. 

Outer  arm.  (Supracla- 
vicular, circumflex, 
external  musculo-cu- 
taneous,  cutaneous.) 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  the  wrist. 
(Supraclavicular,  cir- 
cumflex, external  cu- 
taneous, internal  cu- 
taneous, posterior  spi- 
nal branches.) 


Outer  side  and  front  of 
forearm. 

Back    of    hand,    radial 
distribution. 

(Chiefly  external  cu- 
taneous, internal  cu- 
taneous, radial.) 


Radial  distribution  in 
the  hand. 

Median  distribution  in 
the  palm,  thumb,  in- 
dex, and  one  half  of 
the  middle  finger. 

(External  c  u  t  a  n  e  - 
ous,  internal  cutane- 
ous, radial,  median, 
posterior  spinal 
branches.) 

Ulnar  area  of  hand, 
back,  and  palm,  in- 
ner border  of  forearm. 
(Internal  cutaneous, 
ulnar.) 

Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 

(Chiefly  internal 
cutaneous  and  nerve 
of  Wrisberg  or  1  e  s  s- 
er  internal  cutane- 
ous.) 

Inner  side  of  arm  near 
±"  aad  in  the  axilla. 
(Intercosto-numerai.) 


1024 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Segment. 

Second  to  twelfth 
dorsal. 


Muscles. 

Muscles  of  back  and  ab- 
domen. 
Erectores  spinse. 


First  lumbar. 


None. 


Second  lumbar.        Vastus  internus. 


Third  lumbar. 
Fourth  lumbar. 

Fifth  lumbar. 


First  and  second 
sacral. 


Third,  fourth, and 
fifth  sacral. 


Sartorius;  adductors  of 

thiph. 
Flexors  of  thi^rh. 
Extensors  of  knee. 
Abductors  of  thigh. 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Calf-muscles. 

Glutei. 

Peronei. 

Extensors  of  ankle. 

Small  muscles  of  foot. 

Perineal. 

Muscles  of  bladder,  rec- 
tum, and  external 
genitals. 


Reflex  and  Centers. 

Epigastric  (fourth  to  sev- 
enth dorsal).  Tickling 
mammary  region 
causes  retraction  of 
the  epigastrium. 

Abdominal  (seventh  to 
eleventh  dorsal). 
Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Vaso-motor  centers.  Sec- 
ond dorsal  to  second 
lumbar. 

CremaMeric  (first  to  third 
lumbar).  Stroking  in- 
ner thigh  causes  re- 
traction of  scrotum. 

Pnidlur.  Striking  pa- 
tellar tendon  causes 
extension  of  the  leg. 


Gluteal  (fourth  to  fifth 
lumbar).  Stroking 
buttock  causes  dimp- 
ling in  fold  of  buttock. 

Achillas  tendon.  Over- 
extension causes  rapid 
flexion  of  ankle,  called 
ankle-clonus. 


Plantar  (fifth  lumbar  to 
second  sacral).  Tick- 
ling solo  of  foot  causes 
flexion  of  toes  and 
retraction  of  leg. 

Genital  center. 

Vesical  center. 

Anal  center. 


Sensation. 

Skin  of  the  chest  and  ab- 
domen, in  bands  run- 
n  i  n  g  around  and 
down  w  a  r  d,  corre- 
sponding to  spinal 
nerves. 

Upper  gluteal  region. 
(Intercostals  and  dor- 
sal posterior  nerves.) 


Skin  over  groin  and 
front  of  scrotum.  (Ilio- 
hypogastric, i 11 o  -  i  n- 
gumal.) 

Outer  side  and  upper 
front  of  thigh.  Lum- 
bar region.  (Genito- 
crural,  external  cuta- 
neous.) 

Front  and  outer  side  of 
thigh.  Inner  side  of 
leg  and  foot. 

Inner  side  of  thigh,  leg, 
and  foot.  (Internal 
cutaneous,  long  sa- 
phenous, obturator.) 

Back  of  thigh  and 
outer  side  of  leg  and 
ankle  ;  sole  ;  dorsum 
of  foot.  (External 
popliteal,  external 
saphenous,  musculo- 
cutaneous, plantar.) 

Back  of  buttock  and 
thigh,  side  of  leg  and 
ankle:  sole;  dorsum 
of  foot. 

Circumanal  region, 
anus,  rectum,  penis, 
urethra,  vagina,  per- 
ineum. 

(Small  sciatic,  pudic, 
inferior  hemorrhoidal, 
inferior  jiudendal.) 


To  the  foregoing  table,  which  illustrates  spinal  localization,  should 
be  added  another,  showing  what  functions  reside  in  the  pons  and  medulla, 
as  follows : 


Nuclei. 
III. 

IV. 


VI. 


XII. 


Sphincter  iris.     Ciliary  muscles. 

Levator  palpebrse  superioris.     Rectus  internus  (in  convergence) 
Rectus  superior.     Rectus  inferior. 
Obliquus  inferior. 
Obliquus  superior. 
(Upper  facial  group.) 


V. 

Rectus  externus.  Rectus 
inter,  of  opposite  side 
in  lateral  movements. 


f  (Associated  movement  of  levator  palpebrge.) 
(  Muscles  of  lower  jaw. 


(Lower  facial  group.) 
Muscles  of  tongue. 


VII. — Facial  muscles. 
IX.  f  Muscles  of  pharynx. 
X.  ■;  Muscles  of  esophagus. 
XI.  (  Muscles  of  larynx. 


Sensory  Cortical  Area. — Owing  to  the  extensive  compensation  of  sen- 
sory fibers,  by  means  of  which  each  side  of  the  brain  sends  fibers  to  both 
sides  of  the  body,  it  is  impossible  to  map  out  the  center  with  precision. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  1025 

It  is  generally  believed,  for  reasons  already  stated,  that  the  central 
convolutions  (motor  area)  contain  muscular  and  tactile  sensory  functions. 
These  are  also  spread  out  over  the  parietal  lobe,  and  it  is  possible,  in- 
deed probable,  that  the  sensory  zone  extends  to  the  mesial  surface  of 
the  hemisphere,  as  does  the  motor  area.  That  this  is  the  chief  sensory 
center,  as  claimed  by  some  observers,  is,  however,  very  questionable. 

From  the  cuneus,  fibers  pass  to  the  pulvinar,  forming  the  optic  radia- 
tion of  Gratiolet.  From  the  pulvinar  they  apparently  pass  to  the 
external  geniculate  bodies,  and  thence  to  the  anterior  corpus  quadrigemi- 
num.  The  optic  tracts  arise  by  two  roots  that  curve  round  the  crusta 
on  either  side  and  unite  immediately  in  front  of  the  tuber  cinereum. 
Fibers  from  the  two  tracts  pass  to  the  homologous  sides  of  both  retinge ; 
therefore  the  lesions  posterior  to  the  chiasm  give  rise  to  blindness  of 
half  of  the  retina  on  the   same  side. 

Visual  Centers. — The  exact  center  for  ordinary  vision  is  in  the  cor- 
tex of  the  occipital  lobe  of  the  inner  surface  in  the  region  of  the  calca- 
rine  fissure.  A  higher  center  exists,  probably  located  in  the  angular 
gyrus,  a  lesion  of  which  produces  mind-blindness  ;  this  is  a  condition 
in  vrhich  vision  is  not  lost,  but  the  objects  seen  are  not  recognized 
by  the  individual.  Ferrier  says  that  a  lesion  in  this  region  sometimes 
gives  rise  to  crossed  amblyopia.  The  eye  opposite  to  the  lesions  is  chiefly 
affected,  though  vision  is  also  restricted  in  the  eye  on  the  same  side  of 
the  lesion  (visual  tract). 

Olfactory  Center. — This  is  located  in  the  anterior  part  of  the  uncinate 
convolution,  on  the  inner  surface  of  the  temporal  lobe.  It  is  possible, 
too,  that  fibers  pass  from  this  region  through  the  anterior  commissure. to 
the  cortex  of  the  opposite  hemisphere. 

Auditory  Center. — A  lesion  in  the  posterior  part  of  the  first  temporal 
convolution  produces  a  deafness  in  the  opposite  ear  that  is  transient  in  cha- 
racter, owing  to  compensation.  Bilateral  lesions  produce  complete  deaf- 
ness. Mind-deafness,  or  an  inability  to  understand  spoken  words,  has 
resulted  from  a  lesion  in  the  first  temporal  convolution  of  the  left  side. 

Speech  Center. — The  articulate  speech  center  is  located  in  the  poste- 
rior part  of  the  left  third  or  inferior  frontal  convolution,  and  in  the  ad- 
jacent part  of  the  ascending  frontal  in  right-handed  people  (but  on  the 
right  side  in  left-handed  persons). 

It  is  not  known  exactly  what  part  the  island  of  Reil  plays  in  articu- 
late speech.  Word-blindness  results  from  a  lesion  in  the  angular  gyrus. 
Word-deafness  results  from  a  lesion  in  the  posterior  part  of  the  first  left 
temporal  convolution. 

Taste  Center. — The  area  of  cortical  representation  is  unknoAvn.  By 
some  it  is  located  in  the  gyrus  hippocampus. 

Psychic  Centers. — It  is  possible  that  the  frontal  lobes,  anterior  to 
the  precentral  fissure,  contain  the  psychic  centers.  Such  extensive 
compensation  probably  exists  that  no  ordinary  lesion  produces  mental 
aberration,  but  these  centers  are  probably  represented  by  the  whole 
cortex. 

The  function  of  the  cerebellum  is  that  of  coordination.  Fibers  pass 
from  its  cortex  to  that  of  the  cerebrum,  and  vice  versa.  The  impressions 
derived  from  the  cerebrum  are  believed  to  be  inhibitory. 

Peripheral  impressions  reach  the  cerebellum  through  the  direct  cere- 

65 


1026  DISEASES  OF  THE  NERVOUS  SYSTEM. 

bellar  tracts  of  the  lateral  columns  of  the  cord,  and  also  from  fibers  de- 
rived from  cells  in  the  nuclei  of  the  columns  of  Goll  and  Burdach. 

Motor  impulses  run  from  the  cerebellar  cortex  to  the  motor  region 
of  the  cerebral  cortex  by  way  of  the  superior  or  middle  peduncle,  and  by 
way  of  the  inferior  peduncle  (restiform  body)  to  the  multipolar  ganglion- 
cells  of  the  anterior  horns. 

GENERAL   AND    TOPICAL   DIAGNOSIS. 

Nervous  diseases  are  usually  spoken  of  either  as  being  functional 
or  organic  ;  but,  as  our  methods  of  research  become  more  refined  and 
our  technic  more  perfect,  the  breach  between  these  two  groups  is  being 
gradually  but  steadily  lessened. 

Organic  nervous  diseases  may  be  produced  by  two  types  of  lesions : 

1.  Irritative.,  causing  an  increase  of  function,  continuous  or  inter- 
mittent. 2.  Destructive,  resulting  in  paralysis  of  motion  or  sensation, 
or  both. 

Irritative  lesions  are  prone  to  become  destructive  in  course  of  time. 
They  may  be  operative  in  the  upper  segment,  which  includes  the  brain 
and  fibers  leading  to  or  from  it  as  far  as  the  ganglion-cells  of  the  cord ; 
or  in  the  lower  segment,  including  the  multipolar  ganglion-cells  of  the 
anterior  horn,  together  with  the  peripheral  motor  and  sensory  nerves. 

When  a  complete  pathway  is  involved  a  systemic  disease  is  said  to  be 
produced.  When  two  or  more  paths  or  neuron  complexes  are  simul- 
taneously involved  combined  systemic  disease  results. 

Brain-lesions  may  be  (a)  focal  or  {b)  diffuse.  Cord-lesions  are  either 
(a)  transverse,  {b)  focal,  or  {c)  insular  (a  series  of  foci). 

Cord-lesions  result  in  ascending  or  descending  degeneration,  the  de- 
structive^rocess  travelling,  as  a  rule,  in  the  direction  in  which  impulses 
are  normally  transmitted.  In  the  fillet  degeneration  may  extend  up  or 
down. 

The  theory  has  been  advanced  that  the  vulnerability  of  the  tracts  of 
the  spinal  axis  is  in  direct  proportion  to  the  degree  of  their  functional 
activity ;  hence  the  reflex  (sensory  and  pyramidal)  tracts  are  more  likely 
to  degenerate  under  nutritional  disturbances  or  toxic  processes  than 
other  parts. 

It  has  been  supposed  that  the  tardy  myelination  of  the  pyra- 
midal tracts  predisposes  to  various  nervous  maladies,  and  particularly  to 
those  of  a  convulsive  type.  The  following  may  be  accepted  as  a  general 
rule :  the  motor-nervous  system  is  the  last  to  develop,  the  first  to  lose, 
and  the  last  to  regain,  its  function  ;  while  the  sensory  nervous  system  is 
the  first  to  develop,  the  last  to  lose,  and  the  first  to  regain,  its  function. 
In  making  a  diagnosis  it  is,  therefore,  of  the  utmost  importance  to  try  to 
determine  the  locality  and  extent  of  the  morbid  process,  and  to  ascertain 
whetlier  the  lesion  is  a  focal  or  systemic  one.  The  symptomatology  of 
systemic  diseases  is  pretty  constant,  and,  except  in  their  very  incipiency, 
they  are  usually  not  difficult  of  diagnosis.  The  sym])toms  of  focal  dis- 
eases, on  the  other  hand,  vary,  of  necessity,  according  to  the  location 
of  the  focus.  They  are  often  difficult  and  at  times  impossible  to  diag- 
nose. Especially  is  this  true  of  lesions  occurring  in  the  frontal  lobes 
of  the  cerebrum,  in  the  basal  ganglia,  and  in  the  cerebellum. 

Since  the  study  of  the  motor  centers  and  tracts  has  been  pursued 


GENERAL  AND   TOPICAL  DIAGNOSIS.  1027 

with  so  much  more  success  than  that  of  the  sensory  system,  positive  or 
negative  motor  phenomena  occurring  in  the  course  of  nervous  diseases 
furnish  us  with  much  more  valuable  information  than  do  sensory  mani- 
festations. 

Further,  motor  symptoms  are  objective,  and  consequently  appeal  to 
us  in  a  much  greater  degree  than  the  sensory  symptoms,  which  are 
purely  subjective,  and  the  elicitation  of  which  depends  so  much  upon 
the  mental  capability  of  the  patient. 

Irritative  motor-lesions  produce,  according  to  the  degree  of  irritation, 
either  fibrillary  muscular  twitchings  or  mild  or  severe  convulsions,  tonic 
or  clonic  in  character. 

Destructive  motor-lesions,  according  to  their  extent,  produce  mere 
muscular  weakness,  paresis,  or  actual  paralysis  of  a  single  muscle, 
groups  of  muscles,  or  of  the  entire  musculature  of  one  or  more  limbs. 

Irritative  sensory  lesions  give  rise  to  neuralgia,  hyperesthesia,  or 
hyperalgesia. 

Destructive  sensory  lesions  cause  a  more  or  less  complete  absence  of 
sensation,  as  analgesia,  anesthesia,  or  loss  of  temperature-sense. 

Upper-segment  or  Upper-system  Diseases. — A  lesion  occurring  in  the 
motor  pathway  anywhere  between  the  cortex  and  the  multipolar  cells 
of  the  anterior  horns  (but  not  including  the  latter)  gives  rise  to  the 
following  symptom-complex :  Loss  of  motion,  both  automatic  and  vo- 
litional, and  chiefly  on  the  side  of  the  body  opposite  to  the  lesion.  The 
paralysis  is  usually  spastic  in  type.  The  muscles  resist  passive  move- 
ments, showing  that  their  tone  is  increased.  This  is  relative,  and  is  due 
to  the  removal  of  cerebral  inhibition,  which  allows  the  lower  centers 
free  play.  They  also  tend  to  undergo  shortening,  and  contractures  re- 
sult. Reflexes  are  increased  chiefly  on  the  side  opposite  the  lesion,  but 
also  on  the  same  side,  the  increase  being  the  result  of  the  removal  of 
cerebral  influences. 

Owing  to  inactivity,  the  muscles  of  the  paralyzed  members  undergo 
a  more  or  less  marked  atrophy,  though  there  are  no  degenerative 
changes,  since  the  neuron  bodies  are  intact.  For  the  same  reason  the 
response  to  electric  stimulation  is  not  interfered  with. 

An  irritative  lesion  of  this  upper  system,  particularly  when  operative 
in  or  upon  the  cortical  region,  gives  rise  to  tonic  or  clonic  convulsive 
movements.  When  the  lesion  is  localized  to  a  single  center,  focal  or  so- 
called  Jacksonian  epilepsy  results.  The  cortex  is  wonderfully  tolerant, 
when  the  lesion  is  of  gradual  onset  and  the  parts  accommodate  them- 
selves to  the  slowly  increasing  pressure.  However,  a  local  irritative  le- 
sion may  at  first  cause  widespread  symptoms,  due,  as  Nothnagel  pointed 
out,  to  pressure,  vascular  disturbances,  or  irritative  inhibition. 

Loiver-segment  or  Loiver-system  Diseases. — This  includes  the  periph- 
eral neuron  system.  Since  there  is  no  crossing  of  the  fibers,  the  lesion 
and  resulting  paralysis  are  on  the  same  side  of  the  body.  The  paraly- 
sis, however,  is  of  the  flaccid,  flail-like  variety,  hypotonus  being  present. 
The  muscles  ofi'er  no  resistance  whatever  to  passive  movement,  contrac- 
tures do  not  occur,  and  reflexes  are  lost.  Extreme  degrees  of  wasting 
occur  in  this  type  of  paralysis,  owing  partly  to  disuse,  but  chiefly  to  the 
fact  that  the  neuron  body,  the  nutritional  or  trophic  center  for  the  fiber, 
is  injured.     Pathologic   changes  therefore  take  place  in  the  muscles 


1028  DISEASES  OF  THE  SERVO VS  SYSTEM. 

themselves,  and  form  a  true  degenerative  atrophy.  The  protoplasm 
first  becomes  granular,  and  then  fatty ;  it  then  breaks  down  and  is 
absorbed.  Its  place  is  taken  by  the  connective  tissue,  which  is  both 
relatively  and  absolutely  increased,  so  that  in  the  course  of  time  fibrous 
masses  alone  remain.  Electric  changes  also  occur.  The  muscles  first 
cease  to  respond  to  the  faradic  current,  and  soon  respond  in  an  abnormal 
manner  to  the  galvanic.  Instead  of  short,  sharp  contractions,  they  react 
in  a  slow,  wavy  manner,  ACC  being  stronger  than  KCC.  Irritative 
lesions  of  this  system  cause  fibrillary  muscular  contractions  and  periph- 
eral convulsions,  of  which  laryngismus  stridulus  is  a  type. 


I.  DISEASES   OF  THE   PERIPHERAL   NERVES. 
NEURITIS. 

Definition. — An  inflammation  of  a  nerve  or  of  its  fibrous  envelope. 

Pathologfy. — A  true  neuritis  is  almost  always  an  inflammation  of  the 
nerve-sheath  or  of  the  septa  between  the  fasciculi,  and  usually  begins  as 
a  perineuritis.  The  so-called  parenchymatous  neuritis  is  really  a  degen- 
erative process  ;  it  is  prone  to  follow  neuritis,  and  is  the  result  of  ex- 
cessive or  prolonged  irritation  or  of  pressure  by  the  products  of  inflam- 
mation. The  aff"ected  nerve  becomes  red  and  swollen.  The  sheath  be- 
comes hyperemic  and  the  seat  of  a  round-cell  infiltration. 

We  may  have  a  perineuritis  or  an  interstitial  neuritis.  Again,  these 
mav  he  focal  or  diffuse  {disseminated),  involving  limited  patches  or  con- 
tinuous areas  of  a  nerve.  Finally,  many  nerves  may  be  simultaneously 
affected,  constituting  a  multiple  neuritis.  In  the  parenchymatous  form 
the  ordinary  signs  of  inflammation  are  absent.  The  nuclei  of  the  sheath 
increase  in  size  and  number,  and  the  protoplasm  about  them  increases  in 
amount.  The  white  substance  of  Schwann  becomes  segmented,  breaks 
up  into  droplets,  then  becomes  granular  and  fatty,  and  is  finally  ab- 
sorbed. The  axis-cylinder  becomes  discontinuous  at  the  site  of  disorgan- 
ization of  the  myelin.  Ultimately,  there  may  be  seen  scattered  promis- 
cuously among  the  more  or  less  healthy  fibers  the  withered  nerve-sheaths, 
containing  many  nuclei,  some  granular  debris,  and  pigment.  Occasion- 
ally fatty  aggregations  occur  along  the  nerve.  Leyden  has  termed  this 
condition  lipomatous  neuritis,  but  it  is  not  worthy  of  a  special  name,  as 
it  is  only  a  stage  in  the  ordinary  degenerative  process. 

Parenchymatous  degeneration  is  similar  to  the  secondary  or  Wallerian 
degeneration  previously  mentioned.  It  is  the  chief  lesion  in  multiple 
neuritis,  though  in  this  disease  changes  have  also  been  found  in  the  mul- 
tipolar ganglion-cells  of  the  anterior  horns. 

Ktiologfy. — (rt)  Focal  neuritis  may  be  due  to — (1)  Exposure  or  cold 
(the  so-called  rheumatic  neuritis).  (2j  E.xtension  of  inflammation  from 
neighboring  parts.  (3)  Traumatism — wounds,  compression,  excessive 
stretching  resulting  from  fractures  or  dislocation.  (4)  Microbic  and 
autogenctic  poisons. 

{b)  Multiple  neuritis  may  be  due  to — (1)  Poisons  of  extrinsic  origin 


•      NEURITIS.  1029 

— alcoliol,  carbon  bisulfid,  lead,  arsenic,  mercury,  ether.  (2)  Poisons 
resulting  from  the  infectious  fevers  (typhoid,  diphtheria,  variola,  typhus, 
leprosy,  beri-beri,  measles,  syphilis,  tuberculosis,  septicemia,  malaria,  in- 
fluenza). (3)  Cachexias,  anemia,  carcinoma.  (4)  Auto-intoxication.  (5) 
Cases  arise  in  which  no  definite  cause  can  be  ascertained  ;  these  are  the 
so-called  idio'patMc  or  spontaneous  cases. 

Symptoms. — (a)  Focal  Neuritis. — In  localized  neuritis  the  symptoms 
vary  according  to  the  function  of  the  nerve  involved.  In  the  case  of  a 
sensory  nerve  there  is  pain,  usually  of  a  boring  or  shooting  charac- 
ter, along  its  course  and  distribution.  There  is  also  tenderness  on 
pressure  along  the  nerve,  and  especially  at  its  point  of  emergence  from 
bony  canals.  Weir  Mitchell  believes  this  to  be  due  to  irritation  of  the 
nervi  nervorum.  The  skin  is  generally  hyperalgesic  (though  tactile 
sensation  is  often  lowered),  reddened,  sometimes  edematous,  and  local 
sweatings  may  occur.  In  the  more  chronic  cases  trophic  Symptoms 
eventually  arise,  as  glossiness  of  the  skin  and  an  impaired  growth  of 
the  nails.  When  a  motor  nerve  bears  the  brunt  of  the  attack  fibril- 
lary twitchings  will  be  observed  in  the  muscles  it  supplies,  and  are  soon 
followed  by  more  or  less  impairment  of  motion,  even  amounting  to  paral- 
ysis ;  sometimes  contractures  occur,  and  ultimately  wasting  of  the  mus- 
cles, and  even  reactions  of  degeneration,  take  place.  When  both  motor 
and  sensory  nerves  are  simultaneously  involved  the  symptoms  will  neces- 
sarily partake  of  a  mixed  character.  The  constitutional  symptoms  are, 
as  a  rule,  of  little  moment. 

{h)  Multiple  neuritis  is  an  involvement  of  the  peripheral  nerves  in 
various  parts  of  the  body,  afi"ected  simultaneously  or  in  quick  succession, 
and  due  to  endogenous  or  exogenous  poisons.  Lettsom's  paper,  pub- 
lished in  1789,  embodied  the  first  description  of  the  disease. 

Among  cases  due  to  poisons  of  extrinsic  origin  is  alcoholic  neuritis. 
In  1822,  James  Jackson  of  Boston  clearly  gave  its  clinical  history, 
though  Dumesnil  in  1864  was  the  first  to  publish  the  result  of  an  autopsy 
upon  a  case.  Other  pioneers  were  Leyden,  Buzzard,  and  Ross.  This 
is  the  most  common  type  of  multiple  neuritis,  and  occurs  oftener  among 
women  than  men.  It  results  from  spirit-drinking  in  moderate  amounts 
and  continued  over  a  long  time.  The  onset  is  generally  slow,  being 
preceded  by  gastric  catarrh,  insomnia,  tingling  of  the  extremities,  a 
rapid,  weak  heart,  and  a  tendency  to  sweating  on  exertion.  Some  mus- 
cular twitching  and  paresis  may  exist  contemporaneously,  but  the  loss 
of  power  soon  becomes  more  marked — first  in  the  lower  and  then  in  the 
upper  extremities,  the  extensors  being  chiefly  aff"ected.  Wrist-drop  and 
foot-drop  follow.  Occasionally  paraplegia  and,  more  rarely  still,  a  loss 
of  control  of  the  bladder  and  rectum  take  place.  Fever,  is  rarely  pres- 
ent. Sensory  symptoms  may  vary  from  the  tingling  or  numbness 
already  noted  to  burning  or  boring  pains  of  great  severity.  The  skin 
is  hyperesthetic  at  first,  at  all  events.  Later,  paresthesia  develop,  with 
anesthesia  and  a  more  or  less  decided  loss  of  muscular  sense.  The  mus- 
cles are  tender  when  touched. 

The  cutaneous  reflexes  are  preserved  unless  the  anesthesia  is  marked. 
The  knee-jerks  are  generally  lost,  though  exceptionally  they  may  be  in- 
creased. In  the  less  severe  cases  a  certain  amount  of  incoordination 
may  be  present.     When  this  is  the  case  the  absence  of  the  knee-jerk, 


1030  DISEASES  OF  THE  NERVOUS  SYSTE3L 

the  loss  of  muscular  sense,  ataxia,  and  the  pains  in  the  extremities  sim- 
ulate locomotor  ataxia,  and  the  term  j^seudo-tabes  has  been  applied  to 
the  condition.  Vaso-motor  and  trophic  symptoms  appear,  and  in  some 
cases  the  special  senses  are  involved  (impairment  of  vision,  amblyopia, 
limitation  of  the  color-field).  The  cerebral  symptoms  are  important. 
They  may  be  so  slight  as  to  consist  merely  of  loss  of  memory,  irri- 
tability, perhaps  an  hallucination  or  illusion  (particularly  after  night- 
fall, and  especially  if  the  patient  has  had  insomnia),  or  they  may  be  of 
the  type  and  degree  seen  in  general  paralysis.  The  duration  of  an 
attack  varies  from  a  few  weeks  to  a  year  or  so. 

Arsenic  neuritk  differs  from  the  above  in  that  the  head-symptoms 
are  generally  absent.  The  onset  may  be  much  more  abrupt  and  the 
course  is  usually  shorter. 

Carbon  bisidfid  neuritu  occurs  chiefly  in  workers  in  rubber-factories. 
There  are  noted  intense  frontal  headache,  giddiness,  marked  excitability, 
muscular  cramps,  and  possibly  convulsions.  Saturnine  neuritis  is  con- 
fined to  motor  nerves,  and  especially  to  those  of  the  upper  extremities. 
Very  rarely  some  disturbance  of  sensibility  may  result.  Lesions  of  the 
anterior  cornua  are  more  likely  to  occur  in  saturnine  multiple  neuritis 
than  in  any  of  the  other  varieties.  Head-symptoms  are  not  common, 
but  optic  neuritis  and  convulsions  may  occur. 

Cases  due  to  an  attack  of  some  infectious  disease  may  be  local  or 
multiple,  and  generally  present  the  same  symptoms  as  neuritis  due  to 
any  other  cause.  (1)  Malarial  Neuritis. — According  to  Romberg, 
malaria  gives  rise  at  times  to  "intermittent  paraplegia."  The  legs  of 
the  patient  suddenly  become  paralyzed,  with  or  without  alteration  of 
sensation  or  loss  of  control  of  the  sphincter.  That  the  cause  is  probably 
malarial  is  shown  by  the  fact  that  the  condition  is  periodic,  each  attack 
subsiding  with  a  critical  sweat,  and  finally  yielding  to  quinin.  (2) 
Recurring  Multiple  Neuritis. — A  few  cases  have  been  reported  in 
which  attacks  of  more  or  less  widespread  paralysis,  due  to  neuritis, 
have  recurrtMl. 

Spontaneous  or  the  so-called  idiopathic  neuritis  does  not  differ  from 
the  general  type  of  the  disease,  except  that  no  cause  can  be  discovered 
to  account  for  it. 

Diagnosis. — This  does  not  present  any  difficulty,  as  a  rule.  The 
spontaneous  cases,  in  the  early  stages,  may  simulate  acute  spinal  paraly- 
sis or  acute  ascending  paralysis.  The  fever,  palsy,  electric  change,  and 
the  loss  of  knee-jerks  are  common  to  both,  but  in  acute  spinal  paralysis 
there  are  never  any  sensory  symptoms.  The  palsy  in  idiopathic  cases 
rapidly  spreads,  but  soon  subsides  again. 

In  other  forms  of  peripheral  neuritis  the  onset  is  not  only  apt  to  be 
less  abrupt,  but  some  sensory  symptoms  are  almost  invariably  present ; 
the  distribution  of  the  palsy  is  more  symmetric  bilaterally,  and  after 
it  has  reached  its  acme  no  improvement  takes  place  for  a  few  weeks  or 
months.  In  ascending  paralysis  there  are  no  sensory  symptoms,  the 
knee-jerks  are  preserved,  there  is  neither  muscular  atrophy  nor  electric 
change,  and  the  order  in  which  the  paralyses  supervene  differs  from 
that  of  peripheral  neuritis. 

Cases  of  pseudo-tabes  are  sometimes  confounded  with  locomotor  ataxia. 
The  main  points  of  differentiation  are  included  in  the  following  table : 


BEBI-BERI.  1031 

Pseudo-tabes.  Locomotor  Ataxia. 

The  course  is  shorter,  and  often  results  The   course  is  progressive  from  bad  to 

in  recovery.  worse,  and  chronic  in  nature. 

Pain  is  never  of  the  fulgurant  type.  Fulgurant  pains  often  are  present.    Pain- 
crises  are  almost  diagnostic. 

There  is  tenderness  over  the  nerve-trunks.  There  is  no  tenderness  over  the  nerves. 

Sensory  disturbances   are  more  marked  Sensory  disturbances  are  less  marked. 

(tingling  and  numbness). 

Argyll-Robertson  pupil  is  absent.  Argyll-Robertson  pupil  is  present. 

There  is  a  "foot-drop,"  with  the  typical  No  "foot-drop."    The  toes  are  raised,  and 

"steppage"  gait.  the  foot  is  brought  down  flatly,  with 

the  heel  first. 

Paralysis  is  often  present.  There  is  no  actual  loss  of  power. 

Prognosis. — Peripheral  neuritis  may  terminate  in  one  of  the  fol- 
lowing ways,  according  to  Drs.  Gibson  and  Fleming^:  1.  In  complete 
recovery ;  2.  With  damaged  peripheral  nerves ;  3.  With  injury  to  the 
central  nervous  system,  such  as  to  cause  symptoms  of  ataxia,  spastic 
paraplegia,  or  disseminated  sclerosis ;  4.  In  death,  from  failure  of  the 
organic  centers,  especially  that  of  respiration.  The  prognosis  is  gen- 
erally good,  though  in  the  acute  variety  (from  any  cause)  it  should  be 
guarded,  and  occasionally  is  grave.  Exposure  and  chill,  alcohol,  diph- 
theria, and  beri-beri  give  rise  to  the  most  serious  types,  and  often  cause 
death  by  failure  of  the  heart  or  respiration  or  by  coagula  in  the  vessels. 
Mild  cases  may  entirely  recover  in  a  few  weeks,  while  severe  ones  often 
require  a  year  or  two. 

Treatment. — First  ascertain  the  cause,  and,  if  possible,  remove  it. 
It  may  be  unwise  in  alcoholic  cases  to  stop  the  alcohol  suddenly,  but  each 
case  must  be  judged  on  its  merits.  Rest  is  very  important,  and  all 
sources  of  worry  should  be  stopped.  Locally,  anodynes  may  be  em- 
ployed and  the  part  Avrapped  in  cotton  wool.  In  febrile  cases,  especially 
in  the  earlier  stages,  the  salicylates  are  valuable.  The  general  health 
should  be  toned  up  by  strychnin  and  tonics,  and  by  nourishing  but  eas- 
ily digestible  food.  Further  medication  Avill  depend  upon  the  etiology, 
quinin  being  demanded  in  malarial,  and  mercury  or  the  iodids  in  syphi- 
litic cases.  As  soon  as  the  acute  symptoms  have  subsided  massage  and 
passive  movements  should  be  begun,  galvanism  applied  to  the  muscles, 
and  warm-water  or  sulphur  baths  administered. 


BERI-BERI. 


This  is  a  tropical  disease,  characterized  by  weakness,  wasting  of  the 
muscles,  paralysis,  anasarca,  anemia,  numbness,  pain,  areas  of  anes- 
thesia, and  diminution  or  loss  of  tendon-reflexes.  There  are  two  forms, 
the  acute  and  the  chronic.  Its  etiology  is  obscure,  though  it  is  apt  to 
supervene  upon  any  condition  that  impoverishes  the  physical  or  nervous 
vitality.  Intestinal  parasites  have  been  said  to  cause  it.  Ogata  of 
Tokio  has  described  a  specific  bacillus  ;  Pikelharing  and  Winkler,  how- 
ever, claim  that  it  is  due  to  a  micrococcus.  Whatever  its  cause,  the 
researches  of  these  latter  observers,  together  with  those  of  Baelz  and 
Sheube  in  Japan,  prove  it  to  be  a  peripheral  multiple  neuritis.  The 
symptoms  of  the  acute  form  are  fever,  anemia,  general  edema,  effusion 
into  the  serous  cavities,  dyspnea,  precordial  pain,  vomiting,  and  periph- 
'  Edinburgh  Hospital  Reports,  vol.  iii. 


1032  DISEASES  OF  THE  NERVOUS  SYSTE3T. 

eral  paralysis.  Death  often  results,  even  in  a  few  days,  from  emboli 
or  thrombi  in  the  pulmonary  or  systemic  circulation.  In  the  chronic 
form  the  symptoms  are  less  pronounced.  The  face  is  apt  to  be  puffy, 
and  palpitation  and  serious  cardiac  dilatation  may  occur.  The  gait  is 
tottering,  the  muscles  are  somewhat  wasted,  the  tendon-reflexes  are  lost, 
and  paresthesias  develop. 

The  cases  associated  with  the  cachectic  states  may  be  general ;  though 
usually  they  are  local  and  of  the  interstitial  variety  of  neuritis. 

The  cases  due  to  auto-intoxication  are  usually  associated  with  fever, 
and  at  first  simulate  rheumatism  or  some  infectious  disease.  Soon, 
however,  the  tingling,  pain,  palsy,  loss  of  the  knee-jerks,  and  anesthesia 
reveal  the  neuritis.  Death  may  result  from  cardiac. or  repiratory  paral- 
ysis.    When  life  is  spared  the  convalescence  is  exceedingly  slow. 


NEUROMATA. 


Neuromata,  or  tumors  of  nerves,  have  been  described  as  {a)  true 
and  (h)  false. 

(a)  True  neuromata  consist  of  medullated  or  non-medullated  nerve- 
fibers  (the  myelinic  and  amyelinic  varieties — Virchow),  and  rarely  of 
ganglion-cells  also. 

(6)  False  neuromata  contain  no  nerve-elements.  The  growth  is  situ- 
ated on  the  nerve-trunk  itself,  and  consists  of  either  fibrous,  myxoma- 
tous, gliomatous,  or  sarcomatous  tissue. 

Neuromata  have  also  been  classified  according  to  their  situation  as 
(1)  Stump  neuromata,  or  bulbous  nerves ;  (2)  Subcutaneous  neuromata, 
or  tubercula  dolorosa;  (3)  Xerve-trunk  neuromata;  (4)  Plexiform 
neuromata. 

(1)  Stump  neuromata  develop  on  stumps  or  on  the  ends  of  divided 
nerves  as  the  result  of  traumatism.  They  may  consist  of  fibrous  tissue, 
but  are  usually  myelinic. 

(2)  Subcutaneous  tumors,  or  tubercula  dolorosa,  are  painful,  as  the 
latter  •word  implies,  and  are  apt  to  be  multiple.  In  individuals  so 
afflicted  nerve-trunk  neuromata  may  coexist. 

(3)  Nerve-truyik  neuromata  are  usually  multiple.  In  one  case  quoted 
by  Growers  as  many  as  3020  were  found.  They  may  be  true  or  false. 
In  the  former  case  the  nerve-fibers  are  less  apt  to  be  interfered  with  than 
in  the  heterologous  growth. 

(4)  Plexiform  neuromata  consist  of  beaded  and  tortuous,  interlacing 
neural  cords.     They  are  usually  congenital. 

Htiology. — Neuromata  may  be  due  to  traumatism.  When  multiple, 
however,  they  are  usually  hereditary,  occurring  in  families  of  a  neurotic 
or  strumous  diathesis.      They  are  most  commonly  found  in  men. 

Symptoms. — There  may  be  none.  When  })resent  their  character 
necessarily  depends  on  the  nature  of  the  nerve  involved  and  whether  the 
lesion  is  an  irritative  or  destructive  one.  More  or  less  pain,  numbness 
or  tingling,  paraesthesia,  and  palsy  are  among  the  most  common  symp- 
toms. Various  reflex  manifestations  have  been  described,  and  epilepti- 
form convulsions  have  been  attributed  to  their  presence. 

Treatment. — Apart  from  anodynes,  operative  measures  are  alone 


NEURALGIA.  1033 


of  value,  except  when  the  tumors  are  the  result  of  syphilis,  as  occasion- 
ally happens ;  in  such  cases  specific  treatment  must  be  employed. 

It  must  not  be  forgotten,  however,  that  stump  neuromata  may  occur 
in  those  hereditarily  predisposed,  in  which  case,  as  Bowlby  has  pointed 
out,  their  removal  will  almost  surely  be  followed  by  a  return. 


NEURALGIA. 


Definition. — Neuralgia  [nerve-pain)  is  the  result  of  some  irritation 
directly  or  indirectly  applied  to  a  nerve.  While  this  is  true  of  all  pain, 
yet  the  special  nerve-pain  under  consideration  presents  the  folloAving 
characteristics :  1st.  In  its  distribution  it  follows  the  course  of  a  nerve- 
trunk  or  its  branches.  2d.  It  shows  a  tendency  to  shift  from  place  to 
place,  od.  The  presence  of  painful  points  (points  douloui-eux).  4th. 
Intermission  and  remission  of  pain. 

The  pain  of  neuralgia  varies  both  as  to  character  and  intensity.  It 
may  be  merely  a  mild  ache,  or,  on  the  other  hand,  it  may  give  rise 
to  the  most  excruciating  agony  ;  it  may  be  of  a  throbbing,  boring,  tear- 
ing, shooting,  or  burning  character,  or  it  may  come  on  in  shock-like 
paroxysms.  Any  nerve  in  the  body  may  be  affected.  Quite  often  one 
can  find  no  definite  cause  of  the  neuralgia,  and  as  we  are  not  certain  as 
to  its  ultimate  pathology,  it  may  be  due  to  some  slight  inflammation  of 
the  nerve,  or  to  hyperemia,  ischemia,  exudation,  and  the  like. 

Among  the  lyredisposing  causes  are — (1)  Age,  the  condition  being 
most  common  in  those  between  thirty-five  and  fifty  years,  and  less  so 
above  that  age.     It  is  least  common  in  children. 

(2)  Sex.  On  the  whole,  neuralgia  is  most  common  in  women,  though 
the  severer  grades  are  found  quite  as  frequently  in  men.  Sciatica  is 
more  common  in  men,  while  trigeminal  neuralgia  occurs  more  frequently 
in  women. 

(3)  Heredity.  Neuralgia  is  very  prone  to  occur  in  a  family  in 
which  hysteria,  epilepsy,  or  other  neurosis  or  psychosis  is  present. 

(4)  The  general  physical  condition.  In  persons  reduced  by  illness 
or  by  mental  or  physical  exertion,  and  in  anemia,  neuralgia  is  common. 

(5)  Occupation.  Painters  and  workers  among  metallic  dust  are 
specially  predisposed. 

The  exciting  causes  are — (1)  Exposure  to  cold  and  wet.  (2)  Me- 
chanical, chemical,  or  thermal  irritation,  including  compression.  (3) 
Traumatism.  (4)  Neuromata.  (5)  Infectious  diseases.  (6)  Eheuma- 
tism  and  gout.  (7)  Endogenous  or  exogenous  poisons.  (8)  Local  dis- 
ease in  the  course  of  the  nerve,  or  of  the  mouth,  nose,  or  orbit. 

We  are  hardly  justified  to-day  in  speaking  of  idiopathic  neuralgia. 
Such  cases  probably  result  from  some  endogenous  or  exogenous  poison, 
an  auto-intoxication,  or  malaria,  rheumatism,  syphilis,  some  metallic 
poison,  or  alcohol  or  tobacco.  Finally,  a  form  exists  which  we  speak 
of  in  no  certain  manner  as  "  reflex  neuralgia."  and  which  is  said  to  re- 
sult from  disease  of  the  sexual  or  other  organs  often  remote  from  the 
painful  nerves. 

General  Symptomatology. — The  neuralgic  attack  may  be  of  sudden  or 
slow  onset,  with  or  Avithout  prodromata.  When  the  latter  exist  they  con- 
sist of  a  sense  of  uneasiness,  perverted  sensations,  chilliness,  and  stinging 


1034  DISEASES  OF  THE  NERVOUS  SYSTEM. 

or  slight  burning  pains.  The  pain  may  be  of  the  character  previously 
described,  either  strictly  localized  or  radiating  to  neighboring  nerves, 
and  may  be  aggravated  by  drafts,  movements,  or  mental  perturbation. 
On  pressure  certain  tender  or  painful  spots  will  be  found,  especially 
where  the  nerves  emerge  from  deeper  parts  and  become  superficial.  The 
affected  part  is  usually  hyperesthetic ;  occasionally,  however,  it  is  anes- 
thetic, and  may  continue  so  for  some  time  after  an  attack. 

Reflex  muscular  contraction  may  be  present  in  proportion  to  the  in- 
tensity of  sensory  irritation.  Yaso-motor  symptoms  manifest  them- 
selves in  the  flushing  or  blanching  of  the  afi'ected  part  and  in  increased 
secretions,  as  sweating. 

Trophic  disturbances  may  result  in  temporary  or  permanent  changes. 
To  the  former  belong  the  herpetic  and  urticarial  eruptions,  while  the  latter 
groups  include  change  of  color  in,  loss  of.  or  overgrowth  of  the  hair, 
various  changes  in  the  skin  (as  pigmentation  and  morphea,  and  even 
ulceration,  though  in  the  latter  instance  there  is  probably  a  more  pro- 
found pathologic  change  than  that  which  we  regard  as  the  cause  of  neur- 
algia). Unless  the  attacks  are  severe  or  prolonged,  however,  the  general 
system  seldom  suff"ers. 

Neuralgia  may  be  divided  into  the  following  groups  :  neuralgia  of  the 
head,  neck,  trunk,  upper  and  lower  extremities  ;  neuralgia  of  the  genitals 
and  rectal  region  ;  and  visceral  neuralgias. 

TIC    DOULOUREUX. 

This  is  a  neuralgia  involving  one  or  more  of  the  branches  of  the  fifth 
nerve.  It  varies  greatlv  in  character  and  intensitv  in  different  cases, 
and  in  its  severest  forms  is  one  of  the  most  terrible  of  all  the  diseases 
of  the  nervous  system. 

The  paf]i<ilo)jij  is  doubtful.  In  those  cases  that  have  been  subjected 
to  surgical  operation,  excised  portions  of  the  nerves  sometimes  were 
normal  and  sometimes  contained  a  moderate  number  of  degenerated 
fibers.  In  other  cases  in  which  the  Gasserian  ganglion  has  been 
removed  and  examined,  considerable  sclerosis  of  the  blood-vessels  has 
been  detected,  alterations  in  the  axis-cylinders  of  the  nerves,  and  occa- 
sionally moderate  changes  in  the  ganglion  cells.  It  is  not  known  exactly 
how  these  lesions  jiroduce  the  symptoms,  but  it  is  probalde  that  vascular 
alterations  are  exceedingly  important. 

The  etiology  is  various,  ^neuropathic  heredity  appears  to  play  an 
important  part.  It  is  more  frequently  a  disease  of  late  than  of  early 
life.  Peripheral  irritation  is  fref|uently  found,  and  when  removed  often 
results  in  complete  cure.  Among  the  structures  disease  of  which  is  a 
frequent  cause  of  tic  douloureux  are  the  nose  and  the  cavities  enter- 
ing into  it,  and  the  mouth.  Lesions  of  the  former  structures  com- 
prise chronic  irritations,  spurs,  occlusion  of  the  nasal  openings,  and 
suppuration.  In  the  latter,  abscesses  at  the  roots  of  the  teeth,  irritated 
pulp,  and  occasionally  malpositions  of  the  teeth,  are  among  the  exciting 
factors.     It  is  possible  that  eye-strain  may  also  be  an  exciting  cause. 

The  symptoms  may  be  variable  in  extent,  duration,  and  intensity. 
In  the  mild  form  there  is  only  an  occasional  paroxysm,  limited  to  one 
of  the  branches  of  the  nerve,  such  as  the  type  that  occurs  in  acute 
coryza.     In  the  more  severe  form  there  may  be  repeated  paroxysms,  the 


TIC  DOULOUREUX.  1035 

intervals  varying  from  a  few  minutes  to  several  days,  involving  the  whole 
side  of  the  face,  and  causing,  for  the  time  being,  complete  prostration  on 
the  part  of  the  patient.  The  pain  is  often  radiating,  or  of  a  rending  or 
boring  character,  and  sometimes  so  severe  as  to  cause  nausea.  It  is 
often  accompanied  by  certain  vasomotor  or  secretory  phenomena,  such 
as  flushing,  perspiration,  or  excessive  tear-production.  The  duration 
of  the  attacks  varies  greatly.  The  paroxysms  may  succeed  each  other 
frequently  for  long  periods  of  time,  or  until  the  patient  becomes  insane 
or  commits  suicide ;  in  other  cases,  after  a  few  paroxysms,  the  attack 
passes  oif  and  may  not  return  for  months.  In  some  instances  the  pain 
is  persistent,  and  although  in  these  cases  it  is  rarely  severe,  the  discom- 
fort of  the  patient  is  sometimes  greater.  The  painful  points  are :  for 
the  first  branch,  the  supraorbital  foramen ;  for  the  second,  the  infra- 
orbital foramen ;  for  the  third,  the  mental  foramen.  Often  the  sur- 
rounding portions  of  the  skin,  particularly  those  where  the  periosteum 
is  near  the  surface,  are  tender.  If  the  disease  continues  for  some  time 
there  may  be  trophic  changes,  such  as  the  formation  of  ulcers,  drying 
of  the  skin,  and  the  appearance  of  gray  hairs. 

The  prognosis  depends  largely  upon  the  cause.  In  the  so-called 
idiopathic  cases  it  is  exceedingly  unfavorable. 

The  treatment  consists  first  in  the  removal  of  the  cause,  if  it  can  be 
found.  The  eyes,  nose,  and  mouth  should  be  carefully  examined,  and 
any  source  of  irritation  thoroughly  removed.  For  the  treatment  of  the 
paroxysms,  if  they  are  mild,  the  coal-tar  analgesics  may  be  employed. 
If  severe,  the  only  drug  that  is  at  all  eifective  is  morphia,  which  is  pref- 
erably given  hypodermically.  Of  course,  in  nearly  all  instances,  if  the 
disease  is  chronic,  the  patient  becomes  addicted  to  the  use  of  this  drug. 
Occasionally,  the  external  application  of  a  mixture  of  the  ointments  of 
opium  and  belladonna  has  proved  of  service.  The  general  health  of 
the  patient  should  be  improved  if  possible,  and  the  disease  treated 
expectantly  for  some  time.  If  these  measures  prove  unavailing  re- 
course must  be  had  to  operation,  which  may  consist  of  section  of  the 
involved  branch,  excision  of  a  portion  of  the  nerve,  or,  in  the  most 
severe  cases,  excision  of  the  Gasserian  o;ano;lion.  The  latter  is  a 
serious  operation  and  is  followed  by  dangerous  trophic  lesions,  and 
should  be  performed  only  as  a  last  resort.  Unfortunately,  the  results 
even  of  this  do  not  appear  to  be  permanent. 

NEURALGIA  OP  THE  NECK  AND  TRUNK. 

The  cervical  branches  of  the  dorsal  and  lumbar  nerves  are  involved  in 
this  group. 

1.  Cervico-occipital  neuralgia,  occurring  in  the  occipital  and  posterior 
parietal  region,  is  apt  to  be  quite  severe,  but  when  not  due  to  spondvlitis 
(the  result  of  caries)  or  neoplasms  the  prognosis  is  fair.  It  is  sometimes 
the  result  of  direct  pressure,  as  in  carrying  heavy  loads  on  the  neck  and 
shoulders.  The  painful  spot  is  found  between  the  mastoid  process  and 
upper  cervical  vertebrie.  Falling  of  the  hair  may  also  occur.  This  is 
much  more  apt  to  take  place,  hoAvever,  when  the  occipitalis  minor  is  in- 
volved, as  it  is  said  that  the  latter  is  generally  a  syphilitic  neuralo-ia. 

2.  Phrenic  neuralgia  has  been  described,  but  is  a  rare  condition. 


1036  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  pain  is  in  the  loAver  anterior  thoracic  region,  at  the  points  of  inser- 
tion of  the  diaphragm. 

3.  Intercostal  XeuraJfjia. — The  mi<Mle  intercostal  nerves  are  most 
liable  to  be  aifected.  and  generally  on  the  left  side.  The  posterior  dorsal 
branches  are  seldom  involved.  When  specially  severe  and  persistent, 
intercostal  neuralgia  may  be  a  symptom  of  disease  of  the  cord  or  its 
membranes,  aneurysm  of  the  aorta,  neoplasms,  or  disease  of  the  vertebrae 
or  ribs.  Traumatism  and  cold  also  give  rise  to  it.  This  form  of  neuralo^ia 
is  most  common  in  women,  the  painful  spots  beins  at  the  extremitv  and 
at  the  middle  of  the  ribs.  The  pain  is  of  a  sharp,  lancinating  cha- 
racter and  radiates  along  the  nerve.  It  is  intensified  by  all  movements 
of  the  chest ;  hence  the  affected  side  is  more  or  less  fixed.  Herpes  may 
develop,  but  in  such  cases  it  is  probable  that  a  true  neuritis  exists. 

4.  Mastodynia  is  really  a  variety  of  intercostal  neuralgia,  and  occurs 
almost  solely  among  women.  It  is  very  painful,  and  gives  rise  to  the 
development  of  tender  "  lumps  '  in  the  breast,  simulating  malignant 
disease.      The  paroxysms  are  often  accompanied  by  vomiting. 

5.  Lumho-ahdominal  neuralgia  is  not  a  common  form.  The  pain  is 
chiefly  in  the  lumbar  region,  though  the  hypogastrium.  genitals,  and 
buttocks  may  also  be  involved. 


NEUEALGIA   OF   THE  EXTREMITIES. 

Cervico-hrachial  neuralgia  occurs  in  the  distribution  of  the  four  lower 
cervical  nerves.  When  the  condition  is  bilateral  we  should  look  for 
disease  of  the  cord  or  membranes,  for  new  growths,  or  for  disease  of  the 
vertebrae.  When  unilateral,  any  of  the  causes  already  enumerated  may 
be  operative.  The  radial  and  ulnar  nerves  are  more  frequently  affected 
than  the  median.  The  pain  is  most  apt  to  be  distributed  along  the  whole 
course  of  the  nerve,  but  painful  points  are  found  in  the  following  sit- 
uations— in  the  axilla ;  over  the  brachial  plexus ;  on  the  shoulder, 
where  the  cutaneous  branches  of  the  circumflex  nerve  emerge  through 
the  deltoid  muscle ;  about  the  middle  of  the  outer  surface  of  the  upper 
arm ;  over  the  ulnar  nerve ;  in  the  sulcus  between  the  olecranon  and 
epitrochlea ;  also  near  the  wrist  and  at  the  bend  of  the  elbow  over  the 
musculo-spiral  nerve. 

Femoral  or  crural  neuralgia  is  a  somewhat  rare  type  that  attacks  the 
anterior  surface  of  the  thigh,  the  knee-joint,  and  the  inner  surface  of 
the  leg  and  foot. 

Obturator  neuralgia  is  distributed  along  the  inner  side  of  the  thigh 
down  to,  and  including,  the  knee-joint.  This  form  is  common  in  women 
subject  to  ovarian  diseases. 

Sciatica  stands  next  to  trigeminal  neuralgia  in  the  order  of  fre- 
quency, and  is  by  far  more  common  in  men. than  women.  In  addition 
to  the  ordinary  causes  of  neuralgia — exposure,  compression,  trauma- 
tism— the  condition  may  be  an  early  symptom  of  tabes  or  it  may 
be  due  to  constipation  or  hemorrhoids.  The  painful  points  are  in  the 
gluteal  region  and  the  popliteal  space  or  malleolar  region,  though  ten- 
derness may  be  elicited  along  the  whole  course  of  the  nerve.  The  pain 
is  sharp  and  shooting,  or  more  often  of  a  tearing  variety.  Fine  or  coarse 
tremors  or  spasms  may  be  present,  together  with  some  disturbance  of 
sensation  and  loss  of  power.     Herpes  occasionally  develops  along  the 


NEURALGIA   OF  THE  EXTREMITIES.  1037 

course  of  the  nerve.  This  form  of  neuralgia  is  quite  common,  and  is 
generally  easy  to  recognize,  but  it  may  be  simulated  by  hip-joint  disease, 
psoas  abscess,  or  lumbago. 

Sciatica  may  also  be  caused  by  neuritis,  the  result  of  exposure  or 
compression  by  pelvic  growths,  or  by  the  fetal  head  during  labor.  In 
such  cases  there  is,  as  a  rule,  slight  fever,  and  the  tenderness  on  pres- 
sure and  the  degree  of  pain  are  infinitely  more  severe  than  neuralgia. 
In  severe  cases  the  patient  is  bed-ridden,  but  in  mJlder  attacks  he  can 
be  about ;  walking  greatly  increases  the  pain,  however.  It  is  slightly 
mitigated  by  relieving  the  tension  on  the  nerve,  by  bending  the  knee, 
and  Avalking  on  the  toes.  It  is  an  obstinate  condition,  and  relapses  are 
common. 

The  diagnosis  is  generally  not  difficult.  The  distribution  of  the  pain, 
the  location  of  tender  points,  and  the  character  of  the  gait  suffice  to  pre- 
vent error,  as  a  rule.  The  fulgurant  pains  of  tabes,  in  the  early  stage  of 
the  disease,  are  frequently  mistaken  for  sciatica.  A  rectal  or  vaginal 
examination  should  be  made  to  determine  whether  it  is  a  primary  disease 
or  secondary  to  some  pelvic  condition. 

Neuralgia  of  the  Genitalia  and  Rectum. — These  varieties  are 
not  met  Avith  frequently.  The  former  is  sometimes  a  symptom  of  stone, 
prostatic  disease,  or  stricture,  and  in  women  ovarian  and  uterine  neu- 
ralgias are  generally  hysteric  manifestations.  Coccydynia,  unless  of 
traumatic  origin,  is  almost  solely  found  in  women.  The  pain  in  the 
region  of  the  coccyx  is  excruciating  at  times,  and  may  even  call  for 
operation. 

Visceral  Neuralgia. — As  implied  by  the  name,  these  forms  are 
neuralgias  resident  in  the  various  viscera.  They  most  frequently  attack 
the  stomach  or  bowel,  and  are  recognized  as  colic.  Other  viscera  may 
also  be  involved  (liver,  kidney). 

Treatment  of  Neuralgia. — The  first  requisite  in  the  treatment 
of  neuralgia  is  to  ascertain  whether  it  is  due  to  local  or  general  causes. 
That  of  the  former  class  may  be  caused  by  a  cicatrix,  neuroma,  aneur- 
ysm, neoplasm,  or  by  caries  or  traumatism ;  and  the  treatment  must 
necessarily  be  directed  toward  the  removal  of  the  cause  when  possible. 
When  the  fault  is  a  general  one,  the  neuralgia  may  occur  either  as 
the  immediate  result  of  the  systemic  disease  or  remotely,  as  the  result 
of  the  altered  blood-state  (anemia).  This  is  particularly  well  illustrated 
by  an  attack  of  malaria,  in  which  it  is  obvious  that  success  can  only  be 
obtained  by  attention  to  the  underlying  cause.  It  is  sometimes  necessary 
to  use  an  analgesic,  of  which  morphin  is  certainly  the  best.  Its  thera- 
peutic value  is  most  decided  when  the  drug  is  given  hypodermically,  and 
if  injected  directly  over  the  track  of  the  painful  nerve  (e.  g.  supraorbital 
branch  of  the  fifth),  it  not  only  affords  immediate  relief,  but  also  obviates 
recurrences  of  the  painful  paroxysms  in  many  instances.  It  is,  however, 
scarcely  necessary  to  urge  the  exercise  of  caution,  for  the  morphin-habit 
is  readily  formed  in  these  cases.  The  following  may  also  be  used ;  anti- 
pyrin,  phenacetin,  codein,  veratrum  viride,  aconite,  also  counter-irritants 
and  vesicants,  including  the  galvanic  current.  The  general  tone  of  the 
system  must  be  attended  to,  bad  habits  prohibited,  the  state  of  the 
bowels  regulated,  and  the  eyes  examined  and  corrected  for  errors  of 
refraction.     Rest  is  a  valuable  adjunct  to  any  form  of  treatment.     In 


1038  DISEASES  OF  THE  NERVOUS  SYSTEM. 

neuralgia  of  the  upper  extremities  and  in  sciatica  I  have  often  obtained 
good  results  from  putting  the  limb  in  splints. 

Sciatica  is  often  very  intractable.  If  it  fails  to  yield  to  the  salicyl- 
ates, counter-irritation,  leeches,  and  the  rest-treatment  of  Weir  Mitchell 
may  be  used,  or  nerve-stretching,  either  by  flexing  the  thigh  upon  the 
abdomen  or,  as  a  last  resort,  by  cutting  down  upon  the  nerve  itself. 
Other  nerves  are  sometimes  subjected  to  this  method  of  treatment  also, 
but  less  frequently  than  the  sciatic.  Absolute  rest  in  bed,  with  the  limb 
kept  perfectly  still  by  means  of  sand-bags  or  a  long  splint,  always  gives 
relief,  and  in  some  cases  seems  to  cure.  Alternating  hot  and  cold 
douches  also  give  great  relief  in  some  instances.  Deep  injections  of 
thein,  ether,  or  chloroform  are  sometimes  used,  and  even  distilled  water 
may  give  relief  when  injected  into  the  nerve.  The  use  of  guaiacol 
(tUj-ij— 0.066-0.1332)  in  association  with  chloroform  (iTLx — 0.666)  by 
this  method  has  yielded  very  encouraging  results  in  my  hands. ^ 


DISEASES  OF  THE  CRANIAL  NERVES. 

OLFACTORY   NERVE. 

The  following  morbid  conditions  have  been  described  in  connection 
with  the  sense  of  smell : 

(a)  Hyperosmia  or  Olfactory  Hyperesthesia. — The  sense  of  smell  is 
abnormally  acute,  so  that  objects,  and  even  persons,  can  be  recognized 
by  this  means.     It  occurs  in  hysteria  and  insanity. 

{b)  Parosmia  (perverted  sense  of  smell)  may  occur  for  one  or  for 
many  odors,  and  is  often  associated  with  an  obtunding  of  the  normal 
sense. 

(e)  Subjective  sensations  of  smell  are  due  to  the  same  causes  as  the 
above.  An  olfactory  aura  may  precede  an  attack  of  epilepsy.  Olfac- 
tory hallucinations  occur  occasionally  in  the  insane. 

{d)  Anosmia  or  olfactory  anesthesia  (loss  of  the  sense  of  smell)  may 
be  caused  by — (1)  injury  to  the  peripheral  filament  by  local  disease  of 
the  nasal  mucous  membrane.  (2)  Injury  to  the  nerve-trunk  or  bulb, 
bone-disease,  and  meningitis.  Anosmia  may  occur  during  locomotor 
ataxia.  Pungent  and  powerful  odors  have  been  said  to  cause  loss 
of  the  sense  of  smell,  due  to  excessive  stimulation.  There  may  be  a 
congenital  absence  of  the  olfactory  nerves.  (3)  Centric  lesions,  as 
tumors  in  the  anterior  part  of  the  temporo-sphenoid  lobe.  Hughlings 
Jackson  has  reported  cases  of  unilateral  anosmia  associated  with  aphasia, 
believed  to  be  due  to  simultaneous  involvement  of  the  outer  limb  of  the 
olfactory  nerve  as  it  passes  the  island  of  Reil  to  reach  the  center  and 
Broca's  region.  Opposite  unilateral  anosmia  has  been  described,  due  to 
a  lesion  in  the  posterior  part  of  the  internal  capsule. 

In  testing  the  sense  of  smell  it  is  advisable  to  use  aromatic  oils,  as 
they  only  stimulate  the  olfactory  nerve,  while  ammonia  and  such  strong 
substances  also  stimulate  the  fifth  nerve.  It  is  obviously  necessary  to 
make  a  rliinoscopic  examination. 

Treatment  is  generally  unsatisfactory,  though  the  cause  must  be 

^  "  The  External  and  Internal  Use  of  Guaiacol,"  Therapeutic  Gazette.  Mar.  15,  1895. 


DISEASES  OF  THE  RETINA,   OPTIC  NERVE  AND  TRACT.    1039 

removed  when  possible.  When  the  disturbance  is  due  to  some  general 
condition,  as  hysteria,  it  may  of  course  be  disregarded,  as  it  "will  improve 
with  the  disease. 


DISEASES    OF   THE   RETINA,    OPTIC   NERVE     AND   TRACT. 

The  Retina. — Hemorrhage  into  the  retina  may  be  venous  or  arterial, 
single  or  multiple,  monocular  or  binocular.  It  may  be  part  of  a  general 
vascular  change  ;  occasionally  it  occurs  during  parturition,  but  more 
often  at  the  menopause  ;  it  may  be  an  indication  of  renal  trouble  or  of 
some  primary  or  symptomatic  anemia,  as  in  leukocythemia,  pernicious 
anemia,  or  malaria.  Hemorrhage  is  prone  to  occur  also  in  depraved 
nutritional  conditions,  in  purpura,  and  in  scurvy. 

More  or  less  complete  loss  of  vision  develops  in  these  cases,  either 
suddenly  or  gradually.  If  the  hemorrhage  is  superficial,  the  eye-ground 
is  red  and  swollen  ;  if  deeper,  the  blood  escapes  between  the  fibers  of 
the  retina,  spreads  them  out,  and  assumes  a  flame-shaped  appearance. 

Retinitis. — Three  forms  of  this  condition  are  commonly  described — 
(1)  albuminuric,  (2)  syphilitic,  and  (3)  pigmentary. 

(1)  Albuminuric  retinitis  is  probably  not  a  distinct  aiFection,  but  part 
of  a  general  fibro-vascular  change  associated  with  nephritis.  The  fail- 
ure of  vision  may  precede  the  advent  of  albuminuria,  but  more  often 
the  two  conditions  are  coincident.  It  occurs  in  chronic  nephritis,  espe- 
cially in  the  interstitial  variety. 

The  retinal  changes,  according  to  Gowers,  are  either  hemorrhagic  or 
degenerative.  In  the  former  the  arterial  blood  occupying  the  interstices 
between  the  fibers  assumes  a  striated  or  feathery  aspect,  while  in  the 
degenerative  form  white  patches  of  fatty  degeneration  or  deposits  of 
cholesterin  are  dotted  over  the  fundus  ;  they  may  also  be  grouped  about 
the  macula  lutea,  or  around  the  disk.  Occasionally  the  latter  appears 
swollen,  owing  to  the  effusion  of  serum  into  the  fiber-layer. 

(2)  Syphilitic  retinitis  generally  occurs  in  the  later  stages  of  ac- 
quired syphilis,  and  particularly  in  neglected  cases.  Failure  of  vision 
directs  attention  to  the  eye-ground,  Avhich  is  found  to  have  either  scat- 
tered or  uniformly  distributed  whitish  or  slightly  opalescent  filmy  patches 
upon  it.  The  vitreous  may  be  turbid  also.  Retinitis  is  far  less  common 
than  choroiditis  or  chorio-retinitis. 

(3)  Pigmentary  retinitis  is  essentially  a  chronic  process,  usually  attack- 
ing young  adults,  and,  as  a  rule,  more  than  one  member  of  a  family. 
It  may  also  occur  in  inherited  syphilis  and  in  low  grades  of  vitality. 
The  affected  parts  receive  a  deposit  of  pigment  which  specially  follows 
the  course  of  the  main  arteries.  At  the  same  time  a  circumferential 
annulus  of  pigment  forms.  This  gradually  encroaches  more  and  more 
upon  the  disk,  until  finally  atrophy  ensues. 

Among  retinal  affections  occur  also — 

(a)  Toxic  Amblyopia. — This  is  due,  as  a  rule,  to  tobacco  or  alcohol, 
and  more  rarely  to  certain  drugs  or  lead-poisoning.  Failure  of  vision 
is  gradual  and  progressive,  though  it  rarely  reaches  absolute  blindness. 
The  center  of  the  field  is  chiefly  affected,  and  a  central  scotoma  for  red 
and  green  exists ;  this  is  said  to  be  caused  by  a  chronic  neuritis  begin- 
ning in  the  fibers  that  are  distributed  to  the  macula  lutea. 


1040  DISEASES  OF  THE  NERVOUS  SYSTEM. 

(h)  Hemeralopia,  or  day-hlindness,  may  either  be  functional  or  a 
symptom  of  some  retinal  affection — e.  g.  hyperesthesia  or  albinism,  or 
the  result  of  central  cataract.  Objects  can  either  not  be  seen  at  all  or 
only  indistinctly  during  the  day  or  in  a  strong  artificial  light ;  but  at 
night  vision  is  excellent. 

{(■)  Nyctalopia,  or  night-blindness.  In  this  condition  vision  may  be 
normal  during  the  day  or  in  a  strong  artificial  light,  but  after  nightfall 
or  in  a  darkened  room  objects  can  be  seen  only  uith  difficulty  or  not  at 
all.      It  is  usually  associated  Avith  syphilitic  retinitis. 

Optic  Nerve. — Three  distinct  pathologic  conditions  of  the  nerve  exist 
— viz.  (1)  Perineuritis,  (2)  Choked  disk,  and  (3)  Neuritis.  They  may 
merge  into  one  another,  and  after  lasting  some  time  may  lead  to  (4) 
Atrophy  and  complete  blindness. 

(1)  Perineuritis  is  met  with  in  meningitis,  and  was  suggested  by 
Bouchut  as  a  valuable  diagnostic  sign  in  obscure  cases.  It  is  also  found 
in  certain  cases  of  insolation,  and  may  occur  in  any  fever  in  which  im- 
pairment of  vision  is  a  setjuel.  The  sheath  of  the  nerve  is  supplied  by 
the  blood-vessels  of  the  pia,  while  the  nerve  itself  derives  its  blood-sup- 
ply from  the  anterior  cerebral  artery  ;  therefore  in  perineuritis,  in  the 
early  stages  at  least,  the  disk  remains  normal,  but  is  surrounded  by  a 
zone  of  congestion  and  inflammation.  If  the  action  has  been  severe  or 
prolonged,  either  the  direct  pressure  or  that  due  to  the  contraction  of  the 
inflammatory  material  causes  partial  atrophy  of  the  nerve  and  conse- 
quent interference  with  the  vision. 

(2)  Choked  disk  is  almost  always  bilateral,  and  occurs  in  cases  of 
intracranial  granulomata  or  tumors,  also  in  Bright's  disease  and  syph- 
ilis. The  disk  is  at  first  merely  congested :  soon,  however,  both  the 
arterial  and  venous  circulations  are  interfered  Avith,  and  especially  the 
return  venous  flow ;  then  exudation  of  serum  takes  place.  Sometimes 
secondary  inflammatory  changes  follow.  In  the  early  stages  vision  is  not 
impaired,  but  as  the  exudative  elements  contract,  tlie  interference  with 
the  circulation  becomes  more  exaggerated,  and  in  time  atrophy  of  the 
disk  supervenes.  Should  the  process  be  arrested,  the  retinal  dropsy 
subsides,  and  it  Avill  then  be  seen  that  the  vessels  are  thickened  and  tor- 
tuous, and  stand  out  in  relief  near  the  margins  of  the  disk.  AVhite 
patches  of  atrophy  may  be  scattered  over  the  fundus.  AVhen  the  in- 
flammation and  a  dropsical  eifusion  into  the  disk  exist  simultaneously, 
it  is  difficult  or  impossible  to  differentiate  the  condition  from  primary  or 
descending  optic  neuritis. 

(3)  Xeuritis. — The  optic  nerve  derives  its  blood-supply  from  the  an- 
terior cerebral  artery.  Evidently,  then,  in  cerebral  hyperemia  (arterial) 
from  any  cause  we  have  an  increased  injection  of  the  disk,  but  no  venous 
engorgement ;  hence  there  is  no  dropsy  and  no  tartuosity  of  the  veins. 
Inflammation  mav  beg-in  in  the  disk  or  descend  from  above,  ojiving  rise 
to  plastic  deposits  on  the  retina.  Sight  is  early  interfered  with,  owing 
to  involvement  of  the  conducting  fibers,  which  atrophy  iu  time  unless 
the  condition  ceases.  Then  the  disk  appears  white,  and  the  vessels  show 
upon  it  as  thin  filaments.  This  condition  is  met  with  in  syphilis, 
Bright's  disease,  intracranial  tumors,  and  rarely  in  anemia  and  lead- 
poisoning;  it  may  be  an  advanced  stage  of  perineuritis  or  choked  disk. 

(4)  Optic  Atrophy. — This  may  occur  as  an  hereditary  affection  known 


DISEASES   OF  THE  RETINA,    OPTIC  NERVE  AND   TRACT.    1041 

as  Leber's  disease,  which  chiefly  attacks  young  males,  or  it  may  occur 
during  the  course  of  locomotor  ataxia,  certain  toxemias,  and  diabetes. 
It  may  also  be  brought  about  either  by  conditions  that  produce  brain- 
disease  or  as  a  result  of  the  cerebral  disease  itself. 

In  any  case  there  is  alteration  of  the  field  of  vision,  color-perception 
is  abnormal,  and  there  is  more  or  less  dimness  of  sight.  In  the  hered- 
itary form  the  disk  is  less  white  than  in  the  other,  and  the  vessels  are 
almost  normal  in  appearance  (Fig.  73). 

The  Optic  Tract. — The  lesions  of  the  optic  tract  are  important  rather 
on  account  of  their  situation  than  their  nature.  They  may  exist  without 
corresponding  changes  in  the  retina,  although  when  they  have  lasted  for 
a  long  time  there  is  usually  some  consecutive  atrophy  resulting  from  a 
descending  degeneration  of  the  optic  nerves.  Lesions  of  the  chiasm 
usually  affect  the  decussating  fibers,  causing  blindness  of  the  nasal  halves 
of  the  retina,  and,  in  consequence,  temporal  hemianopsia.  This  condition 
occurs  in  basal  tumors  especially  of  the  hypophysis,  and  has  therefore 
been  observed  in  acromegaly,  in  tuberculous  basal  meningitis,  and  in  hy- 
drocephalus. Lesions  of  either  optic  tract,  if  complete,  causes  homony- 
mous bilateral  hemianopsia ;  if  incomplete,  there  is  irregular  disturbance 
of  the  visual  field,  sometimes  bilateral,  sometimes  unilateral.  It  may  be 
involved  in  hemorrhage,  tumors,  softening  or  basilar  meningitis ;  ordi- 
narily other  structures  are  also  involved,  giving  rise  to  symptoms  of  focal 
disease.  Lesions  anterior  to  the  anterior  corpora  quadrigemina  usually 
cause  more  or  less  destruction  of  some  of  the  other  cranial  nerves,  with 
the  production  of  ocular  palsies,  or  disturbances  of  the  other  special 
senses,  or  anesthesise  or  neuralgias  of  the  face.  A  very  valuable  sign, 
that,  however,  cannot  always  be  elicited,  is  the  failure  of  the  pupil  to 
contract  when  light  is  thrown  upon  the  blind  half  of  the  retina.  This 
is  explained  by  supposing  that  the  pupillary  reflex  center  is  situated  in 
the  anterior  corpus  quadrigeminus.  If  the  lesions  affect  the  optic  thal- 
amus or  the  internal  capsule,  hemiplegia  and  hemianesthesia  are  also 
often  present  or  may  form  the  most  important  symptoms.  Lesions  pos- 
terior to  the  anterior  corpora  quadrigemina  produce  hemianopsia  without 
disturbance  of  the  pupillary  reflex.  These  lesions  are  divided  into  two 
groups,  the  cortical  and  the  subcortical  and  they  may  be  of  two  varie- 
ties, either  irritative  or  paralytic.  The  irritative  lesions  give  rise  to 
hallucinations  of  sight,  which  may  vary  from  the  scotomata  of  migraine 
to  most  complex  visions.  Paralytic  lesions  ordinarily  lead  to  hemian- 
opsia. Occasionally  curious  symptoms  are  produced,  the  visual  field 
being  sometimes  irregular,  whilst  at  others  only  certain  elements  of 
sight  are  affected,  cases  having  been  reported  in  which  the  hemianopsia 
only  involved  the  recognition  of  colors,  not  of  form.  In  all  these  cases 
the  pupillary  reflexes  are  not  affected.  Bilateral  lesions  do  not  always 
lead  to  total  blindness :  sometimes  the  macula  lutea  escapes  and  the  patient 
is  able  to  see  only  by  direct  fixation.  Occasionally  a  single  lesion  will 
produce  total  blindness  in  one  eye,  but  this  is  rare,  and  no  satisfactory 
explanation  has  been  found  to  account  for  it.  Cortical  lesions  are  those 
involving  the  occipital  lobe.  The  center  of  visual  perception  appears  to 
be  in  the  cuneus  and  calcarine  fissure ;  if  this  is  destroyed,  blindness 
occurs.  The  center  for  the  recognition  of  the  object  seen  is  apparently 
upon  the  convex  surface  of  the  occipital  lobe,  probably  in  the  second 


Fig.  73— Diagram  of  tho  visual  apparatus  (after  Vinlet) :  J.O,  LCy,  occipital  lobes  ;  C,  cuneus; 
Rad.  opt.,  optic  radiation  ;  TQn,  anterior  corinis  (inndritreniinus  :  PV,  PU',  pulvinar;  CGe,  external 
geniculate  ganglion  ;  7iO,  optic  tract :  C/T,  optic  cliiMsiu  ;  AO,  <ii)tic  nerve;  (>£>,  right  eye  ;  O't",  left 
eye;  RN,  nasal  half  of  retina  (siip]>licd  by  tlic  oiipnsitc  lu-misphere) ;  RT,  temporal  half  of  the 
retina  (supplied  hv  the  homolnteral  hemisphere);  .1/,  macula  lutea.  A  total  transverse  lesion  at 
1,  2,  or  3  would  caiise  total  lilimiiuss  of  the  right  eye.  A  lesion  at  4,  destroying  the  central  part 
of  the  chiasm,  would  cause  liliuduess  of  the  nasal  halves  of  the  retiuic,  and  therefore  bitemporal 
hemianopsia.  A  lesion  at  5  would  cause  blindness  of  the  riglit  halves  of  the  retina',  and  therefore 
left  homonymous  hemianopsia.  The  pupillary  reflex  would  be  lost  in  the  aft'ected  half  of  the  eye 
in  all  these  cases.  A  lesion  in  the  optic  radiation  would  cause  symptoms  similar  to  those  of  the 
corresponding  optic  tract,  excepting  that  the  pupillary  reflex  would  be  preserved.  Lesions  of  the 
cortex  cause  various  disturbances  of  vision  according  to  the  part  affected.  ^ 


DISEASES  OF  THE  MOTOR  NERVES  OF  THE  EYEBALL.    1043 

and  third  convolutions,  but  it  may  extend  also  into  the  temporal  lobe. 
When  this  is  destroyed  the  patient  can  see  objects,  but  fails  to  recognize 
them ;  this  is  called  mind-hlindness ;  if  total,  this  is  the  result  of  a  bilat- 
eral lesion.  Hemianopsia  is  very  frequently  merely  a  temporary  symp- 
tom, and  as  such  it  may  occur  in  uremia,  apoplexy,  migraine,  and  cer- 
tain intoxications,  especially  that  of  lead.  It  may  also  occur  in  brain- 
tumor,  and  disappear  if  the  pressure  is  relieved,  as  by  trephining.  It 
is  a  permanent  symptom  only  when  the  visual  tract  has  been  involved 
by  some  destructive  lesion.  If  the  patient  is  perfectly  conscious  and 
intelligent,  it  is  not  difficult  to  recognize  it ;  nevertheless,  its  pres- 
ence can  often  be  detected  in  young  children  and  in  those  who  are  only 
partially  conscious  or  unable  to  speak.  This  can  be  accomplished  by 
taking  a  bright  object,  placing  it  behind  the  head,  and  then  bringing  it 
forward  slowly,  first  on  one  side  and  then  on  the  other.  It  will  then  be 
noted  that  the  patient  perceives  it  on  the  hemianopsic  side  only  when  it 
has  been  brought  to  the  middle  line,  whilst  when  moved  on  the  other 
side  the  eyes  will  turn  toward  it  when  it  is  still  a  considerable  distance 
from  this  point.  Another  method  is  to  bring  a  blunt  object  (a  wisp  of 
cotton)  very  nearly  in  contact  with  the  cornea,  first  on  the  one  and  then 
on  the  other  side  of  the  median  line.  The  palpebral  reflex  will  occur 
upon  the  normal  side  whilst  the  object  is  still  some  distance  away;  on 
the  blind  side  only  when  it  has  come  in  contact  with  the  conjunctiva 
(see  Fig.  73). 


DISEASES  OF  THE  MOTOR  NERVES  OP  THE  EYEBALL  (THIRD,  FOURTH, 

AND  sixth). 

The  extrinsic  ocular  muscles  are  supplied  by  these  three  nerves,  while 
the  intrinsic  are  supplied  by  the  third  and  the  sympathetic. 

I.  The  tnotor  oculi,  or  third  nerve,  is  purely  motor,  and  sup- 
plies all  the  muscles  of  the  eye  except  the  superior  oblique  and  external 
rectus,  and  controls  in  part  also  the  ciliary  muscle  and  the  sphincter  of 
the  iris.  Its  apparent  origin  is  from  the  inner  side  of  the  crus  cerebri 
just  anterior  to  the  pons.  It  can  be  traced  through  the  crus,  how- 
ever, to  its  deep  origin  in  a  nucleus  beneath  the  corpora  quadrigemina, 
situated  in  the  floor  of  the  aqueduct  of  Sylvius.  Above  the  crus  it 
pierces  the  dura,  passes  between  the  two  clinoid  processes  of  the  sphe- 
noid bone,  along  the  outer  wall  of  the  cavernous  sinus,  where  it  receives 
some  filaments  from  the  cavernous  plexus  of  the  sympathetic ;  it  then 
divides  into  two  branches  that  enter  the  orbit  through  the  sphenoid 
fissure.  The  superior  and  smaller  division  supplies  the  superior  rectus 
and  levator  palpebrae  superioris,  while  the  inferior  and  larger  branch 
subdivides  into  three  portions,  one  going  to  the  internal  rectus,  another 
to  the  inferior  rectus,  and  the  third  to  the  inferior  oblique. 

Lesions  of  the  third  nerve  result  in  (1)  spasm  or  (2)  paralysis. 

Spasm  rarely  if  ever  occurs  in  all  the  muscles  simultaneously.  Any 
muscle  may  be  affected,  but  the  internal  rectus  and  levator  palpebrae  are 
specially  liable.  The  condition  is  met  with  in  meningitis,  hypermetropia, 
and  hysteria ;  also  in  nystagmus,  in  which  the  spasm  is  clonic  and  bilat- 
eral ;  it  also  occurs  in  albinism,  occasionally  in  coal-miners,  or  it  may 
be  congenital. 


1044  DISEASES  OF  THE  NERVOUS  SYSTEM. 

"When  the  levator  palpebr?e  is  affected  (lagophthalmus)  inability  to 
close  the  eye  results.  Stimulation  of  the  center  or  nerve  may  cause 
contraction  of  the  pupil  (rni/osis),  as  occurs  in  locomotor  ataxia.  The 
same  result  is  brought  about  by  paralysis  of  the  sympathetic. 

Paralysis. — The  nerve  may  be  involved  in  any  part  of  its  course  by 
inflammatory  deposits  or  tumors,  or  the  nucleus  may  be  diseased. 
In  the  latter  case  there  is  usually  ophthalmoplegia. 

Relapsing  and  recurring  palsy  are  two  varieties.  The  first  occurs 
chiefly  in  syphilitic  subjects.  One  nerve  becomes  affected  and  partially 
recovers ;  the  other  one  then  becomes  paralyzed,  and  partially  recovers, 
relapses,  and  so  on.     The  internal  muscles  may  be  involved. 

Recurring  or  periodic  palsy,  the  migraine  opJithalmique  of  Charcot, 
is  a  rare  form.  It  occurs  in  both  sexes,  but  Avomen  are  especially  sus- 
ceptible. It  ma}'  begin  in  infancy  and  recur  at  intervals  for  years,  the 
attacks  being  periodic,  lasting  a  few  days  to  six  or  eight  weeks,  and 
ending  in  complete  recovery.  They  may  be  precipitated  by  some  emo- 
tional disturbance,  by  menstruation,  or  by  exhaustion.  Their  exact 
nature  is  not  understood,  but  they  resemble  migraine  in  that  there  is 
severe  headache  or  pain,  usually  over  one  eye,  and  in  their  association 
with  vomiting. 

Generally  paralysis  of  the  extra-ocular  muscles  is  partial,  and  the 
symptoms  will  vary  according  to  the  muscles  affected.  AVhen  they  are 
all  involved  there  are  ptosis,  divergent  strabismus,  diplopia,  and  con- 
tracted pupil,  with  loss  of  the  light-reflex  and  accommotfation. 

Intra-oeular  Paralysis. — (a)  Cycloplegia,  or  ciliary  muscle-paralysis, 
gives  rise  to  a  loss  of  the  power  of  accommodation,  so  that  "far-sight" 
is  good,  while  "near-sight"  is  blurred  and  indistinct.  This  can  be 
corrected  by  a  convex  glass.  Bilateral  cycloplegia  is  usually  due  to  a 
nuclear  lesion.  It  occurs  sometimes  in  diphtheria  and  in  tabes  dor- 
salis. 

{h)  Iridoplegia. — The  pupil  may  be  dilated  {mydriasis)  from  palsy  of 
the  sphincter  or  spasm  of  the  dilator,  or  it  may  be  contracted  {myosis) 
from  the  antithesis  of  the  above. 

The  iris  has  three  actions — two  reflex  and  one  associated :  First,  a 
reflex  contraction  of  the  sphincter  on  exposure  of  the  eye  to  light; 
second,  a  reflex  dilatation  of  the  radiating  fibers  on  stimulation  of  some 
cutaneous  nerve;  and,  third,  a  contraction  on  accommodation,  usually, 
but  not  necessarily,  associated  with  convergence  (Gowers), 

First,  light-reflex  iridoplegia.  The  iris  reflex  is  lost  in  locomotor 
ataxia,  and  may  be  also  in  syphilis.  Accommodation  and  convergence 
are,  however,  usually  preserved  {ArgyU-Eohertson  pupil).  When  these 
also  are  lost  the  condition  occurs  to  which  Jonathan  Hutchinson  gave 
the  name  ophthalmoplegia  interna. 

In  testing  this  reflex  care  must  be  taken  to  avoid  the  contraction  of 
accommodation.  The  patient  should  look  at  a  remote  part  of  the  room; 
then  a  light  is  brought  suddenly  in  front  of.  and  three  or  four  feet  dis- 
tant from,  the  eye.  One  eye  should  be  examined  at  a  time,  the  other 
being  covered,  but  not  closed. 

Second,  skin-reflex  iridoplegia.  Normally,  painful  stimulation  of 
the  skin  of  the  neck  causes  reflex  dilatation  of  the  pupil,  the  afferent 
impulse   being   carried  along   the  sympathetic.       In   locomotor    ataxia 


DISEASES  OF  THE  MOTOR  NERVES  OF  THE  EYEBALL.    1045 

myosis  often  exists.     In  such  cases  Erb  showed  that  the  skin-reflex  was 
lost  (spinal  myosis). 

Third,  accommodation  iridoplegia,  in  which  the  power  of  accommo- 
dation is  lost.  The  pupil  does  not  become  smaller  when  looking  at 
near  objects.  Westphal  and  Piltz  have  recently  discovered  independ- 
ently, that  in  certain  pathological  conditions  the  pupil  conti-acts  strongly 
upon  closure,  or  attempted  closure  against  resistance,  of  the  eyelids. 
This  reflex  occurs  most  constantly  in  general  paresis.  Its  exact  sig- 
nificance is  not  known. 

II.  The  fourth  nerve,  or  patheticus,  the  smallest  cranial  nerve, 
supplies  the  superior  oblique  muscle.  Its  superficial  origin  is  to  the 
outer  side  of  the  crus  cerebri,  just  in  front  of  the  pons.  The  fibers  can 
be  traced  backward  to  the  valve  of  Vieussens,  in  the  substance  of  which 
it  decussates  with  its  fellow.  Its  deep  origin  is  in  a  nucleus  in  the  floor 
of  the  aqueduct  of  Sylvius,  immediately  behind  and  in  close  connection 
with  the  third-nerve  nucleus.  After  piercing  the  dura  mater  the  nerve 
runs  along  the  outer  wall  of  the  cavernous  sinus  and  enters  the  orbit 
through  the  sphenoid  fissure.  Since  the  superior  oblique  muscle  directs 
the  eyeball  downward  and  rotates  it,  paralysis  causes  defective  down- 
ward and  inward  movements,  and  consequent  diplopia  with  inclination 
of  the  head  forward  and  to  the  sound  side.  When  occurring  alone  it  is 
probably  due  to  a  nuclear  lesion. 

III.  The  sixth  nerve,  or  abducens,  has  its  deep  origin  in  the 
floor  of  the  fourth  ventricle  in  close  proximity  to  the  seventh-nerve 
nucleus.  Its  superficial  origin  is  from  the  lower  part  of  the  pons,  in 
the  groove  between  it  and  the  medulla.  Emerging,  it  pierces  the  dura, 
runs  along  the  cavernous  sinus,  and  enters  the  orbit  through  the  sphe- 
noid fissure  to  supply  the  external  rectus.  Owing  to  its  long  course,  this 
nerve  is  specially  liable  to  injury,  usually  from  pressure  due  to  tumors 
or  from  syphilitic  or  other  forms  of  meningitis.  Paralysis  of  the  muscle 
causes  convergent  strabismus,  owing  to  an  inability  to  rotate  the  eye 
outward  and  consequent  diplopia.  In  nuclear  lesions  the  external 
rectus  of  the  same  side  and  the  internal  rectus  of  the  opposite  side  are 
paralyzed,  conjugate  deviation  resulting,  the  eyes  being  directed  away 
from  the  side  of  the  lesion.  This  is  due  to  the  fact  that  the  sixth  nerve 
gives  ofi"  a  twig  that  runs  to  that  region  of  the  opposite  third-nerve 
nucleus  governing  the  internal  rectus. 

This  muscle  is  not  wholly  controlled  by  the  sixth  nerve,  however,  for 
in  nuclear  lesions  of  the  latter  no  degenerated  fibers  are  found  in  the 
third  nerve ;  and,  further,  when  the  eye  with  the  paralyzed  external 
rectus  is  covered  the  opposite  internal  rectus  will  act,  though  less  readily 
than  normally. 

General  Symptomatology  of  Paralysis  of  the  Bye-muscles. 
— Loss  of  power  in  the  ocular  muscles  is  indicated  by  five  kinds  of  symp- 
toms (Gowers) :  (1)  Limitation  of  Movement. — The  amount  of  limitation 
in  the  movement  of  the  eyeball  is  in  direct  ratio  to  the  degree  of  palsy. 
In  complete  palsy  the  globe  is  ultimately  fixed,  owing  to  contraction  of 
the  unopposed  muscle.  In  partial  paralysis,  as  the  limit  of  movement 
is  approached  the  motion  is  often  jerky  {paralytic  nystagmus). 

(2)  Strabismus. — Owing  to  defective  movement  the  axes  of  the  eyes 


1046  'diseases  of  the  nervous  system. 

do  not  correspond.  "  The  deviation  of  the  axis  of  the  paralyzed  eye 
from  parallelism  with  that  of  the  sound  eye  is  termed  the  primary 
deviation." 

•  (3)  Secondary  Deviation. — '"  If  the  sound  eye  is  prevented  from  see- 
ing the  object,  and  the  patient  looks  at  this  (is  made  to  'fix'  it)  only 
with  the  affected  eye,  the  sound  eye  is  moved  still  farther  in  that  direc- 
tion, and  hence  the  deviation  of  the  visual  axes  is  increased.  This  is 
called  the  'secondary  deviation,'  and  depends  on  the  fact  that  two  mus- 
cles normally  acting  in  unison  are  e(iually  stimulated  (innervated)  for 
any  given  movement.  When  one  is  weak,  the  amount  of  nerve-force 
employed  to  move  the  sound  eye  acts  equally  on  the  impaired  eye,  and 
hence'the  over-action.  In  paralytic  strabismus  fixation  with  the  sound 
eye  shows  the  primary  deviation,  while  fixation  with  the  afi'ected  eye 
reveals  secondary  deviation.  In  ordinary  strabismus  due  to  spasm  this 
does  not  hold  good  ;  it  matters  not  which  eye  is  used,  deviation  remains 
the  same." 

(4)  Erroneous  Projection. — "We  judge  of  our  relation  to  surrounding 
objects  by  the  position  of  the  eyeball  as  indicated  to  us  by  the  degree 
of  stimulation  necessarily  brought  to  bear  on  the  ocular  muscles.  When 
one  of  these  muscles  is  Aveak,  the  additional  stimulation  (innervation) 
necessary  to  move  it  in  fixing  im  object  impresses  us  with  the  idea  that 
it  is  really  farther  away  than  is  actually  the  case,  and  in  attempting  to 
touch  it  the  finger  goes  beyond.  This  erroneous  projection,  or  inter- 
ference of  visual  sense-impressions,  causes  a  disturbance  of  equilibrium 
and  gives  rise  to  vertigo,  which  has  been  named  ''ocular  vertigo." 

(5)  Double  Vision. — This  is  not  due  alone  to  a  difierence  in  the  axis 
of  vision,  causing  images  on  non-corresponding  portions  of  the  retina, 
but  also  to  the  erroneous  projection.  "  If  the  patient  looks  with  both 
eyes,  the  field  of  the  unaff'ected  eye,  being  normally  projected,  does  not 
correspond  with  the  field  of  the  affected  eye ;  the  images  formed  in  the 
two  eyes  are  mentally  referred  to  different  positions;  objects  are  seen 
double  "  (Gowers).  The  "  true  image  "  is  that  one  formed  in  the  sound 
eye,  while  the  retina  of  the  affected  eye  receives  the  "false  image." 

Homonyjnous  or  simple  diplopia  is  that  in  which  the  false  image  ap- 
pears on  the  "same  side  of  the  other  as  the  eye  by  which  it  is  seen." 
This  is  due  to  paralysis  of  an  abductor  muscle — convergent  strabismus. 
Crossed  diplopia  occurs  in  divergent  strabismus,  the  result  of  paralysis 
of  an  adductor.  The  false  image  appears  to  be  on  the  other  side  of  the 
real  object — i.  e.  toward  the  sound  eye. 

Gowers'  mnemonic  is,  "  When  the  visual  lines  (prolonged  ocular  axes) 
cross,  the  diplopia  is  not  crossed." 

Ophthalmoplegia,  a  paralytic  condition  of  the  eye-muscles,  may  be 
partial  or  complete.  Eitherthe  internal  or  the  external  muscles  may  be 
involved,  constituting  ophthalmoplegia  interna  or  e.rterna,  and,  when  both 
are  affected,  total  ophthalmoplegia.  The  lesions  may  be  nuclear  or  pe- 
ripheral. Pressure  due  to  neoplasms,  gummata.  aneurysms,  or  basilar 
meningitis  may  produce  it,  or  it  may  follow  diphtheria.  It  also  occurs 
in  general  paralysis,  progressive  muscular  atrophy,  and  locomotor 
ataxia.  It  may  be  {a)  of  sudden  onset,  due  to  some  vascular  disturb- 
ance ;  (b)  acute — the  polio-encephalitis  superior  of  AVernicke — develop- 


DISEASES  OF  THE  FIFTH  NERVE.  1047 

ing  in  a  few  days  or  weeks  ;  or  (c)  chronic.  In  the  latter  case  symptoms 
of  bulbar  palsy  are  apt  to  be  present  also.  Von  Graefe  has  described  a 
form  of  bulbar  palsy  limite-d  to  the  ocular  nuclei  under  the  name  of 
progressive  ophthalmoplegia. 

The  symptoms  vary  necessarily  according  to  the  muscles  involved. 

The  treatment  consists  in  the  removal  of  the  cause  when  possible. 
In  inflammatory  cases  counter-irritation  is  employed  by  blisters  placed 
on  the  temples,  behind  the  ears,  or  at  the  occiput,  or  by  leeches.  Inter- 
nally, the  salicylates,  mercury,  iodids,  and  general  tonics  are  useful. 
Rarely  a  case  Avill  recover  spontaneously.  Electricity  is  probably  of 
little  value.  The  diplopia,  unless  it  can  be  obviated  by  a  suitable  lens, 
should  be  met  by  means  of  an  opaque  glass. 

DISEASES    OF   THE   FIFTH   NERVE. 

The  trigeminus  nerve  has  an  extensive  origin  from  the  floor  of  the 
fourth  ventricle.  It  supplies  with  sensation  the  whole  region  innervated 
by  all  the  other  cranial  nerves  except  the  first  and  second.  It  resem- 
bles a  spinal  nerve  in  that  it  has  two  roots,  a  motor  and  sensory,  and  on 
the  latter  a  ganglion  (Gasserian).  From  the  latter  arise  three  sensory 
branches — viz.  the  ophthalmic,  superior  maxillary,  and  inferior  maxillary. 
A  motor  root  joins  the  last  named,  the  largest  branch  of  the  fifth  nerve. 

Morbid  conditions  of  the  fifth  nerve  cause  sensory,  motor,  or  gusta- 
tory symptoms.  The  lesion  may  be — (1)  Pontine  hemorrhage,  softening, 
sclerosis,  or  tumor.  (2)  Disease  or  injury  at  the  base  of  the  brain — 
e.  g.  meningitis,  gumma  or  other  tumor,  caries  of  bone.  (3)  Disease 
or  injury  of  the  branches,  as  neuritis,  pressure  due  to  aneurysm  of 
the  internal  carotid  or  to  a  tumor  in  the  pituitary  or  spheno-maxillary 
region,  orbital  cellulitis,  and  punctured  Avounds  of  the  mouth  and  nose. 
(4)  Rarely  fracture  of  the  skull. 

Symptoms. — Sensory  Portion. — In  the  irritative  stage  the  chief 
feature  is  pain  ;  this  may  be  shooting,  boring,  or  burning  in  character. 
Tenderness  along  the  course  of  the  nerve  and  hyperesthesia  may  also 
exist.  Later  anesthesia  develops  in  the  mucous  membrane  of  the  nose, 
mouth,  lips,  tongue,  and,  in  some  cases,  of  the  hard  and  soft  palate 
also.  Muscular  movements  are  sloAver  than  normally,  due  to  sensory 
•interference. 

The  secretions  are  often  increased,  though  at  first  they  are  lessened ; 
hence  the  anosmia,  due  to  dryness  of  the  nasal  mucosa.  Loss  of  sense 
of  taste  may  also  occur.  Other  trophic  changes  are — inflammation  and 
ulceration  of  the  gums,  looseness  of  the  teeth,  and  inflammation  of  the 
eye.  Corneal  opacities,  ulceration,  sometimes  perforation,  and  finally 
complete  destruction  of  the  eye — neuro-paralytic  ophthalmia — are  noted. 
This  is  especially  apt  to  occur  when  the  Grasserian  ganglion  is  involved. 
Painful  and  intractable  herpes  may  develop.  Hemifacial  atrophy  may 
result  from  disease  of  the  fifth  nerve  (Mendel). 

Motor  Portion. — Spasm  or  Paralysis. — Partial  or  complete  inhibition 
of  the  movement  of  the  muscles  in  the  region  supplied — i.  e.  those  of 
the  jaw,  the  masseter,  temporal,  pterygoid,  mylo-hyoid,  and  the  poste- 
rior belly  of  the  digastric.     The  degree  of  palsy  can  be  ascertained  by 


1048  DISEASES  OF  THE  NERVOUS  SYSTEM. 

placing  a  finger  on  each  masseter  or  temporal  muscle  while  the  patient 
alternately  opens  and  forcibly  closes  the  mouth.  In  external  pterygoid 
paralysis  movement  toward  the  sound  side  is  impossible,  and  on  de- 
pression of  the  lower  jaw  it  deviates  toward  the  affected  side.  Ulti- 
mately wasting  of  the  muscles,   with  deformity,   takes  place. 

The  spasm  (the  so-called  "masticatory  spasm"  of  Romberg)  may  be 
tonic  or  clonic.  In  tonic  spasm — trismus  or  lockjaw — the  jaw  is  firmly 
set  and  the  muscles  are  hard,  rigid,  and  sometimes  painful.  This  occurs 
in  tetanus,  in  certain  cases  of  tetany  and  hysteria,  in  caries  of  the  teeth, 
occasionally  after  exposure,  and  in  irritative  centric  or  peripheral 
lesions.  Clonic  spasm  is  more  or  less  continuous  or  intermittent.  The 
former  consists  of  short,  quick,  vertical  or  rarely  lateral  movements 
(e.  g.  chattering  of  the  teeth),  usually  associated  with  some  other  con- 
dition, as  paralysis  agitans,  general  convulsions,  and  the  like,  or  it  may 
exist  alone,  especially  in  women  late  in  life.  The  intermittent  form  is 
rare  and  occasionally  occurs  in  chorea.  Contractions  are  single,  forci- 
ble, and  are  separated  by  some  little  time.  The  tongue  and  cheeks 
may  be  bitten  in  the  attack. 

Gustatory  Portion. — S^/inptoms  referable  to  this  portion  are  not  always 
present  in  disease  of  the  fifth  nerve.  There  may  be  a  loss  of  taste  with- 
out sensory  disturbance,  or  vice  versd,  or  both  may  exist  contemporane- 
ously. Lesions  of  the  nerve-root  or  middle-ear  disease  may  cause  it, 
but  pontine  lesions,  as  a  rule,  do  not.  A  perverted  sense  of  taste — 
parageusia — may  be  present  in  hysteria  and  insanity.  Increased  sensi- 
tiveness— hypergeusia — and  subjective  sensations  of  taste  may  result 
from  irritative  lesions,  and  the  latter  may  precede  an  attack  of  epilepsy 
(as  an  aura). 

The  diagnosis  is  not  difficult  as  a  rule.  Anesthesia  in  the  area  sup- 
plied by  the  nerve,  with  loss  of  taste,  is  fairly  conclusive.  Spasm  may 
be  simulated  in  cases  of  rheumatism  or  rheumatoid  arthritis  involving 
the  temporo-maxillary  articulation. 

Treatment. — The  underlying  cause  should  be  attacked  when  pos- 
sible, and  mercury,  the  iodids,  and  the  salicylates  should  be  administered 
in  specific  cases  and  in  those  due  to  exposure.  Analgesics,  and  even 
opiates,  may  be  necessary.  Sometimes  vigorous  counter-irritation  is  of 
value.  Attention  must  be  paid  to  the  condition  of  the  general  system. 
The  battery  may  be  tried,  preferably  with  the  faradic  current,  or  by 
means  of  electricity  short  and  extremely  rapid  blows  may  be  made  over 
the  nerve. 


DISEASES   OF   THE   SEVENTH   OR   FACIAL   NERVE. 

The  nucleus  of  this  nerve  in  the  floor  of  the  fourth  ventricle  is  in 
relation  with  those  of  the  sixth,  eighth,  and  twelfth  nerves.  Like  the 
spinal  nerves,  it  has  an  upper  and  lower  neuron  or  motor  segment,  the 
former  extending  from  the  cortical  center  in  the  lower  Rolandic  region 
to  the  nucleus,  while  the  latter  runs  from  the  nucleus  to  the  periphery. 
Lesions  may  involve  any  part  of  the  tract,  producing  either  spasm  or 
paralysis. 

Spasm. — This  may  be  idiopathic  or  organic,  and  either  general  or 


DISEASES  OF  THE  SEVENTH  OR  FACIAL  NERVE.  1049 

partial,  aifecting  only  the  orbicularis  palpebrarum  (blepharospasm).  It 
is  sometimes  called  tic  convulsif  or  mimic  spasm. 

Pathology. — The  commonest  cause  appears  to  be  some  psychic  dis- 
turbance. Next  in  frequency  are  peripheral  irritations,  and  particularly 
those  that  involve  the  trigeminus,  as  carious  teeth,  conjunctivitis,  or  some 
nasal  irritation.  Less  frequently  irritation  in  some  other  part  of  the 
body,  as  intestinal  parasites  or  uterine  disease,  may  be  the  exciting  cause. 
Finally,  there  may  be  lesions  in  any  part  of  the  motor  tract  supplying 
the  face,  either  in  the  cortex  (meningeal  tumor,  exostoses,  or  focal  soften- 
ing), in  the  facial  nucleus  in  the  medulla,  or  along  the  course  of  the  facial 
nerve  (aneurysm  or  atheroma  of  the  vertebral  artery).  Morbid  changes 
in  the  nerve  itself  or  in  the  muscles  have  not  been  observed. 

etiology. — As  in  other  functional  diseases,  neuropathic  heredity 
plays  an  important  part.  Sometimes,  indeed,  tic  convulsif  has  ex- 
isted in  a  parent  or  has  occurred  in  several  children  of  the  same  fam- 
ily. Emotional  disturbances  have  frequently  been  the  exciting  cause ; 
besides  these,  there  are  the  various  reflex  irritations.  The  organic 
causes  are  irritative  lesions,  situated  in  some  portion  of  the  facial 
motor  tract.  According  to  GoAvers,  the  functional  form  occurs  only  in 
adult  life.     It  occasionally  follows  facial  palsy. 

The  symptoms  of  the  disease  include,  first,  the  spasm  :  this  is  usually 
a  sudden  clonic  convulsion  of  the  muscles  of  one  side  of  the  face,  with 
closure  of  the  eyelids  and  retraction  of  the  angle  of  the  mouth.  Rarely 
there  are  associated  movements  of  the  palate  and  eyeballs.  The  spasms 
may  be  single  or  they  may  occur  in  groups  frequently  repeated,  or  recur 
constantly  at  more  or  less  irregular  intervals.  Less  frequently  the  con- 
traction may  be  tonic  in  character,  lasting  several  seconds  or  even  minutes. 
These  forms  are  frequently  associated  with  clonic  spasms.  Ordinarily  the 
spasm  is  painless,  though  there  are  certain  sensitive  points,  as  where  the 
branches  of  the  trigeminus  issue  from  the  skull,  and  particularly  over  the 
supraorbital  foramen.  Sometimes  there  is  also  tinnitus  aurium.  Taste 
and  the  muscles  of  the  palate  are  rarely  affected.  The  immediate  exciting 
cause  of  an  attack  may  be  fatigue  or  excitement,  or  it  may  occur  as  an 
associated  movement,  as  in  a  case  that  I  observed,  in  which  spasm  always 
accompanied  the  beginning  of  speaking. 

The  diagnosis  is  usually  easy.  It  may  be  occasionally  confounded 
with  chorea,  especially  when  the  '  .tter  is  chiefly  localized  in  the  face,  or 
with  athetosis  due  to  infantile  brain-lesions.  Recognition  of  the  cause  is 
often  very  difiicult,  and  a  careful  examination  of  the  whole  body  should 
be  made  for  any  possible  source  of  irritation. 

The  prognosis  is  extremely  unfavorable  for  cure,  since  only  in  cases 
of  recent  occurrence,  and  with  a  distinct  source  of  peripheral  irritation,  is 
permanent  recovery  likely.  Ordinarily,  the  disease,  even  if  commencing 
in  a  mild  form,  gradually  progresses  to  the  most  severe  type,  the  intervals 
between  the  attacks  become  shorter,  and  the  attacks  themselves  more 
severe. 

The  treatment  consists  in  the  removal  of  any  source  of  irritation 
and  the  application  of  electricity,  particularly  the  mild  galvanic  currents, 
with  the  anode  over  the  sensitive  points.  Operative  interference,  as 
stretching  the  facial  nerve  (which  rarely  produces  any  result  unless  paral- 
ysis ensues)  or  cutting  the  tendons  of  the  facial  muscles,  may  be  tried  ; 


1050  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  finally,  use  of  antispasmodics,  as  conium,  gelsemium,  morpLin,  and 
the  bromids,  may  give  temporary,  but  rarely  permanent,  relief. 

Paralysis  (Bell's  Palsy). — Depending  on  the  seat  of  the  lesion,  ^e 
have — (a)  supra-nuclear,  (b)  nuclear,  and  (c)  infra-nuclear  palsy.  The 
following  table  presents  the  general  differences  between  upper  and  lower 
neuron  palsy  : 

Supra-nuclear  Paralysis.  Nuclear  and  Infra-nuclear  Paralysis. 

The   upper  part  of  the   face   is  not  af-  All  pax-ts  of  the  face  involved,  including 

fected,  the  muscles  of  the  angle  of  the  the  orbicularis  and  frontalis. 

mouth  being  chiefly  concerned. 

Voluntary  movements  are  more  impaired  Voluntary    and    emotional     movements 

than  the  emotional.  equally  aifected. 

All  reflex  movements  are  normal.  All  reflex  movements  are  lost. 

Electric    reaction    is    normal,    or    only  Reactions  of  degeneration  are  present. 

slightly  impaired  to  both  galvanic  and 

faradic  currents. 

There  is  no  wasting.  Wasting  is  present. 

{a)  Supra-nuclear  paralysis  is  generally  associated  with  hemiplegia, 
the  palsy  of  face  and  limbs  being  on  the  same  side — i.  e.  opposite  the 
lesion,  w^hich  may  consist  of  a  hemorrhage,  tumor,  abscess,  softening,  or 
which  may  be  the  result  of  injury,  and  may  be  situated  in  the  cortex, 
corona  radiata,  or  the  internal  capsule.  When  the  cortical  face-center 
is  alone  involved,  the  limbs  escape  {monoplegia  facialis).  This  form  is 
rare. 

{h)  Nuclear  paralysis  is  due  to  hemorrhage,  tumor,  or  softening  at  the 
site  of  the  nucleus  in  the  medulla.  It  may  also  result  from  an  attack 
of  diphtheria,  and  very  rarely  occurs  in  cases  of  antero-poliomyelitis. 
As  already  noted,  the  symptoms  are  similar  to  those  of  infra-nuclear 
paralysis. 

(c)  Infra-nuclear  paralysis  is  caused  by  pressure  on  the  nerve  at  the 
base  of  the  brain  by  tumors,  meningitis,  aneurysm,  or  hemorrhage.  In 
the  Fallopian  canal  the  nerve  may  be  damaged  by  bone-disease  or  some 
form  of  otitis.  This  is  the  seat,  too,  of  the  so-called  "  rheumatic  neur- 
itis," the  result  of  e.xposure. 

Fracture  of  the  base  of  the  skull  or  injury  to  the  nerve  as  it  emerges 
from  the  stylo-mastoid  foramen  may  result  in  facial  palsy.  Diplegia 
facialis  is  rare,  but  may  be  caused  by  a  single  lesion  in  the  pons,  where 
the  facial  paths  cross,  or  by  two  lesions,  one  on  either  side.  The  causes 
enumerated  above,  when  bilateral,  beget  double  facial  paralysis. 

Lesions  in  the  lower  part  of  the  pons  may  result  in  crossed  hemi- 
plegia, the  fibers  being  involved  in  their  course  between  the  nucleus 
and  the  point  of  emergence  of  the  nerve,  tlie  side  of  the  pons.  The  face 
will  be  paralyzed  on  the  same  side  as  the  lesion,  since  this  latter  is  below 
the  decussation  of  the  facial  tracts,  and  involves  the  outgoing  nerve,  to- 
gether with  opposite  hemiplegia.  In  alternate  or  crossed  hemiplegia 
the  facial  palsy  is  of  the  infra-nuclear  type,  while  in  oi'dinary  hemiplegia 
the  supra-nuclear  type  is  met  with.  Certain  symptoms  of  nerve-irrita- 
tion may  precede  the  actual  palsy  or  may  be  concomitant,  such  as  slight 
pain  and  tenderness,  some  swelling  in  front  of  the  ear,  muscular  twitch- 
ing, and  occasionally  vertigo. 

Symptoms. — The  aff"ected  side  is  immobile  and  expressionless,  and  the 


DISEASES  OF  THE  AUDITORY  NERVE.  1051 

normal  lines  are  diminished  or  abolished.  This  is  seen  most  markedly 
in  those  above  middle  life.  The  eye  cannot  be  closed,  owing  to  droop- 
ing of  the  lower  lid,  and,  as  the  tears  are  not  directed  into  their  proper 
channel,  the  eye  waters.  Voluntary  and  emotional  movements  are  lost. 
Whistling  and  smoking  are  performed  with  difficulty,  if  at  all,  and  food 
collects  between  the  teeth  and  cheek  of  the  affected  side,  owing  to  paral- 
ysis of  the  buccinator ;  in  drinking  the  patient  inclines  the  head  to  the 
sound  side  to  prevent  escape  of  the  liquid  from  the  corner  of  the  mouth. 
The  dilator  naris  is  paralyzed ;  hence  sniffing  is  interfered  with,  and  the 
sense  of  smell  is  lowered  on  that  side. 

When  the  tongue  is  protruded  it  seems  to  be  drawn  toward  the  pal- 
sied side.  This  is  not  the  case,  however,  the  effect  being  due  to  con- 
traction of  the  unopposed  muscles  on  the  sound  side.  All  reflex  move- 
ments are  lost.  The  palate  is  not  affected,  and  sensation  is  not  impaired. 
When  the  nerve  is  involved  between  the  intumescentia  gangliformis  and 
the  origin  of  the  chorda  tympani,  taste  is  lost  in  the  anterior  part  of  the 
tongue.  When  other  parts  of  the  nerve  are  diseased,  taste  is  not  inter- 
fered with,  unless  an  ascending — or,  more  rarely,  a  descending — neur- 
itis develops.  Hearing  may  be  increased,  owing  to  paralysis  of  the 
stapedius,  with  consequent  unopposed  action  of  the  tensor  tympani. 
In  ear-disease  and  in  disease  of  the  base  of  the  brain,  involving  both 
facial  and  auditory  nerves,  hearing  is  lessened.  Some  degree  of  wast- 
ing takes  place  in  the  affected  muscles,  and  both  quantitative  and  qual- 
itative electric  changes  quickly  follow  the  pals3\ 

The  duration  of  an  attack  varies  from  a  few  days  to  several  months 
or  a  year,  and  in  rare  cases  it  is  permanent.  The  onset  is  usually 
prompt,  and  the  acme  of  the  attack  may  be  reached  in  from  a  few  hours 
to  a  couple  of  days. 

Diagnosis. — From  the  table  previously  given  it  Avill  be  easy  to  differ- 
entiate supra-nuclear  from  infra-nuclear  palsy.  In  cases  of  long  stand- 
ing, when  contractures  have  taken  place,  owing  to  the  furrows  thus  pro- 
duced the  affected  side  may  be  taken  for  the  sound  side,  but  on  getting 
the  patient  to  whistle  the  true  state  of  affairs  will  manifest  itself. 

Treatment. — Search  for  the  cause.  If  ear-disease  is  present,  make 
provision  for  free  drainage ;  if  syphilis,  give  iodid  of  potash,  mercury, 
or  both.  In  cases  due  to  cold,  the  so-called  rheumatic  palsies,  counter- 
irritation  is  especially  called  for,  and  cantharidal  collodion,  fly-blisters, 
or  the  actual  cautery  behind  the  ear  or  over  the  occiput  are  very  useful. 
The  bowels  should  be  freely  opened,  and  diaphoretics  or  hot  baths  and 
alkaline  diuretics  administered ;  in  the  inflammatory  stage  small  doses 
of  mercury  are  of  value,  and  later  mercuric  iodid  or  general  tonics. 
Galvanism  should  be  employed  to  stimulate  the  nerves  and  to  help  in 
maintaining  the  tone  of  the  muscles.  When  contractures  threaten  in 
late  cases  the  use  of  electricity  should  be  dispensed  with. 

DISEASES    OF    THE   AUDITORY   NERVE. 

The  eighth  nerve  has  its  deep  origin  in  the  medulla.  The  center  is 
connected  by  fibers  with  the  cerebellum,  probably  by  means  of  an  equi- 
libria! mechanism.  The  auditory  fibers  decussate  in  the  region  of  the 
nuclei,  passing  in  the  posterior  extremity  of  the  internal  capsule  to  the 


1052  UISEASES  OF  THE  NERVOUS  SYSTEM. 

opposite  hemisphere.  The  cortical  center  is  in  the  middle  of  the  first 
temporo-sphenoid  convolution.  Destruction  of  that  of  the  left  side  re- 
sults in  U'ord-deafness  ;  thus,  spoken  words  may  be  heard,  but  are  not 
recocrnized  as  such.  This  is  not  a  common  condition.  Rarely  the  audi- 
tory  tract  may  be  involved  between  the  cortex  and  the  nucleus.  The 
nerve  may  be  implicated  at  the  base  of  the  brain  by  tumors,  aneurysms, 
hemorrhage,  meningitis,  and  traumatism.  Erb  has  described  a  primary 
nerve-degeneration  in  tabes  dorsalis.  Disease  may  attack  the  labv- 
rinth,  either  primarily  or  secondarily  to  ear-disease.  Drugs — quinin, 
apiol,  salicylates — may  cause  deafness  similar  to  the  labyrinthine  variety. 
In  anemia  and  in  other  conditions  in  which  the  general  health  is  below 
par,  also  in  hysteria,  hearing  may  be  affected.  The  lesions  give  rise 
either  to  an  increased  or  diminished  sense  of  hearing : 

[a)  Hyperacusis,  in  which  certain  or  all  sounds  are  intensified.  Paral- 
ysis of  the  stapedius  muscle  causes  low  notes  to  be  heard  with  great  in- 
tensity. Auditory  hyperesthesia  may  also  occur  in  hysteria  or  during 
the  course  of  cerebral  or  general  disease. 

{h)  Dysacusis — difficult  hearing — may  be  due  to  middle-ear  disease, 
or  it  may  exist  as  a  "nervous  deafness,"  the  result  of  labyrinthine  or 
nerve-disease.  These  may  be  differentiated  by  means  of  the  tuning- 
fork.  Xormally,  air-conduction  is  better  than  bone-conduction,  and  if 
in  a  deaf  person  a  tuning-fork  can  be  heard  vibrating  longer  when  held 
against  the  skull-vault  or  temporal  bone  than  in  front  of  the  ear,  there 
is  some  impairment  of  conduction  in  the  meatus  or  middle  ear.  When 
the  patient  is  deaf,  and  yet  the  normal  relation  is  maintained  between 
air-  and  bone-conduction,  the  labyrinth  or  the  nerve  is  at  fault. 

{c)  Tinnitus  aurium — irritation  of  the  auditory  nerve — a  condition 
in  which  subjective  sounds  occur,  such  as  whirring,  buzzing,  ticking,  or 
ringing  in  character.  In  certain  subjects  they  are  worse  at  night  than 
during  the  day,  and  at  times  they  are  paroxysmal ;  as  a  rule,  in  any 
case  they  are  intensified  when  the  general  system  is  below  par. 

Tinnitus  may  be  caused  by  anemic  or  depraved  nutritional  states, 
intra-cranial  aneurysm,  pressure  on  the  cervical  sympathetic  by  enlarged 
glands,  tumor,  or  aneurysm,  impacted  cerumen,  otitis  media,  labyrinthine 
disturbance,  blows  upon  the  head,  excessive  auditory  stimulation,  loud 
noises,  or  it  may  occur  during  an  attack  of  migraine  or  as  an  epileptic 
aura.  In  a  neurasthenic  individual  the  subjective  noise,  no  matter  what 
the  cause,  will  be  accentuated.  The  more  complex  and  elaborate  the 
sound,  the  greater  the  probability  of  its  being  of  central  origin. 

Treatment. — Careful  search  must  be  made  for  the  cause  of  any  of 
these  morbid  conditions  just  described,  and  when  practicable  they  should 
be  removed.  The  system  should  be  brought  into  as  good  a  condition 
as  possible.  In  hyperesthesia  bromids  occasionally  avail.  In  dysacusis 
little  can  be  done  when  the  cause  is  labyrinthine.  The  same  is  true 
when  the  nerve  or  its  centers  are  involved.  Counter-irritation  and 
electricity  may  be  tried  externally,  and  iodids  internally.  These  meas- 
ures should  be  employed  in  tinnitus,  but  with  more  hope  of  relief;  in 
addition,  sedatives  are  generally  called  for,  and  even  morphin  may  be 
necessary  in  paroxysmal  attacks. 


MENIERE'S  I)ISEASE.  1053 

MENIERE'S   DISEASE. 

Definition. — An  aural  or  labyrinthine  vertigo — originally  described 
by  Meniere  in  1861 ;  the  cardinal  symptoms  are  vertigo,  deafness, 
noises  in  the  ear,   and  sometimes  vomiting. 

Pathology. — There  may  be  an  inflammation  or  atrophy  of  the 
nerve-endings.  There  are  also  changes  in  the  labyrinthine  membrane 
from  any  cause  or  from  hemorrhage. 

i^tiology. — Meniere's  disease  is  most  common  after  thirty,  and  is 
rarely  met  ^yith  before  that  age.  It  is  twice  as  common  in  men  as  in 
women.  The  precise  lesion  is  labyrinthine,  and  is  the  result  of  exposure, 
gout,  syphilis,  senile  change,  congestion,  and,  more  rarely,  hemorrhage. 
Any  cerebral  disturbance  or  gastric  or  other  irritation  is  apt  to  induce 
an  attack. 

Symptoms. — Vertigo  is  present,  and  varies  from  an  extremely  slight 
transient  attack,  and  one  that  is  entirely  subjective,  to  one  of  almost 
explosive  violence.  The  patient  may  have  a  sensation  of  having  been 
struck,  and  then  of  falling  heavily  to  the  ground.  The  slight  form  may 
be  continuous  with  more  or  less  frequent  severe  attacks,  or  a  complete 
intermission  of  days,  weeks,  or  months  may  transpire.  The  attacks 
may  arise  without  apparent  cause,  or  as  a  result  of  a  blow  or  even  a 
sudden  movement,  and  occur  during  both  working  and  sleeping  hours. 
The  giddiness,  when  severe,  causes  nausea  and  vomiting,  and,  if  pro- 
longed, bile  is  vomited  as  in  ordinary  bilious  attacks.  When  the  attack 
is  very  acute  momentary  unconsciousness  supervenes.  Nystagmus  and 
diplopia  may  occur  during  an  attack.  Tinnitus  and  deafness  usually 
exist  together,  the  former  being  constant,  but  of  slight  degree,  and  pos- 
sibly worse  during  an  attack ;  it  may  be  entirely  absent  between  the 
attacks.  The  latter  (nervous  deafness)  is  constant  and  of  varying 
severity  in  diiferent  individuals. 

Diagnosis. — The  occurrence  of  vertigo  and  tinnitus  in  a  person 
with  more  or  less  nervous  deafness,  with  or  without  gastric  symptoms, 
establishes  the  diagnosis.  The  tinnitus  and  the  character  of  the  deaf- 
ness usually  sufiice  to  distinguish  this  from  other  forms  of  vertigo.  In 
epilepsy  Avith  auditory  auras  the  period  of  unconsciousness  is  generally 
much  longer,  and  on  regaining  consciousness  the  patient  is  dull  and 
drowsy  for  some  time.  It  is  possible  also,  as  a  rule,  to  elicit  a  history 
of  convulsions. 

Prognosis. — In  some  cases  the  condition  grows  progressively  worse 
until  deafness  supervenes,  when  it  ceases.  Often,  however,  arrest  or 
improvement,  or  even  complete  recovery,  may  be  secured.  In  heart- 
disease  the  shock  may  prove  fatal,  and  in  the  very  acute  but,  fortunately, 
rare  cases  the  prognosis  is  always  bad. 

Treatment. — Counter-irritation  over  the  mastoid  process  and  the 
internal  use  of  bromids  to  lessen  the  morbid  sensibility  Avill  prove  valu- 
able. The  emunctories  must  be  gotten  in  good  condition,  and  any  un- 
derlying disease,  as  syphilis  or  gout,  must  be  treated.  Charcot  suggested 
the  use  of  drugs  that  produce  tinnitus — quinin,  for  instance.  The  cases 
were  worse  at  the  time,  but  some  of  them  seemed  to  improve  subse- 
quently. Gowers  employs  sodium  salicylate  in  5-grain  (0.324)  doses, 
thrice  daily,  believing  that  more  good  arises  when  such  drugs  are  given 


1054  DISEASES  OF  TAE  NERVOUS  SYSTEM. 

in  moderation.  Apiol  might  be  tried  in  this  connection.  Nitroglycerin 
and  the  nitrites  are  sometimes  of  value  in  cases  associated  with  arterio- 
sclerosis. 


DISEASES    OF   THE    GLOSSO-PHARYNGEAL   NERVE, 

The  ninth  cranial  nerve  has  its  origin  in  the  posterior  part  of  the 
floor  of  the  fourth  ventricle,  in  close  relation  with  the  pneumogastric 
nerve.  Our  knowledge  as  to  its  function  is  not  exact,  both  because  it  is 
seldom  if  ever  involved  alone,  and  also,  on  account  of  its  many  connec- 
tions (with  the  trigeminus,  the  facial,  the  pneumogastric,  and  the  sym- 
pathetic nerves),  it  is  difficult  to  say  whether  the  terminal  fibers  in- 
volved represent  the  functions  of  its  roots  or  of  one  of  its  connections 
(Gowers). 

Its  fibers  are  distributed  to  the  tonsils,  the  back  of  the  tongue,  the 
soft  palate,  the  pharynx,  the  Eustachian  tubes,  and  the  tympanic  cavity. 
It  supplies  both  motor  and  sensory  fibers,  but  not  those  of  taste.  This 
nerve  is  involved  in  the  nuclear  degenerations  that  are  spoken  of  as  bul- 
bar palsies.     It  may  be  also  affected  by  meningitis  or  new  growths. 

DISEASES    OF   THE   PNEUMOGASTRIC   NERVE. 

As  already  stated,  the  origin  of  the  tenth  cranial  nerve  is  in  intimate 
relation  with  that  of  the  ninth.  It  is  also  continuous  beloAv  with  that 
of  the  eleventh,  and  all  three  are  associated  with  the  center  for  the 
hypoglossal  nerve.  The  nerve  proper  arises  from  the  side  of  the  me- 
dulla, and  runs  on  either  side  of  the  neck  in  the  sheath  of  the  carotid 
artery,  lying  behind  that  vessel.  It  enters  the  thorax  in  front  of  the 
subclavian  artery  on  the  right  side,  and  between  the  subclavian  and  the 
carotid  on  the  left;  then  it  courses  beside  the  esophagus,  and  is  distrib- 
uted to  the  pharynx,  larynx,  lungs,  heart,  esophagus,  and  stomach,  and 
sends  fibers  to  the  intestines  and  spleen. 

The  esophageal  fibers  are  both  motor  and  sensory,  gastric  fibers  being 
chiefly  sensory.  The  vagus  is  in  part  the  motor  nerve  of  the  intes- 
tines. It  also  contains  both  accelerator  and  inhibitory  fibers  for  the 
respiratory  center,  is  the  cardiac  inhibitory  nerve  and  a  vaso-dilator, 
and  is  said  to  contain   trophic  fibers  for  the  heart  and  lungs. 

Btiology. — The  nerve  may  be  involved  at  its  nucleus  either  by 
hemorrhage  or  softening.  The  nuclei  of  the  ninth,  eleventh,  and  twelfth 
nerves  are  simultaneously  attacked,  either  wholly  or  in  part,  giving  rise 
to  a  group  of  symptoms  known  as  bulbar  j>ahy.  The  tenth  nerve  at  its 
superficial  origin  may  be  compressed  by  ncoi)lasms,  aneurysms,  and  the 
products  of  meningitis ;  in  its  course  down  the  neck  it  may  sufi'er  pres- 
sure, or  may  either  be  tied  in  ligating  the  carotid  artery  or  cut  in  the 
removal  of  a  tumor  or  enlarged  glands.  Very  rarely  it  may  be  injured 
by  incised  or  punctured  wounds,  or  be  the  seat  of  neuritis  due  to  expo- 
sure or  to  some  toxemia.  The  morbid  conditions  of  tlie  pneumogastric 
are  best  studied  by  considering  the  brandies  of  distribution  separately. 

{a)  Pharyngeal  Branches. — The  muscles  and  mucous  membrane  of  the 
pharynx  are  sujjplied  by  branches  of  the  pneumogastric  and  glosso-pha- 
ryngeal  nerves,  constituting  the  pharyngeal  plexus.     The  pharynx  may 


DISEASES  OF  THE  FN EUMO GASTRIC  NERVE.  1055 

be  the  seat  of  spasm  or  paralysis  :  this  is  purely  a  '■  functional  "  condition, 
and  usually  occurs  in  hysteric  {globus  hysterieus)  or  in  nervous  indi- 
viduals. One  of  my  own  patients  (a  woman)  after  some  domestic  trouble 
became  extremely  nervous.  She  complained  of  increasing  difficulty  in 
swallowing,  until  finally  she  could  scarcely  take  liquids,  this  symptom 
becoming  aggravated  Avhen  any  one  was  watching  her.  She  was  cured 
by  the  daily  passage  of  graduated  esophageal  bougies. 

Paralysis  of  the  pharynx  causes  difficulty  in  swallowing,  so  that  food 
remains  in  the  mouth  instead  of  being  passed  into  the  esophagus.  Par- 
ticles often  enter  the  larynx  and  give  rise  to  paroxysms  of  coughing, 
and  at  times  cause  choking.  When  the  soft  palate  is  also  paralyzed, 
the  food  is  regurgitated  into  the  nose.  The  lesion  is  generally  nuclear, 
causing  bulbar  paralysis.  The  root  of  the  nerve  may  be  involved  as  it 
leaves  the  side  of  the  medulla  by  meningitis  or  by  pressure  from  a  neo- 
plasm or  an  aneurysm.     Earely  it  may  be  caused  by  a  toxic  neuritis. 

{h)  Laryngeal  Branches. — The  superior  laryngeal  nerve  furnishes 
sensory  fibers  to  the  mucous  membrane  of  the  larynx  above  the  vocal 
cords,  and  supplies  also  the  cri co-thyroid  and  epiglottidean  muscles. 
The  inferior  or  recurrent  laryngeal  nerve,  which  takes  its  origin  in  the 
superior  thoracic  region,  winds  around  the  arch  of  the  aorta  on  the  left 
side  and  around  the  subclavian  artery  on  the  right,  reaching  the  larynx 
by  running  up  between  the  trachea  and  esophagus.  It  is  the  sensory 
nerve  of  the  larynx  below  the  vocal  cords,  also  of  the  entire  trachea, 
and  supplies  all  the  muscles  of  the  larynx  except  those  named  above. 
It  has  been  shown  that  the  motor  fibers  of  the  larynx  come  from  the 
glosso-pharyngeal  nucleus,  the  pneumogastric  fibers  being  sensory. 

Spasm  of  the  larynx  is  due  to  over-action  of  the  glottis-closers  (the 
adductors),  though  some  cases  described  in  this  category  are  probably 
instances  of  abductor  paralysis.  The  condition  is  rather  rare  in  adults. 
but  quite  common  in  children  (laryngismus  stridulus),  and  particularly 
in  rachitic  subjects.  An  attack  may  also  be  induced  in  those  predisposed 
by  any  form  of  nerve-irritation  or  catarrhal  condition  of  the  respiratory 
tract.  It  may  be  part  of  a  general  neurosis ;  it  is  sometimes  seen  in 
tabes  dorsalis  {laryngeal  crisis);  and  Liveing  reports  that  he  has  seen  it 
take  the  place  of  an  attack  of  migraine.  Spastic  aphoria  consists  of  a 
spasm  induced  whenever  an  attempt  to  speak  is  made.  Laryngeal 
spasms  occur  most  frequently  at  night.  Dyspnea  is  the  most  striking 
symptom,  and  is  so  intense  in  some  cases  that  suffocation  seems  immi- 
nent. The  patient  may  be  cyanotic.  Soon  the  retained  carbonic  acid 
gas  causes  relaxation,  but,  as  the  cords  open  slowly,  the  inspiration  is 
accompanied  by  a  crowing  sound,  and  the  expiratory  sound  is  harsher 
than  normal. 

Paralysis  of  the  larynx  may  be  the  result  of  a  nuclear  degeneration 
(glosso-pharyngeal).  producing  chronic  bulbar  paralysis,  as  already 
mentioned ;  this  form  may  occur  in  disseminated  sclerosis,  tabes  dor- 
salis, general  paralysis  of  the  insane,  and  in  certain  toxemias.  The 
paralysis  is  generally  bilateral ;  rarely  it  is  unilateral. 

Very  rarely  a  cerebral  cortical  lesion  in  the  laryngeal  center  may 
cause  pseudo-bulbar  paralysis.  Since  the  two  centers  are  compensatory, 
the  lesion  must  be  bilateral. 

The  nerve  may  be  involved  at  its  root  or  in  any  part  of  the  trunk. 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  such  lesions  are  usually  unilateral.  The  recurrent  laryngeal  nerve, 
especially  the  left,  is  more  apt  to  be  diseased  than  the  superior,  on 
account  of  its  position.  Thus,  the  arch  of  the  aorta  is  more  frequently 
the  seat  of  an  aneurysm  than  the  subclavian  ;  enlarged  thoracic  glands, 
neoplasms,  and  an  enlarged  thyroid 'can  also  damage  these  nerves.  The 
peripheral  filaments  may  be  attacked  as  part  of  a  multiple  neuritis. 

In  certain  cases  the  muscles  become  weakened  without  being  para- 
lyzed, this  possibly  being  due  to  a  local  neuritis,  or  to  a  congestion  and 
inflammation  of  the  mucous  membrane  from  over-use  {clergymen  s  sore 
throat),  or  as  the  result  of  exposure. 

The  following  are  the  chief  forms  of  paralysis  : 

(1)  Complete  Paralysis. — By  this  is  generally  understood  paralysis 
of  all  except  the  crico-thyroid  and  epiglottidean  muscles,  though  occa- 
sionally these  may  also  be  involved.  Since  the  cords  are  paralyzed, 
phonation  is  impossible.  As  a  rule,  there  is  no  interference  with  respi- 
ration, though  the  pressure  of  the  in-going  air  may  bring  the  cords 
nearer  together,  and  thus  produce  a  certain  amount  of  inspiratory 
harshness. 

As  the  cords  cannot  be  closed,  coughing  is  impossible,  as  the  air 
escapes  through  the  glottis,  and  no  expulsive  force  can  be  given  to  it. 
When  the  paralysis  is  unilateral  these  symptoms  will  of  necessity  be 
modified,  and  some  degree  of  phonation  may  be  possible.  The  most 
common  cause  of  this  condition  is  an  involvement  of  the  recurrent 
laryngeal  nerve ;  the  lesion  may,  however,  be  nuclear  or  in  the  course 
of  the  nerve-trunk. 

(2)  Paralysis  of  the  Abductors. — The  only  special  abductor  muscles 
are  the  posterior  crico-arytenoids.  When  they  are  involved  the  glottis 
fails  to  open  in  inspiration,  and  the  unopposed  adductors  bring  the  vocal 
cords  together.  They  are  still  more  closely  approximated  during  inspi- 
ration by  the  column  of  air,  and  hence  the  prolonged,  stridulous  inspi- 
ratory sound.  Phonation  and  expiration  are  practically  unchanged.  It 
is  (juite  likely  that  many  cases  supposed  to  be  instances  of  hysteric 
spasm  of  the  glottis  are  really  cases  of  abductor  paralysis. 

In  unilateral  paralysis  the  normal  movements  of  the  unaffected  vocal 
cord  prevent  any  marked  degree  of  dyspnea  and  stridor :  phonation  is 
usually  hoarse  and  of  a  low  pitch.  In  cases  of  long  duration  the  symp- 
toms become  more  marked  as  the  unopposed  adductors  undergo  second- 
ary contracture  and  still   further  narrow  the  glottis. 

This  condition  may  be  due  either  to  central  disease  or  to  some  local 
change.  The  abductor  muscles  may  be  degenerated,  while  all  the  other 
laryngeal  muscles  are  healthy,  or  one  or  both  recurrent  nerves  may  be 
affected.  These  nerves  innervate  both  the  abductors  and  adductors,  and 
it  is  not  clearly  understood  why  the  abductors  alone  should  suffer  when 
the  parent  nerve-trunk  is  involved.  At  any  time  it  might  be  a  very 
grave  condition,  for  should  any  swelling  of  the  cords  supervene  nothing 
but  a  prompt  laryngotomy  could  prevent  suffocation. 

(3)  Adductor  Paralysis. — The  cords  move  normally  during  respira- 
tion, and  hence  there  is  no  stridor ;  as  they  cannot  be  approximated, 
however,  phonation  is  impossible.  This  condition  is  met  Avith  in  hys- 
teria, producing  hysteric  aphonia,  in  public  speakers  who  overtax  their 
voices,  and  also  in  laryngitis. 


DISEASES  OF  THE  PNEUMOGASTRIC  NERVE. 


1057 


The  following  table,  from  Gowers'  text-book  on  Diseases  of  the  Ner- 
vous System.,  enables  one  to  get  a  comprehensive  idea  of  the  subject: 


Stjiptoms. 

No  voice  ;  no  cough  ;  stri- 
dor only  on  deep  inspi- 
ration. 

Voice  low-pitched  and 
hoarse  ;  no  cough  ;  stri- 
dor absent  or  slight  on 
deep  breathing. 

Voice  little  changed  ;  cough 
normal :  inspiration  diffi- 
cult and  long,  with  loud 
stridor. 

Symptoms  inconclusive ; 
little  aifection  of  voice  or 
cough. 

No  voice  ;  perfect  cough  ; 
no  stridor  or  dyspnea. 


Signs. 

Both  cords  moderately  ab- 
ducted and  motionless. 

One  cord  moderately  ab- 
ducted and  motionless, 
the  other  moving  freely, 
and  even  beyond  the  mid- 
dle line  in  phonation. 

Both  cords  near  together, 
and,  during  inspiration, 
not  separated,  but  even 
drawn  nearer  together. 

One  cord  near  the  middle 
line,  not  moving  during 
inspiration ;  the  other 
normal. 

Cords  normal  in  position, 
and  moving  normally  in 
respiration,  but  not 
brought  together  on  an 
attempt  at  phonation. 


Lesions. 
Total  bilateral  palsy. 


Total  unilateral  palsy. 


Total  abductor  palsy. 


Unilateral  abductor  palsy. 


Adductor  palsy. 


Sensory  disturbances  of  the  larynx  are  rare,  and  especially  hyperes- 
thesia. Anesthesia  may  be  due  to  hysteria,  or  to  bulbar  paralysis,  or  to 
disease  of  the  superior  laryngeal  nerve.  It  is  dangerous,  as  food  may 
enter  the  Avindpipe. 

(c)  Cardiac  Branches. — These  with  branches  from  the  sympathetic 
form  the  cardiac  plexus.  The  vagus  contains  both  accelerator  and  in- 
hibitory fibers,  but  the  latter  predominate ;  therefore  irritation  of  the 
nerve,  either  centric  or  peripheral,  will  slow  the  heart's  action.  Czermak 
was  able  to  slow  the  action  of  his  heart  by  pressing  a  small  tumor  in 
his  neck  against  the  vagus  nerve.  When  the  function  of  the  nerve  is 
lowered,  inhibition  is  removed  and  the  heart's  action  becomes  rapid. 
This  may  be  brought  about  by  a  toxemic  neuritis,  by  pressure,  accidental 
ligature,  or  by  incised  or  punctured  wounds.  Various  emotions  and 
nervous  states  may  bring  about  the  same  result. 

{d)  Pulmonary  Branches. — Both  accelerator  and  inhibitory  fibers  ex- 
ist, but  in  this  case  the  accelerator  influence  predominates,  so  that  irri- 
tation results  in  increased  respiratory  movements  or  even  in  bronchial 
spasm,  since  the  bronchial  muscles  are  also  supplied  by  this  nerve.  It 
is  this  nerve  that  is  supposed  to  be  concerned  in  the  production  of  asth- 
matic paroxysms.  Therefore,  when  the  nerue-function  is  lowered  the 
respirations  become  much  slower.  The  nerve  is  supposed  to  contain 
trophic  fibers  for  the  lungs. 

{e)  Esophageal,  (/)  Gastric,  and  {g)  Intestinal  Branches. — The  esoph- 
ageal branches  are  rarely  damaged,  and  irritation  (spasm)  occurs  more 
frequently  than  paralysis.  The  pneumogastric  gives  the  sensory,  and 
in  part  the  motor,  nerve-supply  to  the  stomach,  and  irritation  gives  rise 
to  increased  contractions  Avith  some  pain. 

The  sensation  of  hunger  is  supposed  to  be  associated  with  the  vagus 
nerve,  and  vomiting  may  result  from  direct  or  reflex  irritation.     Par- 

67 


1058  DISEASES  OF  THE  NERVOUS  SYSTEM. 

alysis  causes  some  diminution  of  the  gastric  contractions.     Normally, 
the  vagi  accelerate  intestinal  peristalsis. 

Treatment. — It  is  almost  ahvays  impossible  to  remove  the  cause  of 
the  above  conditions.  Syphilitic  lesions  are  probably  the  most  amen- 
able, and  in  the  various  laryngeal  palsies  electricity  may  be  employed, 
though  it  is  of  somewhat  doubtful  utility,  and  in  abductor  palsy  may 
possibly  exert  a  harmful  influence  by  stimulating  the  adductors.  Strych- 
nin and  general  tonics  should  be  administered.  Massage  of  the  larynx 
may  be  tried,  and  in  spasmodic  conditions  attention  should  be  directed 
to  the  general  physical  state.  All  sources  of  nerve-irritation  should  be 
removed  if  possible,  and  bromids,  or  even  chloral,  should  be  given. 

DISEASES    OF   THE    SPINAL   ACCESSORY   NERVE. 

This  nerve  consists  of  two  parts — an  external  or  spinal,  and  an  in- 
ternal or  accessory,  portion.  The  latter  has  already  been  described  in 
connection  with  the  pneumogastric  nerve.  It  forms  the  motor  portion 
of  that  nerve,  and  is  distributed  to  the  laryngeal  and  phai-yngeal  mus- 
cles. The  spinal  element  arises  from  the  multipolar  ganglion-cells  in 
the  anterior  gray  horns  of  the  cervical  cord,  ascends  and  enters  the 
cranium  through  the  foramen  magnum,  and  leaves  it,  after  joining  with 
the  accessory  part,  through  the  jugular  foramen.  It  supplies  the  sterno- 
mastoid  muscles  and  in  part  the  trapezius. 

Injury  or  disease  of  the  nerve  may  result  in  S2)asm  or  paralysis. 
Only  the  spinal  part  is  considered  in  this  section. 

TORTICOLLIS. 
(  Wry-neck.) 

This  may  be  a  congenital  or  an  acquired  condition. 

Congenital  torticollis,  or  "fixed  wry-neck,"  is  the  result  of  an 
atrophy  and  shortening  of  the  sterno-mastoid  muscle,  brought  about 
by  some  intra-uterine  condition  or,  possibly,  by  an  injury  at  birth.  The 
right  muscle  is  most  commonly  affected.  The  head  turns  slightly  to- 
ward the  sound  side  ;  the  eye  may  deviate,  and  curvature  of  the  cervical 
spine  may  develop. 

Facial  asymmetry  is  a  usual  concomitant  of  this  condition.  The 
face  on  the  same  side  as  the  lesion  develops  less  rapidly  than  the  other 
side,  and  in  time  secondary  contracture  of  the  unopposed  muscles  takes 
place.  The  torticollis  can  be  cured  by  tenotomy,  but  the  facial  asym- 
metry persists.  Fixation  is  necessary  for  a  while  Avhen  contracture 
exists. 

Spasmodic  Avry-neck  may  be  tonic  or  clonic.  These  forms  may  co- 
exist, alternate,  or  occur  independently  in  different  individuals.  The 
condition  is  met  with  almost  exclusively  in  adults,  and  occurs  most 
frequently  in  middle-aged  men. 

Pathologfy. — No  macroscopic  or  microscopic  evidence  of  any  lesion 
has  been  discovered,  and  the  condition  is  probably  dependent  upon  an 
over-activity  of  the-  neurons  in  the  various  centers  that  control  the 
muscles  of  the  affected  part. 

Ktiology. — The  influence  of  sex  and  age  has  been  mentioned ;  a 


DEBASES  OF  THE  SPIXAL  ACOESSOBY  NERVE.  1059 

neurotic  hereditv  may  also  predispose.  Torticollis  mav  follow  habit- 
spasm,  or  some  injury  to  the  head  or  neck,  or  exposure  to  cold,  the  latter 
constituting  the  '■  rheumatic  "  type.  In  a  case  of  my  own.  a  man  of  23,  it 
followed  an  attack  of  acute  articular  rheumatism  and  was  associated  with 
high  arterial  tension.  Rarely,  robust,  healthy-looking  individuals  are  at- 
tacked without  any  apparent  cause.  Cervical  caries  may  cause  rigidity  of 
the  neck,  simulating  torticollis.  The  spasm  is  usually  tonic  in  such  cases, 
as  it  is  in  those  of  the  "  inflammatory  "'  type,  where,  in  children  partic- 
ularly, enlarged  and  painful  glands  are  found  under  the  sterno-mastoid. 

Symptoms. — The  occiput  is  drawn  toward  the  shoulder  of  the 
aifected  side,  the  chin  is  elevated,  and  the  face  rotated  more  or  less 
toward  the  sound  side.  The  sterno-mastoid  may  alone  be  afi'ected,  or  the 
trapezius  may  also  be  involved.  In  the  latter  case  greater  depression 
of  the  head  takes  place.  Spinal  curvature  may  ensue,  the  convexity 
being  toward  the  sound  side.  This  only  takes  place  in  cases  that  have 
existed  for  some  time.  Clonic  spasm  is  infinitely  more  distressing  and 
more  apt  to  be  permanent. 

Some  pain  and  muscular  twitching  may  precede  the  onset  of  the 
attack,  though,  as  a  rule,  muscular  contractions  are  the  first  indication. 
These  are  mild  at  first,  and  rarely  abruptly,  more  commonly  slowly. 
they  increase  in  severity.  As  the  case  progresses  other  muscles,  and 
even  those  of  the  arm,  become  involved.  Cases  have  been  described  in 
which  certain  muscles  or  groups  of  muscles  in  the  hand  or  arm  have 
been  primarily  affected,  the  condition  gradually  spreading  from  them. 
The  spasm  usually  ceases  during  sleep.  An  attack  may  cause  pain,  but, 
as  a  rule,  it  induces  merelv  a  feelino;  of  fatigue  in  the  muscles  ;  it  is 
worse  if  the  patient  is  excited  or  emotional.  Bilateral  spasm  may  occur, 
the  muscles  of  both  sides  being  equally  affected  {retro-collic  spasm). 
Gowers  speaks  of  a  case  in  which  the  backward  displacement  of  the  head 
was  so  great  that  the  face  was  horizontal  and  looked  directly  upward. 

Diagnosis. — As  a  rule  this  is  not  difiicult.  When  spasm  is  in- 
duced by  enlarged  and  painful  glands  beneath  the  sterno-mastoid  the 
age  of  the  patient  will  be  of  value  in  determining  the  true  condition. 
This  usually  occurs  in  children :  true  Avry-neck.  on  the  other  hand,  very 
rarely  commences  before  the  thirtieth  year.  Hysteric  spasm  may  also 
simulate  spasmodic  torticollis,  but  it  generally  occurs  in  young  women, 
and  usually  other  evidences  of  hysteria  are  also  present.  The  rheumatic 
type  and  the  rigidity  induced  by  caries  of  the  spine  must  be  differentiated 
from  one  another  and  from  spasmodic  wry-neck.  If  the  rigidity  comes 
on  suddenly,  folloAving  exposure  to  cold  or  wet,  and  the  pain  is  not  in- 
creased at  night  or  by  depressing  the  head  upon  the  spine,  and  is  re- 
lieved by  hot  applications,  the  condition  is  probably  rheumatic.  When 
the  rigidity  and  pain  are  of  slow  onset,  without  history  of  exposure. 
and  the  pain  is  both  worse  at  night  and  is  increased  by  depressing  the 
head  upon  the  spine,  but  is  relieved  by  elevating  the  head,  the  condition 
is  very  probably  one  of  caries  of  the  spine. 

Progfnosis. — Very  rarely  the  torticollis  may  diminish  or  even  cease 
after  an  existence  of  months  or  years.  Usually,  however,  it  is  persist- 
ent, either  being  stationary  or  slowly  increasing  in  severity  and  widen- 
ing in  range.  The  prognosis  must  always  be  guarded,  and  in  severe 
cases  grave  as  to  recovery,  though  the  disease  does  not  shorten  life. 


1060  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — Generally  very  little  can  be  expected  from  medica- 
tion. Bromids,  morphin,  chloral,  hyoscyamus,  or  cannabis  indica  may 
be  tried,  as  may  the  various  forms  of  counter-irritation,  Morphin  ad- 
ministered hypodermically,  has  been  most  effectual  in  some  cases,  but 
the  danger  of  establishing  the  habit  should  not  be  forgotten.  Galvanism 
should  be  tried,  the  negative  pole  being  placed  over  the  occipital  region 
and  the  positive  over  the  affected  muscles.  Nerve-stretching  and  ten- 
otomy of  the  affected  muscles  is  of  very  little  value.  The  only  surgical 
procedure  that  has  proved  of  any  distinct  value  is  neurectomy,  with 
excision  of  a  part  of  the  nerve  to  prevent  reunion.  This  necessarily 
causes  paralysis  and  atrophy  of  the  muscles  supplied ;  but,  since  it  often 
abolishes  the  spasm,  the  slight  loss  of  power  and  the  interference  with 
the  movement  of  the  head  are  comparatively  infinitesimal.  The  results, 
however,  are  not  uniform  even  so  far  as  the  spasm  is  concerned. 

PARALYSIS    OF    THE    SPINAL    ACCESSORY    NERVE. 

The  accessory  portion  has  been  previously  considered  in  describing 
the  laryngeal  branches  of  the  pneumogastric. 

In  the  spinal  portion  the  nuclei  may  be  involved  in  degenerative 
lesions  of  the  motor  region  of  the  spinal  gray  matter.  The  nerve-trunk 
may  be  damaged  by  pressure  from  exudative  products  (meningitis), 
tumors,  or  caries,  with  resulting  paralysis  and  wasting  of  the  sterno- 
mastoid  and,  in  part,  of  the  trapezius.  This  latter  muscle  is  also  sup- 
plied by  the  cervical  nerves.  The  patient  has  difficulty  in  rotating  the 
head  to  the  side  opposite  that  on  which  the  paralysis  exists,  and  the 
affected  muscle  does  not  stand  out  in  movements  of  the  head.  Unless 
secondary  contraction  of  the  unopposed  muscle  sets  in,  no  deviation  oc- 
curs when  the  head  is  at  rest.  The  only  portion  of  the  trapezius  that 
is  involved  in  paralysis  of  the  external  part  of  the  eleventh  nerve 
stretches  from  the  occipital  bone  to  the  acromion.  The  normal  contour 
of  the  neck  is  lost  in  such  cases,  and  the  ability  to  raise  the  arm  is  in- 
terfered with  because  the  trapezius  cannot  fix  the  scapula,  the  fulcrum 
of  the  deltoid.  Bilateral  paralysis  may  occur  as  in  progressive  muscu- 
lar atrophy  ;  if  both  sterno-mastoids  are  involved,  the  head  falls  back- 
ward ;  if  both  trapezii,  it  foils  forward. 

The  treatment  is  that  of  the  underlying  cause.  If  the  lesion  is 
nuclear,  practically  nothing  can  be  done.  If  the  condition  is  due  to 
pressure,  in  some  cases  relief  may  be  obtained.  Electricity  and  mas- 
sage should  be  employed  during  the  recovery  of  the  nerve. 

DISEASES    OF   THE   HYPOGLOSSAL   NERVE. 

The  nucleus  of  the  twelfth  cranial  nerve  is  in  the  most  posterior  por- 
tion of  the  floor  of  the  fourth  ventricle.  It  is  said  by  some  observers 
that  the  nuclei  of  the  fibers  for  the  palate  and  vocal  cords  that  run  in 
the  spinal  accessory  nerve  may  be  in  the  lower  part  of  the  tAvelfth- 
nerve  nucleus. 

The  cortical  center  for  this  nerve  is  in  the  lower  part  of  the  ascend- 
ing frontal  convolution,  in  the  neighborhood  of  the  cortical  facial  cen- 
ter.    This  propinquity  probably  explains  the  simultaneous  involvement 


DISEASES  OF  THE  HYPOGLOSSAL  NERVE.  1061 

of  the  facial  and  lingual  muscles  in  some  cases.  The  hypoglossal  is  the 
motor  nerve  for  the  tongue  and  for  most  of  the  muscles  attached  to  the 
hyoid  bone.      Spasm  or  paralysis  may  follow  disease  of  the  nerve. 

Spasm  may  be  either  unilateral  or  bilateral.  It  is  probably  met  with 
most  commonly  in  hysteria,  or  as  a  part  of  some  general  convulsive 
condition,  as  epilepsy  or  chorea.  It  may  also  be  associated  with  facial 
spasm,  as  mentioned  above.  Irritation  of  the  fifth  nerve  (dental 
caries,  ulceration  of  the  gums)  seems  to  be  responsible  for  some  cases. 
"Paroxysmal  clonic  spasm"  is  a  form  in  which  the  tongue  is  rapidly 
thrust  in  and  out.  Various  sensations  in  the  affected  region  may  pre- 
cede the  attack.  A  rare  form — aplithongia — is  induced  when  an  attempt 
to  speak  is  made.  The  prognosis  in  this  condition  is  good,  and  a  gen- 
eral tonic  treatment  is  indicated. 

Paralysis  may  result  from  supra-nuclear,  nuclear,  or  infra-nuclear 
lesions. 

Supra-nuclear. — The  lesion  may  be  anywhere  between  the  cortex 
(lower  part  of  the  ascending  frontal  gyrus)  and  the  medulla,  and  causes 
paralysis  on  the  opposite  side.  In  this  condition  the  affected  muscles  do 
not  atrophy  nor  do  they  show  any  electric  change. 

Nuclear. — The  lesion  is  usually  degenerative.  It  may  either  be  of 
sudden  onset  (vascular),  less  rapid,  but  still  acute  (inflammatory),  or  it 
may  be  chronic,  as  in  bulbar  palsy  or  tabes  dorsalis.  The  nuclei 
are  so  close  together  that  the  condition  is  almost  invariably  bilateral. 

Infra-nuclear. — The  fibers  may  be  injured  by  the  pressure  of  neo- 
plasms or  by  the  products  of  meningitis  or  of  syphilis.  Disease  of  the 
bone  may  also  involve  the  nerve  in  its  passage  through  the  foramen. 
More  rarely,  some  traumatism  or  disease  of  the  upper  cervical  vertebrae 
may  simultaneously  injure  the  eleventh  and  twelfth  nerves. 

Symptoms. — Paralysis  and  atrophy  of  one  or  both  sides  of  the 
tongue  and  fibrillary  twitchings  may  be  noted,  and  if  the  condition  be 
unilateral,  the  tongue  when  protruded  deviates  toward  the  affected  side. 
Articulation,  mastication,  and  swallowing  are  but  very  slightly  interfered 
with.  In  the  bilateral  form,  however,  these  are  very  much  impaired ; 
the  tongue  cannot  be  protruded  and  lies  motionless  on  the  floor  of  the 
mouth.  The  atrophy  is  muscular.  This  throws  the  mucous  membrane 
into  deep  folds.      Sensation  and  taste  are  unaltered. 

Diagnosis. — If  the  lesion  is  supra- nuclear,  there  is  hemiplegia  on 
the  same  side  as  the  lingual  paralysis,  without  atrophy  of  the  tongue- 
muscles.  When  nuclear,  it  is,  as  has  been  said,  generally  bilateral  and 
forms  part  of  a  bulbar  paralysis.  There  is  also  wasting  of  the  lingual 
muscles.  When  the  fibers  are  involved  in  the  medulla,  there  is  paral- 
ysis of  the  tongue  on  one  side,  of  the  limbs  on  the  other,  and  the  tongue 
deviates  from  the  paralyzed  side  of  the  body.  Outside  the  medulla  the 
condition  is,  as  a  rule,  unilateral,  and  the  spinal  accessory  fibers  are 
frequently  involved.  In  the  nuclear  and  infra-nuclear  varieties  there 
is  wasting  of  the  muscles. 

The  prognosis  is  usually  unfavorable,  and  the  treatment  consists 
of  a  course  of  general  tonics  and  of  mercury  and  the  iodids,  with 
counter-irritation.     Electricity  may  also  be  tried. 


1062  DISEASES  OF  THE  NERVOUS  SYSTEM. 

DISEASES   OF  THE   SPINAL  NERVES. 

DISEASES    OF   THE    CERVICAL   PLEXUS. 

Phrenic  Nerve. — This  nerve  is  usually  involved  as  a  result  of  some 
lesion  of  the  gaiiirlion-cells  in  the  anterior  gray  horns  at  the  level  of  the 
third  or  fourth  cervical  nerve.  The  trunk  may  be  damaged  by  pres- 
sure, as  by  aneurysm  or  neoplasms,  or  by  traumatism,  or  it  may  be  the 
seat  of  neuritis.  More  or  less  immobility  of  the  diaphragm  follows, 
amounting  in  some  cases  to  complete  paralysis.  This  is  not  readily 
seen  with  the  patient  at  rest,  and  in  women  it  is  specially  hard  to  ob- 
serve, as  their  breathing  is  chiefly  of  the  costal  type.  The  abdomen 
moves  in  in  inspiration,  and  out  in  expiration,  forming  the  reverse  of 
the  normal  movements.  Immobility  of  the  diaphragm  may  also  occur 
in  peritonitis,  diaphragmatic  pleurisy,  and  in  large  pleural  efi"usions. 
Exertion  readily  causes  dyspnea,  and  pulmonary  diseases  are  apt  to  be 
exaggerated  as  the  products  of  secretion  accumulate.  This  is  most  apt 
to  occur  when  the  condition  is  bilateral,  as  it  usually  is  in  the  presence 
of  cord-lesions.  Other  muscles  always  suff"er  in  this  form  in  addition 
to  the  diaphragm.  When  the  nerve  alone  is  involved  the  affection  is 
generally  unilateral. 

DISEASES   OF   THE   BRACHIAL   PLEXUS. 

This  may  either  be  involved  in  toto,  or  any  of  its  branches  may  be 
affected  separately,  or  the  nerve-roots  that  unite  to  form  the  brachial 
plexus. 

Considering  first  the  roots,  the  only  nerve  worthy  of  notice  arising 
from  them  is  the  posterior  thoracic,  which  supplies  the  serratus  magnus 
muscle.  This  may  be  injured  directly  by  pressure,  as  in  the  carrying 
of  heavy  loads  on  the  shoulder  or  by  a  fall  or  other  traumatism.  Rarely, 
it  follows  exposure  to  cold.  Its  involvement  may  be  a  part  of  an  ante- 
rior polio-myelitis  or  of  progressive  muscular  atrophy.  When  the  muscle 
is  paralyzed  the  posterior  edge  of  the  scapula  stands  out  prominently, 
and  particularly  when  the  arm  is  moved  forward.  Neuralgic  pains  in 
the  neck  generally  precede  the  neuritis.  The  course  of  the  disease  is 
always  slow.  During  the  early  stage  counter-irritation,  the  iodids  and 
mercury  internally,  and  later  electric  stimulation  to  keep  up  the  tone  of 
the  muscles,  constitute  the  treatment. 

Comhined  Paralysis. — Two  or  more  nerves,  or  even  the  entire  plexus, 
may  be  involved  at  one  time  by  new  growths  in  the  cervical  region, 
neuritis,  stretching  or  rupture  of  the  nerves  by  wounds,  fractures,  or 
dislocations,  and  pai'ticularly  by  subcoracoid  dislocation.  Duchenne 
has  described  a  form  of  palsy  produced  in  infants  during  birth  by  pres- 
sure due  to  some  malposition  or  to  injury  by  the  finger  or  a  hook. 
Brachial  neuritis  may  follow  some  injury  to  one  of  the  nerve-branches 
(ascending  neuritis),  or  it  may  be  primary.  The  latter  variety  is  rare, 
and  usually  occui'S  after  middle  life,  especially  in  cases  with  a  gouty 
history.  Paroxysmal  or  continuous  pain,  increased  by  any  movement 
of  the  arm  and  tenderness  on  pressure  over  the  affected  nerves,  is  the 
chief  symptom.     If  on  the  left  side,  it  simulates  angina  pectoris. 

Individual  Nerves  of  the  Arm. — These  may  be  damaged  by  pressure 


DISEASES  OF  THE  BRACHIAL  PLEXUS.  1063 

due  to  a  tumor,  an  aneurysm,  or  to  callus.  Sleep-palsy  and  crutcJi-pahy 
are  both  pressure-palsies.  The  nerves  may  also  be  contused  or  torn  in 
fractures  or  dislocations,  and  palsy  may  follow  a  fall  or  blow  upon  the 
shoulder ;  I  have  seen  it  occur  in  a  heavy  man  after  a  fall  upon  the 
hand.  Primary  or  secondary  neuritis  may  develop,  and,  very  rarely, 
neuromata  appear. 

The  supra-scapula?'  nerve  supplies  the  supra-  and  infra-spinati  mus- 
cles. Paralysis  causes  imperfect  outward  rotation  of  the  humerus  and 
rotation  of  the  scapula,  with  elevation  and  inversion  of  the  lower  angle. 
Various  movements  of  the  arm  are  thereby  interfered  with,  and  the  limb 
tires  very  readily.  More  work  is  thrown  on  the  deltoid,  and  in  time  it 
hypertrophies,  causing  it  to  stand  out  more  prominently  against  the 
infra-spinatus.     The  skin  over  the  scapula  is  usually  anesthetic. 

The  circumjiex  nerve  supplies  the  deltoid  and  teres  minor  and  the 
skin  over  the  deltoid  and  the  shoulder-joint.  Paralysis  results  in 
inability  to  raise  the  arm  and  in  wasting  of  the  muscles,  with  or  with- 
out anesthesia.     Adhesions  may  form  in  the  joint. 

The  musculo-spiral  nerve  is  more  often  paralyzed  than  any  other 
nerve  of  the  arm,  its  position  rendering  it  particularly  liable  to  pressure. 
It  supplies  the  triceps  and  supinator  muscles,  and  is  the  extensor  nerve 
of  the  arm.  It  also  supplies  the  skin  on  the  radial  side  of  the  dorsal 
surface  of  the  hand,  the  back  of  the  thumb,  and  the  index  and  radial 
side  of  the  middle  finger.  A  lesion  high  up  results  in  paralysis  of  the 
extensors  of  the  elbow,  w^ist,  and  hand,  and  of  the  supinators.  Prob- 
ably the  point  most  commonly  attacked  is  about  the  middle  of  the 
humerus.  In  such  cases  the  triceps  escapes.  The  characteristic  symp- 
toms, however,  are  wrist-drop  and  finger-drop,  consisting  of  an  inability 
to  extend  the  hand  on  the  forearm,  also  the  first  phalanges  of  the  fingers 
and  thumb.  In  pressure-palsies  the  power  of  supination  is  usually  lost 
also.  Sensory  symptoms  vary,  and  are  seldom  pronounced.  There  may 
be  slight  impairment  or  tingling  or  burning  sensations. 

This  condition  can  usually  be  differentiated  from  lead-palsy  by  the 
rapidity  of  onset — by  the  fact  that  pressure-palsies  are  almost  invari- 
ably unilateral,  and  that  the  supinators  are  involved.  Lead-palsy  has 
a  slow  onset  and  is  bilateral,  generally  without  supinator  involvement. 
Loss  of  sensation  precedes  the  pressure-palsy.  The  history  too  will 
generally  throw  some  light  on  the  case.  I  have  seen  a  case  of  right- 
sided  unilateral  wrist-drop  in  a  man  who  w^orked  in  lead  with  his  right 
hand  only.  Bilateral  wrist-drop  may  occur  in  any  form  of  toxic  neur- 
itis, but  the  involvement  of  other  nerves,  the  manner  of  attack,  and 
the  history  of  the  case  will  serve  to  simplify  the  diagnosis. 

Recovery  follows  in  almost  all  cases  of  musculo-spiral  nerve-involve- 
ment, though  in  cases  in  which  qualitative  nerve-changes  have  taken 
place  it  is  necessarily  delayed. 

The  treatment  is  that  of  neuritis. 

The  median  nerve  supplies  the  pronators,  digital  flexors,  except  the 
ulnar  half  of  the  deep  flexor,  the  radial  flexor  of  the  wrist,  the  abduc- 
tor and  flexor  muscles  of  the  thumb,  and  the  two  radial  lumbricales.  It 
furnishes  sensation  to  the  radial  side  of  the  palm  and  front  of  the  thumb, 
and  to  the  front  and  back  of  the  first  and  second  and  half  of  the  third 
fingers.      This  nerve  may  be  the  seat  of  an  injury  or  of  neuritis,  but  is 


1064  DISEASES  OF  THE  NERVOUS  SYSTEM. 

seldom  involved  alone.  The  most  striking  symptoms  are  wasting  of 
the  thenar  eminence  and  an  inability  to  oppose  the  thumb  to  the  tips  of 
the  fingers.  Further  pronation  is  only  possible  in  so  far  as  the  supinator 
longus  subserves  that  function — viz.  the  misposition.  Ulnar  flexion  of 
the  wrist  alone  remains.  Flexion  of  the  phalanges  is  interfered  with. 
Sensation  may  or  may  not  be  lost. 

The  ulnar  nerve  supplies  the  ulnar  flexor  of  the  wrist,  the  ulnar  half 
of  the  deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the 
adductor  and  inner  head  of  the  short  flexor  of  the  thumb,  the  inter- 
ossei,  and  some  of  the  lumbricales.  It  supplies  with  sensation  the  front 
of  one  and  a  half  and  the  back  of  two  and  a  half  fingers  on  the  ulnar 
side.  Paralysis  causes  radial  deviation  of  the  hand  in  flexion  of  the  wrist, 
loss  of  adduction  of  the  thumb,  and  inability  to  move  the  little  finger. 
The  hypothenar  prominence  disappears. 

The  first  phalanges  cannot  be  flexed,  and  the  second  and  third  can- 
not be  extended.  This  is  exaggerated  in  old  cases,  though  still  it  is  not 
so  marked  as  the  "claw  hand"  of  progressive  muscular  atrophy,  since 
the  first  two  lumbricales  escape,  being  supplied  by  the  median  nerve. 
Sensory  symptoms  vary. 

The  diagnosis  is  usually  easy.  It  is  well  to  remember  that,  since 
this  nerve  is  the  lowest  in  its  point  of  origin  of  any  considered  in  this 
group,  ascending  cord-diseases  Avill  involve  it  before  any  of  the  other 
brachial  nerves.  It  may  also  be  damaged  by  disease  limited  to  the  low- 
est part  of  the  cervical  enlargement  of  the  cord. 

DISEASES    OP   THE   LUMBAR   AND   SACRAL   PLEXUSES. 

The  lumbar  plexus  or  its  branches  may  be  involved  by  abdominal 
growths,  enlarged  glands,  psoas  abscess,  disease  of  the  vertebrae, 
neuritis,  and  rarely  by  wounds  or  dislocation  of  the  hip  or  during 
parturition. 

The  Obturator  Nerve. — When  the  power  of  adduction  of  the  thigh  is 
lost  and  the  affected  leg  cannot  be  crossed  over  the  other,  outAsard  ro- 
tation is  somewhat  impaired. 

Anterior  crural  nerve  paralysis  causes  loss  of  power  and  wasting  of 
the  extensors  of  the  knee,  loss  of  knee-jerk,  and  anesthesia  of  most  of 
the  thigh  and  the  inner  side  of  the  leg  and  foot. 

The  superior  gluteal  nerve  supplies  the  gluteus  minimus  and  medius 
muscles.  When  it  is  involved  adduction  and  circumduction  of  the  thigh 
are  lost. 

The  sacral  plexus  and  its  branches  may  be  damaged  by  pelvic  neo- 
plasms or  inflammation,  neuritis  (generally  secondary  to  sciatic  nerve- 
involvement),  pressure  during  labor,  wounds,  dislocations,  aneurysms, 
and  diseases  of  the  bone. 

The  small  sciatic  nerve  supplies  the  gluteus  maximus  muscle.  It  is 
seldom  involved  alone.  Lesions  cause  difficulty  in  rising  from  the  sit- 
ting posture  and  anesthesia  of  the  back  of  the  thigh  and  of  the  upper 
part  of  the  leg  posteriorly. 

The  great  sciatic  nerve  supplies  the  flexors  of  the  leg  and  the  mus- 
cles below  the  knee,  and  also  sensation  to  the  outer  half  of  the  leg,  the 
sole,  and  part  of  the  dorsum  of  the  foot.     Paralysis  causes  more  or  less 


ACUTE  ASCENDING  PARALYSIS.  1065 

interference  with  the  act  of  walking,  anesthesia  in  the  part  supplied,  and 
wasting  of  the  muscles. 

The  external  popliteal  or  peroneal  nerve  supplies  the  tibialis  anticus, 
the  peronei,  the  long  extensor  of  the  toes,  and  the  extensor  brevis 
digitorum  ;  it  also  supplies  sensation  to  the  outer  half  of  the  front  of 
the  leg  and  to  the  dorsum  of  the  foot.  Paralysis  causes  foot-drop  and 
toe-drop,  rendering  it  necessary  to  lift  the  leg  high  in  walking,  so  that 
the  foot  will  clear  the  ground;  this  constitutes  the  steppage  gait  referred 
to  in  the  section  on  Neuritis.     The  region  supplied  is  anesthetic. 

The  internal  jjopliteal  nerve  supplies  the  popliteus,  tibialis  posticus, 
the  calf-muscles,  the  long  flexors  of  the  toes,  and  the  muscles  of  the  sole. 
When  paralyzed,  flexion  of  the  foot  and  toes  is  impossible,  and  sensa- 
tion is  lost  over  the  back  of  the  leg  in  its  lower  part  and  over  the  sole. 
In  old  cases  talipes  calcaneus  results.  The  plantar  nerves  are  rarely, 
if  ever,  involved  alone. 


ACUTE  ASCENDING  PARALYSIS. 

{Landry'' s  Paralysis.) 

Definition. — An  acute  paralysis,  beginning  in  the  legs  and  ascend- 
ing by  way  of  the  trunk  and  upper  extremities,  and  ultimately  involving 
the  meclullar^  centers.  It  usually  runs  a  short  course,  and,  as  a  rule, 
terminates  in  death. 

Pathology. — Although  in  many  cases  neither  gross  nor  microscopic 
lesions  have  been  found,  either  in  the  cells,  peripheral  fibers,  or  muscles, 
it  is  believed  to  be  either  an  acute  myelitis  or  an  acute  polyneuritis, 
the  weight  of  opinion  seeming  to  favor  the  latter  view.  Ross  arrived  at 
the  latter  conclusion  after  an  analysis  of  93  cases.  Nauwerck,  Barth, 
and  Centanni  hold  the  same  belief,  and  the  latter  has  discovered  a 
bacillus  in  the  lymph-spaces  of  peripheral  nerves.  Remlinger  ^  has 
reported  a  case  occurring  in  a  young  man  in  whom  paraplegia  developed 
acutely,  and  eleven  days  later  death  resulted  from  bulbar  involvement. 
Postmortem  the  cord  was  found  congested  in  the  region  of  the  anterior 
horns.  Microscopic  examination  revealed  the  presence  of  inflammation 
in  the  cervical  cord.  The  multipolar  ganglion-cells  of  the  anterior  horns 
were  degenerated,  and  between  them  were  found  streptococci.  Pure  cult- 
ures of  streptococci  were  obtained  from  the  cord  at  various  levels,  but  theji 
were  non-pathogenic  for  the  rabbit.  R.  and  F.  Schultze  and  Sinkler 
have  also  reported  cases  in  which  the  only  postmortem  lesion  was  mye- 
litis, yet,  as  stated,  the  majority  of  observers  believe  it  to  be  a  neuritis. 
That  it  is  primarily  due  to  some  toxemia,  however,  as  originally  claimed 
by  Westphal,  cannot  be  gainsaid.  The  prodromes,  when  present,  are 
suggestive,  and  the  enlargement  of  the  spleen,  which  is  a  constant  con- 
comitant, and  more  rarely  the  lymphatic  enlargement  and  albuminuria, 
are  all  confirmatory.  That  the  poison  should  have  a  selective  tendency, 
since  the  nervous  involvement  is  chiefly  or  solely  motor,  is  not  unique. 
We  meet  with  toxic  paralysis  of  the  motor  muscles  of  the  eye,  also  with 
lead-palsy. 

*  Gazette  hebdomadaire  de  Medecine  et  de  Chirurgie,  No.  27,  1896. 


1066  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Btiology. — No  definite  cause  is  known.  It  has  followed  cold  and 
exposure,  traumatism,  and  the  infectious  fevers,  including  influenza. 
Remlinger's  case,  quoted  above,  followed  malaria.  It  occurs  in  males 
chiefly  between  twenty  and  forty  years. 

Symptoms. — In  the  most  acute  cases  there  are  practically  no  pro- 
dromal symptoms  other  than  malaise  and  possibly  chilly  sensations. 
AVeakness,  followed  in  a  few  hours  or  a  day  or  two  by  paralysis,  de- 
velops in  the  lower  extremities.  One  may  be  involved  a  few  hours 
earlier  than  the  other.  It  spreads  toward,  and  soon  involves,  the  trunk 
also,  and  in  quick  succession  the  arms.  The  third  and  usually  fatal 
stage  is  reached  when  bulbar  symptoms  develop.  Very  rarely  the 
upper  extremities  may  be  first  attacked.  Death  may  occur  in  forty- 
eight  hours.  The  paralysis  is  a  flaccid  one ;  the  muscles  can  be  passively 
moved  without  off"ering  any  resistance.  AVasting  sets  in,  but  no  electric 
changes.  In  less  acute  cases  a  decided  febrile  stage  precedes  the  onset 
of  paralysis,  chills,  fever,  malaise,  and  possibly  formication  or  even  sharp 
pain.  In  any  case  the  later  symptoms  are  pre-eminently  or  solely  motor. 
Sensory  symptoms  when  present  are  very  slight.  Sensation  may  be 
delayed,  and  the  reflexes  are  generally  absent ;  accordingly,  there  is 
edema  or  sweating.  The  bladder  and  rectum  are  not  implicated,  nor 
do  bed-sores  develop.  As  stated,  when  the  bulb  is  attacked  death  gen- 
erally follows,  due  to  cardiac  or  respiratory  failure  or  to  interference 
with   deglutition.     There  are  no  cerebral   symptoms. 

Course. — Death  may  occur  in  from  forty-eight  hours  to  a  few  weeks. 
A  few  cases  of  recovery  have  been  reported,  however,  in  some  of  which 
paralysis  had  been  widespread,  even  reaching  the  bulb,  judging  from  the 
labored  respiration.  When  improvement  takes  place,  it  does  so  in  the 
reverse  order  to  the  onset,  so  that  the  part  last  affected  is  the  first  to 
recover.     It  is  much  slower  than  the  invasion. 

Diagnosis. — The  rapid  onset  of  a  paralysis  that  usually  ascends, 
the  relaxation  of  the  muscles,  slight  wasting,  if  any,  and  the  absence  of 
electric  changes  and  of  sensory  symptoms,  with  or  without  fever,  serve 
to  make  the  diagnosis,  and  to  distinguish  Landry's  disease  from  polio- 
myelitis, neuritis,  and  spinal  hemorrhage.  For  the  diff"erential  diagnosis 
between  Landry's  paralysis  and  acute  myelitis,  see  page  1072. 

Prognosis. — Always  grave,  particularly  if  bulbar  symptoms  occur, 
and  especially  if  they  appear  early. 

The  treatment  is  essentially  the  same  as  that  for  any  acute  disease 
of  the  cord  or  nerves — i.  e.  rest,  freedom  from  all  excitement  or  worry, 
moderate  purgation  and  diaphoresis ;  ergot,  belladonna,  and  iodids  in- 
ternally. Should  the  patient  survive,  electricity  and  massage  should  be 
administered. 


DISEASES  OF  THE  SPINAL   CORD  AND  ITS  MENINGES.     1067 

II.  DISEASES   OF  THE   SPINAL   CORD  AND    ITS 

MENINGES. 

DISEASES   OF  THE  MENINGES. 

Meningitis  is  very  rarely  a  primary  condition.  Both  the.  dura  and 
pia  may  be  involved.  In  the  former  case  the  inflammation  is  usually  due 
to  some  morbid  condition  of  the  vertebrae,  while  in  the  latter  it  is  sec- 
ondary to  some  toxemia,  as  in  pyemia,  sepsis,  pneumonia,  typhoid,  or  the 
acute  exanthemata.  It  may  be  part  of  a  tuberculous  condition  (vide  Tu- 
berculosis, p.  278)  or  of  epidemic  cerebro-spinal  meningitis.  Injuries 
and,  it  is  said,  exposure  to  cold,  also  lead  to  inflammation  of  the  me- 
ninges of  the  cord. 

PACHYMENINGITIS. 

Definition. — Inflammation  of  the  dura  mater.  The  dura  may  be 
involved  on  its  outer  or  inner  surface  {pachymeningitis  externa  or  in- 
terna), or  the  loose  connective  tissue  between  the  dura  and  bony  canal 
may  be  the  seat  of  a  peripachymeningitis. 

Pachymeningitis  externa  is  always  secondary,  and  usually  results  from 
syphilitic  or  carious  affections  of  the  bone,  or  from  pressure  due  to  tumors 
or  to  traumatism.  It  may  either  be  acute  or  chronic.  Of  the  latter 
type,  those  cases  due  to  Pott's  disease  are  most  common.  The  membrane 
is  involved  to  a  greater  or  less  extent.  The  internal  surface  may  escape 
entirely,  or  it  may  be  slightly  roughened  and  adherent  to  the  arachnoid ; 
externally,  however,  the  dura  is  usually  thickened,  I'ough,  and  covered 
with  a  cheesy  material. 

Pachymeningitis  interna  was  first  described  by  Charcot  in  1871,  and 
named  '■^pachymeningitis  cervicalis  hypertrophica."  It  is  of  obscure 
origin.  The  dura  is  generally  much  thickened,  and  gives  the  impres- 
sion of  being  made  up  of  a  number  of  concentric  layers.  The  pia  is 
only  involved  to  a  slight  degree  as  a  rule.  Areas  of  degeneration  may 
occur  in  the  cord,  as  may  also  dilatation  of  its  central  canal.  As  implied 
by  the  name,  this  variety  of  pachymeningitis  is  found  chiefly  in  the  cer- 
vical region,  and  the  clinical  symptoms  result  from  involvement  of  the 
nerve-roots.  It  is  a  chronic  process,  and  has  been  divided  into  three 
periods,  as  follows :  (a)  The  p)ainful  period,  lasting,  as  a  rule,  two  or 
three  months,  in  which  severe  neuralgic  pains  exist,  their  location  being 
determined  by  the  roots  involved.  They  are  mostly  in"  the  occiput  and 
upper  extremities,  however.  Early  there  may  be  hyperesthesia,  numbness, 
tingling,  and,  rarely,  an  herpetic  eruption,  [h)  The  Paralytic  Period. — 
As  a  result  of  compression  of  the  motor  roots  an  atrophic  paralysis  of  the 
upper  extremities  develops.  A  peculiar  selective  tendency  is  manifested, 
the  radial  nerve  being  spared,  while  the  median  and  ulnar  nerves  are 
involved.  This  results  in  a  modified  "claw-hand"  deformity  and  in  an 
over-extension  of  the  wrists,  with  flexion  of  the  fingers.  Anesthesia  may 
be  noted,  (c)  Spastic  Paraplegia. — This  results  when  the  compression 
has  produced  degeneration  of  the  cord.  Generally,  there  are  paresis  of 
the  lower  extremities  and  increased  reflexes,  but  no  muscular  wasting, 
since  the  trophic  centers  are  intact.      Occasionally,  however,  anesthesia 


1068  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  paralysis  of  the  legs  and  bladder  develop,  bed-sores  following,  and 
finally  death  from  exhaustion. 

The  prognosis  is  unfavorable,  practically  all  cases  terminate  in  death, 
but  the  duration  is  variable. 

The  diagnosis  must  be  made  from  amyotropic  lateral  sclerosis,  syrin- 
gomyelia, and  from  pressure  by  tumors.  The  latter  and  cervical  spondy- 
litis often  give  rise  to  almost  identical  symptoms.  Amyotrophic  lateral 
sclerosis  does  not  give  rise  to  sensory  disturbances ;  bulbar  symptoms 
are  often  present,  the  lower  extremities  atrophy,  and  the  bladder  func- 
tions are  preserved.  Syringomyelia  induces  characteristic  changes  in 
thermic  sensibility,  and  often  anesthesia,  but  rarely  severe  neuralgic  or 
radiating  pains. 

Treatment  is  not  of  much  avail.  Potassium  iodid  and  electricity  are 
the  chief  measures. 

Pachymeningitis  haemorrhagica  interna,  or  hematoma  of  the  dura  mater, 
may  occur  in  part  of  the  cord,  and  is  usually  associated  with  a  similar 
condition  in  the  cerebral  dura.  Cysts  may  be  found  in  the  inner  surface 
of  the  dura,  containing  broken-down  blood-cells  and  hematoidin  crystals, 
and  in  their  neighborhood  an  increase  of  fibrous  tissue  may  be  noted. 
The  condition  occurs  most  frequentlv  in  alcoholics  or  general  paralytics. 


LEPTOMENINGITIS. 

Definition. — Inflammation  of  the  pia  mater.  This  may  be  either 
acute  or  chronic. 

ACUTE    LEPTOMENINGITIS. 
{Acute  Spinal  Meningitis.) 

Pathology. — The  vessels  are  injected,  the  membrane  becomes 
cloudy,  a  sero-fibrinous  or  purulent  exudate  either  surrounds  the  cord 
or  may  only  exist  in  patches,  and  in  the  more  severe  cases  the  cord  itself 
is  involved  {ineningomyelitis).  The  spinal  meninges  alone  may  be  in- 
volved to  a  greater  or  less  extent,  but  as  a  rule,  the  cerebral  meninges 
are  similarly  involved.  It  should  be  remembered  that  many  cases  pre- 
senting clinically  the  picture  of  meningitis  show  absolutely  no  post- 
mortem lesions  of  the  cerebral  or  spinal  membranes.  This  is  especially 
true  of  pneumonia  and  influenza. 

Htiology. — This  is  always  microcirganismal,  and  a  great  variety 
of  bacteria  have  been  discovered.  The  most  common  is  the  pneumo- 
coccus,  in  which  case  the  disease  may  or  may  not  be  associated  with 
pneumonia ;  next  in  frequency  is  the  meningococcus ;  and  then  the 
various  pyogenic  cocci,  the  influenza  bacillus,  the  typhoid  bacillus,  etc. 

Symptoms. — These  are  chiefly  pain  in  the  back,  often  excruciating, 
with  fixation,  retraction  of  the  head,  tenderness  on  pressure  along  the 
spine,  tremors  or  spasm  of  the  muscles,  and  various  sensory  disturbances. 
Reflexes  are  early  increased,  and  later  diminished  or  absent.  Should  the 
cord  be  involved,  paralysis,  incontinence  of  urine  and  feces,  and  even  bed- 
sores, may  develop.  The  symptoms  are  more  fully  discussed  in  speaking 
of  the  tuberculous  and  epidemic  varieties. 

Diagnosis. — It  is  often  very  difficult  to  differentiate  the  several 


HEMORRHAGE  INTO   THE  SPINAL  MENINGES.  1069 

varieties  of  spinal  meningitis,  and  equally  so  to  decide  whether  the  case 
is  actually  meningeal  when  some  other  disease  is  present.  Even  bulbar 
symptoms  may  be  present  without  postmortem  lesions ;  I  have  seen  this 
typified  in  a  case  of  Bright's  disease.  The  tuberculous  form  is  readily 
diagnosticated,  especially  if  any  collateral  evidence  of  tuberculosis  ex- 
ists. It  is  a  point  of  some  value  in  the  diagnosis  to  note  the  absence 
of  marked  leukocytosis  in  tuberculous  and  its  presence  in  purulent  men- 
ingitis. The  presence  of  Kernig's  sign  is  in  favor  of  cerebrospinal 
meningitis. 

Sphial  paracetitesis  or  lumbar  puncture.,  first  introduced  by  Quincke 
of  Kiel  in  1891,  is  a  most  valuable  diagnostic  measure  and  simple  of  ap- 
plication. He  was  first  led  to  adopt  it  by  the  knowledge  that  a  free 
communication  exists  between  the  subarachnoid  spaces  of  the  brain  and 
spinal  cord  through  the  foramen  of  Magendie ;  hence  he  conceived  the 
idea  of  a  lumbar  punctui-e  supplanting  the  older  method  of  tapping  the 
lateral  ventricles  in  cases  of  hydrocephalus.  Later,  he  used  it  in  menin- 
gitis. Therapeutically,  it  is  of  little  value,  but  it  often  serves  to  confirm 
the  diagnosis.  The  patient  should  be  in  a  sitting  posture  with  a  slight 
forward  inclination  of  the  trunk.  The  puncture  is  then  made  between 
the  third  and  fourth  lumbar  vertebrse  and  a  little  to  one  side  of  the 
middle  line.  Absolute  cleanliness  should  be  observed,  and  the  needle 
introduced  slowly  until  the  fluid  begins  to  flow  by  its  own  pressure. 

The  prognosis  is  unfavorable  as  a  rule,  particularly  in  the  tuber- 
culous form. 

The  treatment  is  the  same  as  that  of  cerebro-spinal  meningitis 
(vide  p.   131). 

CHRONIC    LEPTOMENINGITIS. 

This  disease  may  follow  the  acute  form  or  be  due  to  chronic  alcohol- 
ism, syphilis,  trauma,  or  disease  of  the  cord. 

Pathology. — The  pia  is  cloudy  and  swollen,  and  often  adherent  to  the 
arachnoid,  or  all  three  membranes  may  be  glued  together.  They  are 
usually  injected.  Usually  there  is  considerable  proliferation  of  fibrous 
tissue.     The  periphery  of  the  cord  is  also  occasionally  affected. 

Symptoms. — These  are  not  well  marked.  Unless  the  nerve-roots  are 
involved  the  symptoms  are  slight  or  none  at  all  exist ;  however,  pains 
of  a  radiating  character,  stiffness,  tremors,  hyperesthesia,  herpes,  and 
even  paralyses,  may  occur.  The  course  is  slow,  and  may  extend  over 
many  years. 

The  prognosis  is  unfavorable  ultimately. 

The  treatment  consists  in  the  use  of  iodids  and  mercury  internally, 
and  the  application  of  baths,  and  counter-irritation  along  the  spine. 


HEMORRHAGE   INTO   THE    SPINAL  MENINGES. 
{Meningeal  Apoplexy  ;  Hematorrachis.) 

{a)  Extrameningeal  hemorrhage  occurs  when  the  blood  is  between  the 
dura  and  spinal  canal. 

{h)  Intrameningeal  hemorrhage  is  that  in  which  the  bleeding  takes 
place  within  the  dura. 


1070  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Large  hemorrhages  are  very  rare  in  any  case,  but  are  more  common 
in  the  extrameningeal  form  ;  they  result  from  trauma  or  rupture  of  an 
aneui'ysm.  The  peridural  space  will  accommodate  a  large  amount  of 
blood  without  giving  rise  to  pressure-symptoms.  Caries  of  the  vertebroe 
or  carcinoma  may  cause  hemorrhage  by  erosion  and  rupture  of  a  blood- 
vessel. The  intra-raeningeal  form  is  somewhat  more  common,  and  may 
either  result  from  meningitis  or  occur  as  a  complication  of  any  of  the 
infectious  diseases.  In  such  cases  the  hemorrhages  are  small  and  scat- 
tered. It  may  also  occur  in  convulsive  disorders  or  in  strychnin-poison- 
ing. Rupture  of  an  aneurysm  at  the  base  of  the  brain  may  give  rise  to 
extensive  hemorrhage,  and  in  a  case  of  syphilitic  ventricular  apoplexy  in 
a  young  man  I  found,  posttnorton,  that  the  blood  had  leaked  out  and 
infiltrated  the  spinal  meninges  for  some  distance. 

Symptoms. — W^hen  the  hemorrbage  is  large  enough  to  cause  pressure, 
the  symptoms  are  very  acute,  apoplectiform  indeed,  but  consciousness  is 
preserved.  Generally,  however,  they  are  quite  indefinite.  In  any  case 
they  depend  upon  the  degree  and  location  of  the  compression.  At  first 
they  are  irritative — viz.  hyperesthesia,  paresthesia,  neuralgic  pains  that 
are  radiating  in  character,  herpes,  muscular  irritability,  tremors,  or  con- 
tractions. Later,  paralytic  symptoms  may  develop,  as  anesthesia  and 
bladder-  and  bowel-symptoms,  girdle  pains,  or,  when  the  lesion  is  high 
up,  interference  with  respiration,  and  pupillary  changes. 

The  diagnosis  is  often  difficult,  unless  the  onset  is  sudden  and 
explosive. 

The  prognosis  depends  on  the  cause  and  extent  of  the  hemorrhage. 
If  small  in  amount,  absorption  is  usually  prompt,  with  little  or  no  dis- 
turbance of  function  remaining. 

The  treatment  consists  of  rest,  ice  to  the  spine,  counter-irritation, 
wet-  or  dry-cupping,  leeches  or  venesection,  ergot,  opium  or  gallic  acid 
internally,  and  later  the  iodids  and  electricity.  In  certain  cases  operative 
procedures,  with  a  view  to  removing  the  clot,  may  be  justifiable. 


DISTURBANCES  OF  CIRCULATION  IN  THE  CORD. 

These  include  (jualitative  and  quantitative  changes  in  the  blood,  and 
morbid  conditions  of  the  vessel-walls. 

The  blood-vessels  may  be  the  seat  of  peri-  or  endarteritis,  and  rarely 
miliary  aneurysms  may  develop.  Embolism  and  thrombosis  also  occur, 
the  former  much  less  frec^uently  than  the  latter,  Avhich  is  prone  to  follow 
sclerotic  changes  in  the  vessels,  giving  rise  to  ischemia  and  ultimately  to 
softening. 

Congestion. — We  are  justified  in  noticing  this  as  a  possible  cord-lesion, 
but  it  is  questionable  if  it  has  any  clinical  significance.  It  is  safe  to  as- 
sume that  it  occurs  in  the  general  stasis  of  circulatory  disorders,  yet  no 
characteristic  symptoms  develop.     It  is  very  rarel}'^  met  with  postmortem. 

Anemia. — This  condition,  like  the  preceding,  rarely  gives  rise  to 
symptoms.  Dr.  William  A.  Hammond  has  described  a  certain  group 
of  symptoms  as  due  to  spinal  congestion,  and  another  to  spinal  anemia. 


HEMORRHAGE  INTO  SPINAL  CORD.  1071 

but  his  teachings  on  this  point  are  not  generally  accepted.  Simple  anemia 
of  the  cord, /5er  se,  cannot  be  recognized  clinically.  Recently  Lichtheim, 
Petren,  Xonne,  and  others  have  called  attention  to  the  fact  that  in  cer- 
tain cases  of  profound  anemia,  and  in  some  of  the  profound  cachexia, 
nervous  symptoms  are  present.  These  consist  of  Aveakness  of  the  lower 
extremities,  incoordination,  and  usually  increased  knee-jerks,  although 
the  latter  may  be  diminished  or  absent.  The  lesions  found  in  these 
cases  are  those  of  combined  sclerosis,  sometimes  with,  sometimes  Avithout, 
involvement  of  Lissaeur's  zone. 

Treatment. — The  indications  are  to  keep  the  emunctories  active. 
High  enemata  should  be  given,  flushing  the  bowels  with  large  amounts 
of  sterile  normal  salt-solution.  Internally,  calomel,  salol,  beta-naphtol, 
arsenic,  and  iron  may  be  employed. 


HEMORRHAGE  INTO   THE  SPINAL  CORD. 

{Uematomyelia ;   Spinal  Ajyoplej:^.) 

This  is  a  very  much  less  frequent  occurrence  than  cerebral  hemor- 
rhage. It  is  usually  due  to  traumatism,  but  may  follow  cold  or  exposure 
or  some  severe  strain  or  over-exertion  (in  the  latter  probably  only  when 
the  vessels  are  atheromatous).  Hemorrhage  may  occur  in  cases  of  mye- 
litis, epidemic  cerebro-spinal  meningitis,  syringomyelia,  tumors  of  the 
cord,  convulsive  disorders,  and  infectious  diseases ;  it  is,  however,  usually 
small.  If  the  hemorrhage  is  extensive,  disruption  of  more  or  less  cord- 
substance  necessarily  follows.  An  area  may  exist  large  enough  to  cause 
distention  of  the  cord  without  rupture,  and  from  this  extravasations  may 
take  place  in  the  cord-substance  above  and  below.  Unilateral  hemorrhage 
may  occur,  the  gray  matter  being  chiefly  involved.  If  of  recent  origin, 
fresh  blood  will  be  found  postmortem;  but  if  of  long  standing,  a  brown 
or  brownish-yellow  area  will  be  noted,  consisting  of  disintegrated  blood- 
corpuscles,  cell-detritus,  and  hematoidin  crystals. 

The  symjjtoms  necessarily  vary  according  to  the  region  involved. 
The  hemorrhage  may  be  sudden,  giving  rise  to  an  apoplectiform  onset ; 
or  gradual,  with  slowly  increasing  symptoms.  There  is  generally  a  back- 
ache, followed  by  paralysis,  a  loss  of  sensation  and  of  the  reflexes,  and 
in  some  cases  a  loss  of  control  of  the  bladder  and  bowel.  In  less  grave 
cases  the  early  symptoms  will  be  those  of  irritation,  while  later  paralytic 
symptoms  supervene.  If  the  hemorrhage  is  slight,  absorption  soon  takes 
place,  with  complete  recovery ;  but  quite  often  more  or  less  paralysis  re- 
mains. Myelitis  develops  in  some  cases,  the  patient  growing  progressively 
worse  and  dying  of  exhaustion.  Dr.  C.  E.  Riggs  has  reported  a  rather 
unique  case  in  a  woman  forty-five  years  of  age,  who  developed  paraplegia 
after  a  nervous  shock  three  years  before  coming  under  his  observation. 
When  he  first  saw  her  she  had  impaired  sensation  of  the  lower  limbs  and 
of  the  trunk  as  far  up  as  the  xiphoid  cartilage.  The  legs  were  spastic,  with 
increased  reflexes.  She  had  neither  lancinating  pains  nor  ataxia,  but 
was  profoundly  anemic,  and  grew  progressively  worse  until  death  ensued 
from  exhaustion.  Postmortem,  an  area  of  extravasated  blood  was  found 
in  the  mid-clorsal  region  of  the  spinal  canal,  and  hardening  degeneration 
was  noted  in  the  anterior  and  crossed  pyramidal  tracts,  direct  cerebellar 
and  posterior  columns,  and  in  Lissauer"s  tract.     The  degeneration  ex- 


1072  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tended  from  the  first  cervical  to  the  fifth  lumbar  vertebra.  This  case 
was  remarkable — first,  from  the  fact  that  the  hemorrhage  of  the  cord  Avas 
due  to  anemia ;  secondly,  on  account  of  the  extent  of  the  degeneration, 
and  particularly  because  of  the  fact  that  Lissauer"s  column  was  involved. 

The  diagnosis  is  always  difficult,  for  when  of  sudden  onset,  unless 
aided  by  the  etiology,  it  will  be  impossible  to  diagnose  the  condition  from 
spinal  meningeal  hemorrhage.  In  other  cases  it  must  be  differentiated 
from  myelitis  and  multiple  neuritis. 

Treatment. — Rest,  ice  locally,  and  the  internal  use  of  ergot  and 
opium  make  up  the  treatment. 


ACUTE  MYELITIS. 

{Myelitis;  Acute  Diffuse  Myelitis ;   Transverse  Myelitis;    Spinal  Malacia.) 

Definition. — An  inflammation,  with  softening,  of  the  cord,  giving 
rise  to  various  groups  of  symptoms  depending  upon  the  region  or  regions 
involved,  and  not,  therefore,  as  constant  in  its  symptomatology  as  the 
systemic  nervous  diseases  (tabes  dorsalis,  lateral  sclerosis). 

Pathology. — The  cord  may  present  little  or  no  change  to  the  naked 
eye,  or  in  the  most  acute  cases  it  may  be  diffluent.  Between  these  ex- 
tremes many  grades  exist  in  which  the  pia  will  be  found  congested  and 
adherent,  the  cord  being  more  or  less  ingested  and  areas  of  softening, 
and  even  cavities,  being  found.  Three  forms  of  softening  are  spoken  of 
by  some  writers — the  red,  yellow,  and  gray — depending  upon  the  pre- 
dominance of  blood,  fat,  or  connective  tissue  respectively.  The  postmor- 
tem finding  depends  upon  the  duration  of  the  disease ;  the  more  chronic 
the  course,  the  greater  the  amount  of  nervous  connective  tissue  (neurog- 
lia), and  in  consequence  sclerosis  will  be  the  predominant  feature.  The 
nerve-cells  and  fibers  are  found  in  various  stages  of  disintegration,  the 
former  being  swollen,  vacuolated,  granular,  and  their  processes  broken  and 
in  many  cases  missing ;  Avhile  the  latter  swell,  the  myelin  breaks  up,  un- 
dergoes fatty  change,  and  is  removed,  and  the  axis-cylinders  finally 
break  up  and  disappear.  A  single  area  of  degeneration  may  exist  cen- 
trally, in  one  half  of  the  cord,  transversely,  or  many  localized  or  widely- 
disseminated  areas  may  be  found  ;  but  above  and  below  all  of  them  will 
be  found  degenerated  fibers — ascending  and  descending  degeneration — 
due  to  a  solution  of  continuity  between  the  cell-body  and  its  axis-cylinder 
process. 

Ktiology. — Myelitis  may  follow  exposure  (especially  in  alcoholics), 
the  infectious  fevers  (chiefly  measles  and  small-pox),  and  it  may  be  due 
to  traumatism  or  disease  of  the  vertebrae  (caries,  malignant  disease). 
Syphilis  is  also  said  to  cause  it,  though  it  may  only  act  as  a  predisposing 
agent.  It  has  also  been  described  as  following  peripheral  neuritis, 
ascending  neuritis,  and  we  meet  with  some  cases  in  which  pregnancy 
seems  to  act  as  the  predisposing  cause.  Embolism  and  thrombosis  may 
rarely  cause  it.  It  is  most  common  in  males,  generally  from  fifteen  to 
thirty  years  of  age. 

Symptoms. — These  will  vary  according  to  the  seat  and  extent  of  the 
lesion.  In  the  most  acute  form  the  course  of  the  disease  is  quite  rapid, 
reminding  one  of  hemorrhage  into  the  cord  or  membranes  ;  the  onset, 


ACUTE  MYELITIS.  1073 

however,  is  not  so  explosive,  and,  though  rapid,  it  is  not  sudden.  It  is 
most  apt  to  follow  cold  or  exposure.  The  most  acute  case  I  have  ever 
seen  occurred  in  an  alcoholic  who  had  lain  out  one  night  in  a  drunken 
stupor.  There  may  be  chills  and  fever,  malaise,  backache,  pains  in  the 
limbs,  and,  rarely,  convulsions ;  quite  often,  however,  there  is  no  warn- 
ing. Motor  weakness  develops,  and  is  rapidly  followed  by  paralysis. 
Some  irritative  sensory  symptoms  appear,  as  hyperesthesia  and  pares- 
thesia, and  then  more  or  less  complete  anesthesia  supervenes.  The  re- 
flexes are  generally  lost ;  there  is  incontinence  of  urine  and  feces,  and 
bed-sores  and  cystitis  develop  Avith  frightful  rapidity.  The  temperature 
now  rises  to  105°  F.  (40.5°  C.)  or  even  higher,  and  typhoid  symptoms, 
exhaustion,  and  death  close  the  scene.  I  have  seen  1  case  that  developed 
in  a  woman  a  few  days  after  delivery  and  proved  fatal  in  six  days. 

Acute  transverse  myelitis  is  the  type  most  frequently  met  with,  how- 
ever, the  lesion  being  generally  situated  in  the  dorsal  cord.  The  consti- 
tutional symptoms  marking  the  onset  are  more  pronounced  than  in  the 
previous  type  and  are  of  longer  duration  ;  but  they  are  much  less  pro- 
nounced in  the  later  stages.  They  are  apt  to  simulate  a  rheumatic 
attack,  with  malaise,  fever,  muscular  pains,  anorexia,  chills,  and  possibly 
sweating.  In  from  a  few  days  to  a  week  spinal  symptoms  reveal  them- 
selves, the  motor  generally  appearing  before  the  sensory  symptoms,  though 
they  may  be  contemporaneous,  or  the  sensory  symptoms  may  even  appear 
first.  In  any  event,  they  are  apt  at  first  to  be  irritative.  The  limbs  will 
feel  tired  and  heavy  and  drag  in  walking,  and  tremors  or  twitching  occur, 
even  cramps,  and  later  paralysis,  partial  or  complete,  in  the  region  involved. 
The  lower  limbs  may  alone  be  involved,  or  when  the  lesion  is  in  the 
cervical  region  paralysis  and  atrophy  of  the  upper  with  a  spastic  condi- 
tion of  the  lower  extremities  may  develop.  The  breathing  is  generally 
diaphragmatic  in  cases  in  which  the  intercostal  muscles  are  involved.  If 
the  lesion  is  still  higher  up,  death  will  quickly  take  place  from  failure  of 
respiration.  Such  cases,  however,  are  more  apt  to  occur  in  the  type 
known  as  disseminated  myelitis,  in  which  bulbar  symptoms  are  prone 
to  appear.  The  sensory  symptoms  at  first  are  those  of  a  tingling  or 
burning  character,  or  formication.  Later,  certain  or  all  forms  of  sen- 
sation may  be  lost,  and,  roughly  speaking,  the  upper  level  of  anesthesia 
corresponds  to  the  level  of  the  cord  involved.  This  "boundary  re- 
gion" is  apt  to  be  hyperesthetic,  and  in  it  the  "girdle-feeling"  is  ex- 
perienced. The  reflexes  may  be  lost  at  first,  but  soon  return,  and  be- 
come exaggerated  below  the  lesion.  The  condition  of  the  trunk-reflexes 
may  enable  one  to  locate  the  position  of  the  cord-lesion.  There  is  not 
much  wasting  of  muscles,  as  a  rule,  nor  does  the  reaction  of  degeneration 
develop,  unless  the  lesion  is  in  the  lumbar  or  cervical  cord,  when  both 
will  occur.  Loss  of  control  of  the  bowel  and  bladder  may  be  among  the 
earliest  symptoms,  though  this  is  not  the  rule.  While  superficial  ulcer- 
ation may  occur  in  any  neglected  case,  the  most  marked  trophic  changes 
take  place  in  those  in  which  the  lumbar  cord  is  involved,  either  directly 
or  by  extension.  In  such  cases,  despite  the  most  assiduous  attention, 
extensive  bed-sores  develop.  The  course  of  the  disease  depends  on  the 
cause  and  the  extent  of  the  lesions.  Death  may  occur  in  a  few  weeks 
from  exhaustion,  heart  or  respiratory  failure,  or  from  kidney-disease  sec- 
ondary to  cystitis.  Recovery  is  the  rule,  though  with  more  or  less  per- 
manent damage  due  to  degeneration  of  some  of  the  paths  of  conduction. 

68 


1074  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — The  distinction  from  hemorrhage  into  the  cord  or  mem- 
branes has  already  been  mentioned.  From  Landry's  paralysis  it  can  be 
separated  by  a  reference  to  the  subjoined  table : 

Acute  Myelitis.  Landry's  Disease. 

Paralysis   is   sudden   and  generally   be-  Paralysis  begins  in  the  feet  and  rapidly 
comes  complete.  spreads  to  the  muscles  of  respiration 

and  deglutition. 

Wasting  and  bed-sores  are  marked.  Trophic  disturbances  are  absent. 

Reactions  of  degeneration  are  distinct.  No  reactions  of  degeneration. 

Early  involvement  of  the  sphincters.  Bladder  and  rectum  are  not  involved. 

Girdle-pains  sometimes  mark  the  height  _.   „ 

of  the  lesion.  Girdle-pains  are  absent. 

Anterior  poliomyelitis  is  not  accompanied  by  sensory  symptoms.  In  pe- 
ripheral neuritis  pain  of  a  shooting  character  is  more  apt  to  be  present, 
and  is  almost  invariably  the  first  symptom  to  appear.  Motor  symptoms 
may  not  appear  for  some  days.  This  is  not  the  case  in  myelitis.  In 
compression  of  the  cord  sufficient  collateral  evidence  can  usually  be  ob- 
tained to  differentiate  it  from  myelitis.  Hysteric  paraplegia  is  occa- 
sionally misleading.  The  character  of  the  patient  and  the  previous  his- 
tory should  be  thoroughly  considered  ;  moreover,  in  this  form  there  are 
no  trophic  changes,  and  as  a  rule  no  bladder-symptoms  ;  at  any  rate, 
there  is  no  cystitis.  Retention  of  urine  may  occur,  but  not  incontinence. 
The  diagnosis  of  myelitis  can  usually  be  made  without  great  difficulty 
from  the  motor  and  sensory  symptoms,  the  preservation  of  the  knee-jerk, 
the  vesical,  rectal,  and  trophic  symptoms,  and  often  from  the  presence  of 
the  girdle-sensation  in  addition. 

Prognosis. — The  most  acute  cases  are  fatal  in  from  three  days  to  a 
week.  Less  acute  cases  generally  recover  with  more  or  less  loss  of  motor 
power. 

Treatment. — Very  little  can  be  done  to  arrest  the  process  in  acute 
myelitis.  The  actual  cautery  should  be  tried  as  a  counter-irritant,  or  an 
ice-bag  may  be  applied  to  the  spine.  The  patient  should  be  placed  on 
an  air-  or  water-bed.  Trophic  changes  should  be  looked  for  daily,  and  at 
the  first  sign  of  their  appearance  alcohol  or  some  stimulating  liniment 
should  be  employed.  If  the  skin  is  broken,  absolute  cleanliness  must  be 
observed,  and  the  wounds  dressed  antiseptically.  It  is  well,  also,  to 
change  the  patient's  position  from  time  to  time  to  avoid  too  long-continued 
pressure  in  any  one  spot.  Ergot  or  ergotin  should  be  given  internally, 
and,  especially  in  specific  cases,  potassium  iodid.  A  general  tonic  and  sup- 
portive treatment  is  indicated,  and  later  massage,  electricity,  and  baths. 


CHRONIC  MYELITIS. 

That  there  are  both  a  subacute  and  a  chronic  form  of  myelitis  is  gen- 
erally conceded,  though  these  types  are  not  sharply  circumscribed.  As 
has  been  previously  mentioned,  it  is  quite  likely  that  many  cases  exist  in 
which  the  clinical  symptoms  do  not  seem  to  warrant  the  diagnosis  of 


CHRONIC  MYELITIS.  1075 

myelitis,  and  yet  extensive  areas  of  degeneration  may  be  found  j^ost- 
mortem.  Even  some  cases  of  supposed  hysteria  may  have  a  distinct 
pathology. 

Pathology. — The  lesions  are  most  apt  to  be  disseminated  or  diffuse, 
though  there  may  be  a  single  focus.  Histologically,  the  chief  differences 
from  the  acute  variety  consist  in  the  greater  amount  of  sclerosis,  the 
thickened  blood-vessels  with  contracted  lumen,  and  an  entire  absence 
of  recent  hemorrhage.  In  some  cases  also  the  pia  is  much  thickened  in 
patches  and  firmly  adherent.  The  nerve-cells  are  either  seen  to  be  in 
advanced  stages  of  degeneration  or  they  have  actually  disappeared. 
Secondary  degenerations,  above  and  below,  proceed  from  the  primary 
foci. 

Htiology. — Any  of  the  causes  capable  of  giving  rise  to  acute  mye- 
litis may  cause  the  chronic  variety,  either  by  acting  slowly  over  a  loner 
period  of  time  or  by  their  influence  upon  a  person  whose  tissues  are  re- 
sistant. A  process  originally  acute  may  become  chronic,  or  a  succession 
of  acute  attacks  may  give  rise  to  a  chronic  condition.  Gout,  alcohol, 
and  syphilis  seem  especially  prone  to  cause  chronic  lesions.  The  condition 
may  also  be  secondary  to  meningitis  and  to  certain  toxic  blood-conditions 
other  than  those  that  have  been  mentioned. 

Symptoms. — Any  symptom  occurring  in  the  acute  may  be  dupli- 
cated in  the  chronic  form,  though  the  onset  of  the  latter  is  gradual. 
The  symptoms  are  more  or  less  obtrusive  according  to  the  region  of  the 
cord  that  is  affected.  If  the  cervical  and  lumbar  regions  are  not  impli- 
cated, no  definite  symptoms  Avill  be  present,  and  probably  there  will  be 
nothing  more  than  subjective  sensations  and  progressive  weakness,  with 
possibly  some  muscular  wasting.  The  most  characteristic  features  of  a 
well-marked  case  are  the  irregular  and  successive  involvement  of  various 
parts.  There  will  be  motor  weakness,  possibly  of  an  arm,  followed  sooner 
or  later  by  sensory  impairment.  Then  one  of  the  lower  extremities  may 
become  involved,  and  ultimately  paralysis  will  supervene.  When  the 
lesion  is  single  this  irregular  onset  is  less  apparent.  In  chronic  trans- 
verse myelitis  of  the  lumbar  region,  for  instance,  there  will  be  paresis  of 
the  lower  extremities,  simultaneously  or  successively  involved.  The  on- 
set, however,  is  gradual,  and  months  may  elapse  before  the  paraplegia 
will  be  complete.  A  girdle-sensation  is  apt  to  be  present,  together  with 
lowered  sensibility,  and  loss  of  sensation  is  very  rarely  absolute.  The 
knee-jerk  is  increased,  ankle-clonus  is  present,  and  in  time  the  muscles 
become  spastic.  The  sphincters  are  frequently  implicated.  Atrophy  of 
the  muscles  is  most  pronounced  when  the  anterior  gray  matter  of  the' 
cervical  or  dorsal  region  is  involved,  but  this  may  occur  in  any  case. 
The  reactions  of  degeneration  can  rarely  be  elicited. 

Diagnosis. — The  gradual,  and  in  many  cases  the  irregular,  onset 
characterize  this  disease.  In  its  various  phases  it  may  simulate  almost 
any  spinal-cord  disease,  and  it  is  most  apt  to  be  confounded  with  tumor, 
pressure  (carious  or  malignant),  primary  lateral  sclerosis,  progressive 
muscular  atrophy,  and  syringomyelia.  Pressure,  whether  due  to  a 
tumor,  to  caries,  or  to  malignant  disease,  is  apt  to  cause  pain  radiatinor 
in  character,  and  the  last  two  usually  present  collateral  evidences  in  the 
deformity  and  cachexia.  The  symptoms,  too,  are  always  bilateral,  while 
those  of  myelitis  may  be  unilateral.     From  progressive  muscular  atropliy 


1076  DISEASES  OF  THE  NERVOUS  SYSTE3f. 

it  may  generally  be  diagnosed  by  the  irregular  course  it  pursues.  Apart 
from  the  painless  ulcerations  and  the  dysesthesia  that  usually  occur  in 
syringomyeUa,  it  may  be  impossible  to  diagnose  it  from  the  latter  disease. 

The  prognosis  is  necessarily  grave.  Recovery  may  be  possible,  but 
it  is  extremely  rare.  The  process,  however,  may  be  arrested  in  some 
cases,  and  the  strictly  focal  forms  are  less  apt  to  prove  fatal  than  the  dis- 
seminated or  diffuse. 

Treatment. — More  can  be  expected  from  general  hygienic  measures 
than  from  the  use  of  drugs.  In  the  early  stages  rest  is  indicated,  but 
it  is  ■well  also  to  employ  passive  exercise,  to  prevent,  if  possible,  a  too 
great  contraction  of  the  muscles.  As  soon  as  expedient — each  case  being 
judged  on  its  merits — the  patient  should  be  taken  out  of  doors.  Change 
of  air  and  of  scene  is  advisable,  as  are  also  baths  and  massage.  Mild 
counter-irritation  may  be  applied  to  the  spine,  but  care  should  be  taken 
to  avoid  the  areas  of  anesthesia.  General  tonics,  iron,  quinin.  arsenic, 
and  strychnin,  should  be  given,  also  mercury  or  the  iodids.  The  greatest 
possible  care  of  the  bladder  should  be  taken  in  order  to  avoid  cj^stitis. 


ANTERIOR  POLIOMYELITIS. 

ESSENTIAL   PARALYSIS   OF   CHILDREN. 
[Atrophic  Spinal  Paralysis.) 

Definition. — A  febrile  disease  of  more  or  less  rapid  onset,  associated 
Avith  muscular  paralysis  and  atrophy,  occurring  chie%  in  children,  and 
most  frequently  in  those  under  three  years  of  age. 

Pathology. — The  condition  is  generally  unilateral,  and  is  a  true 
focal  myelitis ;  hence  we  find  congestion,  softening,  and  even  cavity- 
formation.  Microscopically,  the  chief  feature  observed  is  the  de- 
struction of  the  multipolar  ganglion-cells  of  the  anterior  horn.  If  the 
examination  is  not  made  until  months  or  years  have  elapsed  since  the 
onset,  the  condition  -will  be  about  as  follows  :  More  or  less  asymmetry  of 
the  cord  in  the  region  affected,  with  sclerotic  changes  at  the  site  of  the 
lesion,  and  probably  in  the  pyramidal  tract  also.  The  anterior  nerve- 
roots  of  the  same  side  will  be  found  atrophied,  and  the  muscles  wasted, 
having  undergone  fatty  degeneration  and  fibrous  change. 

i^tiology. — The  precise  cause  is  not  known,  but  the  following  pre- 
dispose to  the  affection — viz.  age,  exposure,  acute  diseases  (particularly 
those  known  to  be  infectious),  and  warm  weather.  The  disease  may 
occur  at  any  age,  but  by  far  the  greatest  number  of  cases  occur  before 
the  third  year  of  life  ;  they  are  about  equally  distributed  between  the 
two  sexes.  Later  in  life  the  condition  is  more  common  in  males,  chiefly 
between  the  ages  of  ten  and  twenty-five.  It  is  rare  after  this  period. 
Epidemics  have  been  described,  and,  notably,  one  occurring  during  the 
summer  of  1894.  Dr.  Caverly  of  Rutland,  Yt.,  then  reported  126  cases 
occun-ing  in  Otter  Creek  Valley,  a  limestone  region  of  Vermont.     At  the 


ANTERIOR  MYELITIS.  1077 

same  time  domestic  animals — horses,  dogs,  and  hens — were  affected  with 
a  paralytic  disease,  this  fact  still  further  supporting  the  idea  of  an 
infectious  origin.     A  similar  epidemic  has  occurred  in  Ohio. 

Symptoms. — The  onset  is  generally  acute,  and  may  be  sudden. 
Constitutional  symptoms  are  present  as  a  rule.  Generally,  the 
sequence  is  as  follows  :  Fever  (usually  slight),  malaise,  possibly  vomit- 
ing (especially  in  children),  muscular  twitching,  headache,  and  rest- 
lessness. In  a  few  hours,  or  after  one  or  two  days,  paralysis  supervenes 
and  quickly  spreads,  involving  a  greater  or  less  area ;  it  then  remains 
stationary  for  from  two  to  four  days  to  from  five  to  eight  weeks,  when 
improvement  takes  place,  beginning  in  the  part  last  affected.  In  some 
cases,  after  a  most  trifling  indisposition  over  night,  paresis  is  met  with  in 
the  morning.  In  a  few  weeks  only  that  portion  remains  paralyzed  that 
is  to  be  permanently  damaged.  Wasting  of  the  muscles  will  be  noticed 
a  week  or  two  after  the  onset  of  paralysis  ;  these  become  flaccid  and 
give  the  reactions  of  degeneration.  Sensory  symptoms  are  very  rarely 
present — so  seldom,  indeed,  that  they  need  not  be  reckoned  with.  The 
reflexes  are  lost,  both  superficial  and  deep,  and  later  contractures  develop 
and  result  in  various  deformities.  The  growth  of  bone  is  seriously  im- 
paired in  some  cases.  Complete  recovery  rarely  takes  place,  nor  is  it  to 
be  expected  when  we  consider  the  destruction  of  the  neuron-body. 

Diagnosis. — Usually  this  is  not  difficult,  except,  possibly,  for  the 
first  few  days  in  some  cases.  Close  scrutiny  will  enable  one  to  differen- 
tiate between  this  disease  and  a  pseudo-palsy  the  result  of  pain  on  active 
or  passive  motion,  as  seen  in  rickets,  scurvy,  and  in  hip-joint  disease. 

Prognosis. — Some  impairment  of  motion  and  more  or  less  wasting 
of  the  muscles  almost  invariably  remain.  Danger  to  life,  however,  is 
very  remote,  though  the  subjects  of  infantile  paralysis  are  predisposed  to 
intercurrent  affections,  since  their  natural  degree  of  resistance  is  lowered. 
The  more  rapid  the  loss  of  faradic  irritability  the  less  the  extent  of  recovery. 

Treatment. — I  think  we  are  justified  in  regarding  this  disease  as 
infectious,  probably  caused  by  a  specific  micro-organism,  although  it  is 
possibly  an  auto-intoxication.  If  this  is  granted,  it  behooves  us  to 
act  promptly  and  render  the  emunctories  in  good  condition.  If  the  case 
is  seen  early,  a  few  doses  of  calomel  may  be  given,  and  these  followed  by 
a  saline.  Copious  enemata  of  boiled  water  thrown  high  up  into  the  bowel 
should  also  be  employed.  Should  the  fever  be  high,  it  must  be  met,  as 
in  any  other  case,  by  sponging  or  even  by  a  cool  bath,  cold  compresses 
to  the  head,  and  internally  by  the  bromids,  aconite,  and  the  spirits  of 
nitrous  ether.  During  the  febrile  stage,  or  at  least  for  a  few  days  or  a 
week,  it  is  advisable  to  keep  the  patient  in  bed.  The  affected  parts  should 
be  wrapped  in  cotton,  and  counter-irritation  may  be  applied  to  the  spine. 
As  soon  as  possible  the  child  is  to  be  taken  into  the  fresh  air.  It  is  of 
vital  importance  to  keep  up  the  general  systemic  tone,  and  hence  the  ne- 
cessity for  fresh  air,  change  of  scene,  and  for  nourishing  but  easily  digest- 
ible food.  During  this  period  massage  and  electricity  should  be  employed, 
together  with  the  administration  of  strychnin.  In  the  later  stages,  when 
contractures  have  set  in,  mechanical  appliances  may  be  necessary  to 
correct  deformity  and  to  give  support. 


1078  DISEASES  OF  THE  NERVOUS  SYSTEM. 


ACUTE,    SUBACUTE,    AND    CHRONIC   POLIOMYELITIS   IN   ADULTS. 

1.  Acute  atrophic  spinal  paralysis  of  adults,  as  the  acute  form  is 
called,  has  essentially  the  same  symptomatology  as  the  corresponding 
disease  in  children,  except  that  the  onset  is  apt  to  be  more  pronounced. 
Convulsions,  however,  scarcely  ever  occur.  When  pain  is  a  prominent 
symptom  ^\e  should  be  guarded  in  making  a  diagnosis.  Initial  pain  is 
significant  of  a  nerve-lesion,  particularly  if  sensory  disturbances  can  be 
found,  and  such  cases  would  indicate  a  neuritis  and  not  a  poliomyelitis. 
Presumably  the  incidence  of  the  poison  has  been  on  the  axon,  and  not 
on  the  neuron-body,  this  view  being  consonant  with  the  complete  recov- 
ery that  is  sometimes  seen  in  adults.  When  true  poliomyelitis  has  ex- 
isted complete  recovery  probably  never  occurs. 

2.  The  subacute  form  has  been  described  by  Duchenne  as  '■'•paralysis 
general  spinale  antcrieure  subaigue."  It  comes  on,  as  a  rule,  without 
apparent  cause,  and  the  initial  symptoms  are  very  slight.  In  a  few  weeks 
failure  of  power  is  noticed  in  the  limbs  and  paralysis  gradually  supervenes. 
After  lasting  for  some  time  partial  recovery  follows,  the  paralysis  and  mus- 
cular atrophy  remaining  in  a  limited  region  only. 

3.  That  chronic  poliomyelitis  exists  has  been  proved  by  Oppenheim 
and  other  observers  ;  yet  it  is  probable  that  most  cases  described  under 
this  heading  have  been  due  to  peripheral  and  not  to  central  lesions.  In 
neuritis,  however,  the  paralysis  is  either  unilateral  or  bilateral,  and  in  the 
latter  case  it  is  symmetric,  differing  in  this  point  from  the  irregular  dis- 
tribution of  centric  disease.  Pain  is  common,  and  there  is  also  tenderness 
along  the  nerve-trunks  as  a  rule. 

Recovery  from  neuritis  may  be  perfect ;  at  all  events,  it  does  not 
present  the  tendency  that  is  met  with  in  poliomyelitis  to  clear  up  per- 
fectly, except  in  a  limited  area. 

Treatment. — The  general  line  of  treatment  that  I  have  given  for 
the  infantile  type  is  equally  applicable  in  these  forms.  Ergot  and  bella- 
donna may  be  used  in  the  early  stages,  and,  later,  mercury  or  the  iodids 
in  small  doses.     Electricity  and  massage  are  of  the  greatest  value. 


ABSCESS  OF  THE  SPINAL  CORD. 

It  is  rare  for  inflammation  of  the  cord  to  give  rise  to  pus,  yet  a  few 
cases  have  been  described.  The  suppuration  is  necessarily  micro-organ- 
ismal  in  origin,  and  as  a  rule  is  either  due  to  some  septicemia  or  trauma- 
tism, or  secondary  to  purulent  meningitis.  The  symptoms  are  those  of 
myelitis,  but  may  be  masked  by  any  associated  condition. 


UNILATERAL  LESION  OF  THE  SPINAL   CORD. 


1079 


UNILATERAL  LESION  OF  THE  SPINAL  CORD. 

(Brown- S^quard^s  Spinal  Paralysis.) 

This  is  not  a  distinct  disease,  but  rather  a  grouping  of  certain  symp- 
toms, first  studied  by  Brown-Sdquard,^  and  hence  bearing  his  name.     It 

is  met  with  particularly  as  a  result 
of  injuries  (knife-thrusts  and  the 
like),  though  it  may  also  be  due  to 
tumor  or  caries  of  the  cord,  to  syph- 
ilis, or  to  any  process  causing 
compression  of  one-half  of  the 
cord.  Such  lesions  intercept  the 
motor  impulses  of  the  same  side; 
the  fibers  having  crossed  in  the 
medulla,  the  sensory  fibers  cross 
in  the  cord  soon  after  entering, 
and  hence  sensation  will  be  absent 
on  the  side  opposite  to  the  lesion 
(vide  Fig.  74).  A  lesion  in  the 
cervical  cord  above  the  arm-nuclei 
causes  motor  paralysis  of  both  arm 
and  leg  of  the  same  side  (spinal 
hemiplegia)  and  sensory  paralysis 
on  the  opposite  side.  If  in  the 
dorsal  or  lumbar  cord,  the  leg  on 
the  corresponding  side  is  para- 
lyzed, while  that  of  the  other  is 
anesthetic.  Lesions  are  seldom 
strictly  confined  to  one  side  of 
the  cord,  but  overlap  a  trifle,  so 
that  there  is  apt  to  be  some  loss 
of  power  on  the  anesthetic  side ; 
this,  however,  may  be  due  to  the 
redecussation  of  a  few  motor  fibers 
at  a  lower  level.  The  side  of  the 
lesion  is  hyperesthetic — a  fact  for  which  no  satisfactory  explanation  has 
ever  been  advanced.  Muscular  sense  is  diminished  or  lost  on  the  same 
side.  Above  the  hyperesthetic  region  an  area  of  anesthesia  commonly 
exists,  and  above  this,  again,  an  area  of  hyperesthesia.  The  reflexes 
are  increased  on  the  side  of  the  lesion  (inhibition  being  removed),  and 
the  temperature  of  that  side  is  usually  higher.  On  the  anesthetic  side 
the  motor  power,  reflexes,  muscle-sense,  and  temperature  are  all  normal. 
Sometimes  the  sensory  symptoms  are  limited  to  loss  of  pain  and  tem- 
perature sense. 

The  following   table,  adapted  from  "Wichmann,  gives  the   principal 
symptoms  for  lesions  of  the  segments  of  the  spinal  cord : 

Cervical  cord :  paralysis  of  the  trunk  and  lower  extremities,  loss  of 
sensation  bounded  by  a  horizontal  line  at  the  level  of  the  lesion. 

1  Med.-Chir.  Trans.,  1889. 


Fig.  74.— Schematic  representation  of  course 
of  main  tracts  in  the  cord,  represented  for  a 
single  pair  of  roots  (Erb):  v.  anterior  roots;  h, 
posterior  roots;  ],  paths  for  motor  and  vaso- 
motor conduction  ;  2,  paths  for  muscular  sense ; 
3,  paths  for  cutaneous  sensibility  on  the  right ; 
1',  2',  3',  the  same  paths  on  the  left.  The  arrows 
indicate  the  direction  of  physiologic  conduc- 
tion. 


1080  DISEASES  OF  THE  NERVOUS  SYSTEM. 

C.  1-4.   Death  as  a  result  of  paralysis  of  the  diaphragm. 

C.  5.  Complete  paralysis  of  the  arms,  including  the  deltoids.  Anes- 
thesia from  neck  down. 

C.  6.  Slight  flexion  and  elevation  of  arm  still  possible  (paresis  of 
deltoid  and  biceps),  hyperesthesia  instead  of  total  anesthesia  on  the  pos- 
terior surface  of  arm  and  forearm. 

C.  7.  Paralysis  of  forearm  except  thumb,  which  is  paretic,  paresis 
of  arm.  Anesthesia  below  line  at  level  of  axilla  and  on  ulnar  side  of 
arm  and  forearm. 

C.  8.  Paralysis  of  small  muscles  of  hand,  paresis  of  muscles  of  arm 
and  shoulder.     Anesthesia  as  above. 

D.  1.  Paralysis  of  trunk,  paresis  of  muscles  of  hand.  Anesthesia 
from  level  of  first  dorsal  spine  and  third  rib.  Hyperesthesia  of  arm. 
Disturbances  of  the  pupil  (myosis). 

D.  2-12.  Paralysis  and  anesthesia  corresponding  to  the  level  of  the 
lesion. 

L.  1.  Paralysis  of  the  legs  including  the  psoas.  Anesthesia  from 
level  of  first  lumbar  spine  and  anterior  superior  spines  of  the  ilia. 
Reflexes  absent  or  increased. 

L.  2.  Paralysis  of  the  legs  except  the  psoas.  Anesthesia  of  the 
anterior  and  posterior  surfaces  of  the  thighs,  hyperesthesia  of  inner  and 
outer  sides.     Reflexes  lost. 

L.  3.  Paralysis  of  the  legs,  of  the  rotation  of  the  thighs,  of  flexors 
of  legs;  paresis  of  the  other  muscles.  Anesthesia  of  the  sacral  region 
of  the  genitalia,  of  the  posterior  surface  of  the  thighs,  and  of  the  legs. 
Reflexes  lost. 

L.  4.  Paral^'sis  as  above,  except  internal  rotation  of  thigh  is  possible. 
Anesthesia  as  above,  except  inner  surface  of  thigh  is  hypesthetic. 

L.  5.  Paralysis  of  biceps,  glutei,  flexors  of  toes,  paresis  of  other  mus- 
cles.    Anesthesia  as  above. 

S.  1.  Paralysis  of  rectum  and  bladder;  paresis  of  muscles  of  legs. 
Anesthesia  of  sacral  region,  genitalia,  and  posterior  surface  of  thigh; 
posterior  and  external  surface  of  the  legs,  and  external  half  of  the 
foot. 

S.  2.  Paralysis  of  the  muscles  of  the  anus  and  of  the  bladder.  Pare- 
sis of  the  legs.  Anesthesia  of  sacral  region,  genitalia,  and  posterior 
surface  of  thigh. 

S.  3.  Paralysis  as  above,  no  paresis  of  legs.  Anesthesia  of  sacral 
region,  region  of  anus,  and  posterior  surface  of  scrotum  and  penis  (or 
of  labia). 

S.  4.  Paresis  of  sphincter  ani  and  bladder.  Small  anesthetic  area 
over  sacrum  and  about  the  anus. 

S.  5.   Small  area  of  anesthesia  over  the  coccyx. 


LOCOMOTOR  ATAXIA. 


1081 


LOCOMOTOR  ATAXIA. 

{Tabes  Dorsalis ;    Posterior  Sclerosis.) 

Definition. — A  systemic  sclerosis  affecting  the  posterior  columns 
of  the  cord.  In  many  cases  foci  of  degeneration  occur  in  the  basal 
ganglia.  The  disease  is  characterized  by  a  loss  of  coordination,  ab- 
sence of  the  knee-jerk,  fulgurant  pains,  and  the  Argyll-Robertson  pupil. 

Pathology. — Macroscopically,  it  may  be  observed — 1.  That  the 
posterior  roots  are  more  or  less  atrophied  and  grayish  in  color. 

2.  There  is  a  thickening  and  adhesion  of  the  spinal  membranes,  with 
some  degree  of  congestion,  particularly  noticeable  in  the  posterior  region 
(not  a  constant  change). 

3.  There  is  a  slight  change  in  the  shape  of  the  cord,  and  the  affected 
regions  assume  a  grayish  tint.  Change  of  color  is  well  seen  after  the 
cord  is  hardened.  Microscopically,  degeneration  of  the  peripheral  sensory 
nerves  Avill  be  found  in  certain  cases  to  be  more  marked  at  the  periphery 
and  to  diminish  as  the  main  trunks  are  reached.  Rarely,  changes  in 
the  motor  nerves  will  be  met  with  also,  but  only  in  cases  in  which  the 
anterior  horns  are  affected.       The  spinal  ganglia  are  usually  normal. 


Fig.  75. — Diagram  of  primary  degeneration-areas  and  secondary  degeneration  of  the  fibers  in 
the  beginning  stage  of  tabes  (Leube) :  psb,  pyramidal  tract ;  ksb,  cerebellar  tract ;  hxuf,  posterior 
root-iibers ;  Iff,  lateral  entrance  of  delicate  root-fibers :  k,  area  of  earliest  degeneration ;  r,  marginal 
zone ;  sg,  substantia  gelatinosa :  cv,  Clark's  columns ;  i.  anterior  zones  (remaining  free) ;  sc,  sensory 
collateral  fibers  ;  hrc,  collateral  reflex  of  posterior  column ;  src,  collateral  reflex  of  the  lateral 
column;  ,  liealthy  fibers  ; ,  degenerated  fibers. 

4.  There  are  degenerative  changes  in  the  posterior,  and  occasionally 
in  the  anterior  roots  (vide  Fig.  75). 

5.  Cord-changes  are  present,  consisting  in  the  early  stages  of  a  de- 
generation of  the  fibers  of  the  Spitzka-Lissauer  column,  of  the  post-root 
zone  of  Charcot,  of  the  fibers  going  to  the  column  of  Clark,  and  of  the 
comma  tract.  As  the  disease  progresses  more  and  more  of  the  posterior 
columns — GoU  and  Burdach — is  involved  with  the  fibers  of  Gower's 


1082  DISEASES  OF  THE  NERVOUS  SYSTEM. 

column,  the  intermedio-lateral  tract,  and  even  the  direct  cerebellar  tract. 
This  latter  is  only  affected,  however,  when  the  cells  of  Clark's  column 
are  involved. 

While  the  chief  incidence  of  the  poison,  whatever  this  may  be,  is 
upon  the  nerve-fibers,  yet  we  do  meet  Avith  cases  in  which  the  posterior 
root-cells  are  diseased ;  as  already  stated,  the  cells  of  the  anterior  horn 
may  be  diseased  also.  There  is  an  overgrowth  of  neuroglia  that 
takes  the  place  of  the  degenerated  fibers,  and  when  the  membranes  are 
thickened  the  strands  of  connective  tissue  dipping  into  the  cord  take  on 
added  growth. 

6.  There  a,ve  cerebral  and  medullary  changes.  There  may  be  some 
change  in  the  nuclei  of  the  columns  of  Goll  and  Burdach  and  in  those 
of  some  of  the  cranial  nerves.  In  addition  to  changes  in  the  nervous 
system,  certain  cases  present  some  morbid  condition  of  the  osseous  sys- 
tem, consisting  of  erosion  of  the  interarticular  cartilages  and  atrophy 
and  absorption  of  the  bony  articulating  surfaces. 

Ktiology. — Bare. — White  races  are  more  susceptible  than  negroes  ; 
and  the  disease  is  less  frequently  met  with  among  the  Jews  than  among 
other  white  classes.  Sex. — Males  are  more  liable  to  the  disease  than 
females,  in  the  proportion  of  10  to  1.  Age. — Most  common  between 
the  ages  of  thirty  and  forty.  Sypfiilis. — Since  Fournier  in  1875  first 
pointed  out  the  relationship  between  these  two  diseases,  the  opinion  has 
steadily  gained  ground,  despite  the  view  of  Leyden  and  other  German 
authorities,  that  a  large  majority  of  tabetic  cases  (observers  diifer  as  to 
the  proportion)  have  an  antecedent  history  of  syphilis.  It  must  be  clearly 
borne  in  mind  that  locomotor  ataxia  is  not  syphilis  of  the  cord  and  brain, 
but  a  distinct  entity,  in  most  cases  of  which,  however,  syphilis  stands  as 
a  predisposing  factor.  It  will  be  remembered  that  in  the  description  of 
anemia  of  the  cord,  lesions  resembling  those  of  tabes  are  found  as  a 
result  of  various  toxemias,  and  it  was  suggested  that  this  might  throw 
some  light  on  those  cases  in  which  no  syphilitic  history  can  be  obtained. 
Exposure  and  sexual  excess  are  possible  factors;  likewise  traumatism. 
Alcohol  is  said  to  cause  tabes,  but  this  is  very  doubtful ;  it  may  certainly 
give  rise  to  pseudo-tabes,  the  peripheral  form.  In  England,  Gowers  has 
noted  that  locomotor  ataxia  occurs  more  frequently  among  urban  than 
among  rural  populations. 

Symptoms. — These  may  be  grouped  into  various  stages:  the  pro- 
dromal, preataxic,  ataxfc,  and  paralytic.  The  prodromal  stage  may  extend 
over  a  number  of  years,  the  symptoms  are  slight  and  often  make  very 
little  impression  upon  the  patient.  They  consist  of  occasional  pains,  usu- 
ally in  the  legs,  of  transient  disturbances  of  the  ocular  muscles  leading 
to  ptosis,  diplopia,  etc.,  occasionally  of  slight  diminution  of  vision,  most 
noticeable  at  night,  and  of  more  or  less  pronounced  impairment,  very 
rarely  exaltation,  of  sexual  power.  The  symptoms  become  characteristic 
only  in  the  preataxic  stage.  The  pains  in  the  legs  become  more  fre- 
quent and  assume  the  typical  fulgurant  or  lancinating  type ;  that  is,  a 
stabbing  or  boring  sensation,  shooting  along  the  limbs  and  lasting  for 
a  brief  interval  of  time.  The  pupils  give  the  Argyll-Robertson  phenom- 
enon (failure  to  contract  to  light),  there  is  permanent  myosis,  nycta- 
lopia, and  the  paresis  of  the  eye-muscles  may  be  still  present  or  may 


LOCOMOTOR  ATAXIA.  1083 

have  disappeared.  There  is  usually  some  disturbance  of  motion,  chiefly 
manifested  at  night,  and  ataxia  may  be  revealed  by  the  finer  tests 
(having  the  patient  hop  -backward  on  one  leg).  The  patella  reflexes 
are  diminished  or  absent.  There  is  now  distinct  impairment  of  sexual 
power  and  difficult}^  in  urination.  The  sensory  symptoms  belong  to 
this  and  the  following;  stao;e. 

The  dominant  symptom  of  the  ataxic  stage  is  the  incoordination  of 
movement.  This  gives  rise  to  the  ataxic  gait.  The  legs  are  kept  far 
apart  and  are  lifted  higher  than  is  necessary  from  the  ground,  they  are 
brought  down  violently,  and  the  gait  is  of  a  peculiar  stamping,  irregular, 
slightly  staggering  character.  Ataxia  of  the  arms  occurs  later  and  is 
manifested  by  difficulty  in  grasping  objects  or  in  accomplishing  finer 
coordinated  movements.  Ataxia  of  the  lower  extremities  may  be  tested 
by  directing  the  patient  to  touch  with  his  toe  an  object  held  above  it, 
or,  when  lying  down,  to  place  the  heel  of  one  foot  upon  the  knee  of  the 
other ;  of  the  upper  limbs  by  directing  him  to  touch  rapidly  the  tip  of  the 
nose  with  the  forefinger,  or  to  spread  the  arms  apart  and  bring  the 
forefingers  rapidly  together.  Loss  of  station,  or  Bomherg's  syiivptom,  is 
tested  by  directing  him  to  stand  with  the  feet  close  toarether  and  to  close 
the  eyes.  The  swaying  of  the  body  w^ill  vary  from  several  inches  in 
either  direction  to  falling  over.  The  reflexes  are  now  completely  abol- 
ished, and  there  is  often  some  wasting  of  the  muscles.  The  sphincters 
are  involved,  there  is  often  difliculty  in  voiding  the  urine,  associated 
with  incontinence,  and  as  a  result  of  careless  catheterization  cystitis  is 
often  acquired. 

The  sensory  symptoms  are  various:  in  addition  to  the  fulgurant  pains, 
there  are  visceral  crises,  characterized  by  sudden  severe  pain  and  dis- 
turbance of  function.  The  most  common  seat  is  the  stomach,  and  the 
crises  are  associated  with  vomiting  of  acid  material.  Crises  may  also 
involve  the  larynx,  liver,  kidneys,  and  rectum.  Diminished  sensation 
aff"ects  the  organs,  nerves,  and  areas  of  the  skin.  There  is  loss  of  sensa- 
tion in  the  testicles  or  breasts,  and  severe  blows  in  the  pit  of  the  stomach 
cause  no  distress.  Biernacki  s  symptom.,  loss  of  sensation  in  the  ulnar 
nerve  is  present.  Areas  of  anesthesia  or  hyperesthesia,  usually  segmental 
in  type,  can  be  detected  upon  the  trunk  or  less  frequently  upon  the 
extremities.  The  girdle  pain  is  a  feeling  of  constriction  that  may  be 
very  uncomfortable  about  some  part  of  the  trunk.  The  paralytic  stage 
inaugurates  the  termination  of  the  disease.  Locomotion  becomes 
impossible  or  can  only  be  accomplished  with  the  aid  of  two  canes,  loss 
of  control  over  the  bladder  is  complete,  the  patient  is  querulent  or  even 
demented,  and  muscular  wasting  and  bed-sores  may  appear.  In  either 
this  or  the  ataxic  stage  the  optic  nerve  may  atrophy,  and  this  is  often 
associated  with  a  remarkable  improvement  in  the  ataxia  that  is  at 
present  inexplicable.  Death  usually  occurs  as  a  result  of  infection, 
either  through  the  bladder  or  lungs,  more  rarely  as  the  result  apparently 
of  exhaustion. 

Course. — Rarely  the  disease  runs  a  very  rapid  course.  The  preataxic 
symptoms — pain,  loss  of  knee-jerk,  Argyll-Robertson  pupil  with  or  with- 
out ptosis  and  diplopia — may  only  exist  a  feAv  Aveeks  before  incoordina- 
tion develops.     The  latter  will  then  reach  its  acme  in  twenty  to  thirty 


1084  DISEASES  OF  THE  NERVOUS  SYSTEM. 

days.  This  is  very  unusual,  however.  As  a  rule,  the  first  or  preataxic 
stage  extends  over  a  period  varying  from  months  to  even  as  long  as 
twenty-five  years.  Dr.  Wm.  Egbert  Robertson  has  related  to  me  the 
case  of  a  man  aged  fifty-eight  who  for  fifteen  years  has  had  fulgurant 
pains  and  an  absence  of  the  knee-jerk,  but  neither  ocular  nor  any  other 
symptoms.  In  some  cases  the  first  stage  may  be  absent.  The  second  or 
ataxic  stage — that  of  incoordination — is  generally  slowly  progressive, 
finally  reaching  a  point  at  which  it  remains  ;  rarely,  more  or  less  improve- 
ment may  follow.  When  optic  atrophy  develops,  ataxia  either  does  not 
appear,  or,  having  done  so,  fails  to  advance.  The  final  stage  in  a  few  cases 
is  only  reached  when  the  patient  has  become  paralyzed  and  bedridden. 

Diagnosis. — This  is  readily  made  when  we  have  a  combination  of 
the  absent  knee-jerk,  fulgurant  pains,  and  the  Argyll-Robertson  pupil. 
However,  the  loss  of  knee-jerk,  associated  with  one  of  the  other  symp- 
toms in  an  otherwise  healthy  man,  is,  to  say  the  least,  highly  suggestive 
of  the  disease ;  the  addition  of  incoordination  serves,  of  course,  to  clinch 
the  argument. 

Differential  Diagnosis. — Peripheral  Neuritis. — The  symmetric  dis- 
tribution of  symptoms,  tenderness  in  the  muscles,  frequent  herpetic 
rashes,  motor  weakness  and  wasting,  pain  (not  fulgurant  in  type),  greater 
prominence  of  parasthesia,  absence  of  the  Argyll-Robertson  pupil,  knee- 
jerk  often  increased  (absent  in  diphtherial  form,  but  other  symptoms  and 
history  serve  to  distinguish  it),  and  later,  either  diminished  or  absent, 
and  the  history  of  the  case,  are  sufficient.  Alcoholic  and  more  rarely 
arsenical  poisoning  give  rise  to  a  condition  closely  resembling  true  tabes 
in  that  there  is  the  loss  of  knee-jerk,  often  sharp  pain,  and  incoordina- 
tion, though  the  latter  symptom  is  never  as  marked  as  in  advanced  tabes. 
The  gait,  however,  is  totally  different,  and  consists  of  the  high  "  steppage  " 
gait  described  in  the  discussion  of  Peripheral  Neuritis. 

General  parali/sis  of  the  insane  may  present  much  difficulty.  Spinal 
symptoms  may  occur  in  general  paresis,  and  conversely  in  certain  cases 
of  tabes  symptoms  of  general  paresis  develop.  Time  alone  will  solve  the 
problem. 

Ataxic  Paraplecfia. — Apart  from  the  absence  of  pain  and  anesthesia, 
incoordination  is  followed  by  a  spastic  condition.  The  knee-jerk  is  much 
exaggerated  and  the  so-called  ankle-clonus  develops. 

Cerebellar  Disease. — The  incoordination  does  not  resemble  that  of 
ataxia ;  optic  neuritis  is  present ;  also  headache  and  vomiting  appear  in 
well-marked  cases.     The  knee-jerk   is  always  present. 

There  are  certain  conditions,  already  described  under  Anemia  of  the 
Cord,  in  which  lesions  of  the  posterior  columns  of  the  cord  occur.  Some 
of  them  are  very  much  like  tabes,  but  do  not  present  the  "  combination 
of  symptoms  "  seen  in  locomotor  ataxia.  As  a  rule,  the  Argyll-Robert- 
son pupil  is  absent,  and  less  frequently  the  lightning  pains  also. 

The  crises  may  be  mistaken  for  disease  of  the  various  organs  involved. 
Repeated  attacks  of  acute  pain,  tabetic  in  character,  and  particularly  in 
adult  males,  should,  however,  excite  suspicion,  and  an  absence  of  the  knee- 
jerk  and  other  characteristic  evidences  will  always  be  present  in  ataxia. 

When  the  chief  lesion  is  in  the  dorsal  region  the  pain  may  be  mistaken 
for  that  of  spinal  caries  or  even  neuralgia  or  rheumatism.     From  caries 


LOCOMOTOR  ATAXIA.  1085 

it  may  be  diiFerentiated  by  tbe  fact  that  in  vertebral  disease  the  pain  is 
more  or  less  localized,  and  that  it  is  much  increased  by  movements.  More- 
over, the  other  symptoms  of  ataxia  are  wanting — e.  g.  ocular  troubles, 
incoordination,  and  absence  of  the  knee-jerk.  The  latter  point  also 
holds  good  in  cases  of  rheumatism  and  intercostal  neuralgia.  For  the 
diagnosis  from  hereditary  ataxia  vide  p.  1084. 

Prognosis. — The  outlook  is  not  particularly  bright.  While,  as 
already  stated,  the  disease  does  not  cause  death,  perfect  recovery  is  never 
obtained.  Of  course  the  prospect  is  much  brighter  the  earlier  the  case  is 
taken  in  hand,  and  some  improvement  may  be  expected  in  most  cases. 
The  fact  that  the  patient  has  had  syphilis  does  not  modify  the  prognosis 
one  way  or  the  other. 

Treatment. — Rest  (first  suggested  by  Weir  Mitchell)  is  imperative 
when  the  patient  commences  treatment,  and  especially  when  pain  is  early 
complained  of,  massage  and  electricity  being  employed  meanwhile  to  keep 
up  the  tone  of  the  muscles.  In  my  opinion  the  rest-treatment  retards 
the  progress  of  ataxia  more  effectively  than  any  other  measure,  but  it 
cannot  be  used  with  the  expectation  of  producing  a  cure.  The  bowels 
should  be  moved  daily,  and  the  urinary  functions  especially  looked  to. 
In  certain  cases  catheterization  is  necessary.  The  patient  should  then 
be  taught,  first,  what  surgical  cleanliness  means ;  and  secondly,  how  to 
use  the  instrument.  Counter-irritation  along  the  spine  and  suspension 
are  useless.  The  diet  should  not  be  heavy,  and  if  gastric  crises  occur 
special  care  should  be  taken  in  this  direction. 

In  cases  giving  a  previous  history  of  syphilis,  mercury  and  the  iodids 
may  be  used ;  it  is,  however,  doubtful  if  they  are  of  any  direct  benefit, 
although  when  the  venereal  disease  is  of  comparatively  recent  date  some 
improvement  in  the  tabetic  lesions  is  possible.  Potassium  iodid  should 
be  used  freely.  Mercury  is  best  introduced  into  the  system  by  inunction, 
and  it  is  my  custom  to  order  one  dram  to  be  rubbed  into  the  arm-pits, 
flanks,  or  inner  surfaces  of  the  thighs  daily  until  the  gums  show  the  spe- 
cific influence  of  the  remedy.  Then  the  inunctions  are  discontinued,  and 
the  potassium  iodid  and  mercuric  chlorid  are  administered  in  combination 
three  times  per  diem.  The  dose  of  the  latter  remedy  should  be  small 
(gr.  -^ — 0.0027),  but  the  iodid  may  be  used  in  ascending  dosage. 

Electricity  is  of  doubtful  utility.  The  galvanic  current  is  to  be 
cliosen,  and  Erb  advises  placing  the  medium-sized  cathode  over  the  cer- 
vical sympathetic,  and  the  larger  anode  near  to  the  spinal  column  on 
the  opposite  side,  moving  it  at  brief  intervals  in  the  downward  direction. 
This  method  must  be  continued  for  many  months.  Frenkel  has  recently 
advocated  the  systematic  education  of  the  muscles  in  coordinated 
movements.  Hydrotherapy  is  a  serviceable  measure  if  judiciously  em- 
ployed. Neither  cold  nor  hot  baths  are  free  from  deleterious  efi'ects,  but 
tepid  baths  (80°-90°  F.— 26.6°-32.2°  C),  combined  with  gentle  friction 
of  the  body-surface,  are  signally  useful.  Among  the  numerous  natural 
springs  enjoying  more  or  less  popularity  there  are  two  in  especially  high 
favor — the  carbonic-acid  thermal  saline  springs  of  Oeynhausen-Rehme  in 
Minden  and  Aix-la-Chapelle  in  Germany.  The  chief  benefit  may,  after 
all,  be  credited  to  the  invigorating  eSect  of  the  changed  environments. 

The  fulgurant  pains,  or  those  of  the  various  crises,  are  occasionally  so 


1086  DISEASES  OF  THE  NERVOUS  SYSTEM. 

severe  as  to  require  bromids,  codein,  or  even  morphin,  though  the  use 
of  the  latter  agent  is  always  to  be  postponed  until  other  means  are 
exhausted.  Antipyrin  or  salol  and  phenacetin  may  also  be  tried  in 
this  connection.  Heroin  is  often  almost  a  specific.  In  any  case  the 
patient  should  live  a  simple,  regular  life,  avoiding  excesses  of  all  kinds, 
and  particularly  sexual  and  alcoholic  indulgences. 


HEREDITARY  ATAXIA. 

{Friedreich's  Disease. ) 

Definition. — An  hereditary  disease,  first  described  in  1861  by  Fried- 
reich. The  symptoms  are  primarily  manifested  in  early  life,  and  the  dis- 
ease is  characterized  by  ataxia,  defective  speech,  nystagmus,  absence  of 
the  knee-jerk,  and  more  or  less  secondary  deformity,  as  spinal  curvature 
or  talipes. 

Patholog'y. — The  postmortem  findings  are  essentially  those  of  loco- 
motor ataxia  and  ataxic  paraplegia.  The  spinal  membranes  are  some- 
what thickened  and  adherent,  especially  over  the  posterior  part  of  the 
cord,  and  that,  too,  chiefly  in  the  lumbar  region.  The  posterior  nerve- 
roots  are  generally  atrophied  and  sclerosed.  The  columns  of  Goll  and 
Burdach  are  degenerated,  particularly  in  the  lumbar  region,  and  to  a 
lesser  extent  in  the  cervical.  Degeneration  is  also  found  in  the  lateral, 
and  to  a  slight  degree  in  the  anterior,  columns.  The  chief  microscopic 
change  is  a  marked  neurogliar  overgrowth,  as  shown  by  D^jerine.  The 
nerve-cells  of  the  cord  are  generally  normal.  Frequently  the  cord  is 
abnormally  small.  Cerebral  lesions  also  have  been  found  in  this 
disease. 

Ktiology. — 1.  Family  tendency  (heredity)  has  a  strong  influence. 
A  single  case,  however,  may  develop  in  a  family. 

Age. — Most  commonly  the  disease  appears  between  the  third  and 
twelfth  years,  though  it  may  appear  earlier. 

Infectious  fevers  (in  particular)  and  other  acute  diseases  frequently 
precede  the  evolution  of  this  complaint.  Trauma  and  many  other  con- 
ditions have  been  described  as  exciting  causes. 

Symptoms. — The  first  evidence  of  the  disease  is  impaired  coordi- 
nation, first  in  the  legs,  and,  later,  in  the  arms  ;  it  is  most  marked  when 
the  eyes  are  closed.  Attention  is  often  called  to  this  symptom  by  the 
fact  that  the  child  stumbles,  ambles,  and  staggers,  and  cannot  walk  prop- 
erly. The  gait,  however,  lacks  the  pronounced  stamp  of  true  ataxia. 
Rutimeyer  has  pointed  out  that  in  many  cases  the  great  toes  are  turned 
upward.  Some  children  never  learn  to  walk.  Romberg's  symptom  is 
generally  present.  Movements  of  the  arms,  when  these  are  ataxic,  are 
irregular  and  jerky,  and  jerky  movements  of  the  head  may  also  be  ob- 
served. Bilateral  nystagmus  develops  and  the  speech  becomes  aff'ected. 
At  first  there  is  a  mere  impediment  (a  stuttering),  but  later  syllables,  or 
even  whole  words,  are  omitted  and  an  unintelligible  jargon  results.      The 


SPASTIC  PARAPLEGIA.  1087 

knee-jerks  are  almost  ahvays  absent.  There  is  no  optic  atrophy,  nor  are 
any  sensory  symptoms  present  as  a  rule.  The  sphincters  are  normal. 
There  are  no  trophic  changes  in  the  skin  or  the  joints,  and  no  visceral 
crises.  Vaso-motor  symptoms — flushing,  sweating — are  sometimes  ob- 
served.    There  is  no  mental  change. 

Talipes  and  spinal  curvature  are  generally  met  with  after  the  disease 
has  existed  for  some  time.  In  old  cases  muscular  weakness  and  wasting 
are  present,  but  there  is  no  electric  change  in  the  muscles. 

The  course  is  always  slow.  It  may  last  for  many  years,  thirty  or 
even  more. 

Diagnosis. — Usually  this  is  not  difficult,  and  especially  when  more 
than  one  case  exists  in  a  family.  The  age,  incoordination,  shambling 
gait,  nystagmus,  scanning  speech,  and  deformity  are  strikingly  charac- 
teristic. 

Differential  Diagnosis. — Locomotor  ataxia  appears  later  in  life,  and  the 
preataxic  stage  (pain,  absent  knee-jerk,  and  ocular  symptoms)  is  gener- 
ally well  marked.  It  is  absent  in  hereditary  ataxia,  nor  does  the  latter 
present  the  sensory  and  visceral  symptoms  met  with  in  the  true  form. 
Further,  the  ga^t  is  very  different. 

Ataxic  ]ja)'a]jleg{a  shovfs  an  exaggerated  knee-jerk,  the  presence  of 
ankle-clonus,  and  an  absence  of  the  ocular  symptoms,  nystagmus,  and 
the  scanning  speech. 

Disseminated  Sclerosis. — Tremors  are  almost  always  present,  but 
these  are  fine  and  never  coarse  as  in  hereditary  ataxia.  There  may 
be  nystagmus,  incoordination,  and  imperfect  articulation,  but  the  cases 
are  isolated  (i.  e.  they  do  not  run  in  families). 

The  prognosis  is  necessarily  bad.  The  disease  is  progressive,  though 
it  does  not  kill  directly.     It  may  last  thirty  years  or  more. 

Treatment. — Little  or  nothing  can  be  expected  from  it.  The  same 
general  treatment  should  be  pursued  as  for  locomotor  ataxia. 


SPASTIC   PARAPLEGIA. 

{Primary  Lateral  Sclerosis;    Spastic  Spinal  Paralysis.) 

Definition. — A  disease  of  the  spinal  cord  characterized  by  loss  of 
power,  contractures,  exaggerated  reflexes,  a  peculiar  gait,  and  by  pre- 
cipitate micturition.  Spastic  paraplegia  (spasm  plus  motor  paralysis)  is 
met  with  as  the  result  of  the  various  pathologic  substrata.  Any  trans- 
verse cord-lesion  above  the  lumbar  region  may  cause  motor  paralysis, 
spasticity,  exaggerated  knee-jerk,  and  ankle-clonus.  The  same  condi- 
tion results  from  a  lesion  in  any  part  of  the  upper  segment,  from  the  cor- 
tical motor  cells  to  the  terminal  arborization  of  the  axon  in  the  cord. 

It  is  believed  that  fibers  of  the  pyramidal  tracts  may  be  primarily  in- 
volved, and,  since  they  course  chiefly  through  the  lateral  cord-region,  the 
resulting  condition  has  been  named  primary  lateral  sclerosis.  This  is 
purely  hypothetic,  however,  for  only  two  uncombined   cases   have  been 


1088  DISEASES  OF  THE  NERVOUS  SYSTEM. 

found.  This  may  be  due  to  the  fact  that  the  disease  does  not  tend  to 
shorten  life,  and  that  therefore  the  same  condition  that  caused  degenera- 
tion of  the  pyramidal  fibers  may  subsequently  act  on  other  fiber-systems. 
Since  in  the  case  of  the  lower  segment  it  is  the  peripheral  portion  of  the 
axon  that,  in  many  cases  at  least,  first  yields  to  the  morbific  influence,  so 
may  it  be  with  the  upper  segment.  In  such  an  event,  however,  the  de- 
generation would  be  an  ascending  one,  and  the  converse  of  that  which  is 
usually  met  with  in  the  motor  tracts.  Thus  we  see  that  the  same  clinical 
condition  may  be  etiologically  quite  different.  The  following  are  the 
chief  varieties  : 


PRIMARY   LATERAL   SCLEROSIS. 

That  this  condition  exists  alone  is  questioned,  as  I  have  already  stated. 
Yon  Stofella  has  repoi'ted  a  case,  but  no  microscopic  examination  was 
made.  Morgan's  and  Dreschfeld's  case,  published  in  1881,  seems  to  be 
the  only  one  that  may  be  regarded  as  a  true  type.  The  only  pathologic 
change  observed  was  in  the  pyramidal  tracts  of  the  anterior  and  lateral 
regions. 

Ktiology. — It  is  most  apt  to  occur  when  there  is  a  neuropathic 
family  tendency.  Age,  generally  between  twenty-five  and  forty,  exerts 
an  etiologic  influence.  Exposure,  acute  disease,  and  traumatism  are  all 
predisposing  causes.  Syphilis  has  been  said  to  predispose  to  the  condition, 
but  if  so  it  is  rather  rare. 

Symptoms. — In  typical  cases  the  onset  is  slow.  The  patient  com- 
plains of  feeling  tired,  and  is  less  capable  of  exertion  than  formerly. 
Weakness  of  the  legs  develops,  and  with  it  increasing  difficulty  in  walk- 
ing. Even  at  an  early  stage  some  rigidity  of  the  muscles  will  be  present 
when  the  limb  is  extended  ;  later  this  becomes  a  prominent  symptom. 
The  spasm  is  at  first  of  little  moment.  It  may  only  be  noticed  in  the 
morning.  When  the  disease  has  advanced,  however,  it  becomes  pro- 
nounced, so  that  it  may  not  be  possible  to  flex  the  limb,  or,  if  flexed  and 
an  effort  is  made  to  extend  it,  it  will  often  spring  forward  like  a  knife- 
blade  in  clasp-like  rapidity.  This  spasticity  is  often  so  marked  that  in 
walking,  so  long  as  the  ball  of  the  foot  touches  the  ground,  clonic  con- 
tractions occur  ;  these  also  appear  when  the  individual  is  in  a  sitting 
posture  unless  his  legs  are  extended.  The  gait  is  characteristic  :  the  legs 
are  stiff,  and  move  with  an  evident  effort,  while  the  toes  scrape  the 
ground.  In  some  cases  the  adductor  spasm  is  so  gi-eat  that  the  logs  can- 
not only  not  be  separated,  but  are  actually  overlapped  in  walking  {cross- 
leg  progression).  In  course  of  time  the  power  of  walking  may  be  lost. 
The  flexor  muscles  are  usually  weakened.  The  knee-jerk  is  very  much 
exaggerated,  a  mere  tap  causing  a  sharp,  quick  response.  Ankle-clonus 
can  always  be  elicited.  Pain  and  other  sensory  manifestations  are  often 
absent,  though  dull  and  fleeting  pains  in  the  back  and  limbs  may  be  com- 
plained of.  The  arms  are  frequently  unafiected.  The  sphincters  are* 
rarely  involved,  and  ocular  symptoms  do  not  occur,  though  nystagmus  is 
occasionally  met  with,  Seguin  states  that  the  ability  to  retain  the  urine 
is  lessened  and  precipitate  micturition  results. 

The   diagnosis  is  not   difficult.     Certain  hysteric  cases  may  occa- 


ATAXIC  PARAPLEGIA.  1089 

sionally  simulate  it  very  closely,  but  these  do  not  present  the  character- 
istic spasticity  of  the  true  form,  nor  is  the  knee-jerk  increased  quite  as 
much,  and  ankle-clonus  is  either  slight  or  absent.  Then,  too,  in  hysteria 
spots  of  anesthesia  are  commonly  met  Avith.  Drs.  Bastian  and  Russell 
Reynolds  have  described  "paraplegia  dependent  on  idea,"  in  which  no 
hysteric  element  entered. 

SECONDARY   SPASTIC   PARALYSIS. 

As  I  have  already  mentioned,  transverse  lesions  above  the  lumbar 
region  (caries,  tumor,  sclerosis,  myelitis)  are  followed  by  degeneration 
of  the  pyramidal  tracts,  and  as  a  result  there  are  weakness  in  the  limbs, 
increased  reflexes,  and  more  or  less  rigidity.  If  the  lesion  is  total  the 
paralysis  is  usually  flaccid  and  the  reflexes  are  lost. 

CONGENITAL   SPASTIC   PARAPLEGIA. 

This  condition,  the  symptomatology  of  which  is  practically  that  of  the 
adult  types  previously  described,  is  almost  always  the  result  of  some  in- 
jury at  birth,  either  instrumental  or  due  to  a  malposition,  as  first  pointed 
out  by  Dr.  Little  and  since  abundantly  confirmed  by  Spencer,  Dr.  Sarah 
McNutt,  Sachs,  and  others.  The  disease  is  probably  always  due  to  men- 
ingeal hemorrhage.  In  recent  cases  more  or  less  extravasated  blood  is 
always  found  over  the  central  convolutions  and  often  at  the  base.  Later, 
cases  show  atrophy  and  sclerosis  of  the  motor  region,  the  blood  having 
been  absorbed.  Nothing  abnornal  may  be  noticed  for  a  few  days  or 
weeks,  though  rarely  convulsions,  or  even  bulbar  symptoms,  may  early 
manifest  themselves.  Generally,  the  child  is  several  months  old  when  the 
mother  first  notices  some  impairment  of  movement,  and  not  until  the  child 
tries  to  walk  will  she  observe  anything  out  of  the  way.  The  abnormality 
varies  from  a  slight  difiiculty  in  walking,  in  which  the  toes  barely  scrape 
the  ground,  to  a  total  inability  to  walk,  owing  to  the  high  degree  of  adduc- 
tion spasm.  Between  these  extremes  are  various  grades  of  talipes  equinus 
and  cross-legged  progression.  Sensation  is  usually  normal.  The  bladder 
and  rectum  are  not  implicated.  Some  cases  present  evidences  of  impaired 
cerebral  development — idiocy  and  imbecility.  Some  observers  have  also 
described  what  they  believe  to  be  an  hereditary  form  of  spastic  paraplegia 
(notably  Drs.  Gee  and  Sachs). 

ATAXIC   PARAPLEGIA. 

This  name  was  given  by  Gowers  to  a  condition  in  which  spastic  para- 
plegia and  ataxia  coexist,  owing  to  simultaneous  involvement  of  the  lat- 
eral and  posterior  columns.  The  posterior  root-zones  escape,  and  hence 
the  retained  reflexes.  This  same  morbid  condition  may  be  met  with  in 
Friedreich's  disease  (hereditary  ataxic  paraplegia),  or  primary  lateral 
or  posterior  cases  may  extend  and  involve  the  posterior  or  lateral  col- 
umns respectively.  Disseminated  sclerosis  may  possibly  present  the 
same  symptoms.  The  type  Gowers  describes  occurs  chiefly  in  males  of 
middle  age.  Traumatism  and  exposure  seem  to  predispose  to  the  dis- 
ease, as  does  syphilis  very  rarely. 

69 


1090  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Symptoms. — THese  develop  insidiously.  Tlie  patient  tires  rapidly, 
and  some  impairment  of  the  power  of  walking  is  observed.  In  turning 
quickly  he  stumbles,  and  there  is  difficulty  in  walking  in  the  dark,  or 
even  in  standing  when  the  feet  are  close  together.  The  reflexes  are  in- 
creased at  an  early  date,  and  spasticity  supervenes  and  is  progressive, 
though  it  never  becomes  as  marked  as  in  uncombined  lateral  sclerosis. 
The  gait  is  somewhat  similar  to  that  met  with  in  locomotor  ataxia,  but 
it  lacks  the  forcible  stamp  already  described.  When  the  arms  are  in- 
volved the  same  ataxia,  Avith  weakness,  spasticity,  and  increased  reflexes, 
is  met  with.  Sensory  symptoms  are  generally  absent,  and  fulgurant 
pains  are  never  present.  When  pain  occurs  at  all,  it  is  of  a  dull  charac- 
ter and  often  in  the  sacral  region.  Optic  atrophy  does  not  occur.  Nys- 
tagmus is  often  seen,  though  other  eye-symptoms  very  rarely  appear. 
Sexual  power  is  lost.  The  sphincters  are  not  usually  involved,  though 
retention  of  urine  may  occur.  Ultimately,  the  case  generally  partakes 
more  of  the  nature  of  a  lateral  sclerosis,  but  the  features  of  a  posterior 
sclerosis  may  rarely  predominate.  Mental  symptoms  often  develop  in 
the  late  stages. 

The  diagnosis  is  easy  in  typical  cases.  The  ataxia,  with  myotatic 
irritability  and  spasticity  in  the  absence  of  sensory  and  ocular  symptoms, 
is  characteristic. 

COMBINED    SYSTEM   SCLEROSIS. 

Ormerod  and  Dana  have  published  valuable  treatises  on  this  subject. 
In  1891.  Dr.  James  Putnam  of  Boston  described  a  group  of  system 
scleroses,  with  diftuse  collateral  degeneration,  occurring  in  enfeebled 
persons  past  middle  life,  and  more  particularly  in  women.  He  had  had 
8  cases,  and  made  autopsies  on  4.  In  the  white  columns  of  the  cord  he 
found  both  recent  and  old  degenerations  and  disintegration  of  the  cells 
of  the  wray  matter.  In  1  case  he  found  some  degeneration  in  the  pe- 
ripheral nerves.  The  chief  symptoms  were  motor  weakness  of  all  four 
extremities,  but  especially  the  lower,  with  some  impairment  of  sensation 
and  general  muscular  wasting.  In  3  cases  there  was  an  exaggerated 
knee-jerk  with  ankle-clonus;  in  1  lancinating  pains,  and  in  another 
incoordination.  The  fatal  cases  ran  a  course  of  three  or  four  years. 
Several  of  them  showed  lead  in  their  urine,  and  Putnam  thinks  that 
this  may  have  been  an  etiologic  factor  in  some  instances. 

The  sf/mptoms  of  combined  sclerosis  partake  of  the  nature  of  loco- 
motor ataxia  and  spastic  paraplegia,  but  are  less  marked  than  either  of 
these  diseases.  The  onset  is  slow,  there  is  more  or  less  incoordination, 
and  Romberg's  symptom  can  be  elicited  as  a  rule.  There  is  loss  of 
motor  power,  and  the  sensory  symptoms  are  slight.  There  may  be  dull 
sacral  pain.  Optic-nerve  atrophy  very  rarely  occurs,  though  there  are 
certain  eye-symptoms.  The  reflexes  are  generally  exaggerated,  and 
"ankle-clonus"   is  present. 

The  diagnosis  is  based  upon  the  presence  of  paraplegia  with  in- 
creased reflexes,  associated  with  sensory  symptoms — paresthesia^ — and 
rarely  pain. 


MULTIPLE  SCLEROSIS.  1091 


REFLEX   PARAPLEGIA. 


Since  this  was  at  one  time  so  warmly  put  forward  by  Brown^Sequard 
as  a  distinct  entity,  it  seems  justifiable  to  speak  of  it,  though  in  the  light 
of  our  present  knowledge  we  are  not  disposed  to  give  it  any  nosologic 
distinction.  It  was  supposed  to  be  due  to  anemia  of  the  cord,  and  to  be 
the  result  of  irritation  reflected  from  a  sensory  nerve  to  vaso-motor 
nerves.  The  so-called  "  urinary  paraplegia "  was  included  in  this 
category. 

INTERMITTENT  PARAPLEGIA. 

Romberg  was  the  first  to  call  attention  to  this  condition.  His  orig- 
inal case  was  that  of  a  woman  aged  sixty-four,  in  whom  paraplegia  de- 
veloped suddenly  with  involvement  of  the  sphincters.  The  sensations 
were  normal.  In  about  twenty-four  hours  she  was  so  much  better  as  to 
be  able  to  Avalk  ;  micturition  was  normal,  but  there  was  some  weakness. 
Kext  day,  however,  the  paraplegia  returned.  These  attacks,  with  almost 
normal  intervals  assuming  a  periodic  character,  induced  him  to  give  qui- 
nin,  which  he  did.  Recovery  was  the  prompt  result.  Erb  and  others 
have  since  reported  cases,  but  it  is  now  believed  that  they  are  due  to 
involvement  of  the  peripheral  nerves  rather  than  of  the  cord. 

Treatment  of  Spastic  Paraplegia. — In  general  the  treatment  is 

the  same  as  that  of  locomotor  ataxia.  This  is  especially  true  if  syphilis 
is  suspected.  Little  can  be  done,  as  a  rule,  for  the  disease  is  usually 
progressive  in  spite  of  all  treatment.  Belladonna  or  hyoscin  seems  to 
lessen  the  spasm  in  some  cases.  Attention  should  be  given  to  the  blad- 
der and  bowel,  particularly  to  the  former.  In  the  congenital  form  ope- 
rative measures  are  often  requisite  to  overcome  deformity. 


MULTIPLE  SCLEROSIS. 

(Insular  or  Disseminated  Sclerosis.) 

Definition. — A  disease  due  to  the  development  of  sclerotic  patches, 
occurring  in  an  irregular  manner  throughout  either  or  both  the  brain 
and  spinal  cord.  It  is  characterized  by  paresis,  intention-tremors, 
scanning  speech,   and  mental  disturbances. 

Pathology. — The  sclerotic  tissue  occurs  especially  in  the  white 
matter,  though  any  part  of  the  cerebro-spinal  axis  may  suffer.  The 
cortex  is  rarely  implicated.  The  spots  are  usually  well  circumscribed, 
gray  or  grayish-red  in  color,  and  on  section  may  be  level  with,  raised 
from,  or  depressed  beneath  the  normal  line  of  section  according  as  to' 
whether  it  is  in  the  early,  hypertrophic,  or  cirrhotic  stage.  The  cranial 
nerves  may  be  involved  at  their  origin,  the  first,  second,  and  tenth  being 
particularly  vulnerable.  The  medullary  sheath  of  nerve-fibers  in  the 
affected  region  degenerates  early,  but  the  axons  are  markedly  resistant. 


1092  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Since  they  are  not  cut  off  from  their  trophic  center,  secondary  de- 
generation is  rarely  met  with.  The  blood-vessels  show  more  or  less 
proliferation  of  the  adventitia,  and  endarteritis  is  not  an  uncommon 
condition.  Whether  this  vascular  change  is  primary  or  secondary  is 
unknown.  Microscopically,  the  sclerotic  areas  are  made  up  of  an  over- 
growth of  neuroglia-cells  and  fibers  and  of  the  ordinary  connective  tis- 
sue. In  certain  cases  these  patches  exhibit  some  tendency  to  involve 
special  parts  of  the  nervous  system,  as  the  lateral  or  posterior  columns. 

Ktiology. — There  is  no  definite  and  known  etiologic  factor.  Among 
the  possible  predisposing  causes  may  be  mentioned  emotions,  trauma, 
heredity,  exposure,  infectious  and  exhausting  diseases  of  any  kind,  and 
perhaps  hysteria.  It  is  important  to  remember,  moreover,  that  it  is 
frequently  impossible  to  diagnose  this  disease  in  its  early  stage  from 
hysteria.  This  point  is  dwelt  upon  particularly  by  Buzzard  and  Bastian, 
and  many  cases  of  supposed  hysteria  have  subsequently  proved  to  be 
cases  of  multiple  sclerosis.  The  difficulty  is  manifestly  greater  when 
the  patient  is  a  woman.  Age  and  sex  are  also,  in  a  sense,  predispos- 
ing causes.  The  majority  of  cases  occur  between  twenty  and  thirty 
years  of  age,  though  the  condition  may  occur  in  children.  Pritchard 
has  collected  over  fifty  published  cases  occurring  between  the  ages  of 
fourteen  months  and  fourteen  years,  and  about  equally  divided  as  to  sex. 
Among  adults  disseminated  sclerosis  is  met  with  somewhat  more  fre- 
quently in  women. 

Symptoms. — These  may  be  described  under  two  headings :  first, 
the  general  symptoms,  or  those  common  to  all  cases  of  the  disease,  and 
not  explicable  from  the  position  of  the  sclerosis ;  and,  secondly,  those 
dependent  on  the  locality  of  the  lesions.  The  disease  is  always  chronic, 
and  either  remissions,  or  one  or  more  intermissions  occur,  and  in  some 
cases  may  extend  over  several  years.  The  first  evidence  of  the  disease 
is  loss  of  foiver,  first  in  one,  then  in  the  other,  lower  extremity.  Later, 
paresis  develops  in  the  upper  extremity.  Sooner  or  later  other  general 
symptoms  appear — viz.  tremors,  nystagmus,  scanning  speech,  increased 
reflexes,  and  optic-nerve  atrophy.  The  tremor  is  volitional  [^intention- 
tremor),  and  when  the  patient  is  at  rest  no  abnormal  movement  i^  mani- 
fest, as  a  rule.  On  attempting  to  use  the  hands,  or  in  walking,  a  fine, 
trembling  motion  of  the  limbs  results.  The  head  may  be  similarly  in- 
volved, and  some  incoordination  is  commonly  associated  therewith. 
The  yiystagmus,  too,  is  brought  out  w^hen  the  eyes  are  in  use.  It  is 
more  marked  in  lateral  than  in  vertical  movements.  Speech  is  slow  and 
deliberate  (staccato  or  scanning),  the  tendon-reflexes  are  increased, 
ankle-clonus  may  be  present,  and  optic-nerve  atrophy  is  of  frequent 
occurrence.  No  alteration  of  sensation  occurs,  other  than  perhaps  some 
numbness  or  tingling.  There  is  no  wasting  of,  nor  electric  change  in, 
the  muscles,  nor  do  bed-sores  occur.  Vertigo  is  usually  present.  The 
mental  phenomena  are  at  first  hysteroid,  and  they  may  never  progress 
beyond  this  point.  In  other  cases  dementia,  or  even  acute  maniacal  out- 
bui'sts,  are  met  with,  but  these  are  rare.  During  this  stage  epileptiform 
or  apoplectiform  attacks  may  occur.  The  symptoms  directly  resulting 
from  the  local  lesions  cannot  be  given  in  detail.  Certain  types  result, 
however,  that  depend  upon  the  tendency  of  the  sclerotic  areas  to  involve 


MULTIPLE  SCLEROSIS. 


1093 


certain  tracts,  and  these  are — first,  a  form  resembling  lateral  sclerosis, 
due  to  implication  of  the  lateral  tract ;  and,  secondly,  a  form  similar  to 
locomotor  ataxia,  in  which  the  posterior  columns  especially  suifer. 

The  diagnosis  is  generally  easy  after  the  disease  has  lasted  some 
time.  The  intention-tremor  and  the  gradual  and  progressive  loss  of 
power,  with  increased  reflexes,  scanning  speech,  and  mental  deteriora- 
tion, are  sufiicient.  The  following  table  gives  the  differential  points 
between  this  disease  and  paralysis  agitans,  locomotor  ataxia,  and  hered- 
itary ataxia  : 


Disseminated 
Sclerosis. 

Rarely  occurs  in 
children.  Gen- 
erally between 
the  twentieth  and 
thirtieth  years. 

No  sensory  symp- 
toms, as  a  rule. 
Sight  may  be  im- 
paired, the  hear- 
ing less  frequent- 
ly. The  Argyll- 
Robertson  pupil 
is  absent. 

Nystagmus  is  pres- 
ent, as  a  rule. 

Reflexes  are  exag- 
gerated ;  ankle- 
clonus  is  present. 
There  may  be 
muscular  rigid- 
ity. _ 

Scanning  speech. 


A.  tremor  is  gener- 
ally present  on 
voluntary  move- 
ments only.  If 
the  tremor  occurs 
during  rest,  it  is 
fine.  Oscillations 
of  the  head  are 
frequent ;  of  the 
trunk,  less  so. 

Mental  disturbance 
is  frequent. 

Gait  is  usually  spas- 
tic and  paretic, 
and  often  uncer- 
tain. 


Paralysis  Agi- 
tans. 

Occurs  in  persons 
over  forty  years 
of  age. 


No  sensory  or  spe- 
cial-sense symp- 
toms of  any  im- 
portance. A  r  - 
g  y  1 1  -  Robertson 
pupil  is  absent. 


No  nystagmus. 

Reflexes  are  nor- 
mal ;  very  rarely 
they  may  be  plus. 
Permanent  mus- 
cular rigidity. 

Speech  is  slow  and 
deliberate  oncom- 
mencing  a  sen- 
tence, but  soon  it 
becomes  hurried. 

Tremor  when  at 
rest.  Voluntary 
movement  may 
make  it  cease 
temporarily.  The 
head  may  shake, 
vs'ith  rather  a 
vertical  than  an 
oscillatory  move- 
ment. 

No  mental  phenom- 
ena. 

The  head  is  bent 
back  and  arched ; 
the  face  is  immo- 
bile and  mask- 
like. The  gait  is 
propulsion,  fes- 
tination,  retro- 
pulsion,  or  latero- 
pulsion. 


Locomotor  Ataxia. 

Rarely   before    the 
twentieth  year. 


Fulgurant  pains  an 
early  symptom. 
Sight  and  hear- 
ing are  commonly 
affected.  Often 
diplopia  and  Ar- 
g  y  1 1  -  Robertson 
pupil  are  present. 

No  nystagmus. 

The  knee-jerk, 
ankle-clonus,  and 
rigidity  are  all 
absent. 


No  speech-defects. 


No  tremor.  Inco- 
ordination  is 
marked.  No  os- 
cillations of  the 
head  or  trunk. 
Romberg's  symp- 
tom is  present. 
Trophic  disturb- 
ances are  com- 
mon. 

Mental  disturbance 
is  rare. 

The  gait  is  stamp- 
ing in  character  ; 
the  legs  are 
moved  stiffly. 
There  is  difficulty 
in  urination. 


Hereditary 
Ataxia. 

Usually  before  the 
twentieth  year. 
Generally  affects 
several  in  the 
same  family. 

Sensory  symptoms 
are  rarely  pres- 
ent. Diplopia 
and  Argyll-Rob- 
ertson pupil  are 
absent. 


Nystagmus  is  fre- 
quent. 

The  knee-jerk  is  lost 
in  the  course  of 
the  disease  ;  it  is 
rarely  increased. 
No  rigidity. 

Speech  is  slow  and 
irregularly  scan- 
ning. 


Incoordination  is 
present,  but  is 
not  increased  by 
closing  the  eyes. 
Static  ataxia  may 
be  noted. 


No  mental  disturb- 
ance. 

The  gait  is  swaying 
and  irregular, 
like  that  of  a 
drunken  man. 
The  legs  are  not 
kept  wide  apart 
as  in  locomotor 
ataxia. 


1094  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  course  usually  extends  over  five  to  ten  or  even  fifteen  years, 
and  death  is  generally  the  result  of  some  intercurrent  affection,  though 
it  may  occur  during  an  apoplectiform  or  convulsive  attack.  Rarely  it 
is  due  to  failure  of  the  heart  or  respiration. 

The  progfnosis  is  always  bad. 

Treatment. — No  remedy  is  of  any  avail.  Silver  nitrate,  mercury, 
the  iodids,  and  arsenic  may  be  tried.  Rest  and  easily  assimilable  food 
are  also  of  prime  importance. 

PSEUDOSCLEROSIS. 

In  1883  Westphal  described  a  case  characterized  by  disturbance  of 
speech,  slowness  of  the  movements,  decrease  of  both  intelligence  and 
irritability,  apoplectiform  attacks,  pronounced  tremor,  spasticity  and  in- 
creased reflexes,  slight  disturbance  of  sensation,  and  no  involvement  of 
the  sphincters.  The  autopsy  was  entirely  negative.  Since  then  similar 
cases  have  been  reported,  especially  by  Strlimpell.  The  disease  usually 
begins  in  childhood  and  causes  death  in  the  course  of  several  years. 

The  diagnosis  cannot  be  made  from  multiple  sclerosis  during  life. 

Treatment  is  useless. 


BULBAR  PARALYSIS. 

( Glosso-labio-laryngeal   Paralysis.) 

Definition. — An  acute  or  chronic  disease,  due  to  involvement  of 
the  motor  nuclei  of  the  medulla  oblongata.  It  is  generally  secondary 
to  some  condition  affecting  other  portions  of  the  motor  path,  and  is 
characterized  chiefly  by  a  difficulty  of  speech  or  of  deglutition.  Three 
varieties  have  been  described  : 

1.  Sudden  or  apoplectiform,  this  being  due  to  hemorrhage,  embolism, 
or  softening.  The  onset  is  always  sudden,  often  with  vertigo,  and  pos- 
sibly vomiting,  with  or  without  loss  of  consciousness.  The  power  to 
articulate  is  impaired  or  lost.  The  lips  and  tongue  are  involved,  and 
hence  the  pendulous  lower  lip,  the  dribbling  of  saliva,  and  the  atrophy 
of  the  lingual  muscles.  There  are  dysphagia  and  generally  frequent 
attacks  of  chokins- 

The  symptoms  are  less  characteristic  than  those  of  the  degenerative 
form.  They  are  less  regular  in  type,  and  usually  are  widespread  at 
first ;  later,  some  improvement  takes  place.  In  other  cases,  after  more 
or  less  of  a  respite,  degeneration  sets  in  and  they  grow  progressively 
worse. 

The  diagnosis  of  this  type  is  not  usually  difficult.  "  Pseudo-bulbar 
paralysis  "  must  be  borne  in  mind,  however,  and  is  a  condition  due  to  a 
bilateral  lesion  of  the  motor  cerebral  cortex  in  the  lower  frontal  parietal 
region  or  of  the  motor  fibers  in  the  course.  There  is  great  danger  to 
life  for  some  little  while  in  these  sudden  cases.  Later  the  prognosis  is 
rather  more  favorable  than  in  the  other  forms. 

2.  Acute  Inflammatory. — Here  the  onset  is  less  abrupt,  requiring  a 


AMYOTROPHIC  LATERAL  SCLEROSIS.  1095 

few  days  to  a  week  to  develop.  But  for  this  fact  the  symptoms  are 
much  the  same  as  in  the  preceding  form. 

3.  Chronic  Bulbar  Paralysis. — This  condition  occurs  chiefly  in  males 
beyond  middle  life.  The  cause  can  seldom  be  discovered,  though  cer- 
tain cases  seem  to  be  of  toxic  origin.  It  may  develop  in  the  course  of 
progressive  muscular  atrophy,  amyotrophic  lateral  sclerosis,  insular 
sclerosis,  or  other  disease  of  the  cord. 

The  symptoms  are  bilateral,  the  tongue  being  usually  the  first  to 
suffer.  The  patient  may  notice  that  he  cannot  speak  for  any  length  of 
time  without  fatigue,  and  that  he  will  then  articulate  indistinctly.  Soon 
he  observes  that  there  is  a  marked  and  progressive  imjjairment  of  speech. 
The  muscles  of  the  lips  and  other  muscles  of  the  lower  part  of  the  face 
atrophy.  He  can  no  longer  whistle.  Speech  is  rendered  still  more  defec- 
tive, owing  to  paralysis  of  the  lips.  The  lower  lip  drops,  and  the  saliva 
constantly  dribbles  from  the  mouth  and  may  be  greatly  increased  in 
amount.  Difficulty  in  swallowing  is  always  present  to  a  greater  or 
less  degree.  Owing  to  the  lingual  paralysis,  the  tongue  can  neither  be 
protruded  nor  can  it  be  used  to  manipulate  the  food  and  make  a  bolus. 
It  is  atrophied  and  the  mucous  membrane  is  wrinkled.  Fibrillar  treyn- 
ors  are  present.  The  larynx  is  involved,  so  that  phonation  is  imperfect, 
but  it  is  not  so  marked  as  the  implication  of  other  parts.  Particles 
that  enter  the  larynx  cannot  be  ejected,  owing  to  motor  paralysis. 
There  are  no  sensory  symptoms,  and  the  power  of  taste  is  normal.  The 
mind  generally  remains  clear,  though  the  patient  is  often  emotional, 
and  cries  or  laughs  without  apparent  cause.  This  type  of  bulbar  palsy 
is  particularly  liable  to  develop  in  the  course  of  progressive  muscular 
atrophy.  The  course  of  the  disease  is  slow,  and  death  is  usually  due 
either  to  inspiration-pneumonia  or  to  interference  with  respiration  or 
circulation. 

The  diagnosis  is  not  difficult,  as  a  rule,  the  bilateral  character  of 
the  symptoms  rendering  them  distinctive.  In  the  pseudo-hulbar  form 
previously  mentioned  the  limbs  are  often  paralyzed  also  (double  hemi- 
plegia). Tumors  rarely,  if  ever,  give  rise  to  such  regular  bilateral 
symptoms.  I  have  met  with  2  cases  of  chronic  bulbar  palsy,  and  1 
occurring  in  the  course  of  Bright's-  disease,  in  which  no  postmortem 
lesion  could  be  found  that  would  account  for  the  condition.  In  neither 
of  the  cases  was  there  much  atrophy,  though  otherwise  they  conformed 
to  the  regular  type. 

Treatment. — The  disease  is  incurable.  Hypodermics  of  strychnin, 
or  of  strychnin,  morphin,  and  atropin,  are  of  value  in  controlling  the 
salivary  flow.  Electricity  is  of  no  value.  Semi-solid  food  is  probably 
the  most  readily  taken,  and  it  is  often  necessary  either  to  use  an  esopha- 
geal tube  or  to  employ  rectal  alimentation. 


AMYOTROPHIC  LATERAL  SCLEROSIS. 

{Charcofs  Disease.) 

Definition. — A  disease  of  the  entire  motor  system,  from  the  cere- 
bral cortex  to  the  muscles  :  characterized  by  loss  of  power,  spastic  symp- 


1096  DISEASES  OF  THE  NERVOUS  SYSTEM. 

toms,  and  muscular  atrophy.  The  first  clear  and  thorough  description 
of  the  clinical  symptoms  and  pathological  anatomy  was  given  by 
Charcot  in  1872/ 

Pathology. — The  pyramidal  tracts  are  degenerated,  the  process 
commencing  either  in  the  cortex,  crura,  or  medulla,  and  extending  to  the 
termination  of  the  neurons  in  the  cord.  The  ganglion-cells  of  the  ante- 
rior cornua  are  atrophic,  there  is  degeneration  of  the  anterior  roots  and 
of  the  muscle-fibers,  the  blood-vessels  in  the  affected  parts  are  dilated, 
and  in  the  early  stages  granular  cells  are  present. 

Htiology. — The  disease  is  more  fre(iuent  in  males  and  usually 
begins  in  early  adult  life.  Exposure  has  sometimes  been  noted  in  the 
previous  history,  but  neuropathic  heredity  does  not  appear  to  have  any 
influence. 

Symptoms. — Three  stages  are  generally  recognized :  (1)  The  in- 
volvement of  the  upper  extremities.  (2)  The  participation  of  the  lower 
extremities.  (3)  The  appearance  of  bulbar  symptoms.  At  first  there 
are  weakness  of  the  upper  arms,  atrophy  of  the  muscles,  and  moderate 
exaggeration  of  the  reflexes  ;  in  the  course  of  a  few  months  the  symptoms 
of  spastic  paraplegia  develop,  all  the  reflexes  are  greatly  increased,  and 
there  are  chin-  and  ankle-clonus  and  dragging  of  the  toes.  The  wasted 
muscles  show  fibrillary  twitchings  and  give  the  reactions  of  degeneration. 
Contractures  then  occur,  the  forearms  are  flexed  on  the  arms,  the  hands 
are  held  in  pronation,  and  the  proximal  i)halanges  of  the  fingers  bent 
backward,  giving  rise  to  the  so-called  ehtv-liaticl.  From  time  to  time 
there  are  tonic  spasms  in  the  muscles,  particularly  in  the  calves  (spinal 
tetanus).  Sensation  is  not  disturbed,  excepting  for  the  occurrence  of 
slight  paresthesia  from  time  to  time,  and  the  sphincters  continue  to 
functionate  normally.  Finally  the  bulbar  symptoms  appear,  and  there  is 
paralysis  of  the  lower  part  of  the  fiice,  Avhich  becomes  rigid  and  expres- 
sionless, with  the  mouth  partly  open  and  saliva  dribbling  from  the 
angles.  Deglutition  and  articulation  become  difticult  or  impossible,  and 
death  finally  occurs  from  exhaustion  or  inspiration-pneumonia.  During 
the  course  of  the  disease  the  intellect  is  slightly  involved.  Memory 
is  impaired,  the  conduct  becomes  childish,  and  there  is  a  tendency  to 
weep  or  laugh  without  cause.  Atypical  cases  occur  in  which  either  the 
lower  extremities  are  first  involved,  or  the  paralytic  symptoms  are  more 
prominent  than  the  spastic  symptoms,  or  the  bulbar  symptoms  appear 
very  early.  The  course  is  steadily  progressive,  and  death  usually  occurs 
within  two  years. 

The  differential  diagnosis  is  to  be  made  from  multiple  sclerosis  by 
the  absence  of  nystagmus,  of  the  intention-tremor,  and  of  sensory  dis- 
turbances, and  by  the  degenerative  changes  in  the  muscles ;  from  trans- 
verse myelitis  by  the  absence  of  sphincter  disturbance  and  of  pain,  and 
the  involvement  of  the  upper  extremities  and  head ;  from  progressive 
spinal  muscular  atrophy  by  the  presence  of  spastic  symptoms;  from 
syringomyelia  by  the  absence  of  sensory  disturbances,  trophic  lesions 
of  the  skin  and  joints,  and  the  greater  regularity  of  the  course ;  from 
pressure  upon  the  spinal  cord  by  the  absence  of  pain  and  sphincter 
disturbance  and  the  involvement  of  the  head  and  nj^per  extremities.  It 
must  be  remembered  that  amyotrophic  lateral  sclerosis  may  be  associated 
with  multiple  sclerosis  or  infantile  spinal  paralysis. 


SYRINGOMYELIA.  1097 

Prognosis. — It  will  be  understood  from  the  foregoing  description 
that  death  is  the  invariable  termination.  The  course  is  progressive,  and 
even  temporary  amelioration  rarely  occurs. 

Treatment. — The  patient  should  be  rendered  as  comfortable  as  pos- 
sible. Arsenic  and  mercury  are  useless,  but  the  hypodermic  injection 
of  strychnin  (see  Progressive  Spinal  Muscular  Atrophy)  may  be  tried. 


SYRINGOMYELIA. 


Definition. — A  neurogliar  overgrowth  of  more  or  less  vertical 
extent,  and  situated  in  the  gray  matter  of  the  cord  in  the  neighbor- 
hood of  the  central  canal.  Its  symptomatology  is  not  constant,  but 
the  follow  ing  have  come  to  be  looked  upon  as  typical  of  most  cases : 
viz.  progressive  muscular  atrophy  and  dissociated  anesthesia  {i.  e. 
impairment  or  loss  of  temperature — and  pain-sense,  with  retention 
of  the  tactile  and  muscular  sense  and  trophic  and  vaso-motor  dis- 
turbances). 

Pathology  and  Etiology. — Tubular  cavities  of  greater  or  less 
extent  are  met  with  in  the  cord  as  a  result  of  two  conditions  existing 
separately  or  in  conjunction — viz.  (1)  hydromyelia,  a  dilatation  of  the 
central  canal  (proved  by  the  cubical  cells  lining  it).  This  is  either  (a) 
congenital,  according  to  Leyden,  or  [h)  acquired,  due  to  pressure  (tumor), 
dilatation  taking  place  above  the  point  of  obliteration.  (2)  Syringo- 
myelia, a  name  given  by  Olliver  to  a  neurogliar  overgrowth  situated 
within  the  gray  matter  of  the  cord.  In  this  cavity-formation  takes 
place  as  a  result  of  hemorrhage  or  degeneration.  The  cavity  is  entirely 
without  the  central  canal ;  it  never  possesses  an  epithelial  lining,  and  is 
not,  therefore,  as  Leyden  supposed,  the  remains  of  congenital  hydro- 
myelia.  While  the  new  growth  in  many  instances  is  gliomatous,  being 
probably  a  rejuvenescence  of  some  vestigial  remnant,  with  subsequent 
hemorrhage  or  degeneration  and  cavity-formation,  yet  in  others  the 
structure  is  not  identical  with  such  neoplasms.  The  latter  have  been 
described  particularly  by  Joifroy  and  Achard.  They  speak  of  it  as  a 
gliosis,  a  secondary  overgrowth,  and  sclerosis  of  the  neuroglia.  In  any 
case,  however,  the  disease  is  most  prone  to  develop  in  the  cervical  and 
upper  dorsal  region,  growing  and  invading  the  posterior  and  postero- 
lateral tracts.  Breaks  and  crevices  in  the  diseased  material  radiate  from 
the  main  cavity.  The  onset  of  the  trouble  generally  takes  place  some- 
where between  the  fourteenth  and  twenty-first  years  of  age. 

Symptoms. — Owing  to  the  fact  that  different  levels  of  the  cord  are 
involved,  and  that  the  extent  claimed  by  the  process  varies  in  different 
cases,  it  will  readily  be  understood  that  no  account,  however  concise, 
will  fit  every  case.  The  disease  is  of  sloiv  onset.  Neuralgic  pains 
develop  in  the  muscles,  and  the  latter  progressively  waste.  The  reflexes 
are  increased  and  more  or  less  spasticity  is  present.  The  lower  ex- 
tremities usually  escape,  though  they  too  may  be  involved,  when  the 
condition  presents  much  the  same  appearance  as  amyotrophic  lateral 
sclerosis.  The  temperature-  and  pain-sense  are  lost,  but  the  tactile  and 
muscular  senses  are  preserved. 


1098  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  special  senses  and  the  sphincters  are  normal.  Ocular  symptoms 
develop  only  when  the  cervical  cord  is  extensively  involved.  Joint- 
changes  may  be  met  with,  and  various  ulcerations,  bullous  eruptions,  or 
wounds  may  be  present,  the  latter  often  being  received  Avithout  the 
patient's  knowledge,  since  loss  of  sensation  is  complete.  These  con- 
stitute a  special  feature  of  the  disease  originally  described  by  Morvan 
of  Brittany  in  1883.  He  had  observed  many  cases  prior  to  that  time, 
but  his  attention  was  specially  called  to  the  matter  by  a  case  of  whitlow 
which  he  incised,  but  to  his  surprise  no  pain  whatever  was  experienced. 
He  described  the  disease  as  affecting  the  upper  extremities,  with  neu- 
ralgia, progressive  paresis  and  wasting,  dissociated  anesthesia,  and,  later, 
painless  whitlows  and  necrosis  of  the  phalanges.  Joffroy  and  Achard 
have  made  three  autopsies  upon  cases  dying  of  this  disease,  and  in 
each  syringomyelia  was  found.  In  Gombault's  case  neuritis  was  present, 
and  the  current  view  is  that  Morvan' s  disease  is  a  combination  of  syringo- 
myelia and  neuritis. 

Diagnosis. — The  loss  of  pain  and  thermic  sense,  with  preservation 
of  the  muscular  and  tactile  senses,  in  association  with  the  muscular 
Avasting,  Avhich  is  most  marked  in  the  upper  extremities ;  and  Avith  the 
spasticity  of  the  loAver  extremities,  constitutes  a  group  of  symptoms  that 
has  come  to  be  regarded  as  typical. 

Differential  Diagnosis. — Hypertrophic  cervical  pachymeningitis  may  be 
mistaken  for  this  disease,  and  vice  versd.  In  this  case,  hoAvever,  the  pain 
is  usually  greater,  the  tactile  sense  is  apt  to  be  lost,  and  possibly  the 
other  senses  also  ;  but  there  is  not  the  dissociation  met  Avith  in  syringo- 
myelia. Amyotrophic  lateral  sclerosis  presents  neither  sensory  nor  trophic 
symptoms,  other  than  the  muscular  Avasting.  Disseminated  sclerosis, 
apart  from  the  tremor  that  is  ahvays  present,  presents  less  trophic  dis- 
turbance. 

The  prognosis  is  ahvays  unfavorable,  though  the  disease  runs  a 
verv  chronic  course,  lasting  even  fifteen  or  twenty  years. 

Treatment. — Nothing  can  be  done,  except  by  attention  to  hygienic 
and  dietetic  details. 


COMPRESSION  OF  THE  SPINAL  CORD. 

It  is  of  importance  to  be  able  to  recognize  this  condition.  To  be  sure, 
it  is  not  always  possible  to  diagnose  it  with  certainty,  but  Avhen  there  is 
a  reasonably  surety  the  question  of  operation  may  arise.  Since  it  has 
so  many  features  in  connnon  Avith  myelitis,  the  necessity  for  reserve  and 
caution  in  arriving  at  a  conclusion  is  manifest,  since  the  latter  condition 
Avould  not  be  benefited  by  any  operative  procedure. 

Pathology. — The  postmortem  findings  Avill  depend  upon  the  degree 
and  duration  of  the  pressure.  The  cord  Avill  be  more  or  less  flattened 
and  distorted  at  the  seat  of  pressure,  and  in  the  early  stages  hyper- 
emic,  and  possibly  softened.  Later  it  is  hard,  sclerosed,  and  of  a  gray- 
ish color,  and  above  and  beloAv  the  compressed  region  degenerated  areas 
■will  be  seen  on  sectioning  the  cord.     Microscopic  examination  reveals 


COMPRESSION  OF  THE  SPINAL   CORD.  1099 

the  same  changes  as  those  met  with  in  any  other  form  of  myelitis.  The 
nerve-roots  will  be  more  or  less  damaged  by  compression. 

Ktiology. — We  may  class  the  causes  of  compression  under  three 
headings — {a)  traumatism  (fractures),  {h)  inflammatory  disease  (caries  of 
the  spine),  and  (r:)  neoplasmata  (including  various  tumors,  gummata,  and 
aneurysm),  but  these  will  receive  separate  consideration  {infra). 

Symptoms. — These  will  vary  according  to  the  site  of  the  lesion 
and  the  extent  of  involvement — i.  e.  the  vertical  extent,  the  degree  of 
pressure  exerted,  and  the  amount  of  inflammation  present.  Two  groups 
of  symptoms  are  present  in  typical  cases — first,  those  due  to  involve- 
ment of  the  roots,  and,  second,  those  dependent  upon  involvement  of 
the  cord  itself — ascending  and  descending  degeneration.  The  former 
gives  rise  to  pain,  neuralgic  in  character  and  radiating  along  the  course 
of  the  nerves.  The  parts  supplied  are  usually  tender,  and  there  may 
be  paresthesia  and  formication.  These  irritative  symptoms  are  fol- 
lowed sooner  or  later  by  those  of  paralysis,  and  hence  the  anesthesia. 
Areas  of  hyperesthesia  may  accompany  the  anesthesia  [cincesthesia  dolo- 
rosa). 3Iotor  symptoms  are  also  irritative  and  paralytic,  and  hence  the 
early  twitching,  or  even  spastic  condition,  and  later  the  loss  of  power, 
or  paralysis.  The  muscles  of  the  affected  parts  waste,  and  qualitative 
and  quantitative  electric  changes  can  be  elicited.  The  second  group, 
due  to  cord-changes,  then  develops,  and  its  symptoms  may  set  in  either 
rapidly  or  slowly.  If  myelitis  promptly  supervenes  and  is  extensive, 
cord-symptoms  of  a  pronounced  type  develop  quickly.  The  parts  below 
the  lesion  will  become  weak,  there  will  be  girdle  pains,  and  a  sense  of 
constriction  or  pain  in  the  legs.  Sensory  symptoms  may  be  absent. 
The  reflexes  are  usually  increased.  If  the  tumor  or  other  cause  of  com- 
pression ceases  to  fail  to  act  for  a  time,  some  improvement  takes  place, 
due  possibly  to  the  subsidence  of  the  myelitis.  If  the  pressure  is  of 
slow  onset,  great  tolerance  is  manifested.  As  is  usually  the  case,  sen- 
sation is  recovered  before  motion.  In  certain  cases,  however,  motor 
power  is  regained,  while  the  muscular  and  tactile  senses  do  not  return. 
In  such  instances,  in  which  the  posterior  columns  bear  the  brunt  of  the 
trouble,  incoordination  results  and  secondary  ataxia  is  met  with. 

Diagnosis. — If  the  combined  symptoms  of  peripheral  and  central 
origin  develop  slowly  in  the  order  named,  compression  is  likely. 
Myelitis  gives  rise  first  to  cord-,  and  only  later  to  peripheral  symp- 
toms ;  hence  the  difiiculty  in  cases  in  which  mj^elitis  develops  quickly. 
Extensive  root-symptoms  are  suggestive  of  meningeal  involvement.  In 
any  event,  too  much  stress  should  not  be  placed  on  the  nervous  symp- 
toms alone.  The  spine  should  be  carefully  examined  and  palpated  for 
points  of  tenderness.  Careful  note  should  also  be  taken  as  to  whether 
there  is  any  limitation  of  movement  or  deformity.  The  family  history 
may  suggest  tuberculosis  (caries  of  the  spine). 

The  prognosis  depends  entirely  upon  the  cause.  Having  ascer- 
tained this,  it  then  depends  upon  the  possibility  of  its  removal. 

Treatment. — In  general  the  treatment  is  that  of  myelitis.  In  cer- 
tain cases  a  surgeon  should  be  consulted,  though  operative  cases  are  the 
exception  rather  than  the  rule,  and  most  may  be  expected  in  cases  of 
caries.  It  is  well  to  impress  upon  the  patient  and  relatives  the  chron- 
icity  of  the  condition,  but  faithful  and  persistent  eff'orts  will  yield  good 


1100  DISEASES  OF  THE  NERVOUS  SYSTEM. 

results.  Rest  is  of  vital  importance,  particularly  when  the  disease  is 
active.  The  patient  should  be  kept  in  bed  in  a  recumbent  position  until 
consolidation  has  taken  place.  Extension  may  be  necessary.  Good 
and  easily  assimilable  food,  and  cod-liver  oil  and  alteratives  should  be 
given.  The  nutrition  of  the  muscles  may  be  improved  by  gentle  fric- 
tion (massage).  As  soon  as  possible  a  plaster  jacket  should  be  put  on 
the  patient,  and  he  should  be  taken  into  the  open  air  and  sunlight. 


TUMORS  OF  THE  SPINAL  CORD  AND  ITS 
MEMBRANES. 

A  GREAT  variety  of  neoplastic  formations,  both  primary  and  second- 
ary in  nature,  may  occur.  The  location  is  of  course  the  most  import- 
ant clinical  feature;  nevertheless,  if  we  would  institute  successful  medical 
or  surgical  treatment  it  is  desirable  to  determine  as  nearly  as  possible 
the  nature  of  the  tumor. 

Extradural  tumors  may  be,  though  rarely,  exostoses  from  the  peri- 
osteal lining  of  the  spinal  canal.  More  frequently  lipomata  or  even  an 
abnormal  development  of  fatty  tissue  between  the  bone  and  the  mem- 
brane is  present.  Of  the  parasitic  growths,  the  hydatid  cyst  is  appa- 
rently the  only  one  that  occurs  in  this  situation. 

The  tumors  of  the  dura  mater  itself  are  chiefly  sarcoma,  gumma, 
and  mvxoma  ;  a  rare  form  consists  of  the  presence  of  plates  of  bone  along 
the  whole  length  of  the  cord.  Occasionally  growths  from  the  bones, 
particularly  carcinomata  and  sarcomata,  may  extend  to  the  membranes. 
Inside  the  dural  sac  both  hydatid  cysts  and  the  cysticercus  may  be 
found.  Tuberculosis  may  occur  either  in  the  form  of  miliary  tubercles 
or  as  tuberculous  masses,  particularly  in  the  cervical  region.  In  the 
pia  mater  and  arachnoid,  myxoma,  lipoma,  fibroma,  endothelioma,  sar- 
coma, and  angio-sarcoma  occur.  Occasionally  cylindroma  and  osteoma 
are  also  found.  A  specimen  with  bony  plates  in  the  dura  was  ob- 
tained from  an  old  woman  Avho  had  syphilitic  lesions  in  other  parts  of 
her  body. 

In  the  cord  itself  the  commonest  tumors  are  glioma  and  sarcoma. 
Gummata  also  occur  (r/Jg  Syphilis,  p.  327).  Cysts  are  sometimes  found. 
The  simplest  form  is  the  dilatation  of  the  central  canal  known  as  hydro- 
myelia ;  the  commonest  are  those  that  occur  as  a  result  of  gliomatous 
softening  in  syringomyelia.  Finally  multiple  neuromata  may  occur 
upon  the  nerve-roots.  The  changes  that  take  place  in  the  cord  are 
destruction  of  the  nervous  tissue  at  the  side  of  the  tumor,  pressure- 
mvelitis,  and  systemic  degenerations  in  the  various  columns.  Curiously 
enough,  complete  restoration  of  function  can  occur,  even  when  the 
svmptoms  of  degeneration  in  the  pyramidal  columns  are  pronounced, 
and  thei-e  is  wasting  of  the  cord  macroscopically,  as  in  the  case  recorded 
by  Gowers  and  Horsley. 

The  etiology  of  these  conditions  varies,  of  course,  with  the  nature 
of  the  growths.  Certain  tumors,  as  lipoma  and  glioma,  are  more  apt  to 
occur  in  advanced  life;  others,  as  the  tyroma,  somewhat  earlier. 

The  symptoms  depend  upon  the  particular  segment  or  segments 
affected,   and  the  situation   in  the  cord   itself  or  its  membranes.      In 


TUMORS   OF  THE  SPINAL   CORD  AND  ITS  MEMBRANES.    1101 

general  the  dorsal  or  lower  cervical  region  is  most  frequently  in- 
volved. 

Disturbances  of  Motion. — If  the  tumor  attains  sufficient  size  to  exert 
considerable  pressure,  paraplegia  always  occurs.  This  usually  com- 
mences upon  one  side,  and  then  more  or  less  rapidly  involves  the  other. 
Exaggeration  of  the  tendon  reflexes  of  the  leg  is  almost  invariable  in 
tumors  above  the  first  lumbar  segment.  Whenever  this  condition  is  at 
all  advanced  there  are  disturbances  of  the  functions  of  the  bladder  and 
rectum.  Spasms  are  sometimes  the  earliest  motor  changes.  Ordinarily 
they  appear  in  the  muscles  of  the  trunk  governed  by  the  segment  that 
has  been  involved;  but  sometimes  they  appear  in  the  legs,  and  are 
usually  more  severe  in  one  than  in  the  other,  and  they  may  be  due 
either  to  pressure  upon  the  motor  roots  or  to  pressure  upon  the  motor 
columns  of  the  cord.  It  is  not  therefore  permissible  to  draw  definite 
conclusions  from  their  location  as  to  the  site  of  the  tumor.  Paresis  is 
commonly  an  associated  symptom,  and  gradually  deepens  into  para- 
plegia.    In  the  latter  stage  contractures  may  also  develop. 

Special  Motor  Symptoms. — If  the  tumor  is  situated  in  the  lower 
portion  of  the  cervical  region,  there  are  often  disturbances  of  motility  in 
a  certain  definite  group  of  muscles  that  are  supplied  by  the  brachial 
plexus.  These  disturbances  may  b'e  ataxia,  tremor,  spasm,  or  paralysis. 
If  the  tumor  be  in  the  dorsal  region,  the  cramp  of  the  intercostal  or 
abdominal  muscles  at  a  particular  level  may  give  rise  to  a  girdle-sen- 
sation;  if  in  the  lumbar  region,  to  disturbances  of  motion  similar  in 
character  to  those  described  in  the  arm.  In  this  locality,  however,  as 
the  nerve-roots  are  longer,  more  of  them  are  apt  to  be  involved  in  the 
pressure,  and  the  symptoms  are  more  extensive. 

Sensory  Symptoms. — Pain  is  usually  the  earliest  symptom.  It  is, 
as  a  rule,  sharply  localized,  severe,  and  paroxysmal,  with  symptoms  of 
dull  neuralgic  aching  between  the  exacerbations.  Certain  forms  of 
pain  are  very  common.  Tumor  in  the  cervical  region  gives  rise  to 
severe  pain  in  one  or  both  arms  and  to  neuralgic  pains  in  the  neck 
and  occiput.  Tumors  in  the  dorsal  region  cause  the  girdle-sensations 
before  described,  or  intense  backache,  often  associated  with  tenderness 
over  the  site  of  the  tumor.  Tumors  in  the  lumbar  region  induce  pain 
in  one  or  both  legs,  often  of  a  burning  character,  and  sometimes  re- 
ferred to  the  soles  of  the  feet.  Hyperesthesia  of  the  skin  is  usually 
found  at  a  level  supplied  by  the  segment  in  which  the  tumor  is  situated. 
Other  sensory  disturbances  are  tingling,  numbness,  and  total  anesthesia. 
A  rare  combination,  in  the  early  stages  of  the  tumor  of  the  spinal  cord, 
is  the  presence  of  anesthesia  in  one-half  the  body  below  the  tumor  and 
of  paresis  or  paralysis  in  the  other  half — that  is,  the  symptom-complex 
of  Broivn-Sequard :  it  almost  invariably  disappears  in  a  short  time 
The  reflexes  are  increased  below  the  level  of  the  tumor.  If  this  is  sit- 
uated in  the  lower  cervical  region,  then  the  cutaneous  reflexes  of  the 
thorax  and  abdomen  are  prompt  and  vigorous  ;  if  in  the  dorsal  region, 
they  are  normal  above  the  site  of  the  tumor,  abolished  in  its  neighborhood, 
and  increased  below,  and  at  the  same  time  there  is  an  enormous  exaggera- 
tion of  the  skin-  and  tendon-reflexes  of  the  legs  ;  if  in  the  upper  portion 
of  the  lumbar  region,  there  may  be  an  abolition  of  the  knee-jerk,  while 
ankle-clonus  is  exaggerated ;  but  ordinarily  all  reflexes  are  abolished. 


1102  DISEASES  OF  THE  XERVOUS  SYSTEM. 

The  muscles  frequently  degenerate,  and  the  electric  reactions  of  degen- 
eration are  found  in  those  regions  that  are  supplied  by  the  anterior 
horn,  or  the  anterior  roots  that  have  been  destroyed  by  the  tumor.  In 
those  tumors  situated  in  the  lumbar  region,  involvincr  a  number  of  nerve- 
roots,  the  wasting  of  the  muscles  of  the  legs  is  usually  very  marked. 
T7'oj}Jne  disturbances  occur  late  in  the  course  of  the  disease,  when  ex- 
tensive bed-sores  may  develop,  exactly  as  in  transverse  myelitis.  Occa- 
sionally vaso-motor  disturbances  {t-dche  spinale.,  localized  edema)  may  be 
observed  in  the  early  stages. 

Course. — Tumors  usually  grow  slowly,  and  therefore  the  symptoms 
are  grailual  in  their  development.  Ordinarily  there  are  periods  of 
arrest  or  even  improvement  that  are  followed  subsequently  by  further 
advance.  The  duration  of  spinal  tumors  is  variable.  Those  of  malig- 
nant nature  or  rapid  growth  may  produce  death  in  a  short  time ;  those 
that  simply  exert  pressure  and  enlarge  very  slowly  may  not  produce 
total  disability  for  several  years.  In  general  it  may  be  said  that  from 
five  to  ten  years  is  the  ordinary  limit  after  the  first  appearance  of  motor 
disturbance.  Some  tumors,  however,  particularly  lipomata,  produce  only 
slight  disturbances  throughout  life,  or  else  no  symptoms  at  all.  remain- 
ing entirely  latent. 

The  diagnosis  involves  three  points :  first,  the  recognition  of  the 
presence  of  the  tumor ;  second,  of  its  site ;  and  third,  of  its  nature. 
The  prodromal  symptoms  of  spinal  tumor  are  often  confounded  with 
nfurahjiii  or  lumhaijo.  It  is  sometimes  possible  to  make  a  dififerential 
diagnosis  by  means  of  the  presence,  in  neuralgic  conditions,  especially 
of  intercostal  nature,  of  the  sensitive  points  along  the  course  of  the  ribs, 
and  of  the  existence,  in  the  case  of  tumor,  of  exaggerated  knee-jerks 
and  sensitiveness  over  certain  portions  of  the  vertebral  column.  In  the 
paraplegic  condition  it  may  be  confounded  with  a  neuritis,  such  as  one 
of  alcoholic  origin.  In  these  cases  the  diagnosis  is  more  difficult  if  the 
tumor  is  situated  in  the  upper  portion  of  the  lumbar  cord ;  nevertheless, 
the  sensory  disturbance  is  slight  in  alcoholic  neuritis,  whilst  it  is  consid- 
erable in  tumoi's  in  the  lumbar  region,  and  often  presents  the  form  of 
ancesthesia  dolorosa,  that  is.  diminished  sensibility  associated  with  con- 
siderable pain.     There  are  also  apt  to  be  disturbances  of  the  sphincters. 

The  intrinsic  diseases  of  the  spinal  canal  give  rise  to  much  greater 
difficulty,  especially  myelitis  and  pac/ii/r/ieningitis  cervicalis..  From  the 
former  the  correct  diagnosis  may  sometimes  be  suspected,  because  in  tumor 
there  are  severe  radiating  pains  and  the  symptoms  are  more  pronounced 
on  one  side  than  on  the  other.  Moreover,  the  symptoms  of  segmentary 
involvement  are  sharper  and  the  root-symptoms  more  characteristic. 
From  pachymeningitis  cervicalis,  a  central  tumor  in  the  cervical  region 
can  be  usually  distinguished  by  the  fact  that  the  radiating  pains  are 
less  severe  and  the  symptoms  not  so  distinctly  bilateral.  It  may  be 
impossible  to  distinguish  a  central  tumor  from  syringomyelia  unless 
the  symptoms  of  root-pressure  are  quite  distinct.  Pott's  disease,  in  its 
early  stage,  may  also  give  rise  to  some  difficulty.  However,  the  rapid 
development  of  the  kyphosis,  and  particularly  the  pain  that  is  elicited 
by  sudden  pressure  upon  the  head,  renders  it  possible,  after  a  reasonable 
period  of  observation,  to  recognize  the  true  nature  of  the  case. 

The  diagnosis  of  the  jjosition  of  the  tumor  has  been  largely  discussed 


LESIONS  OF  THE  CON  US  TERMINALIS  AND   CAUDA   EQUINA.    1103 

in  the  Symptomatology.  The  symptom-complex  may,  however,  be  con- 
siderably disturbed  by  the  presence  of  multiple  tumors.  In  these  cases 
the  majority  ordinarily  remain  latent.  It  must  not  be  forgotten,  how- 
ever, that  the  absence  of  the  knee-jerk  does  not  localize  the  tumor  to 
the  lumbar  region  of  the  cord,  for  it  may  be  abolished  when  the  tumor 
is  situated  in  the  dorsal  region  and  compresses  the  posterior  columns. 
In  general,  it  may  be  said  that  the  presence  of  root-pains  suggests  a 
meningeal  seat,  whilst  pronounced  paraplegia,  or  the  Brown-Sequard 
symptom-complex,  points  to  the  presence  of  a  tumor  in  the  substance 
of  the  cord  itself. 

Finally  the  recognition  of  the  nature  of  the  c/rotvth  can  often  be  made 
from  the  history  of  the  existence  of  a  tumor  or  an  infectious  process  in 
other  parts  of  the  body.  It  must  be  remembered,  however,  that  it  does 
not  always  follow  that  a  tumor  in  the  spinal  canal  is  similar  to  that 
found  elsewhere.  The  presence  of  cerebral  as  well  as  spinal  focal  lesions 
points  very  strongly  to  syphilis. 

The  prognosis  depends  upon  the  severity  of  the  symptoms,  the 
rapidity  of  their  development,  and  the  nature  of  the  growth,  if  this 
should  be  known.  Complete  subsidence  of  all  the  symptoms  may  occur, 
even  after  a  spastic  paraplegia  has  existed.  Of  course  this  is  only  likely 
in  those  cases  in  which  the  tumor  can  be  removed  by  operation  or  ab- 
sorbed through  the  action  of  drugs. 

The  treatment  depends  wholly  upon  the  recognition  of  the  nature 
of  the  tumor ;  if  this  be  syphilitic,  mercury  and  potassium  iodid  should 
be  given  in  full  doses.  If,  on  the  other  hand,  it  is  not  specific,  and 
appears  to  be  extradural,  operation  would  seem  to  offer  a  possibility 
of  cure,  the  famous  case  of  Gowers  and  Horsley  having  demonstrated 
the  practicability  of  removal.  As  the  prognosis  is,  in  general,  unfavor- 
able as  to  cure  and  often  gloomy  as  to  life,  the  clinician  should  not  hesi- 
tate to  recommend  surgical  interference. 


LESIONS  OF  THE  CONUS  TERMINALIS  AND  THE 
CAUDA  EQUINA. 

As  the  spinal  cord  terminates  at  the  second  lumbar  vertebra,  tumors 
or  injuries  below  this  point  produce  symptoms  only  in  so  far  as  they 
compress  or  destroy  the  lumbar  roots.  This  destruction  may  be  partial 
or  complete.  If  partial,  there  are  paralyses  of  various  groups  of  muscles, 
and  circumscribed  areas  of  anesthesia.  There  may  or  may  not  be  a  dis- 
turbance of  the  functions  of  the  bladder  and  sphincters.  If  tLis  be  total, 
there  are  complete  anesthesia,  complete  paraplegia,  flaccid  in  character, 
with  reactions  of  degeneration  in  the  muscles,  loss  of  the  knee-jerk,  and 
rectal  and  vesical  incontinence.  If  only  the  cauda  equina  is  involved, 
there  may  be  isolated  paralysis  of  the  bladder  and  rectum.  These  lesions ' 
may  consist  of  tumors,  such  as  are  found  in  the  membranes  of  the  cord 
or  on  the  nerve-roots,  and  it  should  be  noted  that,  probably  on  account 
of  greater  space  for  their  development,  tumors  in  this  situation  are  apt 
to  be  larger  than  those  in  other  parts  of  the  spinal  canal.  They  may 
also  consist  of  fractures  or  lesions  occurring  as  a  result  of  congenital 
anomalies,  such  as  spina  bifida. 


1104  DISEASES  OF  THE  NERVOUS  SYSTEM. 

III.   DISEASES   OF  THE   BRAIN  AND   ITS   MENINGES. 
DISEASES   OF  THE  DURA  MATER. 

Inflammation. — This  may  be  met  with  on  the  outer  or  inner  sur- 
face [pachymeningilis  externa  or  interna).  Of  the  external  variety  the 
chief  causes  are  (a)  traumatism,  (h)  disease  of  the  bone,  {c)  syphilis,  and 
{d)  middle-ear  disease.  That  due  to  traumatism  is  often  seen,  and  in 
the  mildest  form  is  of  little  moment.  When  severe  and  accompanied 
by  fracture  with  or  without  displacement,  infection  of  the  membranes 
may  either  take  place  at  once  or  later  from  diseased  bone.  That  form 
due  to  caries  or  any  other  form  of  osteitis  is  always  dangerous,  owing  to 
the  possibility  of  infection  of  the  diploe.  The  brain-sinuses  will  then 
become  affected,  and  infected  emboli  may  pass  into  the  circulation,  with 
the  development  of  pyemia.  In  the  syphilitic  variety  the  inner  table 
of  the  skull  is  thickened  and  roughened,  and  more  or  less  pus  and  gran- 
ular material  is  found  between  it  and  the  dura  (see  also  Syphilis  of  the 
Nervous  System).      Sinuses  may  communicate  Avith  the  exterior. 

The  symptoms  are  indefinite  in  mild  cases,  and  may  consist  only  of 
headache.  In  the  severe  forms  there  are  headache^  malaUe,  chills.,  fever., 
drowsiness,  and  later  stupor,  and  rarely  convulsions  and  honorrhar/e,  or 
other  symptoms  of  compression.  The  ophthalmoscope  will  reveal  more 
or  less  evidence  of  choked  disc.  Rigors  are  suggestive  of  the  onset  of 
pyemia. 

The  treatment  varies  with  the  cause.  Antiphlogistic  measures  and 
counter-irritation  are  of  value,  and  in  the  severe  grades  operative  inter- 
ference may  be  necessary.  The  internal  variety  either  occurs  as  a  sim- 
ple inflammation  or  may  be  so  acute  as  to  cause  extravasation  of  blood. 
This  may  organize,  and,  together  with  the  products  of  inflammation, 
cause  a  pseudo-membrane.     Rarely  is  pus  found. 

Hemorrhage. — Hemorrhage  may  be  (1)  extradural — (a)  traumatic 
and  (b)  due  to  rupture  of  a  vessel  by  erosion,  the  result  of  caries ;  or  (2) 
intradural — into  the  so-called  arachnoid  sac — (a)  very  rarely  traumatic ; 
(b)  due  to  injuries  at  birth  ;  (r)  due  to  pachymeningitis  interna:  (d)  met 
with  in  general  paralysis  of  the  insane ;  (t)  occurring  in  the  course  of 
anemia,  scurvy,  or  some  other  profoundly  altered  blood-condition ;  (/) 
in  cardiac,  renal,  or  ])ulmonary  disease;  (</)  the  result  of  strain — e.  g. 
whooping-cough. 

The  symptoms  will  depend  upon  the  circumstances,  whether  the 
amount  of  blood  is  small  or  large,  whether  the  onset  is  gradual  or 
abruj)t ;  they  may  be  further  obscured  by  the  primary  disease,  or  by 
shock  if  the  cause  is  some  trauma.  In  the  slight  forms  absolutely 
nothing  characteristic  exists.  In  others  there  are  headache,  vertigo, 
vomiting,  and  possibly  mental  confusion,  convulsions,  or  co7na  ;  in  fact, 
the  ordinary  symptoms  of  apoplexy. 

The  treatment  is  that  of  cerebral  hemorrhage ;  in  some  cases  opera- 
tion is  justifiable. 

Internal  hemorrhagic  pachymeningitis  or  hematoma  of  the 
dura  mater  is  characterized  by  the  formation  of  a  fibrous  exudate  upon 
the  inner  surface  of  the  dura,  into  which  capillaries  extend  that  subse- 


DISEASES   OF  THE  PIA.  1105 

quently  rupture.  It  is  found  most  commonly  among  the  insane  or  epi- 
leptic.    It  is  rare  in  childhood. 

The  symptoms  are  variable.  The  entire  course  may  be  without  symp- 
toms, or  tLey  may  be  masked  by  the  existence  of  other  conditions. 
More  frequently  there  are  headache  and  convulsions,  folio-wed  later  by 
paralyses,  coma,  and  death.  The  location  of  the  lesion  causes  consider- 
able modification  of  the  symptomatology.  In  the  milder  form  recovery 
frequently  occurs,  or  the  case  may  become  chronic.  If  the  onset  is 
sudden,  the  symptoms  may  resemble  those  of  hemorrhage. 

The  diagnosis  is  always  difficult.  In  children  muscular  contractions 
and  convulsions  are  frequently  met  with ;  in  adults  the  slow  onset  may 
be  the  only  difference  between  this  condition  and  an  attack  oi grand  mat. 
Of  course,  there  is  a  greater  periodicity  in  epilepsy  ;  but  a  repetition  of 
the  attacks  occurs  in  hematoma,  and,  as  already  stated,  the  repeated 
hemorrhages  are  believed  by  some  to  be  the  cause  of  the  lamination  of 
the  false  membrane. 

The  prognosis  is  extremely  unfavorable  in  children,  but  is  much  less 
so  in  adults. 

The  treatment  calls  for  the  use  of  leeches  behind  the  ears  and  over 
the  temples,  the  ice-cap,  and  counter-irritation.  Free  movement  of  the 
bowels  should  be  promptly  secured,  and  later  the  iodids  or  mercurials 
should  be  administered. 

Tumors  are  considered  in  connection  with  Tumors  of  the  Brain. 


DISEASES   OF  THE  PIA. 

Infiatninatioii  (Leptomeriingitis). — This  is  met  with  in  the  follow- 
ing conditions  :  (a)  When  tubercles  develop  on  the  membrane  (vide  Tu- 
berculous Meningitis) ;  (h)  During,  or  as  a  sequel  to,  some  acute  febrile 
disease,  as  pneumonia,  erysipelas  of  the  head  and  face,  small-pox, 
measles,  scarlet  fever,  typhoid  fever,  ulcerative  endocarditis,  and  pyemia  ; 
(c)  Cerebro-spinal  meningitis  :  (d)  Cachexia  :  (e)  Gout  and  Bright's 
disease  ;  (/)  Exposure  to  the  sun  ;  (g)  Traumatism,  even  when  not  ac- 
companied by  fracture ;  (h)  Disease  of  the  bones — caries,  or  secondary 
to  middle-ear  disease  ;  (/)  Extension  from  syphilitic  involvement  of 
the  meninges. 

Inflammation  of  the  pia  (non-tuberculous)  is  more  common  in  males 
than  females,  and  occurs,  as  a  rule,  before  the  twentieth  year.  After 
that  time  it  is  rather  rare. 

Pathology. — In  the  extent  and  degree  of  the  inflammation,  great 
variations  exist.  Is  may  be  either  (1)  limited  to  the  convexity,  with  or 
without  involvement  of  the  sides:  (2)  limited  to  the  base;  or  (3)  gen- 
eral, involving  both  convexity  and  base.  In  the  early  stages  and  in  the 
mild  forms  there  may  be  no  more  than  an  injection  of  the  part.  Later, 
inflammatory  products  are  met  with  and  more  or  less  adhesion  exists. 
Pus  is  also  present  in  some  cases.  This  form  of  leptomeningitis,  unlike 
the  tuberculous  variety,  is  prone  to  attack  the  convexity  of  the  brain.  I 
have  made  an  autopsy  on  one  child  of  twenty  months  in  which  the  in- 
ro 


1106  DISEASES  OF  THE  ^'ERVOUS  SYSTEM. 

flammation  vcas  slight  on  the  convexity,  and  still  less  on  the  sides,  but 
quite  marked  on  the  base,  particularly  about  the  Sylvian  and  cerebellar 
regions  and  the  optic  chiasm.  A  granular  ependymitis  was  found, 
limited  to  the  body  of  the  lateral  ventricles,  and  reminding  one  very 
much  of  a  similar  condition  met  with  in  paralysis  of  the  insane.  The 
ventricles  were  dilated,  and  contained  an  excess  of  fluid,  due  probably 
to  occlusion  of  the  foramen  of  Magendie,  as  Gee  and  Barlow  have 
pointed  out.  No  tubercles  wei'e  found,  nor  did  the  family  history  lead 
me  to  suspect  tuberculosis. 

Symptoms. — These  are  very  varied,  and  naturally  depend  on  the 
seat  and  extent  of  the  inflammation.  Those  cases  in  which  symptoms 
pointing  to  involvement  of  the  base  occur  need  not  be  discussed  here, 
since  they  are  considered  in  detail  under  the  tuberculous  variety.  In  any 
case  headache,  localized  or  general,  is  usually  present.  In  children  too 
young  to  talk  its  presence  is  often  indicated  by  crying  or  putting  the 
hand  to  the  head.  Delirium,  insomnia,  and  coma  are  also  met  with  in 
diflferent  cases.  There  are  more  or  less  fever,  constipation,  a  coated 
tongue,  vomiting,  a  rapid  pulse,  and  the  tdche  cerehrale  may  be  elicited. 
Spasmodic  movements  may  occur,  or  even  general  convulsions.  Of 
course,  in  cases  of  inflammation  of  the  base,  the  cranial  nerves  become 
affected,  and  Ave  \ia,\e  ptosis  or  strabismus,  facial  spasm  ov  palsy,  and,  if 
the  fifth  nerve  is  involved,  sensory  and  trophic  changes.  It  must  be 
borne  in  mind  that  meningeal  symptoms  are  frequently  simulated  by 
the  infectious  diseases,  and  particularly  by  pneumonia  (of  the  apical 
type  generally ;  more  especially  in  children  and  old  people),  typhoid 
fever,  and  influenza.  Such  cases  are  most  likely  due  either  to  vas- 
cular disturbance  of  the  meninges  (congestion)  or  to  a  toxic  enceph- 
alopathy. 

Diagnosis. — Where  no  etiologic  hint  can  be  obtained  tlie  diagnosis 
is  generally  in  doubt  for  two  or  three  days.  There  may  be  nothing  more 
than  a  reflex  irritation  (dental  or  gastro-intestinal),  or  possibly  one  of 
the  infectious  fevers.  The  symptoms  should  be  studied  in  their  entirety; 
one  or  two  supposedly  pathognomonic  signs  should  not  be  allowed  to 
cloud  our  vision.  Having  made  the  diagnosis  of  meningitis,  it  becomes 
important  to  differentiate  the  tuberculous  from  the  non-tuberculous 
variety.  The  family  history  is  of  importance.  In  tuberculous  menin- 
gitis the  focal  symptoms  usually  appear  late,  and  are  due  to  involvement 
of  the  cranial  nerves  at  the  base  of  the  brain,  chiefly  those  controlling 
the  eye.  The  eye-grounds  often  show  a  slight  perineuritis  without 
choked  discs,  and  perhaps  one  or  more  miliary  tubercles.  The  leuko- 
cytes are  slightly,  if  at  all  increased.  There  is  rarely  rigidity  of  the 
neck.  In  other  forms  of  meningitis  this  appears  early.  The  optic 
nerve  shows  intense  inflammation  and  there  is  usually  pronounced 
leukocytosis.  Quincke,  -in  1890,  introduced  his  method  of  lumbar 
puncture.  This  is  of  comparatively  simple  application,  and  has  become 
a  well-recognized  measure.  The  tubercle  bacillus  and  streptococcus 
pyogenes,  also  the  pneumococcus  and  micrococcus  meningitidis,  have 
frequently  been  found  in  the  fluid  withdrawn. 

Prognosis. — This  is  always  grave.  A  percentage  of  cases  of  epi- 
demic cerebrospinal  meningitis,  varying  with  the  nature  of  the  epi- 
demic,   may  recover.     In  all  other  forms  any  termination,   except    in 


DISTURBANCES  OF  CIRCULATION  OF  THE  BRAIN.         1107 

death,  is  exceedingly  exceptional.  Remissions  frequently  occur  in  the 
symptoms,  and  the  course  may  be  very  prolonged.  That  even  tubercu- 
lous cases  may  recover  is  proved,  however,  by  that  of  West,  and  even 
more  strikingly  by  that  of  Baumanu  and  Senile,  who  found  the  tubercle 
bacillus  in  the  cerebro-spinal  fluid.  The  case  recovered,  but  died  some 
months  later  from  an  intercurrent  affection ;  the  diagnosis  gained  addi- 
tional confirmation  from  the  postmortem  findings. 

Treatment. — This  has  been  previously  considered.  It  is  only  neces- 
sary to  add  that  we  are  able  to  do  no  more  in  this  form  than  in  the 
tuberculous.  We  have  no  specific,  and  all  that  can  be  done  is  to  meet 
the  symptomatic  indications.  In  certain  cases — e.  g.  those  secondary 
to  middle-ear  disease — operation  may  seem  justifiable.  When  in  doubt 
the  physician  should  not  delay  action  until  too  late,  but  should  call  in  a 
surgeon  while  some  benefit  may  still  be  hoped  for. 


DISTURBANCES  OF  CIRCULATION  OP  THE  BRAIN. 

HYPEREMIA. 

Definition. — An  abnormal  increase  in  the  amount  of  blood  in  the 
cerebral  capillaries.  The  condition  is  not  in  any  way  associated  Avith 
the  primary  phenomena  of  inflammation. 

What  has  already  been  mentioned  in  the  case  of  hyperemia  of  the 
cord  is  equally  true  in  this  case — viz.  that  while  congestion  undoubtedly 
may  take  place,  there  is  nothing  symptomatically  pathognomonic  in  the 
fact,  and  hence  we  do  not  recognize  it  as  a  definite  clinical  entity. 
"  Congestion  of  the  brain  "  is  rather  a  "  diagnostic  haven  "  and  satisfies 
the  patient,  while  at  the  same  time,  provided  the  assumption  is  not 
made  on  too  superficial  evidence,  it  harms  no  one.  Two  forms  of 
hyperemia  have  been  described : 

1.  Active  hyperemia  is  met  with  in  men  more  frequently  than  in 
women,  and  results  from  over-action  of  the  heart  and  widespread  ob- 
struction to  the  circulation,  as  when  the  surface  capillaries  contract,  or 
there  is  arterial  dilatation,  due  to  excessive  mental  activity  from  any 
cause  or  to  drugs — alcohol,  amyl  nitrite,  nitroglycerin. 

2.  Passive  congestion  is  met  Avith  in  cases  of  obstruction  of  the  cere- 
bral sinuses  and  veins,  and  is  due  to  pressure  on  the  superior  cava  or 
the  innominate  or  jugular  veins  by  tumors  or  aneurysms ;  also  in  suffo- 
cation and  strangling,  in  cases  of  excessive  strain,  and  in  tricuspid  in- 
sufficiency. 

Pathology. — There  are  no  marked  changes  in  the  brain  in  these 
cases.  In  the  active  form  the  gray  matter  will  appear  somewhat  darker 
than  normal,  and  a  macroscopic  section  of  the  white  matter  shows  the 
puncta  vasculosa  to  be  increased.  It  often  leaves  no  trace  postmortem. 
In  passive  congestion  the  veins  and  sinuses  are  engorged  and  more  or 
less  edema  may  be  present. 

The  symptoms  are  described  under  two  headings — 1,  those  of  irri- 
tation, and,  2,  of  depression.     Among  the  former  are  headache,  vertigo, 


1108  DISEASES  OF  THE  NERVOUS  SYSTEM. 

irritahiliti/,  rapid  pulse,  restlessness,  insomnia,  and  special  nervous  phe- 
nomena, as  flashes  of  light,  hyperacusis,  and  even  convulsive  movements. 
The  latter  is  manifested  by  the  obtunding  of  the  senses ;  in  fact,  the 
antithesis  of  the  other.  The  cerebral  symptoms  met  "with  in  febrile 
processes  are  probably  due  either  to  faulty  metabolism  or  to  some  toxin, 
and  should  not  be  regarded  as  the  result  of  hyperemia. 

Treatment. — The  recumbent  posture  is  of  great  importance. 
Leeching,  wet-cupping,  and  venesection  are  sometimes  employed.  Cold 
applications  to  the  head,  bromids  internally,  and  attention  to  the  bowels 
will  be  of  assistance.  Freedom  from  annoyance  and  worry  of  all  kinds 
is  necessary. 

ANEMIA. 

Definition. — A  condition  in  which  an  insufficient  amount  of  blood 
circulates  in  the  cerebral  capillaries. 

It  is  due  to  exhausting  discharges  (diarrhea),  an  abnormally  slow 
pulse  or  weak  heart,  to  hemorrhage,  obstructive  endarteritis  of  the  ves- 
sels supplying  the  brain,  and  to  syncopal  attacks  and  dilatation  of  the 
intestinal  vessels,  owing  to  the  too  rapid  withdrawal  of  ascitic  fluid. 

Pathology. — The  gray  matter  is  quite  pale ;  the  puncta  vasculosa 
are  diminished,  and  sometimes  cannot  be  seen ;  the  cerebro-spinal  fluid 
is  fre(iuently  increased. 

Symptoms. — The  most  exaggerated  type  is  met  with  after  a  pro- 
fuse hemorrhage.  There  are  pallor,  weakness,  vertigo,  headache,  flashes 
of  light,  subjective  noises,  rapid  respiratioti,  cool  skin,  possibly  profuse 
sweating;,  and  in  extreme  cases  coma,  convulsions,  and  death.  AVe  are 
more  familiar  with  the  ordinary  fainting-attack.  When  cerebral  ane- 
mia is  brought  about  more  slowly  "irritable  weakness"  results.  The 
patient  is  either  somnolent,  dull,  and  apathetic ;  or  he  may  be  a  victim 
of  insomnia.  Headache,  vertigo,  tinnitus  aurium,  musca  volitantes,  and 
lowered  muscular  power  are  present.  I^he  patient  becomes  irritable  on 
the  slightest  provocation.  Marshall  Ilall  has  described  a  group  of  symp- 
toms as  "  hydroce])haloid  "  from  their  resemblance  to  hydrocephalus; 
they  occur  especially  in  young  children  after  diarrhea.  There  are  pal- 
lor, hebetude,  contracted  pupils,  and  depressed  fontanels.  The  somno- 
lence may  deepen  into  a  coma  that  often  becomes  more  profound  until 
death  results. 

The  treatment  varies  with  the  cause.  The  recumbent  posture  is 
always  indicated,  and  in  some  cases  it  is  necessary  to  depress  the  head, 
administer  stimulants,  and  even  transfuse  or  inject  a  normal  saline  solu- 
tion. A  light  and  easily  assimilable  diet  should  be  given  during  con- 
valescence. 

EDEMA   OF   THE   BRAIN. 

Definition. — An  infiltration  of  serum  into  the  subarachnoid  space 
and  a  greater  or  less  increase  of  ventricular  fluid,  with  or  without  infil- 
tration into  the  brain-substance. 

Pathology. — The  fluid  is  chiefly  in  the  meshes  and  beneath  the 
membrane.  The  ventricular  fluid  is  increased  in  amount ;  the  brain- 
substance  is  pale,  and  in  some  cases  infiltrated  and  softened.  Micro- 
scopically, lacunae  may  be  seen  in  the  cerebral  tissue,  the  perivascular 


EMBOLISM  AND   THROMBOSIS.  1109 

spaces  are  dilated,  and  some  slight  degree  of  nerve-cell  degeneration  is 
often  present. 

Btiologfy. — Edema  is  met  with  in  Bright's  disease,  in  senile  cere- 
bral atrophy,  and  as  a  result  of  active  or  passive  hyperemia. 

Symptoms. — In  general  the  symptoms  are  those  of  anemia  though 
nothing  definite  is  known  of  them.  Since  the  condition  is  always  sec- 
ondary, it  may  be  that  symptoms  directly  referable  to  the  edema  are 
masked  by  the  primary  condition.  Cases  of  apoplexy  are  seen  occasion- 
ally, in  which  the  only  postmortem  finding  is  an  effusion  of  fluid  into 
the  pia  and  ventricles.     This  has  been  termed  "  serous  apoplexy." 

The  treatment  is  that  of  the  primary  condition. 


EMBOLISM   AND    THROMBOSIS. 
[Cerebral  Softening^ 

!^m.bolism. — Definition  and  Etiology. — The  obstruction  of  arteries 
or  capillaries  by  material  brought  to  the  spot  from  some  other  part  by 
the  blood-current.  The  material,  generally  fibrin,  usually  comes  from 
the  heart,  and  is  either  a  vegetation  of  a  recent  endocarditis  or,  more 
commonly,  of  chronic  valvular  disease ;  it  may  possibly  be  a  fragment 
of  the  valve  plus  the  fibrin  in  ulcei-ative  endocarditis.  In  the  latter 
case  the  plug  is  generally  septic,  giving  rise  to  suppurative  processes. 
An  embolus  may  be  washed  from  the  auricular  recesses,  from  an  aneur- 
ysm of  the  aorta  or  carotid,  or  from  atheromatous  patches ;  rarely  from 
the  pulmonary  veins. 

In  puerperal  women,  and  in  certain  febrile  processes  (diphtheria  and 
pneumonia)  the  coagulability  of  the  blood  is  increased.  Heart-clots 
form,  and  fragments  may  be  washed  into  the  cerebral  vessels.  Owing 
to  the  direction  of  the  vessels  the  embolus  most  frequently  enters  the 
left  carotid,  whence  it  usually  passes  to  the  left  middle  cerebral.  Al- 
most any  cerebral  artery  may  be  obstructed,  but  the  cerebellar  very 
rarely.  Embolism  occurs  most  frequently  between  the  tenth  and  forti- 
eth years  of  life.  The  middle  cerebrals  are  most  frequently  involved, 
and  next  in  order  the  internal  carotid  and  anterior  cerebrals. 

Pathology. — That  region  of  the  brain  that  is  cut  oif  from  its  blood- 
supply  by  the  embolus  undergoes  softening.  The  cortical  changes  are 
less  marked  than  those  of  the  central  ganglia,  since  in  the  former  case 
more  or  less  anastomosis  exists,  and  none  in  the  latter.  When  the  em- 
bolus is  septic  one  or  more  metastatic  abscesses  result.  The  degree  of 
softening  varies  in  different  cases  within  wide  limits.  There  may  be 
nothing  more  than  a  slight  diminution  in  the  consistence,  the  affected  area 
being  somewhat  paler  than  normal,  or  absolute  dissolution  may  occur, 
the  myelin  breaking  up  into  granules,  while  the  tissue  becomes  infil- 
trated with  serum,  and  the  vessels  undergo  hyaline  or  more  often  fatty 
change.  The  color  of  the  part  varies  with  the  amount  of  blood.  In 
recent  cases  it  is  red.  As  the  hemog'lobin  is  absorbed  a  yellow  color 
appears,  and  soon  predominates.  Red  and  yellow  softening  are  found 
chiefly  in  the  cortex.  The  so-called  white  softening  is  met  with  particu- 
larly in  the  white  matter.  A  variety  of  red  softening  in  which  numer- 
ous small  hemorrhages  exist  has  been  termed  capillary  apoplexy,  while 


1110  DISEASES  OF  THE  NERVOUS  SYSTEM. 

plaques  jaunes  is  the  term  given  by  the  French  to  a  form  of  yellow  soft- 
ening often  seen  in  the  cortex  of  old  people.  The  ultimate  changes  de- 
pend in  a  great  measure  upon  the  extent  of  the  lesion.  If  this  is  small, 
the  granular  debris  is  absorbed,  and  the  proliferation  of  connective  tis- 
sue results  in  the  formation  of  a  scar.  On  the  other  hand,  if  large  the 
solid  elements  are  removed,  and  the  cavity  that  remains  contains  more 
or  less  fluid  (a  cyst).  In  many  instances  fibers,  trabeculie,  and  even 
vessels  that  have  escaped  destruction,   pass  through  the  cyst. 

Thrombosis. — Definition. — Obstruction  of  a  vessel  due  to  clotting 
in  situ.  This  may  occur  {<()  in  the  arteries  or  (6)  in  the  veins  and 
sinuses. 

Ix  THE  Arteries. — Etiology. — Thrombosis  results  from  disease  of 
the  vessel-wall,  atheroma,  endarteritis,  or  syphilitic  arteritis,  extension 
from  surrounding  diseased  areas,  traumatism,  in  aneurysms,  in  depraved 
blood-states,  and  at  the  seat  of  lodgement  of  an  embolus.  Thrombosis 
of  a  cerebral  vessel  may  rarely  follow  ligation  of  the  carotid.  In  gen- 
eral we  may  say  thrombosis  results  from  (1)  changes  in  the  vessel-Avall, 
(2)  retardation  of  the  blood-current,  and  (3)  hypercoagulability  of  the 
blood.  It  occurs  most  fretjuently  in  the  middle  cerebral,  basilar,  in- 
ternal  carotid,  and  vertebral  arteries. 

Pathology. — The  changes  in  the  brain-tissue  are  precisely  those  de- 
scribed under  Embolism.  Within  the  vessel  a  clot  is  found  adherent 
to  the  vessel-wall,  and  extending  from  the  nearest  large  branch  on  the 
proximal  side  to  the  contracted  branches  on  the  distal  side.  If  of 
recent  and  rapid  formation,  it  is  always  of  a  red  color.  The  slower  the 
formation  the  paler  the  color.  Such  clots  are  often  laminated.  The 
ultimate  changes  are  contraction  and  atrophy,  or,  more  rarely,  calcifica- 
tion, or  even  softening  and  removal,  tlie  vessel  again  becoming  patulous. 

In  the  Veins  and  Sinuses. — Etiology. — Thrombosis  may  be  (1) 
primary,  due  to  general  causes,  or  (2)  the  result  of  local  changes. 

Primary  thrombosis  is  less  common  than  the  secondary  variety. 
It  is  met  with  in  marasmic  children  (one  of  the  causes  of  infantile 
hemiplegia — Gowers),  in  which  the  clot  is  called  marantic  throm- 
bosis, cachexia,  phthisis,  carcinoma,  and  in  blood-dyscrasiie  (anemia, 
chlorosis). 

Secondary  thrombosis  usually  results  from  an  extension  of  neigh- 
boring forms  of  inflammation,  caries  of  the  bone,  middle-ear  disease,  or 
meningitis.  It  may  also  be  due  to  fracture  of  the  skull  or  compression 
of  a  sinus  by  a  tumor. 

Pathology. — In  primary  thrombosis  the  most  common  seat  is  the  su- 
perior longitudinal  sinus.  From  this  it  spreads  into  the  veins  of  both 
sides,  and  frequently  also  into  the  lateral  sinuses  of  one  or  both  sides. 
In  secondary  thrombosis  the  sinus  nearest  the  local  disease  suiFers. 
The  veins  emptying  into  the  sinus  involved  become  distended,  often 
rupture,  and  in  consequence  the  brain-tissue  and  pia  become  infiltrated. 
When  the  veins  of  Galen  are  blocked  serum  escapes  into  the  ventricles. 
Red,  yellow,  and  white  softening  is  met  with  as  a  final  result  of  the  ex- 
travasation. Secondary  thrombi  are  usually  septic.  Primary  throm- 
bosis is  probably  due  in  many  cases  to  an  excess  of  carbonic  acid  in 
the  blood.  Chlorotic  blood  is  probably  charged  with  it.  The  com- 
parative infrequency,   however,   of  clotting  in  the  cerebral   sinuses   is 


EMBOLISM  AND  THROMBOSIS.  1111 

due  to  the  fact,  recently  shown,  that  they  contain  very  little  carbonic 
acid. 

Symptoms. — Following  Embolism  or  Thrombosis  of  Arteries. — The 
symptoms  necessarily  depend  upon  the  position  and  extent  of  the  lesion. 
Often  it  is  discovered  •postmortem.,  not  having  been  suspected  during 
life.  We  meet  with  many  such  cases  occurring  in  late  adult  life.  Then, 
too,  extensive  lesions  may  occur  in  those  portions  of  the  brain  that 
never  yield  any  localizing  symptoms — the  frontal  region,  for  instance. 
Apart  from  the  etiologic  differences,  the  clinical  pictures  of  embolism 
and  thrombosis  differ  as  follows  :  In  the  former  the  onset  is  sudden, 
without  premonitory  signs,  and  is  in  many  cases  accompanied  by  loss 
of  consciousness.  In  addition  to  symptoms  arising  directly  through 
implication  of  the  particular  part  involved,  there  are  those  of  shock. 
In  the  less  severe  cases  consciousness  soon  returns  and  the  apoplectic 
symptoms  pass  off.  When  more  severe,  coma  supervenes  and  may  prove 
fatal.  AVhen  hyperemia  occurs  in  or  about  the  motor  region  the  irrita- 
tion may-give  rise  to  convulsions.  In  other  cases  delirium  is  a  promi- 
nent feature  ;  hence  three  varieties  of  softening  are  described  by  some 
writers — the  apoplectic,  convulsive,  and  delirious,  from  the  prevailing 
feature.  Thrombosis  may  commence  abruptly,  but  as  a  rule  the  onset 
is  slow,  the  patient  meanwhile  complaining  of  vague  pains,  numbness, 
tingling,  headache,  and  vertigo.  It  is  observed  that  a  gradually  in- 
creasing impairment  of  the  mind  is  going  on,  and  that  motor  weakness, 
slight  at  first,  increases  until  the  function  is  lost.  The  special  symp- 
toms are,  as  stated,  dependent  upon  the  location  of  the  obstruction.  If 
this  is  in  the  middle  cerebral  artery,  the  most  common  seat,  there  will  be 
hemiplegia,  owing  to  destruction  of  the  internal  capsule.  The  trunk  may 
be  spared  and  one  of  its  branches  stopped.  The  latter  run  to  the  third 
frontal,  ascending  parietal,  supramarginal,  angular,  or  temporal  gyri. 
Thus,  then,  we  can  account  for  the  aphasia  so  often  met  with  in  these 
cases  by  the  plugging  of  the  branch  that  supplies  the  third  frontal  con- 
volution of  the  left  side.  If  both  middle  cerebrals  are  plugged,  symp- 
toms develop  that  are  indistinguishable  from  hemorrhage  into  the  ven- 
tricles. This  condition  is  generally  fatal.  Thrombotic  obstruction  of 
the  anterior  and  posterior  cerebral  arteries  rarely  causes  symptoms,  owing 
to  compensatory  circulation.  '•'•  Hebetude  and  dulness  of  intellect  may 
occur  "  (Osier),  with  obstruction  of  the  anterior  cerebral.  Hemianopsia 
may  arise  from  a  lesion  of  the  posterior  cerebral,  since  it  supplies  the 
cuneus.  The  left  cerebral  is  more  often  involved  than  the  right.  In 
either  case  bulbar  symptoms  develop. 

Cerebellar  softening  is  rare.  When  it  does  occur  it  is  usually  in  the 
region  supplied  by  the  posterior  cerebral  artery.  There  may  be  no 
symptoms  if  only  one  hemisphere  is  involved ;  otherwise  they  are  sim- 
ilar to  those  of  cerebellar  disease  due  to  other  lesions. 

Thrombosis  in  veins  and  sinuses  causes  variable  symptoms.  Those 
directly  due  to  the  vascular  disturbance  are  severe  headache,  optic  neur-' 
itis,  delirium,  or  convulsions,  and,  later,  great  depression.  Hemiplegia 
may  result.  When  the  superior  longitudinal  sinus  is  affected,  epistaxis 
is  common,  while  in  lateral-sinus  involvement  post-auricular  edema  oc- 
curs. In'  secondary  cases,  moreover,  we  have  to  reckon  Avith  the  cause. 
Since  this  is  so  often  septic,  septicemic  symptoms  are  the  rule. 


1112  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — Of  Embolism  arid  Thromhosu  of  Arteries. — Very 
little  can  be  done  in  brain-softening.  In  the  early  stages,  however, 
while  it  is  absolutely  impossible  to  repair  the  tissue  already  damaged, 
an  effort  should  be  made  to  prevent  the  spread  of  the  process.  Rest  in 
bed  with  the  head  slightly  elevated  should  be  insisted  on.  When  shock 
is  present  it  must  be  met  by  gentle  stimulation,  ammonium  carbonate, 
and  even  by  alcohol  and  digitalis  in  some  cases ;  hot-water  bottles  may 
be  applied  to  the  body.  Venesection  is  contraindicated.  The  bowels 
should  be  made  to  move  gently  and  purgation  should  be  avoided.  Later, 
as  stated,  symptoms  of  irritation  often  appear.  In  such  cases  the  bro- 
mids  should  be  given,  and  also  a  diaphoretic  mixture,  or  ice  should  be 
placed  to  the  head.  In  any  case  in  which  syphilis,  rheumatism,  gout, 
chorea,  or  other  malady  capable  of  causing  or  adding  to  the  trouble  ex- 
ists, the  original  disease  should  be  treated  promptly  and  thoroughly.  In 
the  mean  time  efforts  should  be  made  to  improve  the  patients  general 
tone  by  the  strict  observance  of  hygienic  and  dietetic  rules. 

Of  Thrombosis  of  Veins  and  Sinuses. — Treatment  in  these  cases  de- 
pends largely  on  the  cause.  In  the  primary  form  it  is  that  of  the  sys- 
temic disease.  Good,  wholesome,  and  easily  assimilable  food  should  be 
given,  together  with  a  tonic  treatment.  In  secondary  thrombosis  care- 
ful search  should  be  made  for  pent-up  inflammatory  products,  which 
should  be  liberated  at  the  earliest  possible  moment.  The  emunctories 
must  act  freely.  Counter-irritation,  applied  to  the  neck,  is  of  question- 
able value,  but  internally  quinin,  iron,  and  strychnin,  and,  if  stimulation 
is  necessary,  ammonia  and  alcohol,  will  all  be  useful. 

VASCULAR    DEGENERATION. 

Arterial. — The  cerebral  arteries  undergo  a  more  or  less  decided  de- 
generative change  in  the  majority  of  people  past  middle  life  (Bichat 
said  seven-tenths).  It  is  met  with  much  earlier,  however,  as  a  result  of 
disease.  Bright's  disease,  rheumatism,  gout,  alcoholism — in  fact,  any 
irritation  of  the  vessel-wall,  whether  autogenous,  the  result  of  faulty 
metabolism,  or  whether  introduced  from  without,  as  alcohol — is  capable 
of  bringing  about  a  change  of  the  inner  seat  of  the  vessel,  to  which 
Virchow  gave  the  name  '"endarteritis  deformans."  The  circle  of  Willis 
and  its  branches  are  the  most  frequent  seats.  Various  stages  may  be 
met  with  in  different  vessels  or  even  in  the  same  vessel — viz.  hyaline 
degeneration,  fatty  degeneration,  liquefaction-necrosis,  atheromatous 
ulcers,   and   calcification. 

Syphilitic  arteritis  is  not  a  true  degenerative  process.  It  is  rather  a 
proliferative  process  in  Avhich  both  intima  and  adventitia  are  involved. 

Venous. — The  veins  are  less  liable  to  disease  than  arteries,  possibly 
because  they  are  more  yielding,  yet  the  same  pathologic  changes  may  be 
met  with  in  them.  They  are  more  commonly  damaged  by  extension  of 
inflammation  from  neighboring  tissues  or  by  pressure. 

Aneurysm. — Dilatation  of  a  vessel  results  from  any  of  the  causes 
above  mentioned.  The  aneurysms  may  be  very  small — miliary — or 
often  as  large  as  a  filbert-nut,  and  rarely  as  large  as  a  hen's  egg.  They 
occur  more  commonly  in  males  than  in  females.  The  middle  cerebrals 
and  basilar  are  most  frequently  attacked,  and  next  come  the  internal 


INFLAMMATION  OF  THE  BRAIN.  1113 

carotid,  the  vertebral,  and  the  anterior  and  posterior  cerebrals.  Miliary 
aneurysms  are  frequently  found  in  enormous  numbers  upon  the  basilar 
branches  of  the  cerebral  arteries. 

Symptoms  of  Aneurysm. — There  may  be  none  ;  but  in  any  case  they 
are  due  to  pressure  exerted  by  the  mass,  and  are  therefore  comparable  to 
tumors  of  the  brain.  In  many  cases  the  first  evidence  of  any  trouble  is 
an  apoplectic  attack,  and  it  is  scarcely  necessary  to  add  that  this  is  usually 
fatal.  In  other  cases  headache,  vertigo,  and  optic  neuritis  are  present, 
and  more  rarely  a  subjective  murmur.  Still  more  rarely  an  objective 
murmur  may  exist. 


INFLAMMATION   OF  THE  BRAIN. 

(Encephalitis.) 

Definition. — Encephalitis,  strictly  speaking,  is  an  inflammation  of 
the  brain-substance,  and  does  not  include  inflammation  of  the  meninges, 
though  in  manv  instances  the  two  conditions  coexist  as  the  result  of  a 
common  cause,  or  one  may  precede  and  give  rise  to  the  other.  Encepha- 
litis is  met  with  in  two  forms — [a)  Focal,  and  (6)  Difiuse. 

FOCAL  ENCEPHALITIS. 
(Abscess.) 

Pathology. — In  very  acute  cases  no  time  is  given  for  encapsulation ; 
when  of  longer  duration,  however,  the  abscess  is  well  circumscribed, 
having  a  well-defined  wall,  within  Avhich  there  are  cell-detritus,  pus,  and 
sometimes  more  or  less  altered  blood.  It  may  be  offensive.  About  it 
the  brain-substance  is  generally  softened  and  edematous.  The  abscess  is 
generally  single,  except  in  pyemic  cases,  and  varies  greatly  in  size  in 
difierent  instances. 

etiology. — Abscess  of  the  brain  is  a  more  or  less  circumscribed 
process,  due  to  (1)  Injury. — In  the  majority  of  cases  of  abscess  following 
head-injuries  either  a  compound  fracture  of  the  skull  exists,  with  or  with- 
out hernia  cerebri  (fungus  cerebri),  or  a  punctured  wound  has  been  made. 
Less  commonly  it  may  follow  a  simple  fracture,  and  rarely  it  is  said  to 
occur  when  neither  a  fracture  nor  even  an  abrasion  of  the  scalp  has  been 
produced.  Meningitis  is  an  almost  invariable  concomitant.  (2)  Exten- 
sion from  some  neighboring  infiaynmatory  focus,  as  from  orbital,  nasal,  or 
aural  disease,  in  which  the  bones  have  usually  become  aff'ected.  (3) 
Pyemia,  in  which  case  the  abscesses  are  apt  to  be  small  and  multiple. 
It  is  also  met  with  occasionally  in  gangrene  of  the  lung,  bronchiectasis, 
ulcerative  endocarditis,  suppurative  hepatitis,  or  bone-disease,  and  rarely 
in  chronic  septic  processes.  (4)  Congenital  Heart-disease. — Little  is 
known  of  this  condition.  Within  the  past  two  or  three  years  Northrup, 
Packard,  Sir  Dyce  Duckworth,  and  Osier  have  reported  such  cases.  (5) 
Obstruction  of  an  artery,  vein,  or  sinus,  whether  of  spontaneous  origin 
or  the  result  of  ligature,  may  give  rise  to  abscess.  Generally,  however, 
the  cerebral  change  is  that  of  softening,  and  not  of  true  suppuration. 
(6)  hitracranial  tumors.     (7)  Infectious  fevers. 


1114  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Symptoms. — These  at  first  are  generally  vague ;  but  in  traumatic 
cases,  and  more  especially  in  those  in  which  a  compound  fracture  of  the 
skull  has  resulted,  the  course  may  be  most  acute,  and/ei'cr,  headache, 
delirium,  and  possibly  vomiting  may  be  seen  quite  early.  These  are  fol- 
lowed by  other  evidences  of  irritation,  soon  by  compression  with  co7ivul- 
sions,  and  then  by  coma  and  death.  In  the  more  chronic  cases  the  symp- 
toms depend  upon  the  size  and  location  of  the  abscess  and  whether  or  not 
a  vent  exists.  In  such  cases  an  intermission  in  the  symptoms  is  occa- 
sionally met  with,  due  to  filling  and  emptying  of  the  sac.  Apart  from 
the  headache,  pyrexia  (not  always  present),  twitching,  and  drowsiness, 
that  occur  in  the  course  of  these  cases,  more  or  less  hemiparesis  commonly 
exists,  except  in  abscess  of  the  frontal  lobes.  The  latter  are  spoken  of 
as  "silent  regions."  An  abscess  may  be  "latent,"  however,  in  almost 
any  region,  these  latent  abscesses  being  typified  in  certain  cases  of  con- 
genital heart-disease.  I  do  not  think  they  were  suspected  during  life  in 
any  of  the  cases  reported  thus  far,  and  therefore  optic  neuritis  has  not 
been  looked  for;  in  other  cases  this  latter  symptom  is  commonly  present. 

Diagnosis. — In  the  acute  cases  following  injury  little  difficulty  pre- 
sents as  a  rule,  though  even  in  this  group  a  latent  period  may  exist. 
With  such  a  history,  however,  the  onset  of  headache,  fever,  delirium, 
and  convulsive  movements  is  decidedly  suspicious,  and,  should  optic 
neuritis  also  exist,  practically  no  doubt  can  remain.  When  dural  or 
nasal  disease  exists  the  head-symptoms  should  be  carefully  studied,  since 
they  are  prone  to  develop  in  ear-disease  soon  after  a  cessation  in  the  dis- 
charge. 

Diflferential  Diagnosis. — Brain-tumor  usually  runs  a  more  chronic 
course,  and  is  seldom  accompanied  by  fever,  at  least  not  until  its  final 
stage.  It  may  be  impossible  to  differentiate  cerebral  abscess  from  men- 
ingitis, and  the  two  conditions  often  coexist,  as  already  stated. 

The  prognosis  is  always  grave. 

Treatment. — When  an  abscess  is  diagnosed  immediate  operation  is 
indicated.  Suspected  cases  may  be  treated  symptomatically  unless  focal 
symptoms  develop.  It  must  be  remembered,  however,  that  in  a  great 
many  cases  no  localizing  symptoms  appear,  and,  since  we  know  that 
most  abscesses  occur  either  in  the  temporo-sphenoidal  lobe  or  in  the 
cerebellum,  when  we  have  reason  to  suspect  the  presence  of  one,  these 
regions  should  be  explored. 

DIFFUSE   ENCEPHALITIS. 

A  good  deal  of  doubt  exists  in  the  minds  of  some  as  to  whether  diffuse 
encephalitis  ever  exists  except  as  a  result  of  traumatism.  Certain  it  is 
that  it  is  less  common  and  much  less  is  known  about  it  than  of  inflam- 
mation of  the  cord.  We  meet  with  it  especially  in  the  frontal  regions  in 
certain  cases  of  general  paralysis  of  the  insane.  The  changes  often  escape 
the  unaided  eye.  Microscopically,  the  vessels  will  be  found  injected  and 
the  perivascular  spaces  distended  with  leukocytes ;  these  latter  escape 
into  the  surrounding  tissue,  which  becomes  softened  and  edematous. 

Symptoms. — It  is  manifestly  impossible  to  give  a  definite  symp- 
tomatology in  the  present  state  of  our  knowledge.  Excepting  the  trau- 
matic cases  the  symptoms  are,  as  a  rule,  chiefly  psychic. 


CEREBRAL   HEMORRHAGE.  1115 

Acute  hemorrhagic  encephalitis  is  a  condition  described  by  Striimpeli. 
The  brain  and  soft  membranes  are  hyperemic  and  slightly  edematous, 
and  throughout  the  brain-substance  there  are  numerous  punctate  hemor- 
rhages. Perivascular  leukocytic  infiltration  is  also  present.  The  eti- 
ology/ is  unknown ;  but  in  some  cases  the  disease  appears  to  follow  influ- 
enza. The  symptoms  are  grave  from  the  first.  There  are  intense  head- 
ache, fever,  unconsciousness,  disturbances  of  motility  that  are  usually 
hemiplegic  in  type,  and  finally  death.  In  less  acute  cases  there  may  be 
delirium,  rapid  emaciation,  and  symptoms  of  involvement  of  the  cranial 
nerves.  The  diagnosis  can  rarely  be  even  suspected.  The  prognosis  is 
invariably  fatal,  and  no  treatment  is  of  any  avail. 

Acute  polioencephalitis,  so-called,  is  a  disease  of  childhood  of  doubt- 
ful pathology.  In  some  of  the  cases  after  recovery  from  the  acute 
process  insular  sclerosis  or  porencephaly  is  present,  with  secondary  de- 
generation in  the  pyramidal  tracts.  The  etiology  is  obscure.  The 
symptoms  resemble  those  of  acute  poliomyelitis  of  the  cord  ;  but  con- 
tractures develop  very  rapidly  in  the  paralyzed  limbs,  and  reactions  of 
degeneration  are  absent  from  the  muscles.  The  prognosis  and  treat- 
ment are  the  same  as  for  the  disease  of  the  cord. 


CEREBRAL  HEMORRHAGE. 

{Cerebral  Apoplexy.) 

Definition. — Hemorrhage  into  the  brain-substance ;  though  bleeding 
into  the  meninges,  which  rarely  co-exists,  is  generally  embraced  in  the 
definition. 

Pathology  and  Htiology. — In  intracerebral  hemorrhage  the  blood 
will  be  found  to  have  infiltrated  the  brain-substance,  and,  if  extensive,  it 
may  have  penetrated  into  the  ventricle.  In  such  cases  the  white  matter  is 
torn  asunder,  leaving  a  ragged  space  that  is  more  or  less  filled  with  recent 
clot  and  fragmentary  gray  matter ;  if  the  ventricles  have  been  entered,  blood 
may  escape  from  the  lowest  into  the  subarachnoid  space.  In  less  severe 
cases  the  territory  involved  is  less  extensive,  and  the  blood  may  occupy  a 
single  space  or  several  small  spaces,  forming  mere  separations  of  the  nerve- 
fibers.  Other  changes  take  place  according  to  the  duration  of  the  case. 
The  blood  changes  color  and  gradually  grows  lighter,  while  reactive  in- 
flammation about  the  lesion  results  in  the  formation  of  a  wall.  The  cyst 
— for  such  it  has  become  through  fatty  degeneration  of  its  contents — may 
remain  as  such,  or  when  the  lesion  is  a  small  one  connective  tissue  may 
form  within  and  a  scar  result.  The  larger  arteries  are  generally  atherom- 
atous, and  an  aneurysm  is  occasionally  met  with  ;  many  miliary  aneur- 
ysms may  be  seen  in  the  course  of  the  smaller  vessels.  It  is  very  seldom 
that  the  actual  source  of  the  hemorrhage  can  be  discovered, 

Second-ary  degeneration  follows  a  lesion  occurring  in  the  motor  region 
(the  cortex  or  internal  capsule),  so  that  sclerotic  changes  can  he  traced 
from  the  cortex  through  the  corona  radiata,  internal  capsule,  crura,  pons, 
and  medulla  to  the  termination  of  the  fibers  in  the  cord. 

Cerebral  hemorrhage  is  generally  of  arterial  or  capillary  origin.    It  is 


1116  DISEASES  OF  THE  NERVOUS  SYSTEM. 

rarely  venous,  and  in  the  latter  case  is  due  almost  always  either  to  trau- 
matism or  to  rupture.  Spontaneous  rupture  generally  results  from  exten- 
sion of  some  neighboring  focus  of  disease  to  the  vessel-wall. 

Andral  states  that  varicose  veins  occur  in  the  pia  and  that  they  occa- 
sionally rupture.  Capillary  hemorrhage  may  follow  the  plugging  of  a 
large  vein,  and  of  the  larger  vessels  any  one  or  more  may  be  involved, 
but  it  has  been  observed  that  hemorrhage  tends  to  take  place  at  par- 
ticular places.  In  more  than  one-half  of  all  cases  the  lenticulo-striate 
artery  (Charcot's  artery  of  cerebral  hemorrhage)  gives  way,  and  damages 
the  lenticular  nucleus  and  internal  capsule.  Other  regions  in  the  order 
in  which  hemorrhage  occurs  are  as  follows :  centrum  ovale,  cortex,  pons, 
peduncle,  cerebellum,  optic  thalamus,  and  the  posterior  and  anterior 
parts  of  the  hemispheres.  Hemorrhage  into  the  cerebrum  occurs  twenty 
times  more  often  than  hemorrhage  into  the  cerebellum  ;  it  may  take 
place  into  the  brain-substance,  into  the  ventricles,  or  into  the  meninges, 
the  latter  form  having  already  been  considered.  Ventricular  hemor- 
rhage in  a  great  number  of  cases  is  caused  by  a  more  or  less  extensive 
laceration  of  brain-matter,  thus  permitting  the  blood  to  escape  into  the 
ventricles.  Not  only  the  lateral  ventricles,  but  the  third  and  fourth 
also,  may  contain  blood. 

Symptoms. — Generally  the  patient  is  seized  without  any  warning, 
but  in  other  cases  headache.,  depression,  possibly  choreaform  movements, 
and  more  or  less  paresthesia  precede  an' attack.  The  loss  of  conscious- 
ness is  usually  the  first  manifestation,  though  for  a  few  moments  before, 
motor  weakness,  with  or  without  spasmodic  movements,  may  exist.  In 
very  slight  attacks  consciousness  may  be  preserved  throughout.  The 
cause  of  the  unconsciousness  is  still  an  open  question.  Niemeyer  re- 
garded it  as  due  to  pressure  acting  either  directly  upon  the  convolutions 
or  by  limiting  the  blood-supply.  This  view  is  scarcely  tenable,  hoAv- 
ever,  for  unconsciousness  occurs  even  when  the  hemorrhage  is  too  small 
to  exert  pressure,  and,  moreover,  the  hemorrhage  and  loss  of  conscious- 
ness are  usually  simultaneous.  The  symptoms  are  in  direct  proportion 
to  the  extent  and  position  of  the  hemorrhage.  The  patient  falls,  the 
face  is  usually  congested,  one  side  often  expressionless,  and  the  cheek 
flaps  during  respiration.  Breathing  is  stertorous  and,  in  grave  cases, 
of  the  Cheyne-Stokes  type ;  the  pulse  is  generally  feeble  for  a  few  mo- 
ments, but  soon  becomes  full  and  bounding  in  character.  The  pupils 
vary,  and  may  either  be  contracted  or  dilated.  There  is  frequently  a 
relaxation  of  the  sphincters,  and  on  raising  the  limbs  it  will  be  found 
that  those  of  one  side  off'er  absolutely  no  resistance.  The  temperature 
is  slisrhtlv  lowered  at  first,  but  after  a  few  hours  rises  to,  or  just  above, 
normal.  In  grave  cases  it  will  either  remain  low  or  will  mount  up  to 
106°  F.  (41.1°  C.)  or  even  higher.  Such  cases  are  usually  fatal.  Con- 
jugate deviation  of  the  head  and  eyes  takes  place  in  some  cases,  the 
deviation  being  toward  the  lesion  and  away  from  the  paralyzed  side  ;  in 
pontine  hemorrhage  the  opposite  to  this  occurs.  As  a  rule,  the  symp- 
toms that  Ave  group  under  the  term  apoplexy — viz.  loss  of  consciousness, 
motor  power,  and  sensation,  with  or  without  relaxation  of  the  sphincters 
— pass  off"  in  twelve  to  twenty-four  hours.  In  fatal  cases  the  coma 
deepens,  but  death  rarely  ensues  under  tAvelve  hours.  In  hemorrhage 
into  the  medulla  or  ventricles  it  may  be  more  rapid. 


CEREBRAL  HEMORRHAGE.  1117 

In  from  twenty-four  to  forty-eight  hours  after  the  onset  febrile  reac- 
tion sets  in,  with  irritative  symptoms  due  to  the  inflammatory  changes 
occurring  about  the  original  lesion.  There  are  fever,  often  delirium, 
twitchings  or  spasmodic  movements  of  a  more  pronounced  type,  and 
sometimes  rigidity  in  the  affected  limbs.  The  temperature  of  the  para- 
lyzed side  is  often  from  one-half  to  two  degrees  higher  than  the  tem- 
perature on  the  sound  side.  Trophic  changes  in  the  form  of  vesicles, 
or  even  sloughing,  may  occur.  Death  may  take  place  during  this 
stage.  Cases  are  generally  fatal  also  in  which  a  second  "stroke" 
follows  closely  upon  the  first,  indicating  a  fresh  hemorrhage.  After 
the  reactionary  period  a  stationary  period  follows ;  sooner  or  later  con- 
trol of  the  damaged  membranes  is  then  gradually,  but  not  perfectly, 
regained.  The  degree  of  recovery  is  dependent  upon  the  resumption 
of  function  of  slightly  damaged  tissue  or  upon  the  compensatory  activity 
of  the  other  side  of  the  brain.  In  well-marked  cases  the  movements  of 
the  affected  side  are  subsequently  ataxic.  In  certain  cases  the  struct- 
ural damage  has  been  too  great,  and  permanent  paralysis  remains,  with 
rigidity,  wasting,  and  secondary  contractures. 

Ingravescent  Apoplexy. — In  certain  cases  the  onset  is  slow,  conscious- 
ness being  lost  gradually.  Coma  deepens  and  the  case,  as  a  rule,  termi- 
nates fatally. 

Simple  Apoplexy. — The  term  "simple  apoplexy  "  is  almost  obsolete. 

Serous  Apoplexy. — The  cases  present  clinical  evidences  of  apoplexy, 
but  the  only  jyostmortem  finding  is  an  excess  of  serum,  and  this  is  in  no 
way  responsible  for  the  apoplexy.  These  cases  probably  belong  in  the 
same  category  as  those  just  mentioned,  but  occur  in  old  persons  whose 
brains  have  atrophied. 

Hemiplegia. — When  this  is  complete  one  side  of  the  face  and  the  arm 
and  leg  of  one  side,  generally  the  same,  are  all  involved.  The  facial 
palsy  is  not  complete,  the  frontalis  and  orbicularis  oculi  escaping.  The 
tongue  when  protruded  deviates  toward  the  paralyzed  side.  As  a  rule 
the  arm  is  affected  to  a  greater  extent  than  the  leg,  and,  indeed,  in 
some  cases  the  face  and  arm  may  alone  be  paralyzed.  The  trunk-mus- 
cles always  escape,  possibly  owing,  as  Broadbent  suggested,  to  the  func- 
tional unison  of  the  spinal  nuclei  of  the  tivo  sides  that  preside  over  them, 
and,  since  they  habitually  act  together,  he  supposed  that  they  might  be 
stimulated  from  either  hemisphere. 

Sensation  is,  of  course,  absent  during  the  period  of  unconsciousness. 
Subsequent  sensory  disturbances  are  not  constant  for  all  cases.  Spots 
of  anesthesia  often  exist  for  a  brief  period,  but  hemianesthesia  is  rare. 
Occasionally  dissociation  of  sensation  is  present,  tactile  sensation  being 
preserved,  whilst  muscular  and  thermal  sensation  is  lost  or  diminished. 
The  stereognostic  sense  is  often  seriously  disturbed  in  these  cases.  A 
lesion  in  or  about  the  posterior  part  of  the  posterior  limb  of  the  inter- 
nal capsule  is  specially  prone  to  give  rise  to  disturbances  of  sensation. 

The  special  senses  may  be  temporarily  perverted  or  their  functions 
in  abeyance,  but  rarely  do  permanent  disturbances  occur.  Transient 
crossed  hemianopsia  usually  occurs,  even  if  the  optic  tract  has  not  been 
directly  involved.  More  or  less  mental  deterioration  may  be  perma- 
nent, however.  The  deep  reflexes  are  increased  on  the  paralyzed  side, 
and  the  superficial  reflexes  are  absent. 

Crossed  Hemiplegia. — When  a  lesion  occurs  in  the  lower  part  of  the 


1118  DISEASES  OF  THE  NERVOUS  SYSTEM. 

pons  the  fibers  of  the  facial  nerve  that  are  involved  have  already  decus- 
sated ;  hence  facial  palsy  occurs  on  the  same  side  as  the  lesion.  The 
fibers  coming  from  the  cortex  are  implicated  before  their  decussation,  so 
that  paralysis  of  the  limbs  occurs  on  the  side  opposite  to  the  lesion. 
Lesion  of  the  crus  may  lead  to  oculo-motor  palsy  of  the  same  side,  and 
palsy  of  the  face,  arm,  and  leg  of  the  opposite  side. 

Course  and  Terminations. — As  previously  intimated,  the  course 
depends  on  the  position  and  extent  of  the  lesion.  In  the  most  extensive 
cases  death  rarely  takes  place  under  several  hours.  Hemorrhage  into 
the  medulla  may  prove  fatal  more  quickly.  In  the  slightest  cases,  per- 
fect recovery  may  take  place  in  a  few  days  or  weeks.  Generally,  how- 
ever, when  little  or  no  improvement  occurs  in  two  or  three  months,  per- 
manent changes  result.  The  facial  muscles  soon  recover,  and  next  the 
leg,  while  at  first  the  patient  is  able  merely  to  move  the  toes.  Daily 
improvement  then  follows  until  he  can  support  his  weight ;  dragging  of 
the  foot,  however,  is  marked  at  first,  and  rarely  disappears  absolutely. 
In  the  mean  time  a  less  pronounced  change  for  the  better  has  been  taking 
place  in  the  arm.  This  member  very  rarely  recovers,  however,  to  the 
same  extent  as  the  leg,  and  secondary  contractures  develop  in  time,  the 
arm  and  hand  becoming  flexed,  wliilst  the  leg  is  extended.  The  hand 
is  usually  bluish  and  cold,  and  swells  if  kept  in  a  dependent  position. 
More  or  less  ataxia  is  constant,  and  rheumatoid  pains  are  apt  to  occur 
during  this  stage.  Other  late  manifestations  that  are  only  occasionally 
met  Avith  are  athetosis,  arthropathies,  post-hemiplegic  chorea,  and 
tremors. 

There  is  no  wasting  of  the  affected  muscles  as  a  rule ;  nor  are  there 
electric  changes,  except  during  the  irritative  period,  when  the  response 
to  stimulation  is  heightened.  Occasionally  marked  atrophy  occurs,  and 
is  due  in  some  cases,  as  Charcot  has  shown,  to  changes  in  the  cells  of 
the  anterior  horns.  In  others  no  such  change  is  found,  and  we  are 
forced  to  regard  tlie  Avasting  as  cerebral. 

Differential  Diagnosis. — Apoplexy  is  to  be  distinguished  from 
other  conditions  causing  unconsciousness,  such  as  cardiac  syncope,  epi- 
lepsy, alcohol  or  opium-poisoning,  insolation,  or  uremia.  If  some  pre- 
vious history  can  be  obtained,  the  difficulty  of  the  diagnosis  is  lessened, 
though  it  may  still  be  great.  In  sz/ticopal  attacks  the  pulse  is  very 
feeble  and  the  face  is  pale,  respiration  being  shallow  and  often  sus- 
pended. The  sphincters  are  hardly  ever  relaxed ;  the  reflexes  are  usu- 
ally preserved,  and  the  skin  is  often  moist.  In  epilepsy  there  is  a  his- 
tory of  previous  attacks,  or,  failing  to  obtain  this,  one  can  usually  learn 
that  a  convulsion  has  immediately  preceded  the  coma.  With  alcoholism 
the  case  is  more  difficult.  The  odor  of  alcohol  on  the  breath  is  of  no 
value,  as  spirits  may  have  been  given  by  a  bystander ;  moreover,  hem- 
orrhage is  common  in  alcoholics  {vide  table  of  diff'erential  diagnosis,  p. 
965).  In  opiian-poisoning  the  coma  comes  on  gradually,  and  when  not 
too  profound  the  patient  can  be  aroused  when  shaken  or  shouted  at. 
The  respirations,  which  are  very  slow  and  deep  at  other  times,  become 
somewhat  quicker  and  shallower  when  he  is  aroused.  In  insolation  the 
temperature  suffices  as  a  rule,  though,  as  stated,  high  temperature  may 
occur  in  apoplexy.  The  presence  of  albumin  is  not  conclusive  evidence 
of  uremic  poisoning  unless  the  centrifuge  and  the  microscope  reveal 
the  presence  of  casts  or  other  indications  of  renal  change;  even  then 


CEREBRAL  HEMORRHAGE. 


1119 


the  case  may  be  one  of  apoplexy  in  a  subject  of  nephritis.  In  the  case 
of  diabetic  coma  the  presence  of  sugar  in  the  urine  serves  to  make  the 
diagnosis.  When  we  meet  with  a  comatose  case  in  which  there  is  abso- 
lutely no  resistance  when  the  limbs  of  one  side  are  raised,  while  those 
of  the  other  still  exhibit  some  tonicity,  particularly  if  the  deep  reflexes  are 
exaggerated  on  the  flaccid  side,  the  probability  is  that  it  is  an  apoplectic 
attack.  It  is  generally  not  possible  to  tell  whether  the  condition  is  due 
to  hemorrhage,  embolism,  or  thrombosis,  though  the  tabulated  points  of 
distinction  (after  Leube,  vide  infra)  will  afibrd  material  aid: 


Emboli. 

Early  adult  life. 

Previous  development  of  atheroma,  car- 
diac disease  following  acute  rheuma- 
tism, sepsis,  chronic  valvular  disease, 
fatty  heart,  general  cardiac  weakness, 
aneurysm. 

Detection  of  emboli  in  other  organs. 


During  the  attack  there  is  an  absence  of 
congestion  of  the  face ;  the  pulse  is 
normal ;  in  cardiac  affections  it  is  ac- 
celerated and  irregular. 

Temperature  normal,  but  shortly  after 
the  attack  it  begins  to  rise,  without 
making  an  unfavorable  prognosis. 

The  attack,  as  a  rule,  is  short,  but  if  there 
is  a  protracted  embolic  infarction,  the 
duration  is  long ;  but  the  circulation 
may  adjust  itself. 

Remote  effects  are  infrequent.  Hemi- 
plegia is  right-sided,  with  aphasia. 


Hemorrhase. 

Late  adult  life  ;  in  early  life  very  rare. 
Atheroma  with  cardiac  hypertrophy. 


History  that  the  patient  up  to  the  time 
of  attack  was  well ;  also  the  finding  of 
casts  in  urine  and  other  symptoms  of 
chronic  nephritis. 

During  the  attack  there  are  noted  flushes 
(reddish)  of  the  face,  pulsating  carotids, 
and  slow  pulse. 

Temperature  during  the  attack  is  sub- 
normal, but  just  previous  to  death  there 
is  an  antemortem  rise. 

The  duration  is,  as  a  rule,  longer.  Coma 
of  long  duration  (about  two  days)  gives 
a  very  unfavorable  prognosis. 

Remote  effects  quite  frequent;  alteration 
in  the  urine — albuminuria,  polyuria. 


At  times  the  ophthalmoscope  reveals 
either  a  recent  or  an  old  embolus  in  the 
arteria  centralis  retinae. 


Ophthahnoscopic  Examination. 

The  retinal  arteries  may  show  various 
stages  of  atheromatous  degeneration  ; 
as  a  result  there  may  be  a  hemorrhagic 
retinitis  or  there  may  be  a  thrombus 
of  the  central  vein  of  the  retinae.  In  a 
few  instances,  in  which  the  hemorrhage 
occurred  in  the  ventricle,  the  pupils 
were  contracted. 


It  is  not  an  uncommon  occurrence  to  have  patients  brought  to  a  hos- 
pital dazed  and  smelling  of  liquor.  These  should  always  be  carefully 
watched,  for  mistakes  readily  occur,  and  many  such  cases  have  been 
condemned  to  a  prison-cell  when  they  were  really  suff'ering  from  cerebral 
hemorrhage. 

Prognosis. — Sufficient  has  already  been  said  on  this  point. 

Treatment. — The  patient  should  be  kept  as  quiet  as  possible  and 
in  the  recumbent  position,  with  the  head  somewhat  elevated.  The 
clothing  about  the  neck  should  be  loosened  to  preveilt  constriction. 
An  ice-bag  may  be  put  to  the  head  and  hot  bricks  or  a  hot-water  bottle 
to  the  feet,  while  sinapisms  may  be  placed  on  the  back  of  the  neck  or 
on  other  parts  of  the  body.     If  the  pulse  is  strong,  full,  and  incom- 


1120  DISEASES  OF  THE  NERVOUS  SYSTEM. 

pressible,  and  the  face  is  congested — venesection  is  probably  justifiable, 
particularly  if  the  age  and  condition  of  the  vessels  support  the  idea 
that  hemorrhage  is  taking  place.  It  must  not  be  done  without  consid- 
eration, however,  since  it  would  be  useless  in  embolism  and  thrombosis. 
The  bowels  should  be  made  to  move  freely  :  a  cathartic  may  be  exhibited 
by  the  mouth  (croton  oil,  gtt.  j  or  ij).  and  at  the  same  time  an  enema 
may  be  given.  When  consciousness  returns  the  patient  should  be  kept 
absolutely  quiet  for  several  days,  and  only  li(|uid  food  permitted.  Later 
an  endeavor  should  be  made  to  keep  up  the  tone  of  the  afi"ected  muscles 
by  massage  and  electricity.  It  is  questionable  if  the  iodids  or  any  other 
drugs  have  an  influence  over  the  subsequent  changes. 


APHASIA. 


Definition. — Impairment  or  total  suppression  of  the  power  of 
speech,  due  to  cerebral  disease.  This  is  a  complex  subject,  and  cannot 
be  more  than  touched  upon  here ;  but  the  chief  disturbances  will  be 
briefly  mentioned,  omitting  any  further  description  of  the  form  due  to 
disease  of  the  bulb  (auartkria),  since  it  has  already  been  dealt  with  in 
speaking  of  Bulbar  Palsy  {vide  p.  1094). 

The  majority  of  cases  of  aphasia  are  met  with  in  connection  with 
hemiplegia.  They  are  apt  to  be  more  marked  in  the  beginning,  owing  to 
the  general  obtunding  of  the  psychic  processes  that  is  induced  by  the 
shock.  Speech  is  the  expression  of  thought  in  words,  and  is  the  result 
of  external  stimulation  in  Avhich  the  impulse  awakens  in  the  mind  a 
recollection  of  similar  impulses  that  have  preceded  it — e.g.  the  sight  of 
a  dog,  sound  of  a  bell,  or  certain  odors  {vide  Fig.  72).  Bastian,  however, 
believes  that  it  is  not  necessary  to  postulate  the  existence  of  a  separate 
center  for  conceptions  or  ideas.  He  believes  that  a  better  knowledge  of 
the  functional  activity  of  the  auditory  and  visual  word-centers  obviates  it, 
and  gives  the  following  three  ways  in  which  the  perceptive  center  may  be 
called  into  activity  :  (1)  By  voluntary  recall  of  past  impressions,  as  in  an 
act  of  recollection  ;  (2)  by  association — that  is,  by  impulses  communi- 
cated from  another  center  during  some  act  of  perception  or  during  some 
thought-process ;  and  (3)  by  means  of  external  impressions. 

Two  principal  forms  of  aphasia  exist :  (1)  Motor,  and  (2)  Sensory.  I 
shall  consider  these  forms  of  aphasia  separately,  although  before  doing 
so  it  seems  necessary  to  indicate  by  means  of  the  accompanying  schematic 
diagram  (Fio-.  73)  the  diff'erent  paths  on  which  the  individual  acts  for  the 
occurrence  ol"  speech  are  fulfilled.  This  will  also  serve  to  furnish  an  easy 
explanation  of  the  symptomatology  of  the  individual  forms  of  aphasia  and 
the  means  by  which  their  discrimination  (from  each  other)  is  possible. 

Motor  Aphasia. — As  stated,  we  meet  with  aphasia  most  frequently 
in  hemiplegia.  It  is  also  met  with  in  certain  cases  of  embolism  and 
thrombosis  and  as  a  result  of  softening  from  any  cause  ;  also  in  certain  cases 
of  brain-tumor  and  in  deaf-mutes.  The  latter  cases  are  not  strictly  in- 
cluded in  the  definition  given,  for,  while  brain-injuries  at  birth  may  and 
do  occasionally  cause  aphasia  either  by  damaging  the  brain  as  a  whole  (im- 
becility) or  in  a  more  circumscribed  fashion,  I  refer  particularly  to  those 
cases  in  which  the  child  is  aphasic  because  he  is  deaf,  for  unless  trained 


APHASIA. 


1121 


through  his  visual  or  tactile  sense  he  has  no  memory-picture  of  words 
from  which  to  draw.  A  child  may  acquire  the  power  of  speech  and 
retain  it  for  several  years,  and  then  become  deaf.  He  will  then  receive 
no  more  auditory  impressions,  and,  unless  trained  as  in  the  preceding 
group,  will  become  aphasic.  Certain  cases  of  congenital  speech-defect 
have  been  described  by  Hodden  under  the  name  "  idioglossia."  Here 
the  children  utter  peculiar  sounds,  constant  for  the  same  words.  As  a 
rule,  their  intelligence  is  not  up  to  the  normal.  In  hemiplegia  the  lesion 
is  usually  in  the  motor,  or  emissive,  center  in  the  foot  of  the  third  frontal 
convolution  (Broca's  region).     In  right-handed  people  this  is  on  the  left 


J 

A<^- \h 

u  V 


Fig.  76.— Diagram  for  the  explanation  of 
the  process  of  speech  (Leube) :  A,  auditory 
perceptive  center  (center  for  the  recognition 
of  sounds) ;  a  A,  acoustic  tract  (auditory- 
tract)  :  L,  center  of  motor  speech ;  L  I,  motor 
speech  tract  (path  for  the  innervation  of  the 
muscles  of  phonation) ;  J,  center  of  ideation 
(higher  concept  center). 


Fig.  77.— Diagram  for  the  explanation  of  aphasia 
(Leube) :  A,  a  A,  L,  L  I,  J,  the  same  as  in  Fig.  71 ; 
A  J L  A,  circle  by  which  speech  is  controlled; 
a  A  LI,  path  used  for  automatic  speech;  J  LI, 
path  used  for  voluntary  .speech  ;  a  A  J,  path  used 
for  the  recognition  of  words  ;  =,  interruption  of 
conduction;  1-S,  forms  of  sensory  aphasia  (1,  cor- 
tical ;  2,  subcortical ;  3,  transcortical) ;  4-6,  forms 
of  conduction-aphasia  (1,  cortical;  2,  subcortical; 
3,  transcortical) ;  7,  conduction-aphasia  (amnesic 
aphasia). 


side  of  the  brain,  and  on  the  right  side  in  left-handed  people.  Bastian 
believes  Broca's  region  to  be  sensory  and  not  motor  {vide  Sensory 
Aphasia,  infra).  A  lesion  in  Broca's  region  causes  the  loss  of  volun- 
tary speech,  nor  can  the  person  repeat  words  after  any  one  or  read 
aloud ;  but  he  can  understand  when  spoken  to,  and,  unless  his  arm  is 
paralyzed,  can  usually  write  from  a  copy.  It  is  rare,  however,  for  a 
lesion  to  involve  so  strictly  limited  a  portion  of  the  cortex.  As  a  rule, 
adjacent  parts  or  commissural  fibers  between  neighboring  motor  centers 
are  involved,  resulting  in  "combined  motor  aphasia."  In  either  case 
automatic  speech  is  perfect,  and  oaths  or  other  expletives  may  be  uttered, 
songs  sung,  or  poetry  recited  unless  the  oro-lingual  centers  are  damaged. 
71 


1122  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Some  observers  claim  that  a  special  center  for  writing  exists  at  the  foot 
of  the  second  left  frontal  convolution.  Ddjerine  denies  this.  In  some 
cases  the  patient  comprehends  when  spoken  to,  and  even  speaks  himself, 
but  he  misplaces  Avords,  and  hence  fails  to  convey  his  meaning.  The 
lesion  in  such  cases  of  paraphasia  is  believed  to  be  in  the  commissural 
fibers  uniting  the  frontal  and  temporal  lobes,  and  is  called  "  Wernicke's 
aphasia  of  conduction." 

Sensory  Aphasia. — This  comprises  various  auditory  and  visual  dis- 
turbances of  speech. 

(«)  Auditory  Disturbances, — The  cortical  center  for  auditory  impres- 
sions is  in  the  posterior  part  of  the  first  and  second  temporal  convolu- 
tions. That  this  region  represents  several  auditory  impressions — viz. 
that  for  words,  music,  and,  in  fact,  sounds  of  any  kind — we  have  abun- 
dant clinical  proof.  Cases  are  reported  in  which  the  patient  recognizes 
all  but  spoken  words.  He  can  read  and  write,  but  Avhen  spoken  to,  hears 
the  words  just  as  one  may  hear  a  foreign  language,  but  cannot  under- 
stand. He  cannot,  therefore,  write  to  dictation.  This  is  "word-deaf- 
ness." Prof,  Edgren  of  Stockholm  has  reported  cases  in  which  the 
patient  is  tone-deaf.  The  sound  is  heard,  but  is  not  appreciated  as  music. 
While  these  various  auditory  impressions  may  occui'  singly,  we  most  com- 
monly meet  with  a  condition  in  which  they  are  all  lost — '"mind-deafness" 
— and  in  every  case,  except  those  possibly  of  the  most  trivial  kind,  more 
or  less  apraxia  (loss  of  knowledge  of  the  use  of  things)  exists  contem- 
poraneously, 

Bastian  gives  four  centers  for  word-memory  as  follows : 

(1)  Auditory  memory,  the  memory  of  the  sound  of  words,  situated  in 
the  posterior  part  of  the  first  temporal  convolution, 

(2)  Visual  memory,  the  memory  of  the  visual  appearances  (printed  or 
written)  of  Avords,  situated  in  the  angular  and  supramarginal  gyri. 

(3)  Kinesthetic  memory,  the  memory  of  tiie  different  groups  of  sensory 
impressions,  resulting  from  the  mere  movements  of  the  vocal  organs  dur- 
ing the  utterance  of  words  (impressions  from  muscles,  mucous  membranes, 
and  skin).  This  he  places  in  Broca's  region,  and  terms  the  glosso-kin- 
esthetic  center. 

(4)  The  cheiro-kinesthetic  center,  not  definitely  located,  he  regards  as 
the  memory-center  of  the  different  groups  of  sensory  impressions  emanat- 
ing from  muscles,  joints,  and  skin  during  the  act  of  writing  individual 
letters  and  words, 

Bastian  does  not  regard  these  four  centers  as  sharply  defined.  He  says 
on  this  point :  "  Although  I  am  not  a  believer  in  the  complete  topographic 
distinctness  of  the  several  sensory  centers  in  the  cerebral  hemisphere,  I 
consider  it  clear  that  there  must  be  certain  sets  of  structurally  related 
cells  or  fiber-mechanisms  in  the  cortex  Avhose  activity  is  associated  with 
one  or  another  of  the  several  kinds  of  sensory  endowment,"  Such  diff'use 
but  functionally  unified  nervous  networks  may  differ  altogether  from  the 
common  conception  of  a  neatly-defined  "  center,"  and  yet  for  the  sake  of 
brevity  it  is  convenient  to  retain  this  word,  and  refer  to  such  networks  as 
so  many  "centers." 

(b)  Visual  Disturbances. — The  visual  perceptive  center  of  Monk  is 
situated  in  the  occipital  lobe  in  the  region  of  the  cuneus  and  of  the  cal- 
carine  fissure.     The  visual  memory-centers  are  in  the  angular  and  supra- 


APHASIA.  1123 

marginal  convolutions.  By  the  visual  memory- center  is  meant  that  part 
in  which  are  stored  memories  of  things,  faces,  or  places.  Memory  is  no 
longer  regarded  as  a  definite  and  fixed  unity,  but  rather  as  a  number  of 
memories,  each  being  closely  related  cortically.  Of  this  also  we  have 
abundant  clinical  proof.  Kussmaul  was  the  first  to  point  out  that  blind- 
ness for  words  can  exist  as  a  separate  entity,  and  for  this  he  proposed  the 
term  "word-blindness."  Letter-blindness  can  also  exist  alone.  Charcot 
speaks  of  a  patient  who  knew  Latin,  Greek,  German,  French,  and  Span- 
ish, but  lost  the  memory  of  some  of  the  Greek  and  German  letters  only. 
In  other  cases  the  patient  may  recognize  the  letters,  but  cannot  form  them 
into  words  or  sentences.  Note-blindness,  according  to  Professor  Edgren, 
is  a  variety  of  amnesia  in  which  the  patient  can  no  longer  recognize 
musical  notes,  though  he  sees  them  as  well  as  ever.  In  still  other  cases 
the  visual  memory  for  objects,  faces,  or  places  may  be  lost.  The  follow- 
ing case  reported  by  Serieux  is  interesting  in  this  connection  :  A  woman 
aged  sixty-two  had  a  stroke,  folloAved  by  paralysis,  and  after  a  second 
attack  epileptic  convulsions  and  hallucinations  of  hearing.  She  was 
found  to  have  deafness  and  paraphasia,  word-blindness,  agraphia,  and 
object-blindness  (apraxia).  She  could  not  recognize  the  friends  nor  the 
objects  that  once  were  quite  familiar  to  her.  Some  time  later  she  died 
with  pneumonia,  and  postmortem  softening  was  found  in  the  left  first 
temporal  (posterior  part)  and  in  the  left  supramarginal  convolutions  ;  also 
on  the  right  side  areas  of  softening  were  noted  in  the  posterior  parts  of 
the  first  and  second  temporal  convolutions  and  in  the  angular  and  supra- 
marginal  convolutions.  This  case  illustrates  the  point  of  which  I  have 
already  spoken — viz.  the  mixed  character  of  the  symptoms,  due  to  simul- 
taneous involvement  of  two  or  more  centers.  That  this  is  the  more  com- 
mon condition  is  not  alone  due  to  the  anatomic  propinquity  of  the  various 
centers,  but  chiefly  to  the  fact  that  they  are  all  Avithin  the  area  supplied 
by  the  Sylvian  artery  and  its  branches.  The  simultaneous  loss  of  these 
several  visual  memories  results  in  the  condition  known  as  "  mind-blind- 
ness." These  sensory  aphasias  are  sometimes  spoken  of  as  "amnesic 
aphasia." 

Eskridge^  has  briefly  summarized  this  subject  as  follows: 

(1)  If  the  lesion  is  in  the  foot  of  the  left  third  frontal  (Broca's)  con- 
volution in  right-handed  persons,  and  in  left-handed  persons  in  the  right 
third  frontal,  the  patient  will  be  unable  to  speak  voluntarily,  to  repeat 
words  after  another,  read  aloud,  think  in  speech,  and  generally  to  write 
voluntarily  or  from  dictation  so  as  to  be  understood ;  but  he  understands 
the  speech  of  another.  He  is  usually  able  to  use  and  to  understand  ges- 
ture-expression. 

(2)  A  lesion  in  the  oro-lingual  center  (lower  portion  of  the  central 
convolutions)  will  cause  paresis  or  paralysis  of  the  oro-lingual  muscles, 
including  the  loAver  side  of  the  face,  and  imperfect  articulation ;  but  the 
patient  will  be  able,  with  a  decided  eff'ort,  to  repeat  words  after  an- 
other, to  talk  voluntarily,  to  think  in  speech,  and  to  write,  although  the 
letters  may  be  imperfectly  formed.  There  is,  as  a  rule,  no  omission  or 
transposition  of  letters  or  words,  unless  the  lesion  is  sufiiciently  extensive 
to  afi'ect  the  adjacent  cortical  centers  or  their  commissural  fibers.  It  is 
possible  that  the  center  is  bilateral ;  that  a  lesion  on  either  side  may  give 

^  Umiversiiy  Med.  Magazine,  Jan.,  1897. 


1124  DISEASES  OF  THE  NERVOUS  SYSTEM. 

somewhat  similar  symptoms  ;  and  that  the  loss  of  function  in  the  affected 
muscles  will  not  be  completely  abolished  by  a  unilateral  lesion. 

(3)  A  lesion  in  the  foot  of  the  second  frontal  convolution  on  the  left 
side  in  right-handed  persons,  or  on  the  right  side  in  left-handed  persons 
(the  probable  orthogi'aphic  center),  will  be  attended  by  disturbances  in 
writing — inability  to  write,  due  to  inability  to  spell.  In  the  only  case  of 
of  this  kind  that  has  been  reported  the  patient  formed  all  letters  well,  but 
omitted,  transposed,  and  substituted  letters  to  such  an  extent  that  his 
writing  was  unintelligible.  He  wrote  Avell  when  words  were  spelled  for 
him. 

(4)  A  limited  lesion  in  the  posterior  two-thirds  of  the  first  and  second 
temporal  convolutions  is  attended  by  word-deafness,  and  an  inability  to 
write  at  dictation  (pure  word-deafness).  A  more  extensive  lesion  in  the 
same  region  results  in  mind-deafness  with  paraphasia,  and  some  disturb- 
ance in  reading  and  writing  will  be  added.  The  greater  the  extent  of  the 
cortical  and  subcortical  areas  involved  the  more  marked  the  paraphasia 
and  other  symptoms  of  sensory  aphasia. 

(5)  A  lesion  involving  the  angular  gyrus  and  adjacent  parts  will  cause 
word-blindness  and  inability  to  read,  also  defects  in  writing,  copying,  and 
speaking.  In  these  cases  paraphasia  is  often  present.  If  the  lesion  affects 
the  parts  posterior  to  the  angular  gyrus,  mind-blindness  may  be  added. 


INTRACRANIAL  GROWTHS. 

Owing  to  their  close  relationship,  new  growths,  both  of  the  brain  and 
membranes,  are  here  considered. 

Pathology. — Rindfleisch  has  classified  intva-cranial  tumors  according 
to  the  tissue  from  which  they  spring,  thus  : 

1.  Having  their  origin  in  the  memhranes,  either  extra-cerebral  or 
intra-ventricular  ;  these  include  tubercle,  gumma,  carcinoma,  sarcoma, 
myxoma,  lipoma,  cholesteatoma,  and  psammoma  ;  small  fibroids  have 
also  been  described.  Enchondroraa  and  osteoma  may  arise  from  the  falx 
or  from  the  bones  of  the  skull. 

2.  From  bIood-vei>seIs  :  to  this  group  belong  aneurysms,  tubercles, 
and  gummata. 

3.  Originating  in  the  neurogliar  tissue :  glioma. 

4.  Originating  in  the  connective  tissue :  sarcoma. 

I  will  here  consider  these  new  growths  in  the  order  of  frequency 
with  which  they  are  met. 

1.  Tubercle  is  most  common  in  children  and  young  adults,  and  is  gen- 
erally multiple  (see  Tuberculosis,  p.  315). 

2.  Sarcoma  is  usually  of  the  round-  or  spindle-celled  variety  ;  there 
may  also  be  melanotic  lympho-  or  fibro-sarcomata.  Sarcomata  are  apt  to 
diffuse  themselves  through  the  brain-substance  quite  rapidl3^ 

3.  Glioma. — Infiltrating  tumors,  generally  single,  and  showing  no  def- 
inite line  of  demarcation  from  the  surrounding  brain-structure.  They 
may  be  soft,  even  telangiectatic,  or  quite  firm.  They  often  run  a  very 
chronic  course. 

4.  Gummata  are  generally  small  and  often  multiple.     They  spring 


INTRACRANIAL   GROWTHS.  1125 

from  the  membranes  or  the  adventitia  of  blood-vessels,  or  from  connective- 
tissue  septa.  Frequently  they  are  attached  to  the  periosteum  of  the 
skull. 

5.  Carcinoma  may  be  primary  or  secondary,  usually  the  latter.  Sec- 
ondary growths  are  generally  small  and  round,  but  in  some  cases  they 
perforate  the  bones  of  the  skull,  producing  a  fungus  hematoides. 

6.  Fibromata  are  not  common.  They  either  grow  in  the  membranes 
or  aid  in  the  formation  of  a  mixed  tumor,  as  fibro-sarcoma.  Other  tumors 
met  with  less  frequently  are  as  follows :  7.  Osteoma;  8.  Enchondroma; 
9.  Myxoma;    10.  Lipoma;    11.  Angioma;    12.  Cholesteatoma. 

13.  Hydatids  are  rare,  and  exceedingly  so  in  America.  They  may 
develop  in  any  part  of  the  brain  or  its  membranes,  and  are  said  to  occur 
most  frequently  in  children.  14.  Cysticerci  may  also  occur  in  the  brain 
or  its  membranes. 

15.  Brain-cysts  are  probably  most  often  due  to  absorption  of  areas  of 
softening  from  any  cause,  but  they  also  occur  between  the  dura  and  skull, 
as  has  been  described.  The  lack  of  cerebral  substance,  due  either  to 
imperfect  development  or  to  atrophy  following  vascular  obstruction  or 
injury  at  birth,  has  been  termed  porencephalia  by  Hesche. 

Ktiology. — Age  and  sex  are  the  chief  factors ;  tuberculosis  is  far 
more  common  in  children  than  in  adults,  while  gummata  when  found 
appear  almost  invariably  in  adults,  as  do  malignant  growths.  As  a  whole, 
new  growths  are  more  common  between  the  twentieth  and  fortieth  years, 
and  males  are  more  often  affected  than  females.  Heredity  and  traumatism 
may  be  disregarded  as  causal  factors. 

Symptoms. — These  are  (1)  General,  and  (2)  Focal. 

G-eneral  Symptoms. — Headache  varies  in  degree  and  character ;  it  is 
not  of  any  value  as  a  localizing  symptom,  nor  is  tenderness  on  pressure. 

Vertigo  in  a  mild  form  is  quite  a  common  symptom.  In  cerebellar 
cases  it  is  often  very  marked. 

Vomiting  occurs  in  most  cases,  and  generally  bears  no  relation  to  the 
time  of  taking  food ;  this  constitutes  an  important  point  in  the  diagnosis. 
The  vomiting  is  apt  to  be  exaggerated  in  cerebellar  tumor. 

Optic  neuritis  is  present,  according  to  Gowers,  in  foui^-fifths  of  all 
cases  ;  in  82  per  cent,  according  to  Oppenheim,  and  in  two-thirds  accord- 
ing to  Knapp.  Gray  believes  this  to  be  misleading  in  a  measure.  We 
are  so  imbued  with  the  fact  that  optic  neuritis  is  a  symptom  of  brain- 
tumor  that  without  it  we  are  apt  to  overlook  the  possibility  of  tumor.  He 
says  it  is  unquestionably  present  as  a  rule  in  the  later  stages,  but  the 
practical  question  he  asks  is,  "  How  often  is  optic  neuritis  in  the  earlier 
stages  when  the  diagnosis  is  obscure?"  Headache,  vomiting,  and  optic 
neuritis  are  "classical  symptoms"  of  brain-tumor,  and  when  met  with 
simultaneously  are  quite  characteristic. 

The  mental  disturbance  is  usually  slight.  Dulness  and  stupor  are 
most  reliable  evidences  of  intra-cranial  growth,  and  especially  when  occur- 
ring with  any  of  the  above  symptoms.  The  patient  may  be  emotional  or 
hysteric.  Pseudo-apoplexy  may  occur  as  the  result  either  of  the  growth 
or  of  hemorrhage  taking  place  about  it. 

Convulsions  are  focal  (Jacksonian),  or  general  convulsions  may  occur. 

Constitutional  and  other  symptoms  may  include  progressive  Aveakness, 
loss  of  appetite  and  of  flesh,  pupillary  changes,  and  changes  in  the  pulse, 


1126  DISEASES  OF  THE  NERVOUS  SYSTEM. 

respiration,  etc.,  and  possibly  slight  fever.  In  certain  tumors  in  the 
basal  ganglia  hyperpyrexia  is  met  -with.  High  fever  is  often  significant 
of  meningeal  inflammation,  as  in  syphilitic  cases. 

The  focal  symptoms  are  of  two  kinds :  fii-st,  those  due  to  direct  local 
action  (irritation  or  compression),  and  second,  those  due  to  changes  oc- 
curring about  the  growth — indirect  irritation,  hemorrhage  or  softening, 
or  merely  congestion ;  thus  can  intermission  or  remission  in  symptoms  be 
explained.     The  chief  regional  symptoms  are  as  follows  in — 

{a)  Tumors  in  the  prefrontal  region.  Headache,  not  limited  to  the 
frontal  region,  with  more  or  less  mental  impairment  and  drowsiness 
(though  this  is  not  constant  by  any  means) ;  and  perhaps  a  disturbance  of 
the  sense  of  smell.  No  motor  or  sensory  symptoms  are  present  as  a  rule. 
The  tumor  may,  however,  grow  backward,  and  either  encroach  on  the 
motor  region  or  cause  motor  symptoms  indirectly.  Downward  growth 
would  result  in  aphasia. 

(b)  Tumors  in  the  motor  region.  The  early  symptoms  are  irritative 
and,  later,  paralytic.  The  former  give  rise  to  spasm,  which  is  often  very 
localized  at  first,  possibly  in  a  few  muscles  (Jacksonian  epilepsy).  More 
or  less  sensory  disturbance — e.  g.  tingling  or  anesthesia — is  generally 
present  also,  thus  supporting  the  view  that  the  motor  cortex  is  also  sen- 
sory. The  point  of  origin  and  direction  of  spread  of  the  spasm  are  val- 
uable localizing  symptoms.  Sooner  or  later  destruction  of  the  area 
csiMses  paralysis.  We  may  have  spasm  in  one  limb  and  monoplegia  of 
the  other  on  the  same  side.  Involvement  of  the  left  third  frontal  region 
causes  aphasia. 

(c)  Tumors  in  the  parietal  lobes.  There  may  be  no  symptoms.  When 
the  posterior  part  is  involved  (angular  or  supramarginal  gyri)  we  may 
meet  with  word-blindness  or  mind-blindness. 

((7)  Tumors  in  the  temporal  lobes  may  be  latent,  or  there  may  be  dis- 
turbances of  taste  and  smell.  If  the  posterior  part  of  the  first  convolu- 
tion is  involved,  we  have  word-deafness  or  other  psychical  disturbance  of 
hearing. 

(e)  Tumors  in  the  occipital  lobes.  A  unilateral  tumor  produces  hemi- 
anopia,  while  a  bilateral  lesion  may  cause  blindness.  In  certain  cases, 
too,  mind-blindness  results,  or  "soul-blindness,"  as  it  was  at  one  time 
called. 

(/)  Tumors  of  the  corpus  callosum  are  often  latent;  they  may,  how- 
ever, cause  unilateral  or  bilateral  motor  symptoms.  Often  some  mental 
aberration  is  noted. 

(//)  Tumors  of  the  corpora  quadrigemina  and  crura  may  be  considered 
together,  since  in  the  former  case  no  distinctive  symptoms  occur  when  the 
tumor  is  small ;  when  large  the  crura  Avill  be  implicated.  In  such  cases 
there  will  be  oculo-motor  paralysis  on  the  same  side  as  the  tumor,  and 
hemiplegia  on  the  other.      Sensory  disturbances  may  occur  also. 

(h)  Tumors  involving  the  base,  when  growing  in  the  anterior  fossa, 
give  rise  to  exophthalmos,  disturbances  of  smell  and  vision,  and  possibly 
to  mental  impairment.  When  in  the  middle  fossa  the  symptoms  are 
chieflv  those  of  involvement  of  the  third  and  fifth  nerve,  consisting  of 
ptosis  and  other  oculo-motor  symptoms  and  facial  neuralgia.  AVhen  the 
tumor  involves  the  pituitary  gland,  amblyopia  or  amaurosis  and  frontal 


INTEACRAyiAL    GROWTHS.  1127 

headache  occur.  Tumors  have  been  found  in  this  region  in  cases  of 
acromegaly  {q.  v.).  When  in  the  posterior  fossa,  facial  neuralgia,  neuro- 
paralytic ophthalmia,  or  seventh  or  eighth  nerve  involvement  and 
crossed  hemiplegia  are  met  with. 

{i)  Tumors  in  or  about  the  haml  ganglia,  if  quite  small,  cannot  be 
diagnosed.  When  of  larger  size  they  cause  hemiplegia  and  sensory  dis- 
turbances by  pressure  upon  the  internal  capsule,  and  hemianopia  by  pres- 
sure on  the  optic  radiation.  They  may  also  cause  obstruction  and  conse- 
quent distention  of  the  ventricles  (internal  hydrocephalus). 

{j)  Tumors  in  the  cerebellum  may  be  latent.  They  give  rise  to  most 
marked  symptoms  when  the  growth  is  in  the  middle  lobe.  In  such  cases 
headache,  vomiting,  vertigo,  and  ataxy  are  pronounced.  The  gait  is  of  a 
reeling  or  staggering  character,  and  there  is  a  tendency  to  fall  in  some 
particular  direction — forward,  backward,  or  to  one  side.  In  addition 
there  may  occur  optic  neuritis,  disturbances  of  vision,  pain  and  stiffness 
in  the  cervical  region,  and  possibly  deafness. 

(k)  Tumors  in  the  ])ons  and  medulla  give  rise  to  cranial  nerve-lesions, 
with  or  without  hemiplegia;  also  to  sensory  disturbances,  and  when  ex- 
tensive they  may  by  pressure  cause  cerebellar  symptoms.  Tumors  in  the 
medulla  may  cause  cardiac  or  respiratory  failure. 

It  is  often  important  from  a  surgical  point  of  view  to  ascertain  whether 
the  growth  is  cortical  or  subcortical.  Xo  absolute  means  of  doing  this 
exists,  though  Seguin  has  formulated  a  fair  working  rule — viz.  when 
localized  clonic  spasm  occurs,  followed  in  some  cases  by  epilepsy  (this 
primary  spasm  Seguin  has  termed  the  "  signal  symptom ''),  and  later  by 
paralysis,  with  local  pain  and  tenderness  and  increased  local  cerebral  tem- 
perature, a  cortical  lesion  is  most  likely.  On  the  other  hand,  when  the 
spasm  is  tonic,  particularly  if  widespread — involving  one  side,  for  instance 
— and  when  the  local  pain  and  tenderness  are  slight  or  absent,  and  the 
cranial  temperature  normal,  the  lesion  is  more  apt  to  be  subcortical. 

Course. — Many  cases  run  a  very  chronic  course.  Others  may  have 
existed  months  or  years  without  symptoms,  and  then  develop  suddenly, 
owing  to  hemorrhage,  thrombosis,  or  acute  softening  about  the  tumor. 
Either  improvement  may  take  place  or  the  case  may  speedily  procfress  to 
a  fatal  termination. 

Diagfnosis. — The  general  symptoms  are  usually  sufficient  to  warrant 
a  diagnosis.  The  gradual  onset  and  progressive  character  without  fever, 
in  the  apparent  absence  of  any  etiologic  factor,  are,  as  a  rule,  enouo-h  to 
indicate  that  a  tumor  is  present,  while  its  location  can  only  be  determined 
by  the  focal  symptoms. 

The  prognosis  is  always  grave.  Syphilitic  growths  are  almost  the 
only  kind  in  which  some  gleam  of  hope  may  be  extended,  and  this  only 
very  rarely;  tubercle  may  recover  by  the  growth  becoming  encapsulated 
and  calcified.  Xothing  can  be  said  as  to  the  possible  duration  of  life. 
Several  years  may  elapse  between  the  appearance  of  the  symptoms  and 
their  fatal  termination,  or  death  may  occur  suddenly. 

Treatment. — In  any  case  recourse  should  be  had  to  mercury  and 
the  iodids,  and  this  treatment  should  be  pushed,  since  it  will  certainly 
benefit  syphilitic  cases,  and  it  is  believed  to  be  of  some  value  even  in  the 
non-syphilitic.      Other    symptoms    should    be   met    as    they   arise.     The 


1128  DISEASES  OF  THE  NERVOUS  SYSTE3L 

question  of  operation  must  be  considered  where  medical  measures  have 
proved  of  no  avail.  Macewen  and  Horsley  in  Great  Britain  and  Keen 
in  this  country  have  pointed  out  its  justifiability.  If  the  situation  of  the 
groAvth  is  favorable  and  the  nature  of  the  tumor  is  not  malignant,  an 
operation  is  likely  to  be  successful.  The  percentage  of  recoveries  is  in- 
creasing as  the  technic  becomes  more  perfect  (see  Bruns,  Gesclnvulste 
der  Gehirn,  etc.). 


CHRONIC  HYDROCEPHALUS. 

This  afifection  is  divided  into  external  and  internal  hydrocephalus. 

EXTERNAL   HYDROCEPHALUS. 

Pathology. — "When  the  skull  is  opened  the  bone  is  usually  found 
to  be  thin  ;  the  dura  is  normal ;  the  arachnoid  is  lifted  from  the  surface 
of  the  cortex  by  a  considerable  accumulation  of  clear  fluid  of  low  specific 
gravity  ;  the  convolutions  ma^^  be  somewhat  flattened,  and  the  cortex 
slightly  thinned.  Upon  microscopic  examination  no  changes  are  found 
in  the  brain-substance.  Sometimes  the  effusion  is  general ;  sometimes  it 
is  sacculated.  In  a  case  of  epilepsy  with  very  marked  neuropathic  hered- 
ity, upon  which  I  recently  performed  an  autopsy,  two  large  subarachnoid 
cysts  were  found  beneath  the  temporal  lobes,  and  smaller  cysts  in  other 
parts  of  the  brain,  flattening  or  separating  the  convolutions. 

Ktiology. — External  hydrocephalus  may  depend  upon  a  congenital 
smallness  of  the  brain  or  upon  a  congenital  enlargement  of  the  skull. 
The  space  between  the  brain  and  the  bone  is  filled  by  an  excess  of  sub- 
arachnoid fluid  {vacuum  dropsy)^  or  there  may  be  a  wasting  of  the  brain, 
such  as  occurs  in  old  age  or  in  chronic  cachectic  conditions. 

The  symptoms  depend  upon  the  form.  In  cases  in  which  there  is 
hypoplasia  of  the  brain  or  in  which  the  brain  has  wasted,  no  pressure- 
symptoms  are  present.  All  the  manifestations  are  purely  psychic  in  na- 
ture, and  similar  to  those  of  microcephaly  or  senile  dementia.  In  cases, 
however,  in  Avhich  the  cranium-cavity  is  abnormally  large,  it  is  probable 
that  the  real  cause  resides  in  a  congenital  excess  of  subarachnoid  fluid. 

The  prognosis  is  gloomy  ;  nevertheless,  it  is  possible  that  the  disease 
may  undergo  spontaneous  cure  as  a  result  of  rupture  into  the  nasal  fossa. 

The  treatment  is  the  same  as  for  the  internal  variety  {vide  infra). 

INTERNAL   HYDROCEPHALUS. 

This  is  a  condition  in  which  one  or  more  of  the  ventricular  cavities  of 
the  brain  are  distended  by  the  cerebro-spinal  fluid.  In  the  congenital 
form  and  in  that  occurring  in  early  childhood,  this  is  associated  with  more 
or  less  enlargement  of  the  skull.  In  the  later  acquired  forms  the  cranium 
does  not  yield  so  readily,  and  the  enlargement  does  not  exist  or  is  slight. 

The  pathology  of  the  condition  vai'ies  with  its  nature.  In  the  con- 
genital forms,  upon  opening  the  head  the  skull  is  found  to  be  thin.     The 


INTERNAL   HYDROCEPHALUS.  1129 

fontanels  and  sutures  are  either  still  open  and  connected  only  by  a  mem- 
brane, or  closed  by  Wormian  bones.  The  dura  may  be  thickened,  but 
usually  is  normal ;  the  substance  of  the  brain  is  slightly  softened — although 
this  is  not  invariably  the  case — and  very  much  thinned.  This  thinning  is, 
as  a  rule,  particularly  noticeable  in  the  corpus  callosum  and  commissures, 
which  may,  indeed,  either  be  torn  apart  or  completely  atrophied.  The 
enlargement  ordinarily  affects  the  two  lateral  ventricles,  the  third  ventri- 
cle, and  the  aqueduct  as  fir  as  its  entrance  into  the  fourth  ventricle, 
which  is  commonly  less  involved  than  the  other  cavities.  The  ependyma 
is  sometimes  smooth,  but  more  often  shows  small  projections,  which,  ac- 
cording to  Virchow,  are  composed  of  brain-substance,  but  in  some  cases 
are  due  to  proliferation  of  the  glia  tissue  beneath  the  ependyma.  The 
enlargement  may  not  be  uniform.  If  due  to  obstruction  of  the  foramen 
of  Monro,  one  or  both  lateral  ventricles  are  usually  enlarged,  whilst  the 
third  ventricle  either  remains  of  normal  size  or  is  diminished.  If  due  to 
enlargement  of  the  pineal  gland,  the  aqueduct  does  not  show  the  funnel- 
shaped  distention.  Another  cause  upon  which  considerable  weight  has 
been  laid  is  the  closure  of  the  transverse  fissure  between  the  cerebellum 
and  medulla.  The  quantity  of  fluid  may  be  enormous,  as  much  as  4  or 
5  liters  (5  or  6  quarts)  having  been  recorded.  The  thinning  of  the  brain- 
substance  is  also  remarkable  when  one  considers  that  a  cerebrum  5  mm. 
(|-  in.)  in  thickness  is  apparently  able  to  perform  a  large  proportion  of  its 
ordinary  psychic  functions.  The  atrophy  seems  to  affect  particularly  the 
white  substance,  especially  the  myelin-sheaths. 

In  cases  of  the  acquired  forin,  unless  they  occur  early  in  life,  the  en- 
largement of  the  skull  is  not  very  noticeable ;  the  substance  of  the  brain 
shows  considerable  softening ;  the  ventricles  are  moderately  enlarged, 
and,  particularly  in  the  chronic  forms  due  to  tuberculosis,  are  consider- 
ably roughened.  The  most  pronounced  cases  are  those  that  occur  when 
there  is  a  tumor  in  the  occipital  fossa  which  compresses  the  veins  of  Ga- 
len. In  these  cases  the  accumulation  of  liquid  is  slower,  the  brain  yields 
more  gradually  to  pressure,  and  the  dilatation  is  more  pronounced.  Ordi- 
narily, there  is  considerable  flattening  of  the  convolutions.  In  a  few  of 
these  cases  inflammatory  changes  in  the  ependyma  have  led  to  partial 
obliteration  of  the  ventricles,  particularly  in  the  anterior  horns  or  the  lat- 
eral ventricles.  Occasionally  also  bands  of  organized  lymph  may  cross 
the  ventricles  in  various  directions ;  the  liquid  is  of  higher  specific  graA^- 
ity  and  contains  more  albumin  than  in  the  non-inflammatory  varieties. 

The  etiology  of  the  congenital  form  is  unknown,  though  the  fact 
that  it  frequently  occurs  in  several  children  of  the  same  family  has  led  to 
the  supposition  that  it  is  dependent  upon  some  hereditary  influence.  In 
some  cases  it  has  been  referred  to  emotional  disturbances  suffered  by  the 
mother  during  pregnancy,  and  in  still  other  cases  an  anatomic  founda- 
tion has  been  discovered,  such  as  enlargement  of  the  pineal  gland  It  is 
generally  supposed  that  the  immediate  cause  is  chronic  ependymitis. 

The  acquired  form  is  usually  secondary  to  inflammatory  conditions 
(particularly  meningitis)  or  to  brain-tumor.  Some  cases,  however,  occur 
in  childhood,  that  are  apparently  not  due  to  either  of  these  causes. 

Symptoms. — The  most  characteristic  appearance  in  congenital  hy- 
drocephalus is  the  globular  enlargement  of  the  head.  Upon  palpation 
the  fontanels  are  found  to  be  still  patulous  and  usually  bulging,  and  the 


1130  DISEASES   OF  THE  NERVOUS  SYSTEM. 

sutures  are  open.  The  head  is  usually  so  heavy  that  it  cannot  be  held 
upright,  but  falls  backward  or  to  one  side.  The  face  appears  propor- 
tionately very  small.  Motility  is  usually  disturbed,  the  legs  are  spastic, 
and  the  child  either  does  not  learn  to  walk  at  all  or  only  long  after  the 
usual  time.  There  are  sometimes  choreic  movements  of  the  upper  ex- 
tremities. The  eyes  frequently  show  nystagmus  and  conjugate  deviation, 
and  often  there  is  either  choked  disk  or  atrophy  of  the  optic  nerve. 
Fischer  has  described  a  systolic  viurmur  that  can  be  heard  if  the  stetho- 
scope is  placed  over  the  anterior  fontanel.  Its  cause  is  unkno-^vn  Con- 
vulsive attacks  are  common ;  they  are  epileptic  in  type,  and,  as  a  rule, 
ultimately  cause  death.  Intelligence  is  usually  considerably  impaired, 
and  sometimes  the  children  are  idiots ;  more  often  they  merely  show  re- 
tardation of  intellectual  development.  Occasionally — and  this  even  in 
the  most  pronounced  cases — the  intelligence  is  •well  preserved.  Henoch 
records  the  case  of  a  boy  three  years  of  age  whose  head  was  75  cm.  (29.6 
in.)  in  circumference,  and  who  could  speak  both  French  and  German. 
Ordinarily,  the  children  are  quiet  and  apathetic,  but  they  may  be  queru- 
lous. Nutrition  is  commonly  seriously  disturbed,  the  children  sometimes 
exhibiting  pronounced  cachexia.  They  may,  however,  be  well  nourished 
and,  to  a  certain  degree,  vigorous.  The  symptoms  of  the  chronic  form 
in  adults  are  those  of  brain-tumor  without  focal  symptoms. 

The  diagnosis  is  ordinarily  very  easy.  Careless  observation  may 
lead  to  confusion  with  rachitis  but  the  square  shape  of  the  head  and  the 
presence  of  other  rachitic  deformities  in  the  skeleton  should  lead  to  a 
prompt  recognition  of  the  true  nature  of  the  case. 

The  prognosis  is  extremely  unfavorable,  the  majority  of  the  children 
dying  about  the  fifth  year.  A  few  cases,  however,  may  live  until  they 
reach  voung  adult  life,  and  still  fewer  apparently  recover  entirely. 

Treatment  is  of  course  difficult.  Potassium  iodid  and  mercury  have 
been  employed  without  much  beneficial  effect.  Cod-liver  oil  may  be  given 
to  stimulate  nutrition,  and  purgatives  occasionally  relieve  pressure-symp- 
toms temporarily.  Among  the  mechanical  procedures  constant  pressure 
upon  the  head  seems  the  most  valuable.  This  can  be  obtained  by  means 
of  strips  of  adhesive  plaster  or  by  the  application  of  an  elastic  band. 
Tapping  the  ventricles  is  occasionally  followed  by  temporary  improve- 
ment, but  is  always  dangerous.  More  satisfactory  is  probably  the  lum- 
bar puncture  recommended  by  Quincke.  If  convulsions  develop,  they 
should  be  combated  by  bromids  and  purgatives. 


SCLEROSIS  OF  THE  BRAIN. 

This  may  be  diffuse  or  focal.  The  diffuse  form  is  usually  a  congeni- 
tal condition,  and  leads  to  a  hardening  of  the  whole  brain,  associated 
with  more  or  less  malformation.  If  it  is  secondary  to  some  vascular 
disturbance  in  early  life,  it  may  be  restricted  to  one  or  more  lobes  on 
one  side.  The  focal  form  occurs  in  insular  sclerosis,  and  as  a  congenital 
lesion.  The  latter  may  be  associated  with  overgrowth  or  contraction  of 
the  neurogliar  tissue,  and  is  spoken  of  as  hypertrophic  or  atrophic  gliosis. 
It  is  usually  associated  with   epilepsy  and  idiocy.     Neurogliar  hyper- 


GENERAL  PARALYSIS  OF  THE  INSANE.  1131 

plasia  is  also  met  -with  in  areas  in  which  the  nervous  tissue  has  been 
destroyed,  no  matter  what  the  cause.  It  occurs,  therefore,  in  both  pri- 
mary and  secondary  degeneration.  The  sclerotic  areas  vary  in  size 
from  very  small  and  even  microscopic  plaques  to  large  and  widely-dif- 
fused ones.  These  scleroses  have  been  considered  under  the  respective 
diseases  to  which  they  give  rise.  Focal  sclerosis,  due  to  scar-formation 
and  characterized  by  an  overgrowth  of  connective  tissue,  occurs  after 
injury  or  hemorrhage. 


GENERAL  PARALYSIS  OF  THE  INSANE. 

{General  Paresis;  Dementia  Paralytica.) 

Definition. — A  chronic  disease  involving  both  the  cerebrum  and  the 
meninges,  and  characterized  by  a  gradual  loss  of  power,  tremors,  and  pro- 
gressive mental  decay. 

Pathology. — The  intima  and  adventitia  of  the  blood-vessels  undergo 
proliferative  changes,  and  the  perivascular  spaces  are  dilated  and  contain 
an  excessive  quantity  of  fluid,  also  cellular  elements.  Obliterative  endar- 
teritis occurs  also.  Atrophy  and  degeneration  of  the  cerebrum  are  met 
with,  chiefly  involving  the  cortex,  particularly  that  of  the  frontal  or  pari- 
etal regions  and  the  anterior  basal  region.  The  ventricles  are  dilated  and 
the  ependyma  is  granular.  The  membranes  are  thickened  and  opaque, 
and  adherent  to  the  surface  of  the  convolutions,  so  that  the  cortex  is  torn 
upon  their  removal.  Hemorrhage  may  take  place  into  the  subdural 
spaces,  and  may  vary  in  amount  from  a  mere  stain  to  the  formation  of 
a  pseudo-membrane. 

Secondary  sclerotic  and  descending  degenerative  changes  may  be  found 
in  the  cord  in  some  cases. 

Ktiology. — As  in  locomotor  ataxia,  a  history  of  syphilitic  infection 
is  obtained  in  a  large  majority  of  all  cases.  The  condition  occurs  more 
frequently  in  men  than  in  women,  and  usually  between  the  thirtieth  and 
fiftieth  years.  Business  or  domestic  troubles,  and,  in  fact,  great  anxiety 
of  mind  from  any  cause,  also  venereal  or  alcoholic  excesses,  serve  more 
or  less  directly  to  induce  the  disease.  Trauma  and  heredity  play  but  a 
minor  part. 

Symptoms. — The  prodromal  stage  may  last  for  months  or  even  years. 
The  symptoms  are  both  mental  and  physical,  either  of  which  may  appear 
first  and  exist  alone  for  some  time,  or  they  may  be  contemporaneous  in 
point  of  onset.  As  a  rule,  some  alteration  of  the  character  and  demeanor 
of  the  patient  is  the  first  evidence  of  the  trouble.  The  patient  sufi"ers 
from  insomnia  and  is  generally  restless,  as  well  as  incapable  of  sustained 
eifort.  He  will  be  forgetful  and  perhaps  careless  where  he  was  formerly 
careful  and  attentive.  The  sexual  passions  are  aroused,  and  the  patient 
may  suffer  from  a  sort  of  erotomania,  sometimes  taking  the  form  of  per- 
version. The  ego  will  figure  prominently  in  his  sayings  and  doings. 
Among  the  physical  signs  are  frequent  twitchings  and  tremors  of  the 
facial  muscles,  particularly  of  those  about  the  mouth  and  the  tongue. 
Tremors  of  the  hand  and  arm  seriously  interfere  with  writing;  tremor 
of  the  lips  and  tongue  renders  the  speech  thick,  blurred,  and  hesitating, 
and  syllables  are  omitted  from  words,  or  even  whole  words  lost  from 


1132  DISEASES  OF  THE  NERVOUS  SYSTEM. 

sentences ;  and  the  pupils  are  frequently  unequal  and  fail  to  react  to 
light.  These  symptoms  extend  over  a  variable  period,  with  one  or 
more  remissions  as  a  rule,  and  sometimes  with  a  complete  intermis- 
sion and  an  apparent  cure.  Sooner  or  later,  however,  the  next  stage 
develops. 

Stage  of  Mania  or  Melancholia. — The  symptoms  of  this  stage  are 
superadded  to  those  of  the  first,  which  by  this  time  have  groAvn  gradually 
more  pronounced  ;  loss  of  potver  usually  is  already  a  prominent  feature. 
Acute  outbreaks  of  mania  are  most  commonly  met  with,  and  are  charac- 
terized by  a  most  remarkable  prodigality  of  thought  and  speech.  The 
patient  believes  himself  to  be  possessed  of  enormous  wealth  or  of  great 
rank  and  power.  He  is  boisterous,  sleepless,  and  constantly  and  actively 
engaged  in  pursuing  his  extravagant  ideas.  In  other  cases  this  delusion 
of  grandeur  (expansive  deliriuni)  is  absent  and  the  patient  is  melancholic. 
This  is  especially  apt  to  be  the  case  if  his  physical  condition  is  lowered 
by  some  intercurrent  disease.  Remissions  of  all  these  symptoms  are  not 
rarely  met  with.  Whether  the  prevailing  type  be  that  of  mania  or  melan- 
cholia, paroxifsms  of  terror  may  occur  from  time  to  time,  or  mania  and  de- 
pression may  alternate.  Epileptiform  or  ajjojjlectiform  attacks  occur,  fol- 
lowed by  paralysis.  In  the  large  majority  of  cases  the  mental  decay  is 
progressive,  until  finally  complete  fatuity  is  reached ;  the  patient  then  be- 
comes bedridden,  bladder  and  rectal  symptoms  develop,  and  possibly  bed- 
sores.    Death  results  from  exhaustion  or  from  some  intercurrent  disease. 

Diagnosis. — This  is  ahvays  difficult,  and  it  is  often  impossible  to 
diagnose  the  disease  in  the  earliest  stages,  particularly  when  the  mental 
phenomena  alone  exist.  The  slight  change  of  character  and  the  occa- 
sional outbursts  of  temper  or  unrestrained  jollity  may  be  regarded  as 
mere  moods  more  or  less  directly  dependent  upon  the  daily  routine.  When 
to  these  symptoms  are  added  the  tremor,  the  defects  of  speech,  the  in- 
equality of  the  pupils,  and  paresis,  the  clinical  picture  gradually  assumes 
definite  shape,  and  ofttimes,  long  before  expansive  delirium  or  melancholia 
develops,  a  positive  diagnosis  is  made. 

Differential  Diagnosis. — The  diseases  with  which  it  is  most  likely  to 
be  confounded  are — (1)  Disseminated  sclerosis,  (2)  Paralysis  agitans, 
and  (3)  Cerebral  syphilis. 

(1)  In  disseminated  sclerosis  the  mental  symptoms  are  even  less  ob- 
trusive in  the  earlier  stages,  the  first  evidence  of  the  disease  being  paresis 
in  the  lower  extremities.  The  tremor  too  is  volitional,  the  speech  is  scan- 
ning, and  nystagmus  is  present.  The  reflexes  are  exaggerated,  and  there 
may  be  spasticity.     INIental  phenomena  generally  develop  later. 

(2)  In  paralysis  ayitans  there  are  frequently  no  mental  changes,  and 
in  any  case  they  consist  of  nothing  more  than  dulness.  The  characteristic 
attitude  and  gait ;  the  tremor  when  at  rest,  which  sometimes  ceases  on 
movement ;  the  speech,  which  is  hesitating  at  first,  then  hurried  ;  the  high- 
pitched  voice ;  the  absence  of  pupillary  changes, — all  mark  paralysis 
agitans.     Remissions  are  uncommon. 

(3)  Cerebral  syphilis  may  also  simulate  paretic  dementia.  The  differ- 
ential diagnosis  is  comparatively  easy  in  most  cases,  however,  and  particu- 
larly if  the  early  history  can  be  obtained.  In  cerebral  syphilis  the  tremor 
may  or  may  not  be  present,  but  no  speech-defect  occurs ;  epileptiform  at- 
tacks are  common  (usually  jx^tit  mal  or  Jacksonian).  and  attacks  of  head- 


CEREBRAL  PALSIES  OF  CHILDHOOD.  1133 

ache  are  frequent  and  usually  severe.  The  condition  often  passes  into 
dementia,  and  then  closely  resembles  general  paresis. 

The  progfnosis  is  gloomy,  and  recovery  very  seldom  occurs.  The 
tendency  is  toward  a  fatal  termination  in  from  two  or  three  to  fifteen 
years. 

Treatment. — Drugs  are  of  no  value  in  a  curative  sense,  except  in 
those  cases  that  are  due  to  syphilis,  when  the  iodids  must  be  pushed. 
Bromids,  morphin,  chloral,  or,  still  better,  sulfonal  or  trional,  may  be 
used  in  combating  the  insomnia  and  attacks  of  delirium.  These  cases 
cannot  be  properly  cared  for  at  home  ;  indeed,  their  removal  to  an  asylum 
is  generally  imperative.  The  tendency  to  bed-sores  must  not  be  forgot- 
ten, and  continuous  rest  in  bed  must  therefore  be  postponed  as  long  as 
possible. 


CEREBRAL   PALSIES   OF  CHILDHOOD. 

Definition. — This  includes  hemiplegia,  the  birth-palsies  of  Gowers 
(diplegia),  and  paraplegia,  each  being  charaterized  by  a  particular  palsy, 
and  in  certain  cases  ■with  rigidity,  and  all  showing  more  or  less  men- 
tal defect. 

1.  Hemiplegia. — Pathology. — Practically  nothing  is  known  of  the 
early  changes  that  take  place  in  most  of  these  cases.  They  are  essen- 
tially chronic,  and  do  not  reach  the  autopsy-table  until  late  in  the  disease. 
A  minority  of  cases,  due  to  some  vascular  disturbance — embolism,  throm- 
bosis, or  hemorrhage — may  be  clear  enough.  The  others  have  been 
ascribed  to  some  one  of  the  folloAving  lesions :  (1)  Polio-encephalitis  of 
Strlimpell,  who  advances  the  view  that  there  is  an  acute  inflammation  of 
the  motor  cortex  similar  to  that  of  the  motor  cells  of  the  anterior  horns. 
(2)  Congenital  encephalitis  of  Yirchow,  believed  by  him  to  be  an  inter- 
stitial inflammation,  with  the  formation  of  yellowish  bodies  in  the  white 
substance,  due  to  the  deposition  of  fatty  granules.  (3)  Meningo-en- 
cephalitis,  with  opacity,  thickening,  and  adherence  of  the  membranes. 
The  later  changes  are  as  follows : 

(a)  Atrophy  or  Hypertrophy  and  Sclerosis. — The  sclerotic  areas  vary 
from  small  plaques  to  extensive  regions,  involving  even  the  entire  cortex 
of  one  hemisphere.  They  are  hard  and  firm,  and  in  the  hypertrophic 
variety  stand  out  beyond  the  normal  tissue-line.  The  blood-vessel  walls 
generally  show  proliferative  changes,  and  the  membranes  are  generally 
thickened  and  adherent,  though  in  some  cases  they  show  very  little  if  any 
change. 

(b)  Porencep)halia. — This  condition,  first  described  by  Heschl  in  1859, 
is  etiologically  very  obscure.  Among  the  causes  said  to  give  rise  to  it 
are  arrest  of  development,  vascular  disturbances,  encephalitis,  and  hydro- 
cephalus. It  consists  of  a  loss  of  cerebral  substance,  cysts  of  various 
kinds  extending  into  the  brain-substance  and  reaching  even  to  the  ven- 
tricles. An  entire  hemisphere  may  sometimes  be  wanting,  and  the  Cra- 
nium is  sometimes  distorted. 

Htiology. — Enough  has  been  said  to  indicate  the  uncertainty  as  to 
the  cause  of  this  condition.     Many  cases  are  congenital,  and  the  large 


1134  DISEASES  OF  THE  NERVOUS  SYSTEM. 

majority  develop  within  the  first  three  years  of  life.  There  may  be  a 
history  of  dystocia,  with  or  without  the  use  of  forceps.  Cerebral  trau- 
matism and  the  infectious  diseases  are  cited  as  having  a  more  or  less  direct 
etiologic  relationship. 

Sytnptoms. — In  many  cases  the  symptoms  are  similar  to  those  met 
with  in  hemiplegia  of  adults.  Without  premonitory  symptoms  a  loss  of 
consciousness  develops  suddenly ;  in  other  cases  local  or  general  convul- 
sions precede  the  unconscious  period;  while  in  still  another  group  con- 
sciousness is  never  lost.  Fever  is  iilways  present,  but  does  not  go  above 
102°  F.  (38.8°  C).  The  hemipler/ia  may  be  of  gradual  onset,  though 
usually  it  is  found  to  be  quite  pronounced  when  consciousness  returns. 
The  face  is  generally  not  involved,  and  even  when  it  is  implicated  the 
upper  parts  (eyelids  and  forehead)  escape.  The  right  side  is  aifected 
most  frequently,  and  the  upper  extremity  to  a  greater  extent  than  the 
lower.  Just  as  we  see  in  adults,  so  it  is  in  children.  The  paralysis  may 
clear  up  in  a  few  days,  leaving  little  or  no  trace  behind,  the  rule  being 
for  the  leg  to  recover  first.  The  arm  may  or  may  not  recover.  Where 
permanent  damage  is  done  the  muscles  waste,  though  usually  but  little. 
Neither  sensory  nor  electric  changes  occur.  The  reflexes  are  increased 
and  spasticity  may  develop  (hemiplegia  spastica  cerebralis  of  Heine). 

These  children  are,  as  a  rule,  mentally  deficient,  varying  from  what 
may  be  regarded  merely  as  stupidity  to  idiocy  or  imbecility.  Speech  may 
not  be  acquired  until  late  or  not  at  all.  It  is  probable,  too,  that  the  cases 
of  "  idioglossia  "  and  congenital  speech-defect,  first  described  by  Hadden, 
belong  to  this  category. 

Various  forms  of  post-hemiplegic  movements  are  quite  common.  These 
may  be  tremors,  choreiform  movements,  or  athetosis,  and  about  half  of 
these  children  develop  epilepsy.  Occasionally  the  latter  is  Jacksonian  in 
type ;  usually,  however,  it  is  petit  mal  or  grand  mal. 

2.  Diplegia,  Birth-palsies,  and  Paraplegia. — These  conditions  are 
described  together,  .since  they  have  the  same  pathologic  substratum. 
They  are  characterized  by  double  hemiplegia  or  paraplegia,  increased  re- 
flexes, often  by  spasticity,  preservation  of  sensation,  and  a  lack  of  mental 
development.  While  hemiplegia  may  or  may  not  be  congenital,  these 
cases  of  congenital  spastic  paraplegia  (or  "  Little's  disease,"  as  it  is  some- 
times called  after  an  orthopedic  surgeon,  one  of  the  earliest  writers  upon 
it)  always  date  from  birth,  though  the  condition  may  not  be  recognized 
until  months  later.  Probably  most  cases  result  from  meningeal  hemor- 
rhage, due  to  the  use  of  forceps  or  other  injury  at  birth,  as  pointed  out 
by  Sarah  J.  McNutt,  or  perhaps  to  a  previous  meningo-encephalitis.  At 
all  events,  whatever  the  earlier  changes  be,  the  later  ones  are  those  of 
atrophy  or  porencephalia.  Van  Gehuchten  has  published  some  interest- 
ing papers  recently  on  this  type  of  infantile  palsy.  His  conclusions  are 
that  it  is  met  with  most  frequently  in  children  born  prematurely,  no  mat- 
ter whether  the  labor  be  a  difficult  one  or  not.  He  calls  attention  to  the 
fact  that  at  this  early  stage  the  pyramidal  tracts  are  non-medullated,  and 
therefore  unable  to  functionate  normally.  The  pons-cerebellar  pathway 
is  the  first  to  myelinate,  the  last  being  the  fibers  of  the  direct  motor  path- 
way, which  become  medullated  from  above  downward  ;  hence  those  to 
the  lumbar  and  sacral  region  are  last  of  all,  and  may  never  become  cov- 
ered.    This  is  in  keeping  with  our  clinical  findings.     The  palsy  may  dis- 


ACUTE  DELIRIUM.  1135 

appear  from  the  face,  then  from  the  upper  extremities,  and,  finally,  or 
perhaps  not  at  all,  from  the  lower  extremities. 

Symptoins. — In  some  cases  a  history  of  convulsions  with  febrile 
attacks  is  obtained ;  in  others  nothing  abnormal  is  observed  until  the 
child  commences  to  walk  and  to  try  to  use  its  arms  in  a  definite  manner. 
The  limbs  will  be  found  more  or  less  rigid,  and  in  a  few  cases  the  face-, 
head-,  and  neck-muscles  will  be  affected.  The  reflexesy^'iW  be  increased, 
though  sensation  is  generally  unchanged.  The  mental  condition  is  almost 
always  very  poor.  Various  grades  of  spasmodic  incoordination  are  met 
Avith  ;  also  choreiform  movements  and  athetosis. 

The  diagnosis  is  not  difficult  if  we  can  obtain  a  definite  history  ;  other- 
wise it  may  be.  The  absence  of  electric  changes  will  serve  to  diff"erentiate 
it  from  anterior  polio-myelitis. 

Prognosis. — The  extent  and  degree  of  paralysis  and  the  character 
of  the  mental  change  are  important  aids  in  forming  a  prognosis.  ■  Taken 
as  a  whole,  the  outlook  is  not  particularly  bright  in  any  case. 

Treatment. — Apart  from  the  treatment  of  the  early  convulsions, 
which  must  be  promptly  met  by  hot  mustard  baths,  enemata,  purgatives, 
and  the  bromids,  little  can  be  done.  Massage  and  faradization  may  be 
tried.  In  view  of  the  results  of  operative  measures  these  are  unjustifiable, 
nor  could  we  expect  to  gain  much,  if  anything,  owing  to  the  nature  of 
these  cases.  Careful  and  systematic  training  is  of  great  importance,  for, 
while  some  remain  imbeciles,  others,  though  very  slow  to  learn,  ultimately 
reward  the  patience  of  the  teacher. 


ACUTE  DELIRIUM. 

{Acute  Delirious  Mania  ;   Typho-mania ;  Acute  Periencephalitis ;  BelVs  Mania.) 

Definition. — An  acute  maniacal  delirium  associated  with  hallucina- 
tions, with  a  febrile  course,  of  limited  duration,  and  of  grave  prognosis. 

Pathology. — Minute  peri  capillary  hemorrhages  are  almost  invari- 
ably present.  In  addition  to  these  there  are  usually  degenerative 
changes  in  the  ganglion-cells.  Often  injection  of  the  pia  and  minute 
hemorrhages  into  the  gray  matter  may  be  observed  with  the  naked  eye. 
Cramer  has  recently  reported  a  case  in  which  the  pericapillary  spaces 
of  the  brain  were  filled  with  mononuclear  leukocytes,  surrounding 
which  were  recent  hemorrhages ;  he  also  noted  the  fact  that  the  gang- 
lion-cells, instead  of  exhibiting  normally-formed  chromophilic  bodies, 
Avere  filled  apparently  Avith  fine  dust. 

Htiology. — The  disease  occurs  in  either  sex  Avith  about  equal  fre- 
quency. Predisposing  conditions  are  neuropathic  heredity,  nervous  dis- 
position, the  presence  of  other  nervous  diseases,  particularly  neurasthenia 
and  epilepsy,  alcoholic  or  sexual  excesses,  and  severe  prolonged  anxiety. 
It  has  been  supposed  (Hertz)  that  abnormal  narroAvness  of  the  jugular 
canal,  which  has  been  noted  in  several  cases,  bears  some  etiologic 
relation  to  it.  It  frequently  occurs  apparently  as  the  immediate  result 
of  menstruation,  parturition,  injuries  to  the-  head,  sunstroke,  acute  infec- 
tious   diseases,  particularly  pneumonia    and  typhoid  fever,   and  it  may 


1136  DISEASES  OF  THE  NERVOUS  SYSTEM. 

develop  in  the  course  of  chronic  mental  diseases.  Occasionally,  however, 
it  appears  to  arise  without  any  definite  cause. 

Symptoms. — The  disease  usually  commences  with  certain  indefinite 
prodromes.  These  consist  of  restlessjiess,  associated  either  with  melan- 
cholia, preoccupation,  or  anxiety.  The  intelligence  becomes  distinctly 
decreased;  the  patient  loses  appetite,  is  constipated,  and  commences  to 
emaciate.  During  sleep  unpleasant  dreams  or  nightmares  almost  invari- 
ably occur.  Sometimes  there  is  a  sense  of  impending  mental  disorder. 
This  period  gradually  changes  to  one  of  defiance,  which  perhaps,  even  in 
the  prodromal  stage,  may  lead  to  violence  and  injury  to  those  in  the  neigh- 
borhood. The  prodromal  stage  rapidh"  passes  to  acute  delirium,  in  which 
two  steps  may  be  recognized — excitation  and  collapse.  The  excited 
stage  commences  suddenly  ;  there  is  great  confusion ;  the  patient  ejacu- 
lates disconnected  sentences  or  words  or  even  syllables.  There  is  great 
anxiety,  and  even  fear,  and  the  patients  exhibit  intense  excitement,  suf- 
fering very  often  with  delusions  of  persecution  by  their  environment,  and 
nearly  always  having  hallucinations,  either  of  sight  or  sound.  Often  their 
minds  are  occupied  by  some  subject  that  had  previously  caused  them  great 
anxiety — either  disgrace,  business,  or  other  misfortune.  The  mania 
is  often  dangerous  ;  indeed,  it  is  likely  that  the  disease  known  as  "  run- 
ning amuck  "  in  the  Malay  Peninsula  is  simply  one  of  the  forms  of  acute 
delirium.  The  patient  soon  becomes  extremely  restless,  throws  himself 
from  one  side  of  the  bed  to  the  other,  and  makes  efforts  to  rise  and  escape 
from  the  room.  The  tongue  is  dry,  the  pulse  rapid  and  weak.  Petechias 
may  appear  upon  the  skin,  and  there  is  nearly  always  more  or  less  fever, 
not  rarely  rising  to  105°  (40.5°  C.)  or  even  more.  Rapid  emaciation  super- 
venes. There  are  all  the  objective  symptoms  of  irritation  of  the  brain — 
myosis  and  increased  reflexes,  and  often  hyperesthesia,  although  the  patients 
pay  little  attention  to  any  injury  they  may  inflict  upon  themselves.  Some- 
times there  seem  to  be  curious  imperative  movements ;  at  others,  impera- 
tive ideas.  In  a  case  that  I  observed  the  patient  rhymed,  very  imper- 
fectly it  is  true,  each  two  successive  sentences.  This  stage  of  excitation 
soon  passes  into  one  of  stupor  and  collapse ;  fever  may  become  even 
higher,  and  the  pulse  still  more  rapid  and  weaker.  The  patient  lies  in  a 
condition  of  muttering  delirium,  with  carphologia.  All  the  symptoms  are 
those  of  profound  exhaustion :  the  eyes  are  hollow,  the  lips  and  teeth 
covered  with  sordes,  and  the  emaciation  extreme.  The  skin  becomes 
dryer,  and  finally  cyanotic,  the  pupils  dilate,  and  there  may  be  marked 
anesthesia.  Death  ordinarily  occurs  at  the  end  of  two  or  three  days 
after  the  commencement  of  this  condition.  Occasionally  the  course  of 
the  disease  is  interrupted  by  intervals  in  which  the  patients  exhibit  more 
or  less  lucidity.  Certain  varieties  have  also  been  described.  Thus  in 
addition  to  the  maniacal  form  authors  speak  of  the  melancholic  and 
paralytie  forms.  In  the  former  of  these  the  patients  exhibit,  in  place 
of  excitement,  profound  depression,  with  fear  of  poisoning  and  positive 
refusal  of  all  food  ;  slight  elevation  of  temperature,  or,  indeed,  a  sub- 
normal temperature,  and  very  rapid  emaciation.  It  is  most  apt  to  occur 
in  patients  previously  debilitated.  In  the  paralytic  form  there  is  vaso- 
motor paralysis  with  cyanosis,  depression,  and  often  stupor.  From  these 
the  patient  passes  into  an  algid  state,  in  which  death  occurs. 

The  differential  diagnosis  is  frequently  difiicult.     In  many  infec- 


DISEASES  OF  UNKNOWN  PATHOLOGY.  1137 

tious  diseases,  i[)articu\a.r[j  jmeumotiia  and  typlioid,  hallucinatory  delirium 
may  develop.  This,  of  course,  must  be  suspected  in  these  diseases,  and 
it  is  advisable,  if  possible,  to  examine  the  blood  in  all  cases  of  acute 
delirium  by  Widals  method.  In  acute  mania  fever  is  rare,  emaciation 
is  not  so  rapid,  and  the  mental  symptoms  are  more  purely  psychical.  In 
general  paralysis,  toward  the  end  maniacal  attacks  may  develop,  but  the 
history  of  the  previous  existence  of  the  disease,  the  presence  of  the 
Argyll-Robinson  pupil,  and  the  absence  of  fever  lead  one  to  suspect  the 
true  diagnosis.  Finally,  in  delirium  tremens  the  fine  tremor  of  the 
hands  and  tongue,  and,  if  possible  to  obtain  it,  a  history  of  recent 
debauch,  should  clear  up  the  diagnosis.  The  course  of  the  disease  is 
variable ;  it  may  vary  from  three  or  four  days  to  as  many  weeks.  Those 
cases  are  most  rapid  in  which  excitation  is  most  profound. 

The  progtiosis  is  most  unfavorable,  and  is  more  so  for  men  (accord- 
ing to  Krafft-Ebingj  than  for  women.  Those  cases  that  were  previously 
debilitated,  either  as  a  result  of  chronic  alcoholism,  or  chronic  exhaustive 
diseases,  or  childbirth,  are  the  most  serious.  Those  that  develop  suddenly, 
and  from  the  beginning  are  very  severe,  are  also  nearly  always  fatal ;  if 
there  are  no  lucid  intervals,  or  if  those  that  occur  are  short  and  imperfect, 
the  prognosis  is  graver ;  and  the  same  is  true  of  those  who  suffer  fi'om 
obstinate  insomnia. 

The  treatment  is  of  course  unsatisfactory.  In  spite  of  progressive 
exhaustion,  bloodletting  is  recommended,  and  calomel  should  also  be  ad- 
ministered in  the  earlier  stages  of  the  disease.  At  the  same  time  the 
temperature  should  be  combated  by  cool  baths,  and  an  ice-bag  should  be 
applied  to  the  head.  Sleep  should  be  obtained  by  the  use  of  chloral, 
bromids,  and  the  more  modern  hypnotics,  which  are  to  be  preferred  to 
morphin.  Hyoscin  seems  to  be  particularly  indicated.  In  the  later  stages 
of  the  disease  stimulants  should  be  administered  freely.  Excellent  results 
have  been  obtained  (Solivetti)  by  the  hypodermic  administration  of  Bon- 
jean's  ergotin.  Nutrition  must  be  maintained  by  forced  feeding  with 
milk,  eggs,  broths,  etc. 


IV.    DISEASES  OF  UNKNOWN   PATHOLOGY. 
EPILEPSY. 

Definition. — A  condition  characterized  by  attacks  of  unconscious- 
ness, with  or  without  convulsions.  We  are  scarcely  justified  in  speaking 
of  epilepsy  as  a  disease.  It  seems,  in  reality,  to  be  a  symptom,  though  in 
many  cases  (the  so-called  idiopathic  cases)  we  know  not  the  underlying 
cause.  The  type  of  cases  in  which  the  unconscious  period  is  very  brief 
(momentary),  with  no  convulsion  following  or  at  most  but  a  slight  rigidity, 
is  termed  petit  mal.  The  more  pronounced  type,  with  prolonged  uncon- 
sciousness and  severe  general  convulsions,  constitutes  grand  mal.  That 
form  first  described  by  Hughlings  Jackson  in  which  the  convulsion  is 
localized,  and  in  which  unconsciousness  may  or  may  not  occur,  is  called 
JacTiSonian,  focal,  or  cortical  epilepsy. 

Patliologfy. — Gray  regards  epilepsy  as  a  symptom,  and  if  this  theory 

72 


1138 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


be  correct,  the  inevitable  question  must  be,  "  Of  what  ?  "  In  certain  cases 
this  can  be  answered  (in  the  organic  cases),  since  the  lesion  is  demonstra- 
ble ;  but  in  others  (functional  or  idiopathic)  there  is  no  demonstrable 
lesion.  Among  the  causes  of  the  former  are  brain-tumors,  meningitis, 
traumatism  inflicted  either  at  birth  or  subsequently,  atrophy  and  sclerosis, 
vascular  disturbances,  syphilis,  and  toxemia,  both  autogenous  and  exog- 
enous. Brown-Se(iuard  pointed  out  in  1857  that  epilepsy  may  some- 
times have  its  cause  in  the  spinal  cord.  Peripheral  lesions  too  may  give 
rise  to  it.  Little  can  be  said  about  the  idiopathic  variety.  Chaslin  has 
endeavored  to  show  that  in  this  form  a  constant  lesion  exists — viz.  a  dif- 
fuse sclerosis  of  the  gray  matter,  a  neurogliar  overgrowth — but  his  views 
have  not  been  corroborated.  After  all,  we  can  only  enumerate  causes ; 
we  do  not  know  in  any  case  how  these  act,  and  we  do  not  knoAv  the 
ultimate  pathology.  Many  writers  apply  the  name  "epilepsy"  only 
to  the  idiopathic  form,  while  others  include  all  apyretic  aifections  cha- 
racterized by  the  occurrence  of  fits,  whether  of  centric  or  peripheral 
origin.  Brown-S^quard  believes  that  the  distinction  between  the  various 
kinds  of  convulsions  is  artificial,  and  that  the  correct  classification  should 
be  based  on  the  knowledge  of  the  cause. 

Ktiology. — The  causes  are  (1)  predisposing,  (2)  exciting  or  deter- 
mining. Among  the  former,  which  refer  particularly  to  the  idiopathic 
form,  are — 

(a)  Age. — The  following  tables  show  the  early  onset  in  a  large  ma- 
jority of  cases  analyzed  by  Gowers,  Hesse,  and  Osier  : 

Proportion  affected. 
, Observers.- 


Aee  at  onset. 

Gowers. 

Before  10 422 

From  11  to  20 


21 
31 
41 
51 
61 


30 
40 
50 
60 
70 
71 

Total, 

Age  at  onset  (Osier). 
1 


Number. 

.  .  74 

.  .  62 

.  .  51 

.  .  24 

.  .  17 

.  .  18 

.  .  19 

.  .  23 


665 
.  224 
.  87 
.  31 
.  16 
.  4 
. 1 

1450 


Age  at  onset  (Osier). 
9 


Hesse. 
.  393 
.  364 
.  Ill 
.  59 
.  51 
.  13 
4 
.      0 


10 
11 
12 
13 
14 
15 


995 

Number. 
.  .  17 
.  .  27 
.  .  17 
.  .  18 
.  15 
.  .  21 
.    .34 


Total, 


437 


(b)  Sex. — In  Gowers'  cases  54.6  per  cent,  were  males,  45.4  per  cent, 
females.  Under  twenty-five  years  of  age  males  are  slightly  in  the  major- 
ity ;  above  twenty-five,  the  reverse  is  true. 

(c)  Heredity. — Family  neuroses  are  common,  but  it  is  decidedly  more 
the  exception  than  the  rule  to  find  either  parent  epileptic.  Fdr^  has  given 
us  the  lineage  of  594  epileptics :  70  had  epilepsy,  166  were  insane,  88 
paralyzed,  21  suffered  from  general  paralysis,  72  from  hysteria,  73  from 
senile  dementia,  33  from  puerperal  eclampsia,  61  from  chorea.     Among 


EPILEPSY.  1139 

the  direct  antecedents  of  tliese  594  epileptics,  1024  cases  of  nervous  dis- 
order had  occurred. 

{d)  Alcohol. — The  causal  relationship  between  an  abuse  of  alcohol  by 
the  parents  and  epilepsy  seems  rather  pronounced.  Fdre  says  that  of 
594  epileptics  examined  by  him,  258  had  parents  who  were  hard  drinkers. 
Echeverria  refers  to  572,  257  of  which  he  believed  could  be  traced  directly 
to  the  abuse  of  alcohol. 

(e)  Syi^hilis  does  not  predispose.  When  it  gives  rise  to  changes  in 
the  brain  and  cord,  which  in  turn  cause  epilepsy,  it  is  in  reality  a  deter- 
mining cause. 

(/)  Mye-strain  is  no  longer  regarded  seriously  as  a  predisposing  influ- 
ence. 

The  exciting  or  determining  causes  are  traumatisms,  various  morbid 
conditions  of  the  membranes  of  the  brain  or  of  the  brain  proper  [e.  g. 
after  hemiplegia),  of  the  spinal  cord  or  membranes,  or  peripheral  irrita- 
tion (dentition,  worms,  a  cicati'ix,  an  adherent  prepuce,  etc.).  Not  a  few 
cases  are  dependent  upon  toxic  substances  in  the  blood,  as  in  uremia  and 
lead-poisoning.  Excessive  indulgence  in  alcohol  or  over-eating  often 
precipitates  the  attack.  Great  emotion,  nervous  shock  (fright),  and 
masturbation  are  also  said  to  be  able  to  bring  it  about,  though  these 
are  rather  doubtful  causes.  There  are  cases  of  bradj^cardia  in  which 
epileptiform  attacks  occur. 

Symptotns. — Petit  Mai. — In  this  condition  the  majority  of  cases 
belong  to  the  following  type  :  The  attack  begins  suddenly  ;  perhaps  while 
talking  to  the  patient  his  expression  suddenly  becomes  blank,  the  face 
pales,  the  pupils  dilate,  and  he  is  evidently  not  conscious.  In  a  moment 
or  two  he  gathers  his  scattered  senses,  picks  up  the  thread  of  the  conver- 
sation, and  continues  to  unwind  it.  Very  often  he  is  not  cognizant  of 
any  lapse  of  time  or  has  but  a  vague  idea.  If  carefully  watched  for,  fine 
clonic  movements  may  be  observed  in  many  cases,  it  may  be  of  the  facial 
muscles  or  of  the  hands.  Convulsions  never  occur,  the  dominant  feature 
being  the  unconsciousness.  On  regaining  consciousness  the  patient  may 
act  strangely  and  appear  dazed ;  it  is  seldom,  however,  that  he  falls  in 
attacks  of  this  kind.  Occasionally  a  peculiar  dreamy  state  takes  the  place 
of  an  ordinary  attack,  or  the  individual  may  be  the  victim  of  imperative 
ideas.  Falret  has  described  a  condition  {epilepsie  larve)  known  as 
masked  epilepsy,  in  which  maniacal  outbursts  or  explosions  of  passion 
occur. 

Grand  Mai  or  Haut  Mai. — In  many  cases  some  subjective  symptom 
precedes  the  actual  attack.  In  its  most  specialized  form  it  is  termed  an 
aura,  and  includes  any  phenomenon,  motor  and  sensory,  that  ushers  in  an 
attack.  While  the  aura  differs  in  different  cases,  it  is  almost  invariably 
constant  in  the  same  case,  so  that  one  will  have  a  subjective  sensation  of 
sound,  another  of  light,  either  flashes  or  colors,  etc.  There  are  other 
signs  that  occasionally  antedate  an  attack,  and  which  may  or  may  not 
precede  each  attack  (headache,  drowsiness,  change  of  disposition,  palpita- 
tion, perverted  appetite,  sexual  or  other,  etc.).  Many  attacks  begin  pre- 
cipitately with  absolutely  no  previous  warning.  In  such  cases  the  patient 
may  or  may  not  utter  a  piercing  sound  (epileptic  cry),  falling  at  the  same 
time,  no  matter  where  or  in  what  position  he  may  be.  Hence  the  danger 
to  which  epileptics  are  always  subjected.     A  peculiar  onset  occurs  in  the 


1140  DISEASES  OF  THE  NERVOUS  SYSTEM. 

so-called  '■'- py^ocursive  epilepsy, '\  in  which  the  patient  suddenly  starts  off 
and  runs  some  distance  before  the  paroxysm  begins. 

Paroxysmal  Period. — In  many  cases,  whether  preceded  by  an  aura  or 
not,  this  stage  is  ushered  in  by  a  spasm  that  is  tonic  in  character.  The 
patient  falls,  perhaps  because  of  the  loss  of  consciousness,  though  in  those 
cases  in  which  he  drops  precipitately  he  is  probably  thrown  by  the  vio- 
lence of  the  spasm.  The  head  is  usually  extended,  the  muscles  of  the 
larynx  and  trunk  contracted,  and  hence  the  epileptic  cry  and  the  dys- 
pnea, while  the  loAver  limbs  are  generall}^  extended,  the  upper  semiflexed, 
and  the  fingers  tightly  clenched.  This  period  of  rigidity  lasts  but  a  few 
seconds  before  dome  convulsions  appear. 

Intercurrent  contractions  vary  in  diff"erent  cases  from  very  mild  move- 
ments to  those  so  severe  as  to  toss  the  individual  about.  The  face,  pale 
at  first,  becomes  congested,  and  the  jaw  works  in  churning  the  saliva  into 
a  froth  ;  this  is  blood-tinged  when  the  tongue  is  bitten.  The  respiration 
is  jerky,  gasping,  and  there  may  be  a  loss  of  control  of  the  bladder  and 
bowels.  In  idiopathic  cases  this  stage  lasts  from  one  to  five  or  six  min- 
utes. The  spasms  gradually  diminish,  and  without  regaining  conscious- 
ness the  patient  passes  into  a  deep  sleep,  immediately  preceded  in  some 
cases,  however,  by  coma  in  which  the  breathing  is  stertorous.  During 
the  sleep,  Avhich  lasts  about  an  hour,  the  patient  is  completely  relaxed. 
On  waking  he  usually  appears  confused  and  complains  of  feeling  tired. 
His  limbs  may  ache  for  several  days. 

Occasionally  attacks  follow  one  another  in  quick  succession,  with  no 
period  of  consciousness  intervening  {status  epilepticus) — a  very  dangerous 
condition. 

Post-epileptic  phenomena  are  variable.  The  patient  may  become 
maniacal,  homicidal,  or  may  simply  be  mentally  deficient  for  a  few  days, 
with  perhaps  some  slight  speech-disturbance.  In  the  course  of  time  every 
epileptics  brain-power  deteriorates.  Paralysis  sometimes  occurs,  is  usually 
transient,  and  may  be  unilateral  or  bilateral. 

Nocturnal  Epilepsy. — In  this  condition  the  attacks  occur  at  night,  and 
may  be  entirely  unknown  either  to  the  patient  or  his  friends.  He  com- 
plains from  time  to  time  of  feeling  tired  on  rising  in  the  morning,  his 
limbs  and  head  ache,  and  he  is  generally  duller  than  usual ;  he  may  even 
be  confused.  Such  a  history  is  suggestive,  and  the  suspicion  is  strength- 
ened if  in  addition  he  has  urinated  involuntarily  or  if  blood-spots  are 
found  on  his  pillow. 

Jacksonian  epilepsy  is  characterized  by  spasm  that  is  generally  local 
in  character ;  in  fact,  it  is  always  so  in  the  beginning,  though  occasionally 
it  may  spread  and  become  general.  Consciousness  is  preserved  in  the 
milder  forms.  Tingling  or  other  subjective  sensations  may  precede  an 
attack.  They  are  usually  due  to  some  irritation  of  the  motor  cortex 
(tumors,  meningitis,  softening,  trauma,  etc.).  Subcortical  lesions  and 
certain  toxemic  conditions  can  also  give  rise  to  it. 

Diagcnosis. — When  a  definite  history  is  obtainable  the  diflficulty  of 
the  diagnosis  is  less,  particularly  if  an  aura  occurs.  The  attack  can  be 
frequently  diagnosed  from  other  epileptoid  conditions  at  the  time  by  the 
explosive  onset,  the  brief  tonic  and  somewhat  longer  clonic  spasm,  pro- 
found unconsciousness  followed  by  a  deep  sleep,  and  when  these  are  pres- 


EPILEPSY.  1141 

ent  by   an  involuntary  passage   of  urine,    frothing  at  the  mouth,   and 
bitincr  of  the  tongue. 

Differential  Diagnosis. — In  uremia  the  state  of  the  urine  (catheterize 
if  necessary),  and  often  the  odor,  serve  to  differentiate  it.  It  may  be 
impossible  to  detect  fraud,  so  perfectly  is  the  disease  simulated  by  those 
anxious  to  excite  pity,  judicial  or  otherwise,  or  by  those  whose  accom- 
plices rifle  the  pockets  of  sympathetic  bystanders.  Hysteria  may  also 
resemble  it  very  closely,  (rowers  has  tabulated  the  chief  diiferences  as 
follows : 

Epilepsy.  Htsteroid. 

Apparent  cause     .    .    .  None.  Emotion. 

Warning --^nV;  but  especially  unilateral     Palpitation,  malaise,  choking. 

or  epigastric  aura.  bilateral  foot-aura. 

Onset Always  sudden.  Often  gradual. 

Scream At  onset.  During  course. 

Convulsion Eigiditv  followed   by    "jerk-     Rigidity     or      ''struggling," 

ing  ;  '■  rarely  rigidity  alone.         throwing  about  of  limbs  or 

head,  arching  of  back. 
Biting    .......  Tongue.  Lips,  hands,  or  other  people 

or  things.     Very  rare. 

Micturition Frequent.  Never. 

Defecation Occasional.  Never. 

Talking Never.  Frequent. 

Duration A  few  mini;tes.  More  than  ten  minutes,  often 

much  longer. 
Restraint  necessary  .    .  To  prevent  accident.  To  control  violence. 

Ten'mination Spontaneous.  Spontaneous       or       induced 

(water,  etc.). 

Prognosis. — Inherited  epilepsy  very  rarely  is  cured.  Brown-Sequard 
says  most  emphatically  that  idiopathic  cases  are  occasionally  cured :  I 
would  rather  suggest  that  perhaps  they  get  well.  Cases  that  are  evidently 
symptomatic  are  curable  if  the  cause  can  be  removed.  Death  is  seldom 
due  directly  to  an  attack.  Fatal  accidents  may,  however,  be  caused  by 
an  attack. 

Treatment. — "When  an  aura  occurs,  advantage  may  indirectly  be 
taken  of  it  to  aid  in  abortino-  the  attack — viz.  bv  emploving  the  galvanic 
method,  or  by  constricting  the  limb  in  which  the  aura  occurs,  or  by 
forcibly  moving  the  head,  putting  snuff  up  the  nose,  ice  to  the  spine, 
etc.,  according  to  the  special  indication.  Every  effort  should  be  made  to 
lessen  the  liability  of  danger  to  the  patient — first  from  falling,  and 
secondly,  from  the  violence  of  the  spasms.  One  may  at  times  be  justified 
in  using  ether  or  chloroform  by  inhalation  to  control  the  severity  of  the 
convulsions.  After  loosening  the  clothing  and  putting  a  cork  or  some- 
thing between  the  teeth  to  prevent  biting  the  tongue,  nothing  more  can 
be  done  at  the  time.  Between  the  attacks  special  care  should  be  taken 
to  put  the  system  in  good  condition,  and  all  sources  of  worry  and  irrita- 
tion should  be  removed  as  far  as  possible.  Particular  attention  should  be 
given  to  the  stomach  and  bowels.  The  food  should  be  light  and  easily 
digestible. 

As  to  medicinal  measures,  the  bromids  are  of  the  greatest  value.  The 
sodium  and  potassium  salts  are  most  commonly  employed,  the  former, 
as  a  rule,  being  better  borne  by  the  stomach.  They  may  be  oriven 
in  milk  or  in  one  of  the  medicated  waters.     Strontium  bromid  has  been 


1142    •  DISEASES  OF  THE  NERVOUS  SYSTEM. 

used  rather  extensively  of  late,  and  has  yielded  excellent  results.  While 
idiosyncrasies  are  met  with,  it  may  generally  be  given  in  from  15-  to  30- 
gr.  doses  (0.972-1.944)  three  or  four  times  a  day,  and  preferably  after 
meals.  Each  case  must  be  treated  accoixling  to  its  special  indications. 
Symptoms  of  bromism  (acne,  sore  throat,  drowsiness,  and  gastric  disturb- 
ance) should  be  carefully  guarded  against.  Should  they  develop,  the 
dose  of  bromid  must  be  reduced,  and  Fowler's  solution  administered  for 
a  few  days.  H.  C.  Wood  recommends  that  the  latter  should  be  given 
continuously  with  the  bromids,  thereby  preventing,  or  at  all  events  lessen- 
ing, the  liability  to  bromism.  Other  remedies  sometimes  employed  are 
nitroglycerin  (hypodermically),  cannabis  indica,  silver  nitrate,  zinc,  borax, 
chloral,  antipyrin,  trional,  and  tetronal.  Surgical  measures  occasionally 
yield  good  results,  this  being  particularly  true  in  focal  epilepsy.  In  idio- 
pathic epilepsy  removal  of  the  motor  cortex  has  been  tried  in  those  cases 
in  which  an  aura  suggested  a  local  origin — e.  g.  in  a  center  for  a  particular 
group  of  muscles.  The  results  have  naturally  been  less  encouraging  than 
in  Jacksonian  epilepsy,  though  sufficiently  so  to  justify  its  adoption.  W. 
Alexander  of  Liverpool  has  ligated  the  vertebral  artery  in  36  cases,  his 
object  being  to  produce  anemia  of  the  brain ;  19  cases  were  either  cured 
or  permanently  benefited.  He  has  also  removed  the  superior  cervical 
sympathetic  ganglia  of  both  sides  in  another  group  of  cases,  with  20  per 
cent,  of  either  cures  or  improvement.  Neither  of  these  measures  has 
ever  been  widely  adopted,  however. 


MIGRAINE. 

{Hemicrania ;  Sick  Headache.) 


Definition. — A  neurosis  characterized  by  severe  attacks  of  headache, 
often  paroxysmal  and  more  or  less  periodic,  with  disturbances  of  vision 
and  Avith  or  without  nausea  and  vomiting. 

Pathology. — This  is  profoundly  obscure,  since  no  lesion  has  ever 
been  discovered.  By  some  it  is  thought  to  be  a  vaso-motor  disturbance. 
Arterio-sclerosis  has  been  present  in  many  cases,  but  this  is  also  frequently 
met  with  where  no  sign  of  migraine  has  ever  occurred.  Very  rarely  the 
disease  has  been  observed  in  some  subjects  to  replace  an  attack  of  epilepsy 
or  even  to  alternate  with  true  epileptic  attacks. 

Etiology. — The  condition  is  frequently  hereditary,  and  in  the  large 
majority  of  the  cases  that  I  have  seen  it  has  been  transmitted  by  or 
through  the  mother.  Various  other  neuroses  are  common  in  families 
subject  to  this  condition.  Females  are  more  frequently  affected  than 
males,  and  migraine  seems  to  be  associated  with  diseases  peculiar  to 
women,  especially  menstrual  disorders.  Among  the  exciting  causes  may 
be  mentioned  gastric  disturbances,  dental  irritation,  naso-pharyngeal  dis- 
eases (adenoids,  etc.),  eye-strain,  grief,  emotion — in  short,  anything  that 
tends  to  lower  the  physical  or  mental  tone  occurring  in  those  hereditarily 
predisposed.  Recently  attention  has  been  called  to  auto-intoxication 
(leukomainic  poisoning)  as  a  cause  of  certain  cases. 

Symptoms. — As  a  rule,  the  patient  can  prognosticate  an  attack. 


MIGRAINE.  1143 

In  the  cases  of  slow  onset  he  may  feel  indisposed  for  some  hours  before, 
being  languid,  with  general  discomfort  and  perhaps  nausea.  In  other 
cases  various  subjective  sensations  occur,  lasting  from  a  few  minutes  to 
several  hours.  Of  these,  disturbances  of  vision  are  most  common,  such 
as  flashes  of  light,  spectra,  visions  of  animals  or  weird  forms,  or  scotoma, 
etc.  Auditory  sensations  are  rare,  as  are  those  of  the  other  special  senses. 
After  these  phenomena  have  existed  for  some  time  headache  supervenes, 
when,  as  a  rule,  they  cease.  The  pain,  at  least  in  the  beginning,  is  usually 
unilateral,  as  the  name  suggests,  though  later  it  may  and  often  does  in- 
volve the  entire  cranium,  spreading  from  a  single  point  of  origin — over 
one  eye,  for  instance.  The  affected  region  may  be  tender  to  the  touch  or 
it  may  be  the  seat  of  numbness  or  tingling.  Nausea  and  vomiting  com- 
monly occur,  with  or  without  vertigo.  A  brief  period  of  unconsciousness 
occurs  in  some  cases,  and  spasmodic  movements  may  also  be  observed 
occasionally.  This  fact  is  of  particular  interest,  since  it  serves  to  support 
the  view  that  migraine  is  in  some  way  related  to  epilepsy,  and,  as  has 
been  stated,  attacks  of  migraine  and  epilepsy  may  alternate.  Unlike 
epilepsy,  migraine  does  not  tend  to  impair  the  mental  faculties,  no  matter 
how  long  the  patient  has  been  afflicted.  During  an  attack,  however,  he 
may  have  melancholia  or  be  incapacitated  mentally  and  physically  for  two 
or  three  days. 

Course. — The  disease  generally  begins  in  early  life,  and  in  nearly 
half  of  the  cases  before  the  fifteenth  year,  recurring  with  a  certain  degree 
of  periodicity  until  old  age,  when  it  often  passes  away.  It  may  cease  in 
women  at  the  menopause,  and  in  men  between  the  fortieth  and  fiftieth 
years. 

The  prognosis  is  good  as  far  as  life  is  concerned.  This  disease  is 
incurable,  though  the  condition  of  the  patient  may  be  alleviated. 

Treatment. — The  management  of  the  disease  may  be  considered 
under  two  heads :  (1)  treatment  of  the  attack,  and  (2)  the  treatment  be- 
tween the  attacks,  which  necessarily  includes  prevention.  The  patient 
should  be  put  to  bed  in  a  slightly  darkened  room,  and  all  sources  of  noise 
and  confusion  should  be  removed  as  far  as  possible.  The  attack  may  be 
so  severe  as  to  justify  the  use  of  morphin  hypodermically.  The  coal-tar 
derivatives  have  met  with  most  favor,  however,  as  remedial  measures,  and 
preferably  antipyrin  and  phenacetin,  though  their  occasional  depressing 
effect  should  be  borne  in  mind.  The  following;  has  given  excellent  results 
in  my  hands  : 

I^.   Caffein.  citrat.,  3ss  (2.0) ; 

Phenacetin, 

Sodii  bicarb.,  da.  z]  {^•^)\ 

Pulv.  aromat.,  gr.  xij  (0.777). 

M.  et  ft.  chartge  No.  xij. 
Sig.  One  every  three  hours. 

Acetanilid  may  often  be  substituted  for  phenacetin  with  apparent  ad- 
vantage. In  twenty-four  hours  this  may  be  discontinued,  and  potassium 
bromid  should  be  given  in  liq.  ammon.  acetatis  in  doses  of  gr.  x  to  xv 
(0.648—0.972).  Local  applications  of  menthol,  or  fly-blisters  may  be 
employed,  or  even  superficial  points  may  be  made  with  the  actual  cautery. 
Electricity  is  of  little  avail.     The  electric  percuteur  or  hammer,  however, 


1144  DISEASES  OF  THE  NERVOUS  SYSTEM. 

has  given  good  results.  It  consists  of  a  hammer  driven  at  great  speed 
by  electricity,  thus  enabling  short  sharp  blows  to  be  directed  to  the 
part. 

Between  the  attacks  the  general  health  should  be  carefully  looked 
after.  The  uric-acid  diathesis  is  common  in  subjects  of  migraine.  Haig 
staunchly  advocates  the  use  of  salicylates  in  such  cases  in  addition  to  the 
dietetic  measures.  Anemia  should  be  treated  by  iron  in  some  form,  dial- 
yzed  or  Blaud's  pill,  or,  with  those  who  prefer  the  organic  preparations, 
ferratin  or  peptomangan  m-ay  find  favor.  The  bowels  should  be  kept 
soluble  by  means  of  some  saline  (Hunyadi,  etc.),  or  by  the  fluid  extract 
of  cascara  sagrada.  The  extract  of  cannabis  indica  is  employed  by  some 
over  a  long  period  of  time,  just  as  the  bromids  are  in  epilepsy.  It  is 
given  in  doses  of  gr.  i  to  ^  (0.0162-0.0324)  two  or  three  times  a  day, 
after  meals.  While  exercise  and  fresh  air  are  admirable  adjuvants  to  any 
form  of  treatment,  it  must  not  be  forgotten  that  fatigue  invites  an  attack. 
Proper  rest,  care  and  regularity  in  dieting,  and  the  avoidance  of  excite- 
ment are  the  chief  points  to  be  observed. 


ACUTE  CHOREA. 

{St/denham^ s  Chorea ;  St.  Vitus's  or  St.  Anthony^s  Dance.) 

Definition. — The  type  of  chorea  described  by  Sydenham  is  a  more 
or  less  acute  disease,  in  certain  respects  resembling  an  acute  infectious 
process,  and  by  some  regarded  as  such.  It  has  a  special  predilection  for 
children,  and  is  characterized  b}'  involuntary  muscular  contractions,  by 
usually  slight  and  rarely-marked  mental  change,  by  a  great  liability  to 
endocarditis  and  a  tendency  to  recurrence,  particularly  during  the  spring 
and  fall. 

Pathology. — No  definite  lesion  can  be  ascribed  to  the  disease, 
though,  as  is  usual  in  such  cases,  a  great  variety  of  lesions  have  been 
described.  Chief  among  these  is  the  embolic  theory,  advanced  by 
Kirkes  and  subscribed  to  by  Bastian  and  Hughlings  Jackson.  Since 
emboli  are  not  found  in  every  case,  however,  they  cannot  be  the  sole 
cause.  The  infectious  theory  has  also  been  mentioned  above,  and  certain 
cases  unquestionably  seem  to  be  due  to  micro-organismal  activity.  For 
instance,  the  same  organism  has  been  found  in  the  brain,  heart,  and  the 
blood,  or  in  the  vegetations  on  the  valves.  Many  cases  develop  suddenly, 
following  fright  or  some  other  nervous  shock,  though  these  can  scarcely 
be  included  in  either  of  the  two  classes  just  mentioned.  Acute  chorea 
may  also  be  due  to  functional  instability  of  the  nerve-centers,  or  it  may 
possibly  result  from  tlie  irritation  of  antitoxins. 

Htiologfy. — (1)  Age. — By  far  the  greatest  number  of  cases  occur 
before  the  tAventieth  year  ;  in  fact,  tlie  condition  is  rare  after  that  age, 
most  cases  occurring  between  the  tenth  and  fifteenth  years. 

Sex. — Females  are  most  frequently  attacked,  and  probably  in  two- 
thirds  of  all  cases. 

Race. — Acute  chorea  is  rarely  met  with  except  among  the  white  races. 

Infectious  diseases  do  not  seem  to  have  any  predisposing  influence. 


ACUTE  CHOREA.  1145 

The  relationship,  however,  between  chorea  and  rheumatism  is  difficult 
to  ascertain.  The  milder  form  of  this  latter  trouble  can  be  readily  over- 
looked in  young  children,  but  if  we  include,  as  Sturges  does,  all  cases 
with  a  history  of  "growing  pains,"  the  relation  is  of  course  greater. 
English  statistics  show  a  higher  percentage  with  a  rheumatic  history  than 
those  of  any  other  country,  probably  because  rheumatism  is  more  com- 
mon in  that  country  than  elsewhere.  In  the  United  States  unmistakable 
rheumatic  attacks  occur  in  but  a  small  proportion  of  choreic  patients 
either  before  or  during  the  actual  attack  of  chorea.  The  latter  disease 
may  be,  as  I  have  repeatedly  observed,  followed  by  rheumatism  later  in 
life. 

Endocarditis. — As  has  already  been  stated,  some  observers  regard 
chorea  as  the  result  of  a  cerebral  embolus  due  to  fragments  of  fibrin 
being  washed  from  the  valves  and  carried  into  the  circulation  to  the  cere- 
bral vessels.  Endocarditis  occurs  in  the  vast  majority  of  cases  of  chorea, 
but  as  an  effect,  not  a  cause. 

Pregnancy. — Chorea  occurring  during  pregnancy  is  apt  to  be  severe. 
It  is  most  prone  to  develop  during  the  earlier  months,  and  especially  in 
primipar^e.     It  often  assumes  the  maniacal  type. 

Heredity. — In  about  10  per  cent,  of  the  cases  a  history  of  chorea  can 
be  obtained  in  other  members  of  the  family.  Children  of  neurotic  stock 
are  more  susceptible  than  those  of  a  normal  type,  and  in  such  individuals 
worry,  fright,  or  mental  shock  from  any  cause,  also  the  strain  of  puberty 
or  of  education,  are  very  liable  to  induce  an  attack.  I  have  several 
times  seen  chorea  follow  attacks  of  religious  fervor  in  young  girls. 

The  influence  of  reflex  irritation  is  probably  much  overrated,  whether 
intestinal,  genital,  or  from  ocular  defects. 

Symptoms. — The  common  or  ordinary  form  is  frequently  met  with, 
particularly  at  seasonal  changes  (H.  C.  Wood),  and  especially  during  the 
spring  and  fall.  Primary  attacks  may  occur  at  any  time,  but  recurrent 
outbreaks  are  most  prone  to  develop  in  the  spring.  There  is  a  slight 
affection  manifested  by  restlessness,  disturbed  rest  at  night,  and  by  irreg- 
ular and  spasmodic  muscular  movements,  that  are  most  marked  in,  or  en- 
tirely confined  to,  the  upper  extremities,  the  head,  or  the  facial  muscles ;  or 
the  condition  may  be  unilateral.  More  or  less  muscular  weakness  is  pres- 
ent and  the  patient  tires  very  readily.  The  child's  disposition  is  changed, 
outbursts  of  temper  being  quite  common  on  the  slightest  provocation. 
Fever  is  absent  in  this  form  unless  complications  exist,  though  when 
severe  joint-troubles  or  endocarditis  is  present  the  temperature  will  rise. 
Anemia  is  often  present,  and  with  it  headaches,  irritable  heart,  and  hemic 
murmurs,  very  rarely  giving  rise  to  symptoms.  Indeed,  in  some  instances 
not  even  a  murmur  can  be  heard,  though  postmortem  records  of  cases 
with  a  history  of  chorea  show  that  in  most  of  them  the  valves  are  affected. 
The  mitral  valve  is  most  commonly  involved,  the  endocarditis  usually 
being  of  the  verrucose  type.  There  are  rarely  any  sensory  symptoms, 
severe  pain,  at  all  events,  being  extremely  rare.  Little  dependence  can 
be  placed  on  complaints  of  tingling  or  burning  pain,  unless  it  is  volun- 
tarily spoken  of,  for  the  mental  make-up  of  choreic  patients  is  such  that 
they  are  apt  to  dwell  upon  slight  ailments  suggested  to  them  through  lead- 
ing questions.     The  reflexes  do  not  differ  from  those  of  normal  children. 

There  is  a  more  severe  type  of  chorea  in  which  the  movements  arc  so 


1146  DISEASES  OF  THE  NERVOUS  SYSTEM. 

pronounced  as  to  incapacitate  the  patient.  The  psychic  symptoms  are 
generally  more  marked  also,  and  speech  may  be  interfered  with  to  such 
an  extent  as  to  render  articulation  unintelligible.  Such  a  condition  may 
occur  primarily,  but  it  is  probably  met  with  more  often  after  one  or  more 
mild  attacks.  The  gravest  form  of  chorea  is  clwrea  msaniens,  in  which 
the  movements  are  violent  and  constant.  Speech  is  much  affected,  in- 
somnia is  marked,  and  fever  and  maniacal  delirium  develop,  followed  in 
some  cases  by  a  typhoid  condition  and  death. 

The  course  is  from  six  to  twelve  weeks,  though  the  most  trifling 
cases  may  recover  in  a  month  or  less.  Others  persist  six  months  or  even 
more.  In  about  two-fifths  of  all  cases  there  is  more  than  one  attack, 
while  Gowers  has  reported  one  case  in  which  there  were  nine  recurrences. 
Dr.  W.  Egbert  Robertson  observed  the  case  of  a  girl  nine  years  of  age  in 
whom  the  first  attack  occurred  at  the  age  of  six.  She  had  four  attacks 
in  three  years,  each  one  being  more  pronounced  than  the  former.  In  one 
of  my  own  cases  two  attacks  occurred  annually — spring  and  autumn — for 
two  years.  A  fatal  issue  is  very  rare  in  children,  and  absolute  recovery 
is  the  rule.  The  maniacal  form,  which  usually  develops  in  adults,  espe- 
cially in  pregnant  women,  as  previously  stated,  is  more  often  fatal,  though 
recovery  is  also  the  rule  in  such  cases. 

Diagnosis. — As  a  rule,  this  is  quite  simple.  The  age  of  the  patient, 
the  mode  of  onset,  and  the  character  of  the  movements  suffice  to  prevent 
mistakes,  though  the  condition  may  be  simulated  more  or  less  closely  by 
hereditary  ataxia.  Here,  however,  the  existence  of  other  cases  in  the 
family,  the  nystagmus,  the  peculiar  scanning  speech,  the  swaying,  almost 
reeling  gait,  and  the  tendency  to  contractures  will  usually  be  sufficient  to 
differentiate.  Yet  all  these  symptoms  may  be  slight,  and  the  case  may 
be  under  observation  some  time  before  its  real  nature  is  ascertained.  The 
same  is  true  of  cerebral  sclerosis.  It  is  only  by  a  careful  study  of  such 
cases  in  their  entirety  that  a  differential  diagnosis  can  be  made.  The 
movements  may  be  practically  the  same  in  both  conditions. 

It  may  be  well  to  call  attention  to  the  possibility  of  meeting  with  a 
case  that  has  been  treated  by  arsenic  to  the  point  of  saturation,  when  the 
true  nature  of  the  trouble  will  be  masked  by  the  arsenic-poisoning  and 
signs  of  peripheral  neuritis.  Such  a  case  was  presented  by  Stengel  at 
the  Philadelphia  Pediatric  Society  not  long  ago. 

Treatment. — This  is  largely  hygienic — a  fact  that  must  be  strongly 
dwelt  upon  in  discussing  with  the  parent  the  management  of  the  patient. 
The  avoidance  of  all  forms  of  nerve-strain  is  of  the  utmost  importance,  and 
the  amount  of  school-work  and  home-study  should  be  carefully  inquired 
into,  and  all  excess  absolutely  prohibited.  In  the  milder  forms  rest  in 
bed  is  not  imperative,  but  active  exercise  must  be  forbidden,  since  it 
invites  cardiac  troubles,  the  tendency  to  heart-involvement  already  being 
great  in  chorea.  In  the  more  severe  forms  rest  in  bed  is  a  sine  qud  non. 
In  any  case  an  abundance  of  rest  is  called  for,  and  when  insomnia  is 
present  it  should  be  promptly  handled.  An  important  element  of  the 
treatment  that  is  sometimes  indispensable  is  the  change  of  environ- 
ment, associated  with  rest.  As  a  rule,  the  patients  do  best  in  a 
warm  climate  and  at  the  seashore.  The  bromids  should  first  be  tried 
internally,  and  a  warm  bath  administered  just  before  bedtime.  In 
other  cases  morphin  or  chloral  may  be  required,  though  it  must  not  be 


HUNTINGDON'S  CHOREA.  1147 

forgotten  that  the  latter  is  a  cardiac  depressant ;  chloralamid  or  sulfonal 
should  therefore  be  given  the  preference.  Trional  has  also  given  good 
results  in  my  hands.  The  bowels  must  be  regulated,  and  the  diet  should 
be  light  and  wholesome,  with  an  abundance  of  fruit  and  fresh  vegetables. 
When  anemia  is  present,  it  is  to  be  met  by  the  use  of  some  one  of  the 
preparations  of  iron.  Should  reflex  irritation  be  found  to  exist,  it  should 
be  corrected  at  once.  Of  the  therapeutics  of  the  disease  not  much  can  be 
said.  "We  have  no  specific,  but  the  two  most  useful  drugs  are  arsenic 
and  cimicifuga,  the  former  as  Fowler's  solution,  and  the  latter  as  the  fluid 
extract.  Fowler's  solution  should  be  given  in  3-  to  5-drop  doses  three 
times  a  day  for  a  few  days,  and  then  increased  1  drop  per  diem  until 
the  point  of  tolerance  is  reached  or  the  physiologic  action  is  manifest. 
The  remedy  is  now  to  be  continued,  but  in  reduced  dosage.  The  late 
Hiram  Corson  first  warmly  recommended  cimicifuga  in  the  treatment  of 
chorea,  and  I  have  found  the  combined  use  of  this  drug  and  arsenic  to  be 
more  prompt  and  efiicient  than  the  latter  alone,  particularly  in  protracted 
cases.  Other  drugs  have  been  employed,  but  with  meager  results  ;  among 
these  are  the  zinc  and  silver  salts  and  belladonna.  Antipyrin  has  also 
been  used  a  great  deal  of  late,  but  with  no  more  promise  than  is  given  by 
the  drugs  just  enumerated. 


HUNTINGDON'S    CHOREA. 

[Chronic  Progressive  Chorea.) 

Definition. — An  hereditary  disease  afi'ecting  many  members  of  a 
family,  developing  in  early  adult  life,  and  characterized  by  irregular 
muscular  contractions,  incoordination,  and  progressive  dementia.  The 
disease  was  first  definitely  described  by  Huntingdon  in  1872,  but  other 
writers  had  already  alluded  to  it. 

Pathology. — The  changes  found  consist  of  chronic  pachy-  and 
leptomeningitis,  chronic  hemorrhagic  encephalitis,  characterized  by 
round-cell  infiltration  of  the  cortex,  degeneration  of  the  ganglion-cells, 
proliferation  of  the  neuroglia,  sclerosis  of  the  blood-vessels  with  dilata- 
tion of  the  perivascular  and  lymph-spaces,  and  numerous  hemorrhagic 
foci  (Facklam).  There  are  also  atrophy  of  the  brain,  slight  irregular 
changes  in  the  spinal  cord,  and  multiplication  of  the  nuclei  in  the 
muscles. 

Ktiology. — The  disease  is  strictly  hereditary,  and  has  been  traced 
through  five  generations.  The  ofispring  of  parents  that  escape  are  for- 
ever immune.  It  occasionally  alternates  with  idiocy,  epilepsy,  and 
various  degenerative  conditions.  It  appears  to  be  endemic  in  certain 
localities,  and  still  exists  upon  the  southern  shore  of  Long  Island,  Avhere 
Huntingdon  first  observed  it. 

Symptomatolgy. — The  choreiform  movements  commence  insidi- 
ously and  only  in  the  rarest  cases  become  pronounced.  They  are 
usually  susceptible  to  voluntary  inhibition  and  disappear  during  sleep. 
They  usually  commence  in  one  extremity  and  then  gradually  invade  the 
other  parts  of  the  body.     There  is  considerable  incoordination  of  move- 


1148  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ment.  The  mental  symptoms  consist  of  progressive  dementia,  irrita- 
bility often  attaining  maniacal  violence,  delusions  of  persecution,  and 
rapid  diminution  of  intelligence.  In  some  cases  the  mental  changes  are 
very  slight. 

The  course  is  steadily  progressive,  but  the  patient  may  live  to  an 
advanced  age. 

Diagfnosis. — The  only  condition  likely  to  cause  confusion  is  senile 
chorea  with  dementia.  In  this  the  mental  symptoms  are  usually  slight 
and  the  motor  symptoms  more  violent.  The  family  character  of  the 
disease  is  also   lacking. 

Treatment  is  entirely  symptomatic. 


RHYTHMIC   CHOREA. 

{Hysteric  Chorea.) 


In  this  condition  rhythmic  choreic  movements  occur,  and  affect  any  of 
the  special  groups  of  muscles  or  the  single  muscles.  It  may  be  confined 
to  the  abdominal  muscles  {salaam  convulsions),  or,  as  in  a  case  under  my 
care  at  present,  it  may  involve  only  the  sterno-cleido-mastoid  muscle. 

The  diagnosis  is  readily  assured  by  the  rhythmic  character  of  the 
movements  occurring  in  an  hysteric  temperament. 


CHOREIFORM  DISORDERS. 

PARAMYOCLONUS   MULTIPLEX. 

Definition. — This  is  a  disease  of  unknown  pathology,  first  described 
by  Friedreich,  and,  as  its  name  implies,  characterized  by  clonic  contrac- 
tions in  various  groups  of  muscles. 

Its  etiology  is  obscure.  Heredity  unquestionably  plays  an  import- 
ant part,  nearly  all  the  patients  having  among  their  ancestry  cases  of 
one  or  more  forms  of  nervous  disease.  It  usually  develops  in  early  adult 
life,  and  is  probably  more  common  in  males.  In  one  case  that  I  observed 
it  was  associated  with  idiocy. 

The  symptoms  of  the  disease  consist  of  clonic  contractions,  occur- 
ring chiefly  in  the  muscles  of  the  extremities  and  the  trunk  and  only 
occasionally  involving  the  muscles  of  the  face.  These  contractions  are 
very  sudden ;  so  much  so  that  they  have  been  described  as  lightning-like. 
Voluntary  movement  diminishes  them  somewhat,  emotional  disturbance 
increases  them  considerably,  while  during  sleep  they  disappear.  The 
poAver  of  the  muscles,  their  size  and  nutrition,  remain  unimpaired.  The 
electric  reactions  are  normal,  but  electric  stimuli  and  any  cutaneous  irri- 
tation are  apt  to  precipitate  an  attack.  The  tendon-reflexes  are  increased. 
Sometimes  the  patient  gives  vent  to  a  peculiar  grunt,  which  is  probably 
due  to  involvement  of  the  larynx  and  diaphragm.  In  some  of  the  cases 
sensitive  points  have  been  found  over  the  spinal  column,  and  not  a  few 
have  presented  other  stigmata  of  hysteria. 


CHOREA   ELECTRIC  A.  1149 

The  differential  diagnosis  is  rather  difficult,  as  it  is  necessary  to 
distinguish  the  disease  from  chorea  electrica  and  the  maladie  des  tics  of 
De  la  Tourette ;  between  it  and  the  former  there  is  really  no  essential 
difference.  Chorea  electrica  occurs  in  children,  and  the  spasms  are  per- 
haps less  affected  by  voluntary  movement  and  more  apt  to  be  rhythmic. 
In  the  maladie  des  tics  the  movements  are  more  coordinated,  and  usually 
are  a  repetition  of  some  reflex  or  voluntary  action.  Moreover,  the  patient 
is  apt  to  emit  more  or  less  intelligible  sounds.  If  there  is  any  real  dif- 
ference from  clonic  convulsions  occurring  in  hysteria,  it  is  only  in  the 
presence  of  hysteric  stigmata  in  the  latter  and  the  increase  in  the  muscular 
contractions  under  observation.     The  disease  usually  begins  insidiously. 

In  the  non-hysteric  form  the  prognosis  is  serious,  very  few  of  the 
cases  ever  showing  permanent  improvement. 

The  treatment  consists  of  rest,  hypodermic  injections  of  morphin, 
and  the  application  of  electricity.  The  latter  seems  most  effective  when 
applied  to  the  spinal  column,  a  constant  galvanic  stream  being  employed 
and  the  anode  being  placed  over  the  sensitive  vertebrae.  It  is  not  un- 
likely, however,  that  these  cases  are  of  an  hysteric  nature. 

CHOREA   ELECTRICA. 

Chorea  electrica  is  the  name  applied  to  at  least  two,  and  probably 
three,  varieties  of  spasmodic  disease.  The  first,  chronologically,  is  that 
of  Bergeron.  The  disease  occurs  most  frequently  in  children  between 
the  ages  of  seven  and  fourteen  years. 

Its  causes  seem  to  be  heredity,  anemia,  and  fright.  In  some  cases 
dilatation  of  the  stomach  has  been  observed,  and  it  is  believed  that  it 
bears  somewhat  the  same  etiologic  relation  to  this  disease  that  it  does  to 
tetany. 

Symptoms. — It  usually  commences  rather  suddenly,  and  is  character- 
ized by  lightning-like  contractions  in  the  muscles  of  one  extremity, 
although  occasionally  it  may  affect  the  whole  body.  These  are  somewhat 
rhythmic  and  painless,  and  do  not  affect  the  nutrition  of  the  muscles. 
They  are  slightly  increased  if  the  patient  attempts  to  inhibit  them,  but 
disappear  entirely  during  sleep.  Occasionally  the  respiratory  muscles 
are  involved,  causing  peculiar  sounds.  Ordinarily  the  mind  of  the 
patient  is  unaffected ;  in  some  cases,  however,  there  is  slight  melancholia 
or  anxiety  during  the  attack. 

The  diagnosis  consists  in  differentiating  the  condition  from  paramyo- 
clonus multiplex  and  the  maladie  des  tics. 

The  prognosis  is  extremely  favorable. 

The  treatment  consists  in  the  administration  of  arsenic  and  the  cor- 
rection of  the  anemia  and  the  gastro-intestinal  disorders  if  any  exist. 

A  second  form,  very  similar  to,  if  not  identical  with,  this  has  been  de- 
scribed by  Henoch.  It  occurs  at  the  same  age,  and  is  characterized  by 
the  same  symptoms,  with  the  difference  that  the  contractions  are  usually 
localized  in  the  muscles  of  the  back  and  shoulder,  and  are  almost  iden- 
tical with  those  produced  by  a  moderate  induced  current.  Usually  one 
side  of  the  body  is  more  affected  than  the  other. 

The  etiology  appears  to  be  that  of  chorea,  and  cases  have  occurred 
after  acute  articular  rheumatism  and  fright. 


1150  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  prognosis  is  somewhat  more  severe  than  in  the  form  described  by 
Bergeron. 

Treatment. — Arsenic  is  without  effect,  but  occasionally  the  bromids 
are  useful.  Henoch  himself,  however,  prefers  a  prolonged  treatment  with 
the  galvanic  current,  which  he  has  seen  produce  cure. 

A  third  disease,  closely  allied  by  its  symptoms  with  the  two  preceding, 
but  probably  of  very  different  etiology,  is  the  cJiorea  electrica  of  Dubiiii, 
a  disease  endemic  in  Northern  Italy.  It  occurs  at  all  ages,  affects  both 
sexes,  and  appears  to  be  of  an  infectious  nature.  Occasionally  congestion 
of  the  meninges  has  been  found  ;  in  other  cases  there  are  inflammatory 
lesions  in  other  parts  of  the  body,  and  particularly  in  the  lungs. 

Symptoms. — The  disease  commences  with  severe  pains  in  the  head, 
the  neck,  and  the  lumbar  region.  After  a  brief  interval  contractions 
occur  in  the  muscles,  usually  appearing  first  in  the  upper  extremities,  but 
rapidly  becoming  general.  They  are  almost  continuous,  and  are  separated 
by  approximately  equal  intervals,  so  that  they  are  distinctly  rhythmic  in 
character.  From  time  to  time  there  are  attacks  of  general  convulsions, 
that  may  occur  as  often  as  four  times  per  day,  and  are  usually  followed 
by  paresis  of  the  limbs.  There  is  slight  hyperesthesia  of  the  skin,  and 
usually  more  or  less  fever. 

The  i^rognosis  is  extremely  unfavorable,  death  occurring  in  90  per 
cent,  of  the  cases.  The  duration  of  the  disease  varies  from  two  or  three 
days  to  four  or  five  months,  death  usually  occurring  from  heart-failure 
while  the  patient  is  comatose. 

No  satisfactory  treatment  has  been  suggested. 

FIBRILLARY  CHOREA  (Morvan). 

This  is  an  affection  characterized  by  fibrillary  contractions,  appearing 
first  in  the  muscles  of  the  buttocks  and  in  the  posterior  portion  of  the 
thigh  ;  it  may  subsequently  extend  to  the  muscles  of  the  body,  and  even 
to  those  of  the  upper  extremities,  but  never  affects  the  muscles  of  the 
neck  and  the  face.  It  occurs  between  the  ages  of  sixteen  and  twenty- 
two  years,  and  affects  chiefly  males.  Occasionally  it  follows  excessive 
fatigue.  According  to  Morvan,  the  lesion  is  situated  in  the  anterior  cor- 
nua,  commencing  usually  in  that  governing  the  sciatic  nerve,  and  extend- 
ing upward  for  variable  distances. 

The  symptoms  consist  of  irregular  contractions  of  bands  of  fibers  in 
the  muscle,  giving  rise  to  slight  irregular  tremors  and  disappearing  upon 
voluntary  movement.  Occasionally  there  is  a  slightly  increased  secretion 
of  sweat  in  the  affected  members,  and  the  skin  may  become  somewhat 
pinker  than  normal. 

The  diagnosis  is  easy,  though  the  disease  may  occasionally  be  confused 
with  the  lightest  forms  of  paramyoclonus  multiplex. 

The  j)rognosis  is  favorable,  though  relapses  sometimes  occur. 

The  treatment  consists  in  the  administration  of  tonics. 

ATHETOSIS. 

Chorea  affecting  one  side  of  the  body  may  precede  or  follow  an  attack 
of  hemiplegia.     In  the  former  case  the  choreic  movements  usually  com- 


ATHETOSIS.  1151 

mence  two  or  three  days  before  the  apoplectic  attack  ;  they  affect  the  side 
that  is  subsequently  to  be  paralyzed,  may  be  more  or  less  severe,  and  are 
usually  most  pronounced  in  the  arm.  As  soon  as  paralysis  has  occurred 
they  disappear.  Post-hemiplegic  chorea,  on  the  other  hand,  comes  on 
some  days  or  weeks  after  the  attack,  and  is  usually  permanent. 

Athetosis,  a  condition  first  described  and  named  by  Hammond,  is 
closely  allied  to  post-hemiplegic  chorea.  It  may  be  either  partial,  affect- 
ing one  side  of  the  body  and  following  a  distinct  focal  lesion  of  the 
brain  in  some  part  of  the  motor  tract,  or  else  general,  in  which  case  it  is 
called  idiopathic,  and  is  often  found  in  cases  in  which  a  subsequent  post- 
mortem examination  fails  to  reveal  any  lesion. 

PatJiology. — The  local  lesions  causing  athetosis  are  particularly  those 
of  the  optic  thalamus.  It  is  also  the  commonest  sequel  of  cerebral  in- 
fantile palsy.  These  cases  usually  follow  a  circumscribed  encephalitis, 
but  may  also  be  due  to  thrombosis  or  embolism.  In  any  event,  the  sub- 
sequent condition  of  the  brain  is  usually  that  of  porencephalia,  and  it 
may  also  follow  congenital  porencephalic  conditions. 

The  etiology  of  the  idiopathic  or  general  form  is  not  so  well  known. 
It  sometimes  develops  in  children  born  after  prolonged  and  difficult  labor, 
particularly  when  instruments  have  been  used.  It  may  be  associated 
with  microcephalia,  idiocy,  or  pai*alyses. 

The  symptoms  of  the  disease  consist  of  peculiar  ivorm-lihe  movements^ 
most  marked  in  the  fingers  and  toes,  and  then  in  the  muscles  of  the 
arm  and  leo;,  but  often  also  involving  the  face.  The  movements  of 
the  fingers  are  very  characteristic,  and  seem  to  be  produced  by  the  com- 
bined action  of  the  interosseous  muscles  and  the  extensors  of  the  fingers ; 
as  a  result,  the  latter  are  bent  at  the  metacarpo-phalangeal  joints,  whilst 
all  the  phalangeal  joints  are  extended,  in  old  cases,  as  a  result  of  con- 
stant pulling,  usually  somewhat  over-extended.  At  the  same  time  the 
fingers  are  in  constant  irregular  rhythmic  movement.  The  arm  is  swung 
to  and  fro,  bent  and  straightened  at  the  elbow,  pronated  and  rotated. 
The  movements  of  the  toes  are  analogous  to  those  of  the  fingers.  In 
the  muscles  of  the  face  contractions  and  relaxations  occur,  giving  rise 
to  peculiar  grimaces  and  somewhat  interfering  with  speech.  In  those 
cases  in  which  athetosis  develops  after  a  lesion  of  the  optic  thalamus 
there  is  often  associated  hemianesthesia;  in  those  following  cerebral 
infantile  palsy,  sensibility  is  intact.  The  muscles  show  no  trophic  dis- 
turbances, and,  indeed,  may  be  slightly  hypertrophied  as  a  result  of 
constant  exercise.  The  idiopathic  form  is  usually  bilateral ;  the  gait  is 
curious  and  characteristic,  the  patients  appearing  to  be  constantly  on  the 
point  of  falling,  although  they  seldom  do  fall,  and  maintain  their  equi- 
librium almost  by  a  miracle  ;  whilst  the  arms  swing  violently  and  the 
face  exhibits  a  series  of  grimaces. 

The  differential  diagnosis  of  the  disease  must  be  made  from  hemi- 
plegic  chorea,  into  which,  according  to  Leube,  it  may  sometimes  pass, 
but  the  character  of  the  movements  in  the  two  conditions  is  very  dis- 
tinct. It  is  sometimes  more  difficult  to  distinguish  athetoid  movements 
limited  to  the  face  from  the  facial  tic  or  facial  chorea.  In  such  cases  a 
history  of  some  infantile  cerebral  injury  will  point  to  athetosis,  and  the 
character  of  the  movements  should  also  be  considered. 

The  prognosis  is  hopeless  as  regards  cure. 


1152  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — Improvement  may  sometimes  be  obtained  in  the  idio- 
pathic cases  by  the  administration  of  arsenic  or  the  bromids.  Hammond 
has  employed  nerve-stretching  with  asserted  good  results. 

HABIT   SPASM   (Go7cers). 

This  is  not  regarded  as  a  true  form  of  chorea,  though  the  affection  is 
nevertheless  characterized  by  localized  contractile  movements.  We  owe 
to  Dr.  S.  Weir  Mitchell  the  first  accurate  description  of  "habit-spasm." 
It  occurs  with  great  frequency  in  girls  from  seven  to  fourteen  years  of 
age.  General  ill-health  (a  neuropathic  state)  seems  to  precede  the  devel- 
opment of  the  disease  in  most  cases,  though  by  no  means  in  all.  Among 
specific  causes  may  be  mentioned  overwork  at  school,  fright,  eye-defects 
(refraction-errors — De  Schweinitz),  nasal  obstructions,  and  the  occurrence 
of  the  disease  in  the  parents  or  other  older  members  of  a  family. 

Symptoms. — In  its  commonest  form  there  may  be  seen  spasmodic 
movements  of  certain  muscles  of  the  face  (grimaces),  particularly  vigorous 
winking  or  twitching  of  one  side  of  the  mouth  or  of  the  cervical  muscles, 
associated  frequently  with  a  quick  toss  of  the  head  to  one  or  the  other 
.side,  and  sometimes  with  a  peculiar  sniff. 

Less  frequently  the  choreic  movements  manifest  themselves  in  a  shrug 
of  the  shoulder  or  a  jerky,  sobbing,  irregular  respiration,  occasionally 
accompanied  by  a  laryngeal  sound — a  cough  or  bark.  Some  authors 
mention  strange  tricks  that  are  practised  by  these  children,  and  Osier  ^ 
speaks  of  a  boy  at  his  clinic  who  was  in  the  habit  every  few  moments  of 
putting  the  middle  finger  into  the  mouth,  biting  it,  and  at  the  same  time 
pressing  his  nose  with  the  fore  finger. 

The  prognosis  in  the  immense  majority  of  cases  is  eminently  favor- 
able, recovery  ensuing  within  three  or  four  months ;  but  in  a  small  con- 
tingent the  condition  lasts  throughout  life,  usually  as  a  localized  mus- 
cular spasm  (grimace),  despite  treatment. 

The  treatment  embraces  two  important  steps :  the  removal  of  all 
discoverable  causes,  for  which  a  most  careful  search  must  be  instituted ; 
and  the  betterment  of  the  general  physical  and  psychic  condition. 

In  subjects  whose  health  is  impaired,  efforts  to  restore  the  normal 
vigor  of  the  constitution  by  fresh-air  exercise,  cold  baths  with  friction 
of  the  body-surface,  abundance  of  suitable  food,  massage,  and  the  ad- 
ministration of  hematinics,  particularly  iron,  are  to  be  assiduously  carried 
forward.  Arsenic  has  been  advised,  and  in  one  of  my  own  cases  proved 
curative  ;  it  is  to  be  employed  in  augmenting  doses  in  the  same  manner 
as  in  acute  chorea  {vide  p.  1147). 

GENERAL   TIC. 
[Maladie  des  Tics  conmdsif;  Maladie  de  Gilles  de  la  Tourette.) 

Definition. — A  disease  apparently  psychic  in  nature  and  character- 
ized by  coordinated  spasmodic  movements,  explosive  sounds  or  words, 
and  imperative  ideas,  without  intellectual   disturbance. 

The  pathology  of  the  disease  is  unknown.  It  occurs  in  those  suf- 
fering from  neuropathic  heredity,  and  usually  indirectly.     It  most  fre- 

1  Text-Book  of  Medicine,  p.  996. 


GENERAL   TIC.  1153 

quently  commences  in  childhood — that  is,  before  puberty — and  affects 
either  sex.     The  exciting  cause  is  usually  some  emotional  disturbance. 

Symptoms. — The  disease  generally  commences  in  the  orbicularis  pal- 
pebrarum, the  first  movement  being  an  uncontrollable  winking.  This, 
as  a  rule,  is  rapidly  associated  with  movements  of  the  muscles  of  the  face, 
causing  the  patient  to  exhibit  various  grimaces  ;  finally,  other  muscles  of 
the  body  may  be  involved,  and  the  patient  is  compelled  to  repeat  many 
times  some  apparently  purposeful  and  coordinated  movement,  as  the 
brushing  away  of  insects  or  the  stroking  of  the  beard.  From  time  to 
time  he  emits  sounds  that  may  be  either  inarticulate  cries  or  imitation 
of  some  animal,  as  the  crowing  of  the  cock  or  the  barking  of  the 
dog,  or  the  repetition  of  some  obscene  word  (coprolalia).  These  move- 
ments are  partially  under  the  control  of  the  will,  and  are  diminished  by 
occupation,  but  increased  by  emotion.  At  other  times  the  patient  is  com- 
pelled to  imitate  sounds  that  he  has  just  heard,  no  matter  how  unusual  or 
unexpected  (ecJiolalia).  A  more  curious  symptom  is  the  imitation  of 
movements  that  he  has  observed  (echokinesis),  which  may  lead  to  most 
absurd  or  painful  results.  I  heard  of  one  man  who  threw  himself  vio- 
lently to  the  ground  when  he  saw  another  man  fall ;  and  of  another  hav- 
ing killed  his  baby,  which  he  held  in  his  arms,  by  throwing  it  violently 
away  from  him  in  imitation  of  a  man  handling  fagots.  Still  another 
psychic  symptom  is  the  occasional  development  of  imperative  ideas. 
These  usually  take  the  form  of  a  desire  to  recall  some  unimportant  word 
or  syllable  [onofnato mania)  or  the  performance  of  difficult  problems  in 
mental  arithmetic  (arithmomania).  One  of  my  patients,  a  boy  of  four- 
teen years,  before  undertaking  a  definite  act  Avould  repeat  the  words 
"ten,  ten,  ten,"  three  times,  followed  by  a  rapid  count  of  figures  from 
one  to  ten.  If  riding  in  a  public  conveyance,  he  would  do  the  same, 
endeavoring  to  finish  before  reaching  a  definite  place,  as  a  street-corner, 
or  before  hearing  the  sound  of  the  voice  or  whistle  of  the  conductor  if 
in  a  trolley-car.  A  failure  to  accomplish  the  task  was  cause  for  intense 
mental  worry.  These  patients  are  usually  affected  at  the  same  time  with 
a  certain  degree  of  melancholia  or  anxiety  that  interferes  to  some  extent 
with  their  normal  life.  The  disease  is,  as  a  rule,  very  obstinate,  and 
ordinarily  continues  throughout  life. 

The  differential  diagnosis  is  usually  rather  difficult.  From 
chorea  it  may  be  distinguished  by  the  coordinated  character  of  the  move- 
ments and  by  the  presence  of  coprolalia,  also  by  the  fact  that  the  move- 
ments can  usually  be  controlled  partially  by  the  will ;  from  hysteria  by 
the  absence  of  stigmata  and  the  presence  of  coprolalia ;  from  paramyo- 
clonus multiplex  it  may  be  known  by  the  coordinated  character  of  the 
movements  and  the  absence  of  increased  reflexes. 

The  prognosis  is  unfavorable  for  cure;  death,  however,  almost 
never  occurs  as  the  result  of  the  disease. 

The  treatment  is  symptomatic,  and  consists  in  putting  the  patient 
in  the  most  favorable  physical  condition  possible ;  also  hydrotherapy, 
change  of  climate,  tonics,  and  the  correction  of  any  atonic  condition 
are  all  useful  measures.  Potassium  bromid  to  a  certain  extent  controls 
the  paroxysms  when  they  become  very  severe. 

73 


1154  DISEASES   OF  THE  NERVOUS  SYSTEM. 


SALTATORIC    SPASM. 
{Jumpers;  Latah;  Palmus.) 

Definition. — This  is  a  term  applied  to  a  peculiar  clonic  contraction 
occurring  in  the  lower  legs  of  a  patient  on  attempting  to  stand  upright. 
The  disease  was  first  described  by  Bamberger.  It  appears  to  occur  more 
frequently  in  men  than  in  women,  and  usually  in  individuals  who  have 
suffered  from  other  functional  diseases.  Occasionally  it  appears  in  those 
who  exhibit  hysteric  phenomena.  The  condition  may  develop  after  severe 
exertion,  and  sometimes  appears  during  convalescence  from  an  acute  dis- 
ease. In  one  of  my  own  cases  the  condition  suddenly  arose  in  the  course 
of  habit-chorea.     Saltatoric  spasm  is  not  a  clinical  variety  of  true  chorea. 

Symptoms. — When  the  patient  attempts  to  stand  violent  clonic  con- 
vulsions take  place  in  the  muscles  of  the  legs,  particularly  of  the  calves. 
These  may  cause  the  patient  simply  to  rise  on  his  toes,  or  they  may  be  so 
severe  as  to  cause  him  to  spring  from  the  ground,  in  which  case  he  usually 
falls.  As  soon  as  he  lies  down  the  spasms  disappear,  but  they  may  be 
produced  in  patients  lying  in  bed  by  pressing  against  the  feet. 

The  prognosis  is  generally  favorable.  The  attacks  usually  last  for 
a  period  of  from  two  days  (Gowers)  to  a  few  weeks,  but  a  few  cases  have 
been  recorded  that  persisted  throughout  life.  Gowers  recommends  dia- 
phoretic treatment.  Antispasmodics  may  also  be  employed,  and  in  those 
cases  with  hysteric  stigmata  suggestion  is  useful. 

CHOREA   MAJOR. 
{Pandemic  Chorea.) 

This  is  a  form  of  hysteria  {hysteric  chorea).  As  early  as  the  Middle 
Ages  it  prevailed  as  a  pandemic  affection,  and  was  definitely  traceable  to 
religious  ardor,  excitement,  or  feeling.  Writers  upon  the  subject  fre- 
quently instance  an  outbreak  that  occurred  among  the  pioneer  settlers  in 
Kentucky.  The  convulsive  movements  are  general,  violent,  and  continu- 
ous ;  they  are  aggravated  by  attempts  at  voluntary  control. 

The  diagnosis  rests  chiefly  upon  the  causal  religious  excitement,  the 
character  of  the  convulsions,  and  the  associated  hysteric  manifestations. 

The  treatment  is  wholly  mental  and  moral,  with  the  occasional  use 
of  drugs  to  produce  quiet  and  sleep. 


PARALYSIS  AGITANS. 

{Shaking  Palsy^  Parkinson' s  Disease.) 

Definition. — A  chronic  disease  characterized  by  a  tremor ;  by  the 
peculiar  character  of  the  speech  and  gait,  and  by  a  progressive,  but  very 
seldom  complete,  loss  of  power. 

Pathology. — Lesions  that  are  probably  only  senile  in  type  have 
been  fre([uently  described.  There  are  peri-  and  endarteritis,  irregular 
degenerations  in  the  posterior  columns,  and  numerous  amyloid  bodies. 
Other  observers  have  noted  changes  in  the  motor  cells  of  the  cerebral 
cortex. 

Ktiology. — Paralysis  agitans  is  a  disease  of  adult  life,  developing  in 


PARALYSIS  AGITANS.  1155 

the  large  majority  of  cases  between  the  fortieth  and  forty-fifth  years  ;  it 
is  met  with  more  often  in  men  than  in  women.  Xo  definite  etiologic  fac- 
tor is  known,  though,  as  Avith  most,  if  not  all,  nervous  diseases,  it  is  pre- 
disposed to  by  mental  strain,  worry,  or  trouble  of  any  kind. 

Symptoms. — The  first  evidence  of  the  disease  is  the  tremor ^  slight 
at  first,  and  in. the  extremities,  the  hand  usually  being  the  first  to  betray 
it.  The  movement  is  very  characteristic,  the  thumb  and  fore  finger  being 
approximated  as  in  the  act  of  making  a  pill.  Ax  the  same  time  the  hand 
is  semi-rotated  and  the  forearm  trembles  more  or  less  as  a  whole.  The 
upper  arm  is  either  but  slightly  or  not  at  all  affected.  The  legs  are  also 
but  slightly  implicated.  The  tremor  is  most  noticeable  when  the  patient 
is  sitting  with  one  leg  crossed  over  the  other,  the  foot  then  being  sure  to 
be  in  more  or  less  constant  motion.  When  the  head  is  involved  (rather 
the  exception  than  the  rule)  the  motion  is  a  nodding  one.  The  tremors 
cease  when  the  patient  sleeps,  but  are  continuous  during  waking  hours, 
though  it  is  not  rare  to  meet  with  cases  in  which,  during  purposeful  acts 
necessitating  the  use  of  the  affected  parts,  the  tremors  diminish  or  even 
cease  temporarily,  to  return  as  soon  as  the  voluntary  motion  is  completed. 
The  latter  movements,  it  will  be  noticed,  are  awkward,  and  as  the  disease 
advances  they  become  more  and  more  stiff.  This  rigidity,  with  its  conse- 
quent impairment  of  activity,  is  another  cardinal  feature  of  the  disease. 
The  patient's  movements  are  slow  and  apparently  measured.  There  is 
some  impairment  of  power  also,  but  it  is  slight,  and  may  be  rather  from 
disease  than  from  a  direct  nerve-  or  muscle-involvement. 

Two  of  the  most  striking  symptoms  of  the  disorder  are  the  gait  and 
attitude  of  the  patient.  He  walks  with  head  and  body  bent  forward, 
eyes  directed  toward  the  ground  a  short  distance  ahead,  and  takes  short, 
mincing,  and  somewhat  hurried  steps  (festinatioii),  giving  one  the  im- 
pression that  he  is  about  to  fall,  which  he  would  do  but  for  each  successive 
step,  which,  as  it  were,  gives  him  a  fresh  center  of  gravity.  His  station 
is  equally  striking.  The  head  and  back  are  bent  forward,  the  feet  are 
kept  some  little  distance  apart,  and  one  in  front  of  the  other,  while  the 
arms  are  slightly  flexed  and  pendulous.  From  time  to  time  the  patient 
will  make  a  slight  forward  movement  [propulsion),  or  else,  if  walking, 
bend  or  fall  backward  {retropulsion).  The  facial  muscles  are  set, 
the  eyebrows  arched,  and  the  whole  expression  is  ''mask-like."  The 
general  slow  character  of  all  movements,  except  walking,  which  is  neces- 
sarily quicker,  is  imparted  to  the  speech,  though  after  a  sentence  is  begun 
the  balance  may  be  rendered  normally  or  even  hurriedly.  The  voice  may 
be  high-pitched.  There  are  no  trophic  or  sensory  symptoms,  and  the 
reflexes  are  normal.  Apart  from  the  difiidence,  amounting  in  some  cases 
to  a  positive  dislike  for  meeting  people,  and  the  melancholia  occasionally 
induced  bv  brooding  over  the  affliction,  there  are  no  mental  changes. 

Course. — The  disease  is  almost  always  of  slow  onset  and  of  insidious 
progress.  A'ery  rarely  the  earlier  symptoms  may  develop  somewhat  rap- 
idly, but  in  every  case  their  further  progress  is  slow.  Disappearance  of 
tremor  has  been  observed  in  the  side  affected  by  a  subsequent  hemiplegia. 
The  course  may  be  interrupted  from  time  to  time ;  even  seeming  im- 
provement may  take  place,  but  it  is  not  maintained.  The  disease  lasts 
for  years,  and  the  patient  usually  dies  of  some  intercurrent  disease. 

The  diagnosis  is  not  at  all  diflicult  when  the  tremor,  attitude,  gait, 


1156  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  rigidity  have  developed.  During  the  earlier  stages  it  may  be  con- 
founded with  multiple  sclerosis,  though  this  condition  develops  earlier, 
and  the  volitional  character  of  the  tremor,  the  nystagmus,  and  the  scan- 
ning speech  should  serve  to  differentiate  it. 

Treatment. — The  medical  management  of  the  disease  is  absolutely 
without  avail.  No  drug  has  been  found  to  exercise  the  slightest  influence 
on  its  course.  Graduated  exercise,  however,  tepid  baths,  and  massage 
should  be  employed  to  keep  up  the  tone  of  the  muscles. 


OTHER  FORMS  OF  TREMOR. 

1.  Hereditary  tremor  has  been  described  by  C.  L.  Dana,  who  has  also 
reported  interesting  cases.  It  may  commence  in  infancy  and  continue 
till  old  age,  unaccompanied  by  detectable  lesions. 

2.  Simple  tremor,  lasting  a  longer  or  shorter  period  (oftener  it  is  com- 
paratively brief),  is  a  rare  condition  and  Avithout  serious  possibilities.  Its 
etiology  is  unknown,  though  it  is  sometimes  aggravated  by  nervous  shocks 
and  other  debilitating  conditions. 

3.  Senile  Tremor. — This  is  common  in  old  persons,  and  rarely  appears 
before  three-score-and-ten  years.  It  is  excited  by  muscular  motions,  is 
always  fine,  and  aff'ects  chiefly  the  hands  and  arms ;  more  rarely  the  neck 
is  also  involved,  and  the  head  may  then  be  seen  to  tremble. 

4.  Toxic  Tremor. — This  results  from  the  action  of  alcohol,  lead,  mer- 
cury, tobacco,  and  other  poisonous  substances.  I  recently  saw  a  case  that 
followed  the  prolonged  use  of  arsenic  for  an  anemic  condition. 

5.  Smoker's  tremor  is  a  recognized  variety.  The  tremulousness  pro- 
duced by  alcohol,  lead,  and  opium  will  be  considered  in  the  discussion  of 
poisoning  from  these  substances  {vide  The  Intoxications). 

6.  Hysteric  tremor  Avill  receive  more  elaborate  mention  elsewhere  (vide 
Hysteria,  p.  1164). 


TETANY. 


Definition. — A  disease  of  unknown  cause,  characterized  by  parox- 
ysms of  tonic  cramp  that  usually  affect  the  flexor  muscles  of  the  extremi- 
ties, by  sensory  disturbances,  and  by  a  peculiar  alteration  of  the  electric 
reaction  of  the  muscles. 

Pathology. — Distinct  morbid  lesions  of  the  nervous  system  have  not 
been  found  in  all  cases.  Slight  vascular  changes  in  the  brain  and  cord 
and  vacuolization  of  the  ganglion-cells  have  been  described,  but  these  are 
not  peculiar  to  this  disease.  It  has  been  suppose<l  that  changes  ought  to 
be  found  in  the  motor  nerves,  but  the  most  careful  observers  have  failed 
to  detect  them. 

histiology. — Tetany  may  occur  in  epidemics,  and  has,  therefore,  been 
supposed  to  be  infectious.     There  is  some  doubt,  however,  whether  these 


TETANY.  1157 

epidemics  are  cases  of  true  tetany  or  are  hysteric  in  nature.  There  is 
also  some  evidence  that  it  is  due  to  an  intoxication  occurring  in  the  course 
of  some  other  morbid  condition.  Tetany  is  frequently  associated  with 
infectious  diseases  ;  it  also  occurs  in  connection  with  gastro-intestinal  dis- 
orders, especially  dilatation  of  the  stomach,  diarrhea,  and  intestinal  para- 
sites, during  pregnancy  and  lactation,  and  it  is  associated  with  the  myx- 
edema that  develops  after  the  removal  of  the  thyroid  gland.  Exposure  to 
cold  has  often  preceded  the  disease.  Occupation  seems  to  exert  a  remark- 
able influence  upon  the  predisposition  to  it,  the  great  majoritv  of  those 
affected  being  shoemakers  or  tailors.  In  childhood  males  are  far  more 
frequently  attacked  than  females,  but  in  adult  life  this  proportion  is  re- 
versed. Heredity  may  have  some  influence,  since  tetany  often  occurs  in 
several  members  of  the  same  family.  It  is  much  more  common  in  the 
winter  months,  and,  curiously  enough,  it  appears  to  be  endemic  in  certain 
localities,  particularly  Leipsic  and  Vienna. 

The  symptoms  fall  naturally  into  two  groups :  (1)  Those  of  the  par- 
oxysm, and  (2)  Those  of  the  interval.  (1)  The  first  symptoms  of  an  attack 
usually  consist  of  peculiar  sensory  disturbances  in  the  limbs,  either  ting- 
ling, formication,  pain,  or  numbness,  and  these  may  precede  the  attack  for 
some  hours  or  even  days.  Stiffness  of  the  muscles  usually  begins  in  the 
fingers.  There  may  be  slight  clonic  movements  at  first,  but  this  is  not 
frequent.  The  limbs  are  symmetrically  involved.  The  spasjii  commences 
first  in  the  hand,  the  fingers  being  straightened  and  flexed  upon  the  hand, 
and  bunched  so  that  the  hand  has  been  likened  to  that  of  the  scrivener 
or  obstetrician.  The  spasm  then  extends  to  the  muscles  of  the  forearm 
and  arm,  and  usually  also  to  the  feet  and  lower  limbs.  If  the  cramp  is 
slight,  the  pain  may  be  insignificant,  but  ordinarily  it  is  severe,  and  is 
increased  by  attempts  to  overcome  the  contractures.  The  muscles  are 
hard,  painful  upon  pressure,  and  occasionally  fibrillary  twitchings  may  be 
observed.  There  is  sometimes  a  slight  edema,  and  often  sweating  of  the 
limbs.  The  paroxysms  may  last  for  several  minutes-  or  for  several  hours 
or  even  days,  and  may  even  persist  during  sleep.  If,  however,  the  period 
is  very  long,  remissions  are  usually  observed.  Sometimes  a  series  of 
paroxysms  may  occur  with  considerable  regularity.  Attacks  are  more 
likely  to  occur  at  night,  and  they  may  also  be  brought  on  by  prolonged 
and  severe  muscular  effort,  or  by  emotional  shocks.  Besides  the  pares- 
thesise  in  the  affected  extremities,  the  patient  may  suffer  from  severe 
headache  or  pain  in  the  back  and  neck. 

(2)  The  symptoms  of  the  interval  are — Trousseau's  sign — i.  e.  the 
possibility  of  causing  an  attack  by  prolonged  pressure  upon  the  main 
nerve-trunks  or  vessels  of  the  limbs.  Frank el-Hochwart  has  shown  that 
pressure  upon  the  nerves  is  essential ;  pressure  upon  the  vessels  acting 
secondarily  if  at  all.  Chvostek's  sign  is  a  peculiar  excitability  of  the  mus- 
cles of  the  face,  so  that  spasms  are  produced  if  the  trunks  of  the  facial 
nerve  are  lightly  percussed  by  a  hammer.  This  occurs  in  other  condi- 
tions, particularly  the  cachexise,  but  in  most  cases  of  tetany  the  spasm 
occurs  if  the  skin  of  the  face  is  lightly  stroked ;  and  this  reaction  appears 
to  be  pathognomonic.  ErKs  sign  consists  of  a  greatly  increased  electric 
excitability  of  the  muscles,  and,  occasionally,  of  an  alteration  of  the  electric 
reaction,  so  that  ACIC  may  be  greater  than  KCIC.  Moreover,  AOTe  is 
often  obtained,  and,  in  at  least  2  cases,  KOTe  has  also  been  noted.     The 


1158  DISEASES  OF  THE  NERVOUS  SYSTEM. 

last  two  reactions  occur  in  no  other  condition.  Hoffmann's  sign  consists  of 
an  increased  reaction  of  the  sensory  nerves  to  electric  stimuli.  The  facies 
of  the  patient  is  peculiar  and  characteristic.  The  face  is  slightly  swollen, 
dusky,  and  expressionless,  hut  if  carefully  examined  usually  no  edema  can 
be  detected.  Often  this  swelling  is  also  found  in  the  hands  and  feet,  and 
may  be  associated  with  distinct  enlargement  of  the  veins.  Even  during 
the  interval  the  feet  when  at  rest  have  a  tendency,  particularly  in  children, 
to  assume  a  slightly  inverted  and  extended  position. 

The  sensory  disturbances  are  of  considerable  importance.  Often  in 
the  affected  limbs  there  may  be  slight  diminution  in  sensibility.  In  addi- 
tion to  this,  there  are  changes  that  can  only  be  described  as  true  hysteric 
stigmata — i.  e.  hemianesthesia,  or  symmetric  areas  of  insensibility  to  pain 
or  touch.  Often  there  are  points  of  special  sensitiveness  on  the  spinal 
column,  and  in  some  cases  pressure  upon  these  will  precipitate  an  attack. 
Distinct  trophic  changes  have  also  been  observed,  consisting  of  herpetic 
eruptions  along  the  course  of  the  nerve-trunks,  falling  out  of  the  hair,  and 
sometimes  even  painless  ulceration.  The  contractures  are  not  invariably 
limited  to  the  extremities.  Sometimes  the  muscles  of  the  neck,  back,  and 
larynx  are  involved ;  sometimes  also  the  diaphragm,  and  occasionally  the 
compressor  urethrae.  Involvement  of  the  larynx  gives  rise  to  stridulous 
respiration  ;  involvement  of  the  diaphragm  to  severe  dyspnea ;  when 
the  urethra  is  compressed  there  is  retention  of  the  urine.  Fever  occurs 
in  about  one-half  the  cases ;  it  is  slight  and  generally  limited  to  the 
paroxysm.  The  urine  usually  contains  a  large  amount  of  phosphates, 
and  less  frecpiently  indicun  is  present  in  excess. 

The  differential  diagnosis  is  very  easy,  as  a  rule,  if  the  patient  is 
seen  during  a  paroxysm.  The  severer  forms  may,  however,  be  con- 
founded with  tetanus  or  meningitis.  Tetany  can  be  distinguished  from 
the  former  by  the  fact  that  the  spasm  begins  at  the  ])eriphery  and  rarely 
affects  the  muscles  of  the  jaw.  From  the  latter  it  may  be  diagnosed  by 
the  absence  of  coma  and  the  slighter  de":ree  of  fever.  The  diatrnosis 
from  certain  forms  of  ergotism  is  more  difficult,  and  can  often  be  made 
only  by  careful  attention  to  the  etiology.  The  hysteric  forms  cannot 
always  be  differentiated,  for,  as  has  been  stated  above,  hysteric  stigmata 
occur  in  true  tetany  ;  but  an  epidemic  occurring  among  young  Avomen 
should  give  rise  to  a  suspicion  of  the  true  nature  of  the  malady. 

Prognosis. — The  duration  varies  from  a  few  days  to  many  months, 
the  most  obstinate  forms  being  those  due  to  thyroidectomy  and  chronic 
diarrhea.  The  disease  cannot  be  said  to  have  disappeared  until  the  cha- 
racteristic symptoms  of  the  interval  (Trousseau's,  Erb's,  and  Chvostek's 
signs)  can  no  longer  be  elicited.  The  prognosis  is  usually  favorable, 
nearly  all  cases  tending  to  spontaneous  cure.  Death,  however,  may  occur 
from  chronic  diarrhea,  from  respiratory  failure  when  the  diaphragm  is 
involved,  and  from  cachexia  strumipriva. 

The  treatment  is  purely  symptomatic.  The  patient  should  be  placed 
in  the  most  favorable  hygienic  conditions  and  given  plenty  of  nourishing 
food.  During  the  spasm  bromids  or  chloroform-inhalations  seem  to  give 
the  best  results.  The  most  important  therapeutic  measure  is  the  correc- 
tion of  the  underlying  cause.  Thus,  in  children  rachitis  is  almost  invari- 
ably associated  with  tetany,  and  the  most  efficient  remedies  are  iron  and 
cod-liver  oil.     Intestinal   disorders   should  be   treated  according   to   the 


INFANTILE  CONVULSIONS.  1159 

principles  laid  down  in  the  discussion  of  these  diseases.  The  form  due  to 
removal  of  the  thyroid  gland  always  disappears  under  a  course  of  thyroid- 
medication,  while  that  occurring  during  pregnancy  usually  persists  until 
delivery. 


INFANTILE  CONVULSIONS. 

{Eclampsia  Infantilis.) 

UxDER  this  term  are  grouped  a  number  of  conditions,  with  convulsive 
.attacks  as  the  common  symptoms. 

Pathology. — The  pathologic  changes  may  be  divided  into  two 
groups  :  (1)  those  bearing  an  etiologic  relation  to  the  convulsive  attacks, 
and  (2)  those  that  are  merely  consecutive.  Among  the  former  are  me- 
ningeal bleeding,  tumor,  gliosis  (either  hypertrophic  or  atrophic),  and 
hydrocephalus.  Then  there  are  general  conditions  that 'seem  to  predis- 
pose to  this  condition  or,  at  any  rate,  are  frequently  associated  with  it, 
such  as  rachitis.  The  consecutive  lesions  are  hemorrhages  into  the 
meninges  or  into  the  substance  of  the  brain  and  the  spinal  cord,  an  in- 
crease in  the  amount  of  cerebro-spinal  fluid,  and  congestion  of  the  pia 
or  the  substance  of  the  brain. 

The  causes  are :  1.  Organic  brain  lesions.  2.  Neuropathic  ten- 
dency, that  is  manifested  later  as  hysteria  or  epilepsy.  3.  Emotional 
disturbances,  as  fright.  4.  Rickets,  in  about  30  per  cent,  of  all  cases. 
5.  Acute  infectious  disease,  especially  as  an  initial  symptom  of  pneu- 
monia, and  more  rarely  of  scarlet  fever,  small-pox,  and  pernicious  ma- 
larial infection.  6.  Inflammation  of  the  serous  membranes,  as  menin- 
gitis, where  the  relation  is  direct,  or  pleuritis  or  peritonitis.  7.  Kidney 
disease,  in  which  they  are  uremic.  8.  Peripheral  irritation ;  dentition 
has  long  been  supposed  to  be  a  chief  factor  in  their  causation,  but  it  is 
now  believed  that  the  chief  cause  is  the  presence  of  rickets.  Intestinal 
parasites  have  also  been  found,  particularly  the  ascaris  lumbricoides, 
and  the  convulsions  have  ceased  after  their  expulsion.  9.  Debility, 
especially  that  resulting  from  gastro-intestinal  disorders. 

The  symptoms  of  the  attack  vary  according  to  its  intensity.  In  the 
most  severe  form  they  resemble  in  all  respects  those  of  an  epileptic  seizure. 
At  first  the  eyes  deviate  upward  or  to  one  or  the  other  side,  and  the  gaze 
becomes  fixed  and  staring;  next  there  are  tivitchings  of  the  muscles  of  the 
face,  sometimes  slight  and  limited  to  one  side,  and  sometimes  general, 
often  involving  the  muscles  of  mastication  and  giving  rise  to  trismus  or 
gnashing  of  the  teeth.  Next  there  are  tetanic  contractions  of  the  extrem- 
ities, the  fingers  being  strongly  flexed,  the  hands  flexed  upon  the  arms, 
and  the  feet  in  the  position  of  pes  equinus  or  sometimes  in  the  dorsal 
flexion,  and  both  legs  and  arms  rigidly  extended.  Often  the  muscles  of 
the  trunk  are  involved,  and  there  is  either  opisthotonos  or  respiratory 
cramp,  with  excessive  hardness  of  the  abdominal  muscles.  This  rigid 
condition  is  interrupted  at  brief  intervals  by  sudden  twitchings,  or  occa- 
sionally the  convulsion  becomes  clonic  instead  of  tonic,  and  there  are  re- 
peated*^extensions  and  contractions  of  the  extremities,  shaking  of  the  head, 
and  quivering  of  the  whole  body.     As  a  result  of  the  respiratory  cramp, 


1160  DISEASES   OF  THE  NERVOUS  SYSTEM. 

cyanosis  rapidly  develops  and  may  reach  an  extreme  degree.  The  forced 
respirations  give  rise  to  a  foam  that  collects  about  the  lips,  and  is  often 
mixed  with  blood  from  the  bitten  tongue.  Urine  is  often,  and  feces  occa- 
sionally, passed  involuntarily.  In  nearly  all  cases  unconsciousness  is 
complete.  Many  of  the  slight  attacks  are  accompanied  by  a  cry  or  by  an 
attack  of  screaming.  The  tetanic  state  usually  lasts  for  a  minute  or  two  ; 
then  there  are  a  few  clonic  movements,  relaxation  becoming  rapidly  com- 
plete, and  the  spasm  is  ended  b}^  a  few  deep  respirations.  The  child  may 
return  to  consciousness,  although  it  is  usually  drowsy  or  stupid,  or  it  may 
pass  into  a  deep  sleep  from  which  it  cannot  be  aroused.  Often  in  the  lat- 
ter condition  attacks  w^ill  recur  at  irregular  intervals,  and  sometimes  a 
single  attack  may  continue  for  some  time,  although  from  time  to  time 
there  are  slight  twitchings  followed  by  partial  relaxation  (^status  eclamp- 
ticus — Lewis).  The  attack  may  come  on  suddenly,  or,  as  is  more  fre- 
quently the  case,  it  may  be  preceded  by  a  period  of  restlessness  and  irri- 
tability. A  milder  form  of  the  spasm  consists  of  sudden  fixation  of  the 
eyes,  slight  twitching  of  the  body,  and  a  peculiar  dusky  pallor  that  passes 
away  in  a  few  moments.  In  other  rare  cases  consciousness  may  persist, 
although  the  patient  is  aphasic.  Laryngismus  stridulus  is  an  analogous 
condition  (inde  Diseases  of  the  Larynx,  p.  477). 

The  diagnosis  of  the  condition  is  very  easy.  The  recognition  of 
the  cause,  however,  is  very  important  and  often  difficult.  Every  case 
should  be  first  examined  for  rickets,  and  then  the  gums  should  be  inves- 
tigated ;  also  the  condition  of  the  child's  nutrition  and  the  presence  of 
symptoms  of  gastric  or  enteric  irritations.  If  fever  exists,  it  is  import- 
ant to  discover  its  cause.  The  character  of  the  convulsion  is  often  of 
value  in  distinguishing  between  the  idiopathic  or  reflex  type  and  that 
due  to  organic  brain-disease.  Convulsions  beginning  immediately  after 
birth,  or  an  injury,  either  persisting  or  else  disappearing  gradually,  are  prob- 
ably caused  by  meningeal  hemorrhage.  An  attack  of  a  Jacksonian  type 
would,  of  course,  indicate  the  presence  of  a  focal  lesion  ;  and  if  this  be  a 
tumor,  there  will  probably  be  bulging  of  the  anterior  fontanel,  severe 
headache,  and  the  ophthalmoscope  will  reveal  a  neuro-retinitis.  If,  after 
the  attack,  pareses  or  paralyses  are  present,  a  focal  lesion  is  still  more 
likely.  Hydrocephalus  is  usually  recognized  with  ease.  Some  cases 
exist,  however,  in  which  it  is  impossible  to  discover  any  adequate 
cause. 

The  prognosis  varies  according  to  the  etiology.  In  cases  with 
organic  brain-disease  it  is  unfavorable  as  regards  cure.  In  those  forms 
that  precede  epilepsy  or  functional  nervous  diseases  the  spasms  usually 
disappear  after  the  first  dentition,  and  the  patients  appear  to  have  recov- 
ered for  a  time.  In  those,  however,  in  whom  the  symptoms  are  due  to 
some  peripheral  irritation  or  to  rachitis,  the  outlook  is  fair,  although 
even  these  now  and  then  develop  into  permanent  epilepsy.  The  convul- 
sions themselves  are  either  often  immediately  fatal,  or  so  exhausting  to 
the  patient  that  he  succumbs  readily  to  the  disease  that  produced  them. 
In  these  cases  the  prognosis  depends  upon  the  frequency  and  severity  of 
the  attacks,  death  usually  terminating  those  in  which  the  status  eclampti- 
cus  has  been  established.  The  prognosis  for  ultimate  cure  depends  also  in 
part  upon  the  length  of  time  that  the  condition  has  existed  ;  if  but  for  a 
short  time  before  an  arrest  has  been  established,  recurrence  is  much  less 


OCCUPATION-NEUROSES.  1161 

likely.     Gowers,  however,  says  that  even  after  a  year's  duration  perma- 
nent cure  may  sometimes  be  obtained. 

The  treatment  naturally  falls  into  two  paints — that  of  the  attack  and 
that  of  the  interval.  Unquestionably,  the  most  efficacious  antispasmodic 
that  we  possess  for  this  condition  is  chloroform.  A  few  drops  may  be  put 
upon  a  handkerchief  and  held  carefully  over  the  nose  and  mouth  of  the 
little  patient.  A  very  small  quantity  usually  suffices,  and  the  effect  is 
almost  instantaneous.  In  addition  to  this,  chloral  and  the  bromids  may 
be  given  by  the  rectum,  and  it  is  often  useful  to  add  to  these  one  of  the 
coal-tar  antipyretics,  particularly  antipyrin.  Morphin  may  be  given 
hypodermically.  Formerly  hot  mustard-baths  Avere  much  in  favor,  but 
unless  they  do  good  at  once  they  are  not  likely  to  be  of  any  use.  In  a  very 
obstinate  case  under  my  care  they  were  absolutely  valueless,  and  were  re- 
placed by  momentary  immersion  in  ice-cold  baths  and  vigorous  friction, 
which  seemed  to  act  very  favorably.  If  any  known  source  of  irritation 
is  present,  as  an  overloaded  stomach,  it  should  be  relieved  at  once,  if  pos- 
sible, by  the  stomach-tube  or  an  emetic.  An  enteritis  may  be  tempo- 
rarily benefited  by  an  enema  or  by  a  moderate  dose  of  calomel.  The 
treatment  during  the  interval  depends  upon  the  nature  of  the  cause.  If 
rachitis  exists,  it  should  be  treated  according  to  the  principles  laid  down 
in  my  discussion  of  this  disease.  If  dentition  is  suspected,  the  gums  may 
be  lanced,  but  this  should  only  be  done  when  they  present  distinct  signs 
of  irritation.  Gastro-intestinal  disorders  of  any  kind  should  be  relieved 
as  soon  as  possible,  and  intestinal  parasites  must  be  expelled.  In  infec- 
tious diseases  the  convulsions  usually  disappear  after  the  initial  stages,  and 
require  no  further  attention.  In  organic  brain-disease,  providing  it  be 
not  syphilitic  in  nature,  very  little  can  be  done.  Finally,  in  those  cases 
in  which  no  cause  can  be  discovered  bromids  are  the  only  resource,  and 
should  be  given  in  sufficient  doses:  from  gr.  iij-v  (0.194  to  0.324)  per 
day  to  children  of  six  months,  and  from  gr.  v  to  x  (0.324  to  0.648)  to 
those  between  six  and  sixteen  months. 


OCCUPATION-NEUROSES. 

Definition. — Conditions  in  which  the  performance  of  certain  habitual 
coordinated  movements  is  prevented  by  the  development  of  cramp,  tremor, 
paralysis,  or  pain.  The  commonest  form  is  writers'  cramp  (graphospas- 
mus,  mogigraphia,  scriveners'  palsy). 

The  pathology  of  this  condition  is  unknown.  It  is  probably  purely 
functional,  and  the  discovery  of  appreciable  lesions  is  not  to  be  expected, 
though  nodular  thickening  of  the  peripheral  nerves  has  been  described 
in  a  few  cases. 

The  etiology  is  various.  Males  are  far  more  frequently  affected 
than  females,  the  condition  usually  occurring  in  early  adult  life,  although 
children  are  not  exempt.  The  condition  always  occurs  in  those  whose 
occupation  demands  much  writing,  and  Gowers  lays  great  stress  upon 
improper  methods  of  holding  the  pen,  particularly  those  in  which  most 
of  the  writing  is  done  from  the  wrist ;  that  is,  with  the  muscles  of  the 


1182  DISEASES  OF  THE  NERVOUS  SYSTEM. 

forearm  and  hand.  As  scrivener's  palsy  occurs  sometimes  in  those  that 
write  properly,  and  as  a  similar  condition  is  not  uncommon  in  other  oc- 
cupations, it  seems  unlikely  that  this  is  the  most  important  cause.  A 
person  with  a  neurotic  temperament  is  far  more  apt  to  be  aifected  by  the 
disease  than  one  with  a  normal  nervous  system  ;  we,  therefore,  frequently 
find  it  associated  with  hysteria,  neurasthenia,  or  great  bashfulness,  and 
not  infrequently  it  is  possible  to  elicit  a  neuropathic  heredity  in  the  family 
history.  It  is  also  met  with  in  certain  other  nervous  diseases  (epilepsy, 
locomotor  ataxia — in  the  early  stage.)  Often  the  patients  admit  that  at 
the  time  the  disease  developed  they  were  suffering  from  severe  anxiety. 

Symptoms. — Motor. — When  the  patient  attempts  to  write  there  is 
usually  a  cramp  of  the  flexor  muscles  of  the  forearm,  so  that  the  pen  is 
held  more  or  less  rigidly,  and  it  is  almost  impossible  to  control  its  mo- 
tions. Less  frequently  there  is  a  cramp  of  the  extensor  muscles,  so  that 
the  fingei'S  are  spread  and  it  is  impossible  to  hold  the  pen  at  all.  Some- 
times there  is  a  sudden  twitching,  and  the  pen  may  be  thrown  altogether 
out  of  the  hand.  The  spasm  is  nearly  always  tonic  in  character,  but 
often  it  is  associated  with  a  fine  tremor,  and  at  times  there  are  clonic 
movements.  In  some  cases,  and  particularly  those  occurring  in  patients 
showing  hysteric  stigmata,  there  is  a  coarse,  irregular  tremor,  most 
marked  when  the  patient  is  under  observation.  Paresis  is  frequently 
associated  with  the  cramp,  so  that  the  arm  soon  becomes  tired  and  it  is 
almost  impossible  to  write.  This  fatigue  may  in  a  few  moments  progress 
to  almost  complete  paralysis  of  the  arm,  but,  curiously  enough,  both 
fatigue  and  paralysis  disappear  as  soon  as  some  coordinated  movement 
other  than  writing  is  undertaken. 

Sensory. — Pain  is  very  common,  and  is  neuralgic  or  cramp-like  in 
character,  being  referred  either  to  the  muscles,  bones,  or  joints.  In 
intensity  it  varies  from  a  dull  ache  to  the  most  excruciating  burning,  and 
may  form  the  only  symptom,  the  muscles  performing  their  work  perfectly. 
At  times  it  is  sharply  localized  to  one  particular  joint,  affecting  either  the 
metacarpal  bones  or  the  fingers.  Quite  often  the  patient  complains  of  a 
tingling  or  burning  sensation  in  the  limb,  or  it  may  be  numb  and  the 
hand  feels,  when  writing,  as  if  a  heavy  weight  were  attached  to  it.  Often 
there  is  tenderness  either  of  the  muscles  or  the  nerves,  which  may  be 
localized  in  certain  points.  In  very  severe  cases  vasomotor  disturbances 
occasionally  occur.  The  disease  ordinarily  commences  slowly.  At  first 
the  subject  notices  that  the  handwriting  is  not  quite  as  perfect  as  before, 
a  stroke  occasionally  going  astray ;  later  distinct  spasms  appear,  and 
these  are  finally  associated  with  pain. 

The  diagnosis  is  usually  easy.  Care  must,  however,  be  taken  not 
to  call  every  disturbance  of  writing  writer's  cramp ;  thus  in  paralysis 
agitans,  in  slowly-developing  hemiplegia,  in  multiple  sclerosis,  and  in 
locomotor  ataxia  disturbances  of  writing  frequently — in  fact,  almost  in- 
variably— occur.  Moreover,  those  cases  in  which  hysteria  or  neuras- 
thenia seems  to  be  at  the  bottom  of  the  trouble  should  be  carefully  differ- 
entiated from  those  that  are  apparently  idiopathic. 

The  prognosis  is  rather  unfavorable,  though  complete  cure  is  some- 
times attained. 

The  treatment  consists  first  in  a  total  cessation  of  writing  ;  if  this 
is  impossible,  various  mechanical  devices  may  be  employed  to  use  another 


PERIODIC  PARALYSIS.  1163 

set  of  muscles  or  the  old  ones  rather  differently,  such  as  a  thick  penholder 
or  one  constructed  with  supports  for  the  fingers.  Local  treatment  of  the 
arm  in  the  form  of  electricity  should  be  advised  ;  the  anode  of  a  constant 
galvanic  current  of  medium  intensity  should  be  placed  over  the  sensitive 
points  on  the  nerves  and  over  the  bodies  of  the  muscles.  Massage,  and 
particularly  careful  and  systematic  exercises,  are  also  of  great  value.  At 
the  same  time,  the  general  condition  of  the  patient  must  not  be  neglected. 
In  cases  associated  with  hysteria,  hypnotism  may  be  employed,  and  in 
those  associated  with  neurasthenia  a  treatment  appropriate  to  this  con- 
dition. If  possible  the  patient  should  learn  to  use  a  type-writer  and 
abandon  penmanship  altogether.  Operative  treatment  is  more  likely  to 
do  harm  than  good. 

The  other  occupations  in  which  this  disease  occurs  are — telegraphy, 
playing  on  musical  instruments,  cigarette-rolling,  milking,  and  sewing. 
Striimpell  suggests  that  stuttering  is  an  analogous  affection  of  speech. 


PERIODIC  PARALYSIS. 

{Paroxysmal  Familiar  Paralysis — Goldflam.) 

Definition. — A  disease  characterized  by  paroxysmal  attacks  of 
complete  paralysis,  and  alteration  in  the  electrical  reactions  and  struct- 
ure of  the  muscles,  occurring  in  many  members  of  a  family. 

Pathology. — Excised  fragments  of  muscle  show  rarefaction  of  the 
fibers  and  slight  vacuolation,  without  multiplication  of  the  nuclei  or 
proliferation  of  the  connective  tissue. 

l^tiologfy. — The  disease  is  purely  hereditary.  Both  sexes  are 
aiFected.  The  attacks  appear  to  be  more  frequent  in  summer,  and  often 
seem  to  occur  after  overfilling  the  stomach. 

Symptoms. — The  attacks  are  preceded  by  prodromes  in  the  form 
of  vague  discomfort  or  paresthesia.  The  patient  then  usually  falls 
asleep  and  awakens  completely  paralyzed.  Speech,  deglutition,  and  the 
sphincters  are  unaffected.  During  the  attack  there  is  often  transient 
albuminuria,  with  blood-cells  in  the  urine.  The  reflexes  are  abolished. 
The  paralysis  lasts  from  twelve  hours  to  three  days,  and  then  there  is 
an  outbreak  of  perspiration,  with  gradual  recovery,  the  muscles  of  the 
head  first  regaining  power.  During  the  interval  the  muscles  react 
slowly  to  faradism  and  galvanism,  and  are  easily  thrown  into  CaC 
tetanus.  The  muscular  changes  have  been  demonstrated  in  chil- 
dren of  an  affected  family  in  whom  the  disease  had  not  yet  de- 
veloped. 

Diagnosis. — Usually  easy.  Goldflam  was  once  puzzled  by  a  case 
of  acute  ascending  paralysis. 

Prognosis. — The  disease  does  not  kill ;  but  there  appears  to  be  no 
tendency  to  recovery. 

Treatment. — This  involves  only  caring  for  the  children  during 
the  attack.  Even  persistent  starvation  does  not  decrease  their  fre- 
quency. 


1164  DISEASES  OF  THE  NERVOUS  SYSTEM. 

HYSTERIA. 

Definition. — A  condition  of  the  general  nervous  system  partaking 
of  the  natures  of  both  a  neurosis  and  a  psychosis,  and  characterized  by  a 
vast  multiplicity  of  clinical  manifestations,  all  indicative  of  a  loss  of 
voluntary  contnjl  over  the  inhibitory  Avill-powers. 

Pathology. — Hysteria  is  to  be  regarded  as  essentially  a  morbid 
entity,  without,  however,  any  tangible  pathologic  features.  The  most 
careful  postmortem  examinations  of  subjects  who  have  while  in  life  mani- 
fested pronounced  hysteric  symptoms  have  failed  to  reveal  any  organic 
nervous  alterations,  however  slight.  The  occurrence  of  the  affection  in 
men  as  well  as  in  women  excludes  the  former  theory  of  a  uterine  path- 
ology, which,  though  an  idle  fancy,  held  sway  for  so  many  centuries  and 
gave  origin  to  the  name  by  which  the  condition  is  generalW  recognized. 

Ktiology. — There  are  a  large  number  of  predisposing  and  exciting 
factors,  all  of  Avhich,  however,  may  be  grouped  under  a  few  dominant 
heads.  Thus  among  the  former  must  be  mentioned,  pre-eminently, 
heredity.  The  investigations  of  many  neurologists  and  alienists  of  divers 
lands  have  gone  far  to  demonstrate  that  at  the  foundation  of  the  vast 
majority,  if  not  of  all,  of  the  hysterias  is  to  be  discovered  an  inherited 
neurotic  tendency  or  temperament.  The  family  histories  of  these  patients 
generally  reveal  a  large  number  of  consanguineous  neurotic  or  hysteric 
individuals. 

The  diseased  condition  in  question  is  apparently  in  close  relationship 
with  the  various  psychoses  and  major  neuroses  (epilepsy,  chorea,  tetany). 

In  the  process  of  transmission  one  generation  may  entirely  escape  the 
pernicious  influence,  and  successive  generations  may  manifest  strikingly 
different  evidences  of  the  disease,  in  one  the  neurotic  and  in  another  the 
psychic  element  predominating.  A  curious  phenomenon  that  is  worthy 
of  mention  is  the  apparent  contagiousness  of  hysteria :  moreover,  the 
baleful  influence  one  neurotic  individual  exerts  over  the  unfortunates  of 
this  temperament  explains  the  so-called  "hysteric  epidemics"  that  have 
swept  over  communities,  and  even  over  vast  tracts  of  land  or  entire  coun- 
tries, at  different  periods  of  the  world's  history.  Similar,  though  limited, 
outbreaks  may  still  be  seen  in  the  nervous  wards  of  hospitals  or  in 
religious  and  political  conventions,  and  these  depend  largely  upon  the 
geneml  prevalence  of  the  neurotic  disposition  untempered  by  a  virile 
will-power. 

The  hysteric  temperament  may  be,  and  often  is,  fostered  by  improper 
and  pernicious  modes  of  life,  especially  by  luxurious  and  sensuous  living 
and  by  the  habit  of  gratifying  every  desire  of  the  will  during  early  life. 
It  is  manifested  at  this  early  stage  of  the  individual's  existence  by  hyper- 
sensitiveness,  brilliancy,  undue  enthusiasm,  and  a  more  or  less  erratic 
turn  of  mind. 

Sex  is  a  strongly  predisposing  cause  of  hysteria,  and,  while  it  is  by 
no  means  limited  to  females,  the  great  majority  of  instances  of  the  disease 
occur  among  girls  and  women.  Rarely,  however,  instances  of  a  most 
rebellious  nature  occur  in  the  opposite  sex. 

Age. — The  condition  is  generally  encountered  between  the  ages  of 
fifteen  and  thirty  years.  After  the  latter  age  the  frequency  of  the  dis- 
ease rapidly  diminishes,  and  prior  to  the  onset  of  puberty  the  cases  re- 


HYSTERIA.  1165 

corded  are  also  comparatively  few  in  number,  although  exceptionally  it 
is  seen  in  infancy. 

A  very  influential  factor  in  the  production  of  the  disease  is  the  lack 
of  proper  mental  development.  It  stands  to  reason  that  those  who  axe 
coarse  and  illiterate,  and  who  have  not  been  taught  the  lessons  of  self- 
control,  and  who  are  subject  to  the  various  and  multiplex  superstitions 
that  are  ever  prevalent  among  the  masses,  will  respond  more  quickly  and 
more  generally  to  the  causes  that  tend  to  destroy  mental  equilibrium. 
Hence,  hysteria  or  insanity  shows  its  rankest  development  among  those 
whose  education  and  culture  are  defective.  This  is,  however,  by  no 
means  an  inevitable  law,  for  over-stimulation  of  the  faculties  may  be  just 
as  deleterious  as  under-stimulation,  and  some  of  the  brightest  lights  of 
the  world  have  manifested  at  various  periods  of  their  lives  decided  hysteric 
symptoms. 

Improper  hygienic  surroundings,  tending  as  they  do  to  enervation 
and  physical  depression,  are  influential  predisposing  factors  in  the  evolu- 
tion of  hysteria.  In  addition  to  poor  and  insufficient  food,  lack  of  proper 
ventilation,  overcrowding  in  foul  habitations,  and  insufficient  bathing, 
must  be  mentioned  the  enervating  influence  of  hot  and  moist  climates. 
It  is  generally  conceded  that  more  cases  of  hysteria  occur  in  the  warm 
than  in  the  colder  portions  of  the  temperate  zones,  and  that  this  propor- 
tion increases  pari  passu  with  the  height  of  the  temperature. 

Finally,  the  causal  influence  of  the  chronic  toxemias  (alcoholism, 
morphinism,  absinthism,  saturnism  and  intoxications  by  other  metals) 
is  to  be  mentioned.  In  systemic  poisoning  the  depraved  condition  of 
the  physical  reacts  upon  the  mental  organism,  and  sooner  or  later 
hysteric  manifestations  may  be  found  to  coexist  with  the  original  toxic 
phenomena. 

The  excitiyig  causes  of  hysteria  may  be  grouped  as  follows  : 

(1)  Most  commonly  psycho-neurosis  follows  some  profound  emotion 
or  mental  or  moral  shock.  Thus,  in  neurotic  males  it  may  be  excited 
by  excessive  and  protracted  business- worry  or  excitement,  or  by  active 
competition  in  certain  lines  of  occupation,  or  by  some  heavy  and  unex- 
pected monetary  reversal.  In  females  it  is  not  uncommon  as  a  sequel 
to  the  establishment  of  puberty  and  the  menstrual  function,  or  to  the 
physiologic  arrest  of  menstruation  at  the  period  of  the  climacteric.  Espe- 
cially is  it  prone  to  develop  in  young  and  illegitimately  pregnant  women, 
or  during  the  first  pregnancy  in  newly-married  women  of  a  neurotic  tem- 
perament. Great  religious  excitement  during  the  progress  of  a  revival- 
wave  and  profound  political  upheavals  have  been  most  potent  in  estab- 
lishing the  disease  in  numerous  instances ;  and  other  profound  mental 
impressions,  of  fear,  grief,  or  great  and  unexpected  joy,  have  assumed 
the  exciting  r61e. 

(2)  Extreme  physical  prostration,  the  result  of  some  very  acute  or 
much  protracted  chronic  disease,  may  exert  an  etiologic  efiect.  Thus, 
some  of  the  most  marked  and  intractable  forms  of  the  disease  have  re- 
sulted from  the  specific  fevers  (typhoid,  typhus,  and  the  other  exan- 
themata), while  it  is  not  rare  in  a  varying  degree  in  the  final  stages  of. 
tuberculosis,  chronic  nephritis,  and  other  grave  constitutional  afi"ections 
of  long  standing. 

(3)  The  so-called  '' traumatic  hysteria  "  has  come  to  occupy  a  prom- 


1166  DISEASES  OF  THE  NERVOUS  SYSTEM. 

inent  place  in  the  etiologic  category  of  the  disease.  Especially  do  we 
find  the  incurable  varieties  of  hysteria  resulting  from  a  slight  or  it  may 
be  a  more  severe  traumatism.  It  must  be  remembered  that  a  considerable 
period  of  time  may  intervene  between  the  date  of  the  injury  and  the  ap- 
pearance of  the  initial  hysteric  symptoms,  so  that  in  all  cases  it  becomes 
of  the  utmost  importance  to  make  a  careful  study  of  the  patient's  history 
for  signs  of  traumatism,  however  remote.  It  has  also  been  noted  that  oft- 
repeated  minor  traumatisms  may  essentially  result  in  some  hysteric  mani- 
festations. So  well  recognized  has  this  fact  become  that  it  is  not  unusual 
to  discover  an  hysteric  element  in  certain  occupational  ailments.  Thus 
the  irritable  neurasthenic  condition  of  the  centro-spinal  axis  so  common 
among  the  employees  of  railroads,  and  known  as  the  "irritable  hysteric  " 
or  "railroad  spine,"  is  now  acknowledged  as  the  type  of  this  traumatic 
hysteria.  In  fact,  any  slight  injury  or  a  blow  upon  the  head  or  a  trivial 
injury  of  another  portion  of  the  body,  especially  if  it  be  brooded  upon, 
may  ultimately  cause  hystero-epilepsy. 

(4)  Finally,  in  a  limited  number  of  cases  sexual  excesses  and  mastur- 
bation are  the  influential  factors  in  the  production  of  hysteria.  The 
sexual  origin  of  the  disease,  which  was  formerly  the  chief  etiologic 
theory,  has  now  come  to  occupy  only  a  minor  causative  role,  but  the  tend- 
ency to  entirely  abolish  it  as  a  cause  of  the  disease  is  as  much  an  error 
in  the  opposite  direction.  These  sexual  cases,  though  few  in  number,  do 
exist,  and  are  especially  to  be  found  among  the  class  of  so-called  sexual 
perverts. 

Clinical  History. — Clinically,  hysteria  presents  three  well-marked 
stages,  known  respectively  as  the  prodromal,  the  crmvuhive,  and  the 
latent.  The  latter  is  also  designated  as  the  intereonvuhive  stage  or  the 
period  of  the  stigmata,  and  during  this  period  the  number  of  the  sj'mp- 
toms  and  their  complexity  almost  baflie  attempts  at  classification  ;  they 
can,  however,  best  be  portrayed  by  presenting  them  under  the  heads  of 
the  various  systems  {vide  infra). 

(1)  The  Prodromal  Stage. — The  prodromes  are  invariably  present,  and 
at  times  they  are  more  marked  than  at  others.  They  are  evident  alike 
to  both  patient  and  physician,  and  are  largel}"  psychic  in  nature.  There 
is  noted  a  marked  mental  depression  associated  with  introspection,  and,  it 
may  be.  with  a  form  of  mild  mania  or  of  melancholia.  A  condition  of 
aprosexia  develops,  and  the  patient  becomes  irritable,  restless,  and  dis- 
contented. The  mental  derangement  may  manifest  itself  in  the  form  of 
delusions  or  nightmare,  and  there  is  a  characteristic  neglect  of  the  toilet 
and  attire.  Naturallv,  there  result  disturbances  of  the  grastro-intestinal 
tract — viz.  anorexia,  nausea,  vomiting,  constipation,  and  perversions  of 
taste.  The  patient  is  pale,  and  the  expression  assumes  an  anxious  or,  it 
may  be,  vacant  cast.  These  phenomena  persist  for  several  days,  and  are 
followed  by  emotional  disturbances — spasms  of  hysteric  laughing  and 
crying — that  immediately  precede  the  aura,  which  is  as  marked  a 
feature  in  hysteria  as  in  epilepsy.  It  may  assume  one  of  a  number  of 
forms,  but  more  commonly  it  has  an  ovarian,  a  cervical,  a  cerebral,  or 
a  surface  or  cutaneous  origin  (unilateral).  Very  frequently  the  convul- 
sion is  preceded  by  a  condition  of  extreme  sensitiveness  and  pain  in  one 
or  both  ovarian  regions,  so  that  the  lightest  touch  at  a  point  on  the 
abdominal    surface    one    inch    above    Poupart's   ligament,    and    midway 


HYSTERIA.  1167 

between  the  pubis  and  the  anterior  superior  iliac  spine,  will  elicit  ex- 
quisite tenderness.  This  is  so  constant  and  characteristic  that  many 
patients  can  invariably  predict  the  onset  of  the  convulsion.  Not  infre- 
quently the  aura  begins  in  the  neck,  the  patient  experiencing  a  sensation 
as  of  a  ball  lodging  in  the  throat  {globus  hystericus) :  this  is  due  to  a 
spasmodic  contraction  of  the  muscles  of  the  pharynx  and  esophagus,  and 
is  accompanied  by  tachycardia  and  a  sense  of  suffocation.  If  the  aura 
originate  above  the  scalp,  it  is  characterized  by  the  sudden  appearance, 
generally  in  the  top  of  the  head,  of  a  severe  neuralgic  pain,  as  if  pro- 
duced by  the  entrance  of  a  nail  {clavus  hystericus) ;  this  is  frequently 
associated  with  vertigo  and  tinnitus  aurium.  The  aura,  finally,  may 
appear  in  the  form  of  spots  of  cutaneous  tenderness,  mainly  localized 
upon  the  trunk,  to  which  areas  has  been  given  the  name  of  hyster- 
ogenous  zones. 

(2)  The  Hysteric  Convulsion. — Closely  following  upon  the  footsteps  of 
these  pi'odromes,  and  immediately  following  the  aura,  the  hysteric  convul- 
sion may  appear.  Most  commonly  this  is  epileptoid  in  nature  ;  rarely  it 
assumes  a  less  common  type.  Hence  it  becomes  necessary  to  describe 
several  of  the  forms  of  the  convulsions — viz.  (a)  the  epileptoid  (hystero- 
epilepsy) ;  (h)  the  gymnastic  (clownism) ;  (c)  the  emotional  catalejytic,  or 
dramatic  ;  and  (tZ)  the  delirious.  All  of  these  forms  may  be  present  in 
the  same  attack,  the  one  passing  quickly  into  the  other,  or,  as  in  the 
abortive  cases,  one  or  the  other  form  will  predominate.  Briefly  described, 
the  characteristic  features  are  as  follows  : 

(a)  Epileptoid  [Hystero-epilepsy). — Immediately  upon  the  appearance 
of  the  aura  the  patient  commonly  emits  a  shriek  and  falls  upon  the  floor 
or  in  some  convenient  place,  taking  special  care  to  do  herself  no  injury  : 
this  is  in  strong  contradistinction  to  the  true  epileptic  spasm.  The  head 
and  limbs  are  thrown  about  by  more  or  less  violent  clonic  muscular 
spasms,  and  at  times  a  condition  of  opisthotonos  or  other  trunkal  contor- 
tion (emprosthotonos,  pleurosthotonos)  may  be  noticed  ;  these  muscular 
movements,  however,  are  more  or  less  volitional,  and  are  not  the  aimless 
movements  of  the  true  epileptic.  The  patient  may  or  may  not  foam  at 
the  mouth.  There  is  a  constant  twitching  of  the  eyelids  and  the  eyes 
are  rolled  about,  but  apparently  retain  a  more  or  less  observant  expression. 
Consciousness,  as  a  rule,  is  not  fully  lost.  The  facial  muscles  are  distorted, 
rapid  changes  of  expression  being  noted  {liysteric  trismus),  and  respira- 
tion is  somewhat  impeded.  As  the  convulsion  passes  oif  the  movements 
gradually  subside,  and  the  patient  generally  sinks  into  a  state  of  quies- 
cence or,  it  may  be,  into  a  light  sleep.  This  may  be  followed  by  complete 
temporary  recovery,  or  the  epileptoid  may  pass  into  one  of  the  other  forms 
of  the  convulsive  seizure.  The  duration  of  the  spasm  as  described  is  usu- 
ally longer  than  that  of  a  true  epileptic  seizure. 

(h)  The  Gymnastic  Form  (Clownis?n). — This  stage  is  characterized  by 
violent  and  grotesque  muscular  movements.  Here  are  to  be  grouped  all 
of  the  more  curious  manifestations  of  the  disease  recorded  in  the  history 
of  medicine.  The  most  difficult  feats  of  the  contortionist  are  performed 
with  apparent  ease ;  the  patient  may  suddenly  begin  to  dance  or  jump  at, 
a  most  astonishing  rate,  persisting  in  the  movements  until  she  drops  from 
pure  physical  exhaustion.  The  so-called  religious  ceremonies  of  the 
Shakers  of  Lebanon,  Pennsylvania,  and  of  the  Jumpers  of  the  Middle 


1168  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Ages,  are  manifestations  of  this  form  of  hysteria.  In  children  the  attack 
may  appear  as  the  so-called  beast-mtmicri/,  in  which  the  movements  or 
sounds  of  the  lower  animals  may  be  simulated ;  such  is  also  the  explana- 
tion of  the  condition  known  as  spiwious  Jti/drdphobia.  Eclampsia  nutans, 
the  "  nodding  spasm  "  or  '•  salaam  convulsion  "  of  young  children,  is  like- 
wise a  sub- variety  of  this  form  of  the  disease.  Consciousness  is  never  lost 
during  this  period. 

(c)  The  Emotional  Cataleptic,  or  Dramatic  Form. — In  this  form  the 
patient  seems  to  suffer  from  delusions  or  hallucinations  that  are  apparently 
the  outcome  of  the  preceding  condition.  The  emotion  that  is  most  devel- 
oped in  the  patient's  moral  constitution  now  dominates  his  spasmodic  ac- 
tions. As  Lloyd  aptly  expresses  it :  "  The  third  period  of  the  hysteric 
convulsion  is  one  of  dramatic  representation  of  emotional  images,  and  these 
are  of  countless  varieties,  according  to  time  and  person."  All  of  the  mani- 
festations of  the  cataleptic  state  are  present.  Sensation  is  largely  abolished, 
consciousness  is  retained,  and  the  patient  is  usually  able  to  recall  events 
that  have  transpired  during  the  period.  Especially  common  now  is  the 
assumption  of  dramatic  and  passionate  attitudes,  which,  as  described  by 
Richer,  include  "  the  attitude  of  the  cross,  of  defence,  of  menace,  of  ap- 
peal, of  lubricity,  of  ecstasy,  of  dread  of  animals  (as  rats),  of  scorn,"  and 
the  like.  The  Ijody  of  the  patient  retains,  at  times  for  indefinite  periods, 
whatever  position  is  first  assumed  {hysteric  catalepsy).  In  some  cases  the 
patient  falls  into  a  condition  of  apparent  sleep  or  narcolepsy  {hysteric  sleep, 
hysteric  somnolence,  Itysteric  trance)  of  varying  degrees  of  intensity;  this 
may  persist  for  any  period  of  time,  from  a  hour  or  two  up  to  weeks,  months, 
or  even  years.  In  these  extreme  cases,  while  the  patient  at  first  appears 
to  be  in  a  normal  sleep,  sooner  or  later  the  body  assumes  a  corpse-like 
appearance,  with  pale,  waxy  skin,  almost  imperceptible  respiration  and 
cardiac  action,  and  a  subnormal  temperature. 

{d)  The  Stage  of  Delirium. — The  final  stage  of  the  hysteric  convulsion 
is  but  a  continuation  of  the  preceding  period,  with,  however,  a  cessation 
of  the  muscular  movement  to  a  great  extent.  The  tendency  now  is  to 
delirium  of  a  mild  type,  tinged  with  more  or  less  melancholia.  Conscious- 
ness is  maintained  throughout  this  stage,  and  there  now  appear  some  curi- 
ous motor  phenomena  that  may  persist  for  days  or  weeks.  These  may 
consist  in  the  abolishment  of  muscular  power  in  various  portions  of  the 
body.  Very  often  associated  with  these  motor  phenomena  is  noted  a  con- 
dition of  mutism  that  lasts  for  indefinite  periods  of  time. 

Hysteric  paralyses  occur,  and  may  simulate  any  form  of  the  organic 
paralyses  (monoplegia,  hemiplegia,  paraplegia).  In  many  cases  the  patient 
is  left  with  a  more  or  less  permanent  spasm  of  a  single  set  of  muscles  or 
of  associated  sets.  These  so-called  hysteric  contractions  may  affect  any 
portion  of  the  bod3\  One  arm  may  be  bent  at  the  elbow  or  one  leg  at 
the  knee ;  in  the  former  case  the  fingers  are  rigidly  Contracted  and  em- 
brace the  thumb,  which  is  crossed  upon  the  palm,  while  in  the  latter  the 
toes  are  strongly  flexed  upon  the  plantar  surface  and  the  foot  is  inverted. 
The  ankle-  and  knee-jerk  persist.  In  other  cases  a  curious  spastic  gait 
is  produced  that  closely  simulates  that  of  spinal  sclerosis.  The  muscles 
of  the  hips,  shoulder,  back,  and  neck  (hysteric  torticollis)  may  share  in  the 
process.  In  women  the  muscles  of  the  diaphragm  and  abdominal  walls 
may  be  involved  (hysteric  pseudo-eye  sis).     Hysteric  rotatory  spasm,  hys- 


HYSTERIA.  1169 

teric  atJietosis,  and  hysteric  tremor  are  all  dependent  upon  a  spasmodic 
action  of  the  muscles  affected.  The  convulsive  seizure  generally  is  of 
short  duration,  lasting  but  fifteen  to  thirty  minutes.  Occasionally,  how- 
ever, there  is  developed  a  prolonged  convulsive  status,  during  which  time 
the  patient  continually  falls  from  one  convulsion  into  another,  until  one 
hundred  or  more  may  be  recorded  and  the  excess  of  nervous  power  is 
exhausted. 

(3)  The  Latent  or  Interconvulsive  Stage,  or  Period  of  the  Stigmata. — 
After  the  convulsive  attack  the  patient  enters  upon  a  more  or  less  pro- 
longed interval  of  comparative  quiet;  this  is  characterized,  however,  by 
numberless  and  varied  phenomena — the  hysteric  stigmata.  The  whole 
course  of  the  affection  may  be  comprised  in  this  period,  convulsions  being 
absent.  As  I  have  already  stated,  these  can  best  be  described  under  the 
heads  of  the  various  systems  : 

(a)  The  Nervous  System. — This  presents  the  most  characteristic  hys- 
teric stigmata.  They  are  generally  grouped  into  the  three  classes  of 
motor,  sensory,  and  psychic. 

The  motor  symptoms  have  already  been  referred  to  in  part  in  the  de- 
scription of  the  hysteric  convulsion.  They  embrace  every  variety  of  mus- 
cular pathology,  from  obdurate  paralysis  to  and  including  tremor,  inco- 
ordination, and  tonic  spasm  or  contraction.  The  hysteric  paralyses,  as 
stated,  may  be  absolute  or  partial,  and  either  general  or  limited  to  groups 
or  to  individual  muscles,  and  may  simulate  any  variety  of  true  paralysis 
of  organic  origin.  There  is  usually  noted  an  exaggeration  of  the  reflexes 
of  the  affected  side,  muscular  wasting  may  or  may  not  be  present,  and  it 
is  not  at  all  uncommon  to  find  associated  contractures  and  sensory  phe- 
nomena. The  paralyzed  limb  or  limbs  show  evidences  of  circulatory  dis- 
turbances, as  edema  and  bluish  discoloration.  In  the  paraplegic  cases  it 
is  unusual  for  trophic  disturbances  (bed-sores)  to  appear ;  some  atrophy 
of  the  affected  muscles  may,  however,  be  noted.  Hysteric  tremors  are 
not  infrequent,  and  are  usually  well  marked  and  persistent.  They  are 
generally  associated  with  contractures  and  other  hysteric  stigmata. 

Hysteric  incoordination  (Jiysteric  ataxia)  has  also  been  termed  astasia- 
abasia ;  it  is  one  of  the  rarest  of  the  motor  phenomena  of  hysteria.  The 
name  implies  an  inability  to  stand  or  walk,  although  muscular  power  in 
the  legs  and  trunk  is  retained  (vide  Astasia-abasia,  p.  1181).  Hysteric 
contractures  may  occur  as  distinct  phenomena  or  may  be  associated  with 
some  form  of  hysteric  paralysis.  Usually  the  contractures  occur  with 
startling  abruptness,  and  are  most  intense  and  persistent,  resisting  even 
the  effects  of  sleep  and  the  anesthetics.  There  may  be  associated  sensory 
phenomena.  The  toes  and  the  fingers  are  most  frequently  the  seat  of 
contracture,  but  the  muscles  of  the  face  and  neck  may  likewise  share  in 
the  affection. 

Sensory  Symptoms. — The  anesthetic,  hysteric,  and  paresthetic  vari- 
eties are  noted.  Patients  showing  hysteric  anesthesia  are  able  to  run 
pins  into  themselves  without  showing  the  slightest  degree  of  suffering. 
The  anesthesia  may  be  general  or  it  may  involve  but  half  of  the  body  or 
scattered  areas  of  the  cutaneous  surface.  Segmental  anesthesia  is  the 
term  applied  to  that  condition  in  Avhich  a  limb  or  a  portion  of  a  limb  is 
involved.  Not  only  is  the  skin  affected,  but  often  the  deeper  tissues  as 
74' 


1170  DISEASES  OF  THE  XERVOUS  SYSTEM. 

well,  and  there  is  generally  some  vasomotor  involvement,  as  is  shown 
by  the  fact  that  punctures  by  a  needle  are  not  followed  by  bleeding. 
There  is  often  associated  an  anesthesia  of  one  or  more  of  the  special  senses 
{hysteric  amaurosis  or  blindness,  hysteric  deafness,  and  hysteric  anosmia). 
The  conjunctivae  very  fre(iuently  escape.  The  anesthesia  is  severe,  as  a 
rule,  immediately  after  an  hysteric  convulsion,  but  it  may  be  entirely  absent 
throughout  a  given  case  of  hysteria.  There  is  often  contraction  of  the 
field  of  vision  or  inversion  of  the  color-fields,  the  red  being  more  exten- 
sive than  the  blue. 

Hysteric  hyperesthesia  is  also  a  frequent  clinical  manifestation,  and  is 
generally  confined  to  limited  areas,  as  the  ovarian,  mammary,  or  spinal 
regions,  or  to  one  of  the  larger  joints  {hysteric  joint),  simulating  organic 
disease  of  the  part.  These  conditions  can  be  recognized  by  etherizing 
the  patient,  when  perfect  mobility  of  the  affected  joint  is  noted.  When 
one  of  the  mammae  is  involved,  the  organ  becomes  exceedingly  painful  to 
the  touch  and  slightly  edematous  (hysteric  breast).  Hysteric  j^^restliesice 
include  the  common  varieties  of  formication,  dead  fingers,  and  the  like. 

Psychic  Symptoms. — These  have  already  been  mentioned  among  the 
prodromal  symptoms — violent  and  capricious  changes  of  temper,  mental 
depression  and  unrest,  melancholia,  and  a  notable  lack  of  volitional 
power  whereby  the  patient  becomes  especially  open  to  the  suggestions 
of  the  hypnotist.  Such  patients  may  develop  into  that  strange  condition 
known  as  '"double  consciousness." 

(//)  The  Digestive  System. — Among  the  usual  clinical  manifestations 
of  this  group  may  be  mentioned  anorexia  (which  may  be  complete),  a 
strange  and  persistent  perversion  of  taste,  occasional  uncontrollable  vomit- 
ing without  nausea  {hysteric  vomiting,  anorexia  nervosa),  marked  dyspep- 
sia, and  at  times  extreme  emaciation  with  dryness  and  a  parchment-like 
feel  of  the  skin.  Excessive  flatulence  and  the  peristaltic  unrest  of  Kiiss- 
maul  may  be  marked  symptoms,  as  may  also  either  diarrhea  or  constipa- 
tion. Hysteric  lieniatemesis  is  the  result  of  swallowing  blood ;  this  is 
usually  drawn  from  the  gums  or  tonsils,  or  it  may  be  taken  secretly  by 
the  patient  from  other  external  sources. 

((')  The  Respiratory  System. — Difl^culty  of  respiration  {hysteric  dys- 
pnea) is  not  uncommon,  and  is  characterized  by  an  extreme  rapidity  and 
shallowness  of  tlie  respiratory  movements.  These  are  much  out  of  pro- 
portion to  the  heart-beats,  and  are  unassociated  with  cyanosis.  In  other 
cases  the  disturbance  assumes  the  form  of  uncontrollable  yawning,  sneez- 
ing, or  hiccoughing,  due  probably  to  a  spasmodic  action  of  the  involun- 
tary muscles  of  the  bronchial  tubes  and  diapliragm.  Hysteric  cough  is 
a  troublesome,  and  very  often  a  stubborn  symptom,  occurring  espe- 
cially in  young  females.  It  is  dry  and  barking,  and,  as  a  rule,  unaccom- 
panied by  expectoration.  At  times  it  may  be  followed  by  hysteric 
hemoptysis,  in  which  there  is  an  escape  of  light-red  fluid  from  the 
pharyngeal  mucosa.  Hysteric  aphonia  is  also  frequently  noted ;  in  this 
condition  the  patient  scarcely  speaks  in  an  audible  whisper.  In  such  cases 
restoration  of  the  voice  is  as  of  sudden  occurrence  as  is  its  loss.  In  one 
of  my  own  cases  aphonia  manifested  ahnost  true  intermittence  for  a  period 
of  five  years,  Avhile  during  tlie  last  two  years  or  over  it  has  stubbornly 
persisted  even  without  remission. 


HYSTERIA.  1171 

{d)  The  Vascular  System. — Hysteric  tachycardia  is  often  noted,  and 
much  less  frequently  hysteric  bradycardia  appears.  A  rariety  of  jjseudo- 
angina  is  not  of  rare  occurrence  {vide  Angina  Pectoris,  p.  671).  Very 
frequently  the  patient  exhibits  a  localized  flushing  of  the  skin  {hysteric 
erythema),  and  especially  of  the  face  and  neck,  or,  as  has  already  been 
noted,  there  may  be  an  apparent  bloodlessness  of  a  part. '  Profuse  general 
or  localized  sweating  is  not  uncommon,  and  may  at  times  be  bloody. 

Hysteric  fever  may  be  mentioned  here  as  a  rare  manifestation,  the 
bodily  temperature  usually  being  normal  in  hysteria.  The  elevation  of 
temperature  may  be  moderate  or  there  may  be  an  extreme  hyperpyrexia 
(110°-120°_  F.— 43.3°-48.8°  C),  without  grave  results.  If  this  be 
associated  with  localized  neuralgia,  it  becomes  a  difficult  matter  to  diagnose 
between  the  neurotic  condition  and  organic  disease  of  the  apparently 
affected  part. 

(e)  The  Urinary  System. — An  excessive  flow  of  urine  {hysteric  i)olyuria) 
is  of  very  common  occurrence,  while  the  opposite  condition  {anuria)  is 
much  rarer. 

Diagnosis. — The  diagnosis  of  hysteria  must  depend  largely  upon 
the  history  of  the  attack,  the  previous  history  of  the  patient,  and  the 
recognition  of  the  features  of  the  neurotic  temperament.  Individuals 
possessing  this  habit  are  generally  spare  of  body,  of  quick  movements, 
brilliant  and  changeable  eyes,  an  emotional  disposition,  and  unstable  men- 
tal equilibrium.  Close  and  judicious  inquiry  among  the  friends  will, 
as  a  rule,  elicit  a  history  of  previous  hysteric  seizures  of  laughing  and 
crying.  The  great  tendency  of  the  profession,  unfortunately,  is  to  over- 
look true  organic  conditions  and  ascribe  the  patient's  symptoms  purely  to 
an  hysteric  attack.  Moreover,  it  must  not  be  forgotten  that  even  genu- 
ine hysterics  may  develop  true  organic  disease,  either  during  an  attack 
of  hysteria  or  in  the  intervals,  and  these  intercurrent  affections  may, 
though  rarely,  terminate  fatally. 

Differential  Diagnosis. — Very  important  is  it  to  distinguish  between 
hysteric  and  true  paralyses,  and  betw'een  hysteric  and  organic  abdom- 
inal tumors.  In  the  following  tables  the  most  striking  points  of  difi"er- 
ence  between  these  conditions  have  been  set  down : 

Hysteric  Palsies.  Organic  Palsies. 

Occur  without  a  previous  history  of  or-  Are  always  secondary  to  organic  spinal 

ganic  disease,  but  with  a  neurotic  his-  or  brain-disease  or  to  traumatism. 

tory.     Traumatism  may  be  the  cause. 

Are  accompanied  by  other  hysteric  stig-  Hysteric  stigmata  are  absent. 

mata  or  perversions  of  sensation. 

Are  not  accompanied  invariably  by  wast-  Are  always  accompanied,  sooner  or  later, 

ing  of  the  muscles  involved.  by  muscle-wasting. 

Keactions  of  degeneration  are  absent.  Reactions  of  degeneration  are  present. 

The  paralysis  is  apt  to  be  more  or  less  The  paralysis  is  permanent  and  marked. 

transient  and  shifting. 

The  power  of  motion  returns  before  sen-  Sensation  first  reappears. 

sation. 

In  hysteric  hemiplegia  the  facial  muscles  The  facial  muscles  of  the  same  or  oppo- 

are  not  involved.  site  side  are  always  involved  in  true 

hemiplegia. 

Anesthesia  generally  causes  relaxation  of  Organic  paralytic   contractions   are   not 

hysteric  contractions.  affected  by  anesthesia. 


1172  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Hysteric   Abdominal  Tumors  (Pseudo-  Organic  Abdominal  Tumors. 

CFESIS). 

Almost    invariably    occur    in    neurotic  Occur  irrespective  of  sex. 

women  near  the  menopause. 

The   percussion-note   is  invariably  tym-  The  percussion-note  over  the  swelling  is 

panitic.  dull,  or  a  dull  tympany. 

Anesthesia  causes  a  disappearance  of  the  Anesthesia  has  no  effect  upon  the  tumor. 

tumor. 

Is  variable  as  to  size  and  tonicity.  Slowly  but  steadily  progresses  in  size. 

Is  accompanied  by  tympany  and  flatu-  The  bowels  are  not  always  distended  by 

lence.  gas. 

The  differential  diagnosis  between  hysteria  and  true  neurasthenia,  and 
epilepsy,  will  be  found  in  the  discussion  of  the  latter  two  affections. 

Prognosis. — As  regards  death,  the  prognosis  in  hysteria  is  good ; 
true  hysteric  patients  never  die  of  the  disease,  nor  does  the  hysteric 
spasm  ever  result  fatally.  As  to  an  ultimate  cure,  however,  the  prognosis 
is  very  doubtful.  If  the  disease  occur  early  in  life  and  if  there  is  a 
marked  congenital  neurotic  tendency  manifested  in  the  patient,  there  is 
almost  no  hope  of  effecting  a  permanent  cure.  In  the  acquired  cases, 
under  proper  moral  and  hygienic  control  great  benefit  may  be  effected  or 
even  an  absolute  cure  recorded. 

Treatment. — Of  the  Temperament. — Accurately  speaking,  the  treat- 
ment of  hysteria  should  be  begun  before  birth.  Neurotic  women  bearing 
children  should  be  subjected  to  a  course  of  rest-cure  and  mental  and 
moral  suasion,  and  the  condition  of  their  nervous  systems  should  receive 
the  careful  attention  of  the  attending  physician.  Neurotic  children  re- 
quire the  greatest  care  during  the  developmental  period.  A  strong  phy- 
sique must  be  secured  by  proper  attention  to  out-of-door  exercise,  and, 
for  the  time  being,  even  at  the  expense  of  mental  culture.  Such  children 
should  not  be  subjected  to  the  "cramming"  process  so  common  in  our 
modern  courses  of  education,  but  should  be  trained,  if  possible,  at  home, 
where  the  element  of  competition  may  be  eliminated.  Systematic  hours 
of  study  and  of  recreation  (with  absolute  rest  from  study  during  the 
summer  months),  and  opportunities  of  travel  and  change  of  air  and  scene, 
Avill  work  Avonders  in  these  liyperesthetic  little  individuals.  Especially  at 
the  time  of  puberty  is  the  greatest  of  care  required  in  order  to  avoid  an 
additional  strain  upon  the  already  seriously  taxed  nervous  system.  In 
addition  to  the  foregoing  a  strict  watch  must  be  kept  over  the  moral 
nature  of  the  child.  The  satisfaction  of  every  whim  and  the  lack  of 
moral  suasion  are  the  surest  ways  to  develop  the  hysteric  temperament. 
When  possible  the  child  should  be  taken  away  from  the  enervating  in- 
fluences of  city  life.  The  diet  should  be  })lain,  but  nutritious,  and  all 
over-indulgence  is  to  be  absolutely  prohibited.  Frequent  bathing  and 
friction  of  the  skin  are  very  beneficial,  as  well  as  careful  regulation  of  the 
emunctories  generally. 

The  Hysteric  Convulsion. — During  the  hysteric  seizure  the  patient 
must  be  carefully  watched,  and  suitable  measures  should  be  adopted  to 
cut  short  the  attack  ;  all  extreme  measures,  and  severity,  however,  are 
unwai-rantable.  Cold  plunge-bathing,  the  dashing  of  cold  water  into  the 
face,  or  the  hypodermic  injection  of  apomorphin,  thereby  producing  a 
profound  mental  shock,  may  have  a  beneficial  effect.     Pressure  over  the 


HYSTERIA.  1173 

ovary  or  upon  one  of  the  large  vessels  (as  the  carotid)  will  sometimes 
promptly  induce  a  termination  of  the  attack. 

Internal  Treatment, — In  this  period  of  the  disease  it  is  probable  that 
most  can  be  done  to  improve  the  condition  of  the  patient.  In  addition 
to  the  general  laws  of  mental  and  physical  regimen  already  advanced,  the 
patient  should  be  taught,  as  far  as  is  possible,  the  undignified  condition 
into  which  she  is  sinking,  and  advised  and  encouraged  to  exert  powerful 
efforts  to  control  her  nervous  organism.  To  this  end  she  should  also  be 
given  full  doses  of  the  nerve-sedatives  and  antispasmodics  (valerian,  asa- 
fetida,  sumbul,  musk,  and  camphor),  together  with  the  general  tonics 
(iron,  arsenic,  strychnin).  I  have  repeatedly  found  the  rest-cure  of  Weir 
Mitchell  especially  beneficial  at  this  time ;  it  is  fully  described  under 
Neurasthenia  (vide  p.  1177). 

Hypnotism  has  commanded  considerable  attention  during  this  stage  of 
the  disease,  and  it  is  claimed  that  under  the  suggestion  of  the  hypnotist 
an  absolute  cure  very  frequently  follows.  This  is  not  altogether  true, 
however,  for  while  many  patients  are  undoubtedly  benefited  by  this  pro- 
cedure, the  good  result  must  be  attributed  not  alone  to  the  suggestion  of 
the  operator,  but  also  to  the  profound  mental  effect  produced  upon  the 
patient  by  the  mysterious  process. 

In  the  treatment  of  the  organic  manifestations,  which,  it  must  be  re- 
membered, are  dependent  entirely  upon  the  general  nervous  condition, 
the  physician  is  called  upon  to  exercise  the  greatest  amount  of  tact.  As 
far  as  is  possible  the  mind  of  the  patient  must  be  directed  away  from  the 
affected  part.  The  irritable  Madder  must  be  treated  by  internal  remedies, 
as  boric  or  benzoic  acid,  salol,  or  the  compound  infusion  of  buchu,  and  not 
by  local  irrigation  and  catheterization. 

Hysteric  vomiting  may  not  require  any  special  medication.  Occasion- 
ally, however,  it  may  be  relieved  by  rectal  alimentation.  Cocain  hydro- 
chlorate  in  the  form  of  a  10  per  cent,  solution  (dose  internally),  and  the 
application  of  mild  counter-irritation  or  of  a  small  fly-blister  over  the  epi- 
gastrium will  be  useful.  Cannabis  indica,  acetanilid,  phenacetin,  and 
antipyrin,  in  small  doses  and  only  when  absolutely  needful,  will  relieve 
hysteric  neuralgias.,  especially  the  cephalalgia.  For  the  pseudo-angina 
pectoris,  digitalis,  strophanthus,  caffein,  amyl  nitrite,  or  nitroglycerin,  or 
a  combination  of  these  drugs  in  suitable  doses,  may  be  exhibited. 

'For  the  pelvic  hyperesthesia  of  hysteric  females  local  applications  (tinc- 
ture of  iodin,  croton  oil,  or  a  small  fly-blister)  over  the  ovarian  region  may 
prove  very  beneficial. 

Hysteric  palsies,  either  general  or  local,  and  hysteric  disturbances  of 
the  special  senses,  must  be  treated  on  general  principles.  As  far  as  is 
possible  the  patient's  attention  must  be  directed  from  the  affected  part  or 
parts,  and  an  occasional  local  blistering,  the  use  of  galvanism  and  massage, 
with  daily  friction,  will  be  of  service,  especially  when  they  are  supple- 
mented by  an  appropriate  course  of  internal  medication. 


1174  DISEASES  OF  THE  NERVOUS  SYSTEM. 

NEURASTHENIA. 

Definition. — Functional  exhaustion  and  irritability  of  the  nerve- 
centers.  Neurasthenia  is  the  expression  of  an  abnormal  sensitiveness 
(irritability)  in  response  to  stimuli,  and  of  weakness  of  the  nerve-centers 
presiding  over  the  organic  functions.  Several  varieties — cerebral,  spinal, 
cardiac,  and  gastric — have  been  distinguished,  owing  to  the  fact  that  the 
predominating  featui'es  may  be  manifested  by  single  organs  or  systems  of 
the  body.  That  the  disease  is  essentially  generalized  in  all  instances, 
however.   I  do  not  doubt.     It  is  not  a  psychosis. 

Pathology. — A  variable  degree  of  weakness  of  the  sympathetic  cen- 
ters, permitting  congestions  on  trivial  provocation,  is  obvious,  but  there 
are  no  discoverable  lesions  (coarse)  in  the  nerve-centex's  that  are  peculiar 
to  the  affection.  C.  Y.  Hodge  ^  has  invited  attention  to  certain  changes 
in  nerve-cells  during  the  active  exercise  of  their  function,  and  something 
of  pathologic  importance  has  been  added  to  our  previous  knowledge  by 
his  observations.  There  are  many  causes  and  associated  affections  that 
present  a  variety  of  morbid  lesions,  but  they  are  purely  incidental.  It 
should  be  pointed  out  here  that  neurasthenia  is  often  found  in  association 
with  other  functional  nervous  disorders — a  fact  that  has  not  only  caused 
mental  confusion  among  certain  authors,  but  has  also  led  to  the  belief 
among  others  that  as  a  distinct  affection  it  does  not  exist. 

Ktiology. — The  causes  are  divisible  into — 1,  predisposing;  and  2, 
exciting.  Among  the  former  {a)  heredity  heads  the  list.  A  clear  history 
of  nervousness  or  morbid  irritability  in  one  or  both  parents  (oftener  the 
father)  is  at  times  obtainable.  Ancestors  that  were  sufferers  from  gout, 
rheumatism,  syphilis,  tuberculosis,  and  chronic  alcoholism,  all  diseases 
that  exhaust  vitality,  may  have  transmitted  to  their  offspring  a  strong 
neurasthenic  disposition.  The  latter  have  inherited  a  small  stock  of  ner- 
vous enerffv  with  which  to  begin  life's  unceasing  struggle. 

Of  other  predisposing  factors  may  be  mentioned  in  particular  (h)  im- 
proper training,  mental  and  physical,  and  (c)  the  character  of  the  mental 
pursuits,  those  entailing  strains  being  especially  deleterious,  (c?)  Age  and 
sex  are  not  without  appreciable  effect,  most  cases  occurring  between  the 
twentieth  and  fiftieth  years,  when  the  Avork  and  worry  of  life  are  maximal ; 
they  are  more  frequent  in  men  than  in  women. 

Exciting  Causes. — According  to  my  own  observations,  traumatism  has 
an  active  potency,  though  it  is  probably  not  the  most  frequent  cause. 
Overwork^  at  least  in  America,  is  responsible  for  a  greater  number  of 
cases  than  anv  other  single  factor,  and  in  estimating  its  effects  the  rela- 
tivity  of  individual  nerve-capital  must  be  carefully  considered.  Asso- 
ciated causes  are  to  be  observed  in  unpleasurable  emotional  excitement, 
mental  worriment,  particularly  if  dependent  upon  love-affairs,  and  sexual 
excesses.  Ahuse  of  the  sexual  organs,  excessive  venery,  masturbation, 
and  the  like  are  powerful  in  producing  neurasthenia.  Finally,  as  stated 
under  Pathology,  the  condition  may  be  induced  by  other  functional  and 
organic  affections  (symptomatic  neurasthenia). 

Symptoms. — The  subjective  symptoms  are  protean  and  varied,  but 
these  are  often  learned  only  after  close  interrogation,  the  patient  being 
unduly  reticent  as  a  rule.     Among  the  more  prominent  and  numerous 

^  Journal  of  Morphology,  vol.  v.  No.  11,  p.  95. 


NEURASTHENIA.  1175 

features  entering  into  the  symptom-complex  of  neurasthenia  are  great  irri- 
tability, pTiyslcal  fatigue  without  adequate  reason,  even  to  a  feeling  of 
utter  exhaustion  on  rising  in  the  morning,  disturbed  sleep,  headache,  with 
a  sense  of  weight  and  constriction,  impairment  of  memory,  anorexia,  and 
constipation ;  the  patient  is  very  irritable,  dispirited,  is  fearful,  and  fre- 
quently sinks  into  a  state  of  absolute  dejection.  Female  sufferers — and 
less  frequently  males  also — may  manifest  strong  emotions,  and  in  such 
cases  the  condition  presents  many  points  of  resemblance  to  the  milder 
forms  of  hysteria.  The  external  appearances  may  be  indicative  of  sound, 
vigorous  health  ;  oftener,  however,  the  physiognomy  is  worn  and  anxious. 

The  motor  phenomena  include,  besides  readily  oncoming  exhaustion  of 
the  muscular  strength  under  exercise,  a  variable  condition  of  the  tendon- 
reactions.  On  the  whole,  however,  they  are  increased.  Muscular  tremors 
(fine)  are  sometimes  present,  and  particularly  when  neurasthenia  is  the 
result  of  trauma  or  fright  (Dercum),  and  spasmodic  contractions  (usually 
brief)  of  small  isolated  groups  of  muscular  fibers  of  the  face,  trunk,  or 
extremities  are  observed. 

The  sensory  disturbances  are  varied  and  sometimes  striking.  The 
patient  makes  constant  complaint  of  feeling  "tired"  or  "never  rested," 
and  indeed  sometimes  betakes  himself  to  bed  for  this  reason.  A  feeling 
of  "lightness,"  giddiness,  and  even  true  vertigo,  may  occur  and  recur, 
and  rarely  the  latter  symptom  is  wellnigh  continuous.  The  headache  (pre- 
viously mentioned)  is  often  wholly  dependent  upon  mental  work,  since  it 
disappears  with  the  cessation  of  the  latter.  Another  form  oi  pain  is  a 
dull  aching  that  may  be  generalized,  though  more  commonly  it  is  con- 
fined to  the  small  of  the  back  and  limbs.  Spi aal  tenderness,  ^hQw^owoiht 
for,  may  often  be  elicited  over  certain  circumscribed  areas  or  mere  points, 
and  it  may  be  combined  with  a  deep-seated  ache  or  an  exacerbating  pain 
("spinal  irritation  ").  Cutaneous  hyperesthesia  is  common,  but  anesthe- 
sia is  not  found  in  uncomplicated  neurasthenia.  Numbness,  either  spon- 
taneous or  as  the  result  of  slight  pressure,  is  a  conspicuous  feature  for  a 
variable  period  upon  or  near  to  the  nerve-trunks,  and  linked  with  it 
there  may  be  a  generalized  or  localized  feeling  of  coolness  of  the  body- 
surface,  or  of  pricking  sensations  (formications)  and  circumscribed  sub- 
jective sensations  of  heat  and  burning. 

The  psychic  symptoms  grow  out  of  the  same  fundamental  conditions 
as  do  the  physical  symptoms — i.  e.  fatigue  of  the  nerve-centers.  As 
would  be  expected,  then,  the  capacity  for  sustained  mental  work  is  gener- 
ally lessened,  and  the  power  to  concentrate  or  rivet  the  attention  upon 
any  subject  as  well.  The  patient  is  self-centered,  sensitive  to  a  degree, 
easily  angered,  and  is  morbidly  suspicious.  His  emotional  nature  is 
unstable,  and  the  mental  depression  (before  mentioned)  deepens  until  it 
approaches  true  hypochondria. 

Iiisornnia.  varying  in  form,  is  frequent,  and  disturbances  of  the  organs 
of  special  sense  are  not  wanting=  The  eye  presents  the  most  important  fa- 
tigue-symptoms. Vision  may  be  imperfect  (blurred),  and  continuous  close 
use  of  the  eyes  be  impossible.  There  is  a  lack  of  power  of  accommodation 
and  retinal  hyperesthesia  may  supervene.  The  pupils  may  be  unnaturally 
large.  All  forms  of  tinnitus  constantly  arise  in  neurasthenia,  and  may 
lend  so  vivid  a  coloring  to  the  clinical  picture  that  the  real  nature  of  the 
attack  is  liable  to  be  overlooked.     I  have  recentlv  seen  a  case  of  the  sort 


1176  DISEASES  OF  THE  NERVOUS  SYSTEM. 

occurring  in  a  clergyman  (thirty-six  years  old),  in  whom  the  diagnosis  of 
aural  disease  had  previously  been  made.  This  symptom,  like  all  others 
due  to  neurasthenia,  may,  however,  be  associated  with  genuine  organic 
diseases  of  the  ear  (otoneurasthenia).  Disturbances  of  taste  also  tend 
to  appear,  but  they  ai-e  of  minor  importance.  Vasomofor  disorders,  such 
as  hot  flushes  and  profuse  sweats,  commonly  arise  in  consequence  of 
the  diminished  tone  of  the  arteries ;  these  form  quite  distressing  fatigue- 
symptoms.  Visible  throbbing  of  the  superficial  vessels  and  of  the  ab- 
dominal aorta,  and  rarely  also  of  the  veins  and  the  capillary  pulse,  occur 
in  the  affection  {vide  Aortic  Regurgitation,  p.  597).  The  urinary  phe- 
nomena may  excite  particular  attention  owing  to  their  prominence,  and 
this  remark  applies  especially  to  the  frequent  combination  of  neurasthenia 
and  lithemia  {lithemic  neurasthenia).  Oxaluria  and  transient  glycosuria 
and  albuminuria  may  also  be  present.  The  daily  amount  of  urine  is 
often  small,  and  less  frequently  it  is  large.  The  sexual  apparatus  is  weak 
and  irritable,  as  shown  by  frequent  seminal  emissions  (nocturnal)  and 
incomplete  erections,  and,  if  the  subject  be  married,  by  premature  ejacu- 
lation. The  fear  of  becoming  impotent  often  renders  the  mental  attitude 
of  those  really  potent  such  as  to  excite  the  keenest  compassion.  The 
orgasm  in  the  female  and  the  emission  in  the  male  are  followed  by  a  sense 
of  prostration  and  mental  depression. 

The  somatic  disturbances  referable  to  the  heart  (palpitation,  precordial 
pain)  have  been  considered  under  Neuroses  of  the  Heart,  and  the  various 
gastro-intestinal  features  in  the  discussion  of  Neuroses  of  the  Stomach. 
Reference  has  already  been  made  to  several  clinical  varieties  based  upon 
the  predominance  of  special  and  localized  groups  of  symptoms — e.  g.  when 
the  reigning  features  are  spinal  the  variety  is  termed  spinal  neurasthenia  ; 
when  these  are  presented  by  the  sexual  apparatus,  sexual  neurasthenia  ; 
and  so  on ;  but  I  am  in  entire  accord  with  Dercum  when  he  avers  that 
groups  of  symptoms  cannot  be  considered  as  sufficient  ground  for  the 
division  of  neurasthenia  into  separate  forms.' 

Diagnosis. — That  cases  of  neurasthenia  are  misdiagnosed  as  other 
conditions,  and  the  reverse,  I  feel  convinced.  An  important  matter  at 
the  outset  is  to  avoid  confounding  the  neurasthenic  symptoms  (secondary) 
of  various  local  and  general  organic  diseases  with  the  primary  form  by  a 
careful  exclusion  of  the  latter.     From  hysteria  the  diagnosis  is  as  follows : 

IIvsTERiA.  Neurasthenia. 

By  nature  a  psycho-neurosis.  A  true  neurosis. 

Occurs  in  individuals  presenting  a  marked  Occurs  as  the  result  of  nerve-tire,  over- 
hereditary  taint.  work,  and  the  like  in  individuals  not 

necessarily  presenting  hereditary  taint. 

The  onset  is  frequently  abrupt.  The  onset  is  always  gradual. 

The  clinical  features  are  dependent  upon  Is  characterized  by  a  notable  lack  or  in- 

an  excess  of  nervous  energy.  sufficiency  of  nerve-force. 

Presents  the  characteristic  stigmata,  as  These  are  absent, 
paralysis  and  anesthesia  in  most  cases. 

Is  sometimes  accompanied  by  violent  con-  Convulsive  seizures  never  occur, 
vulsive  seizures. 

Neuralgic  attacks  are  infrequent  or  alto-  Neuralgic  attacks  are  very  common, 
gcther  absent. 

Insomnia  is  not  marked.  Insomnia  is  very  common. 

*  Nervous  Diseases  by  Amei-ican  Authors,  p.  73. 


NEURASTHENIA.  1177 

Hysteria,  it  is  to  be  remembered,  may  be  a  complication  of  neuras- 
thenia, and  this  association  must  be  distinguished  from  simple  hysteria. 

Prognosis. — Neurasthenia  is  a  curable  disease  if  appropriate  treat- 
ment be  commenced  before  secondary  structural  changes  set  in  and  render 
the  use  of  the  most  approved  measures  of  no  avail.  In  long-standing 
cases  deleterious  habits  (morphinism,  chloralism,  alcoholism)  are  some- 
times developed  and  prevent  the  possibility  of  a  cure.  Hysteria  (the 
complication)  tends  to  delay,  but  does  not  preclude,  recovery. 

Treatment. — The  first  step  should  be,  after  locating  the  major  cause 
or  causes,  to  remove  them,  or,  if  this  be  impossible,  to  minimize  their 
baneful  influence  so  far  as  may  be.  For  example,  if  the  conditions  have 
been  induced  by  overwork  of  the  brain,  rest  for  the  organ  must  be  pro- 
cured ;  if  sexual  excesses  have  been  the  obvious  responsible  factor,  rest 
for  the  sexual  apparatus  is  imperatively  demanded.  In  the  next  place, 
the  mental  and  moral  environment  must  be  conducive  to  contentment  and 
to  wholesome  forms  of  exercise  of  the  mind.  In  this  way  the  exhausted 
stock  of  nervous  energy  can  be  often  increased  by  the  natural  recuperative 
forces  alone.  Indeed,  successful  removal  of  the  essential  etiologic  influ- 
ences is  in  the  milder  forms  followed  by  prompt  recovery.  In  not  a  few 
instances  the  symptoms  disappear  as  the  result  of  a  prolonged  sojourn  in 
a  suitable  climate  or  by  travel  for  a  considerable  period  with  its  ever- 
accompanying  change  of  scene,  though  it  is  well  in  doing  so  to  avoid  the 
din  and  excitement  of  large  cities.  The  compulsory  rest  and  complete 
isolation,  combined  with  the  purity  of  atmosphere,  afforded  by  a  sea-voyage 
sometimes  work  admirable  results.  Unfortunately,  many  subjects  suffer- 
ing with  neurasthenia,  and  particularly  males,  are  either  unable  or  un- 
willing to  arrest  the  loss  of  nervous  function  by  ceasing  their  excessive 
activities.  In  the  majority  of  instances,  for  the  reasons  above  stated, 
certain  other  measures — hygienic  and  medicinal — are  to  be  advised. 

Next  to  the  importance  of  removing  the  exciting  agents,  stands  rest. 
In  severe  and  long-standing  cases  this  should  be  made  as  nearly  absolute 
as  possible,  while  in  the  milder  forms  merely  lengthening  the  hours  for 
sleep  or  rest  in  bed,  as  first  pointed  out  by  Dr.  S.  Weir  Mitchell,  often 
suflices.  The  amount  of  rest  must  be  accurately  proportioned  to  the 
necessity  of  individual  cases.  To  Dr.  S.  Weir  Mitchell  belongs  the  credit 
of  having  introduced  the  "rest-cure"  in  the  management  of  this  disease. 
This  mode  of  treatment  in  very  old,  and  in  profound  cases  produces  cura- 
tive effects  unobtainable  in  any  other  manner,  though  it  does  not  give 
complete  restoration  to  health,  as  a  rule,  and  must  be  variously  modified 
in  individual  instances.  It  embraces  not  only  absolute  rest,  but  also 
"passive  exercise"  and  forced  feeding.  Both  body  and  mind  must  re- 
ceive rest;  hence  confinement  often  is  not  sufiicient,  and  the  patient  must 
also  be  strictly  isolated  from  friends  and  relatives,  particularly  if  hysteria 
be  associated. 

The  patient  is  to  be  put  in  charge  of  a  properly  selected  nurse,  who 
will  afford  agreeable  entertainment  by  suitable  conversation  and  reading 
under  the  instructions  of  the  physician.  In  desperate  cases  the  patient 
should  not  be  allowed  to  feed  himself,  must  not  rise  to  void  the  urine  or 
feces,  nor  even  turn  in  bed  without  the  help  of  the  nurse. 

The  neurasthenic  also  demands  a  special  dietary,  that  is  to  be  made  up 
at  first  of  milk.     This  should  be  administered  in  small  quantities  at  the 


1178  DISEASES  OF  THE  ySRVOUS  SYSTEM. 

beginning  (giv  or  v — 120.0  or  148.0,  every  two  hours),  and  slowly  and 
gradually  increased  until  at  the  end  of  a  week  or  ten  days  large  quanti- 
ties are  taken  (sviij-x — 236.0—300.0  every  two  hours).  When  whole 
milk  cannot  be  readily  digested  skim-milk  should  be  employed.  To  the 
milk,  should  the  patient  become  decidedly  hungry,  may  be  added  in  the 
course  of  five  or  six  days  very  light  nutrients  (plain  boiled  rice,  a  soft- 
boiled  egg)  and  a  little  later  meats  (lamb-chop,  steak).  Constipation 
calls  for  the  use  of  unbolted  bread  (graham),  fresh  and  stewed  fruits, 
and  butter.  This  simple  dietary  is  to  be  enriched  until  three  large  meals 
are  taken  daily — "  such,  for  instance,  as  a  breakfast  of  fruit,  cracked 
wheat,  one  or  two  soft-boiled  eggs,  or  a  good-sized  steak,  well-served 
chops,  bread  and  butter,  and  milk  ;  a  dinner  of  a  good  slice  of  roast  beef, 
with  vegetables  and  boiled  rice  (in  place  of  potatoes).  The  supper  should 
remain  as  a  light  meal  of  bread,  butter,  fruit,  light  pudding,  and  milk  "' 
(Dercum).     Tea,  coffee,  and  alcohol  should  be  avoided. 

Passive  exercise,  massage,  and  electricity  form  an  essential  part  of  the 
"rest-cure,"  though  the  former  should  not  be  commenced  until  the  second 
or  third  day.  At  first  it  should  be  continued  for  a  few  minutes  only,  and 
consists  of  gentle  rubbing  or  light  strokes.  As  tolerance  becomes  estab- 
lished massage  should  be  practised  for  a  longer  period  (about  an  hour). 
Deeper  rolling,  kneading,  and  spiral  manipulations  are  then  allowable. 
The  dii'ection  of  the  venous  blood-current — toward  the  center  of  the  body 
from  the  periphery — is  to  be  borne  in  mind,  and  all  massage-motions  are 
to  be  made  in  the  same  direction.  This  measure  is  to  be  carried  out  by 
the  nurse,  who  should  be  a  well-trained  masseuse  and  thoroughly  ac- 
quainted with  the  details  of  her  work.  Electricity,  like  massage,  com- 
pensates for  the  lack  of  exercise.  The  slowly-interrupted  faradic  current 
is  to  be  selected,  and  the  aim  should  always  be  to  induce  satisfactory  con- 
tractions with  the  least  amount  of  pain.  The  current  should  be  applied 
to  the  individual  muscles,  one  of  the  extremities  being  selected,  and  the 
poles  applied  over  the  motor  points,  passing  from  muscle  to  muscle  until 
all  have  been  faradized.  The  time  of  each  sitting  should  not  exceed  half 
an  hour.  The  entire  body  should  also  receive  the  faradic  current  (rapidly 
interrupted).  A  large  sponge  moistened  with  salt  water  is  applied  at  the 
nape  of  the  neck,  and  another  to  the  soles  of  the  feet,  and  the  strongest 
current  tolerable  is  thus  used.  This  process  should  be  continued  from 
fifteen  to  twenty  minutes,  and,  like  the  faradization  of  the  single  muscles, 
it  is  to  be  repeated  at  intervals  of  twenty-four  hours. 

The  rest-cure  in  all  of  its  details  should  be  continued  for  a  period 
ranging  from  four  to  eight  weeks.  The  patient  should  leave  his  bed  in 
the  most  gradual  manner,  and  should  sit  up  for  a  few  minutes  only  at  first, 
the  time  being  gradually  lengthened ;  soon  exercise  may  be  commenced 
in  a  like  manner  and  be  cautiously  increased.  During  this  period  of 
convalescence  it  is  my  custom  to  omit  the  electric  treatment,  Avhile  the 
massage  is  continued  at  intervals  of  two  or  three  days  for  some  weeks. 
After  the  patient  has  reached  the  point  of  marked  improvement,  as  evi- 
denced by  a  large  appetite,  the  disappearance  of  the  most  pronounced 
subjective  symptoms,  and  especially  by  a  substantial  gain  of  weight 
(twenty  to  twenty-five  pounds — 11.3  kgms.),  he  should  be  advised  to 
make  a  change  of  air  to  the  country,  or  t^  the  mountains  or  the  sea- 
shore (if  it  be  not  the  summer  season). 


ACROMEGALY.  1179 

Hydrotherapy  is  positively  and  rationally  serviceable  in  the  manage- 
ment of  neurasthenia.  The  water  may  be  employed  in  the  form  of  the 
shower,  spray,  bath,  or  pack,  and  is  most  efficacious  when  quickly  applied 
for  a  few  moments  and  followed  by  vigorous  towelling  to  reinforce  the 
action  of  the  cold.  A  portion  of  a  garden-hose  with  a  sprinkler  is  read- 
ily attached  to  the  water-pipe  in  the  bath-room  and  furnishes  the  read- 
iest means  of  applying  cold  water.  Extreme  caution  is  necessary  at  the 
beginning  of  the  application  of  cold  to  the  surface,  since  there  are  neur- 
asthenic subjects  that  not  only  fail  to  receive  benefit,  but  are  rendered 
worse  thereby,  in  consequence  of  a  highly  sensitive  organization. 

Drugs  are  of  minor  importance  in  the  treatment,  and  their  routine  use 
is  to  be  condemned.  Laxatives  are  often  needful,  and  in  my  experience 
broken  doses  of  calomel,  followed  by  a  saline,  or  the  fluid  extract  of 
cascara,  have  proved  most  effective.  For  a  further  consideration  of  the 
treatment  of  the  gastro-intestinal  symptoms  the  reader  is  referred  to  Neur- 
oses of  the  Stomach. 

Strychnin  is  constantly  being  employed  in  the  treatment  of  this  affec- 
tion, but  its  use  should  be  limited  to  the  more  profound  types.  Full  doses 
are  required  if  we  would  expect  good  results.  In  cases  in  which  anemia 
is  marked  arsenic  may  be  employed  with  advantage.  Phosphorus  has  also 
been  recommended,  but  it  tends  to  disturb  the  digestive  organs  and  rarely 
gives  striking  general  results. 


ACROMEGALY. 

(  Giantism.) 


Definition. — A  disease  first  recognized  and  described  by  Marie,  and 
characterized  by  a  progressive  and  peculiar  enlargement  of  the  face  and 
extremities. 

Pathology. — Those  cases  that  have  been  examined  postmortem  have 
shown,  as  the  most  constant  change,  an  enlargement  of  the  pituitary  body, 
with  a  corresponding  dilatation  of  the  sella  turcica,  and  a  persistence  of 
the  thymus  gland.  Less  frequently  there  is  fibroid  degeneration  of  the 
thyroid  gland.  A  few  cases,  however,  have  been  reported  in  which  one 
or  all  of  these  organs  were  normal.  The  lips,  tongue,  and  trachea  are 
usually  considerably  enlarged,  and  the  sexual  organs  may  either  be  hyper- 
trophied  or  atrophied,  the  latter  condition  being  more  common  in  the 
uterus  and  testicles.  The  bones  of  the  extremities  and  face  are  thick- 
ened, apparently  chiefly  as  a  result  of  hyperplasia  of  the  spongy  portion, 
and  Klebs  has  shown  that  the  peripheral  vessels,  particularly  those  in  the 
affected  bones,  are  also  larger.  Occasionally  there  are  hypertrophy  of  the 
heart  and  enlargement  of  the  spleen  and  liver. 

The  etiology  of  acromegaly  is  unknown.  Marie  believes  that  it  "is 
a  form  of  systematic  dystrophy  analogous  to  myxedema,  and  probably 
due  to  interference  with  the  function  of  the  pituitary  body.  Freund 
holds  that  it  is  a  sort  of  inversion  of  growth  associated  with  alteration  in 
the  sexual  organs  at  puberty.  Klebs  believes  that  it  is  due  to  a  neoplas- 
tic condition  of  the  vascular  tissues,  associated  with  a  functional  persist- 


1180  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ence  of  the  thymus  gland.  Various  diseases  have  preceded  the  develop- 
ment of  acromegaly,  but  none  with  sufficient  regularity  to  indicate  that 
the  subsequent  appearance  of  the  latter  condition  was  other  than  acci- 
dental. Both  sexes  are  about  equally  affected,  and  the  disease  ordinarily 
commences  in  adolescence. 

The  earliest  Symptom  is  usually  an  increase  in  the  thickness  of  the 
fincrers  and  toes,  so  that  rings,  gloves,  and  shoes  are  too  small  and  can  no 
longer  be  worn.  This  enlargement  is  chiefly  in  thickness,  although  there 
is  also  a  certain  amount  of  increase  in  length.  Both  the  soft  and  hard 
parts  are  affected.  The  nails  are  flattened,  longitudinally  ridged,  and 
more  friable  {spade-like  hand).  The  face  becomes  considerably  enlarged  ; 
the  supraorbital  ridges  project,  giving  rise  to  a  rather  simian  aspect;  the 
nose  becomes  broader  and  longer;  the  cheek-bones  project ;  but  the  most 
positive  characteristic  is  the  enormous  enlargement  of  the  lower  jaw,  so 
that  it  becomes  broader  and  prognathous,  and  the  lower  teeth  can  no 
longer  be  brought  in  apposition  with  the  upper.  The  spinal  column  is 
ordinarily  kyphotic,  the  change  affecting  the  upper  dorsal  and  cervical 
regions.  Frequently  there  is  also  an  associated  scoliosis.  The  rest  of  the 
skeleton  remains  unaffected  for  a  long  time  ;  finally,  changes  may  be  ob- 
served in  the  clavicles,  sternum,  ribs,  pelvis,  and  particularly  in  the  pa- 
tellae. The  skin  sometimes  shows  slight  pigmentation  ;  the  hair  is  rough 
and  may  become  thinner ;  the  muscles  occasionally  exhibit  increased 
electric  excitability,  and  less  frequently  there  is  muscular  atrophy  with 
reactions  of  degeneration.  The  lips,  tongue,  and  tonsils  are  usually  en- 
larged, and  the  larynx  is  increased  in  dimensions,  so  that  the  voice  be- 
comes deep  and  rough ;  this  is  a  very  characteristic  symptom  in  women. 
Ordinarily,  an  area  of  dulness  can  be  detected  in  the  upper  part  of  the 
sternum  that  has  been  ascribed  to  the  persistence  of  the  thymus  gland. 
The  tendon-reflexes  may  either  be  normal,  diminished,  or  abolished.  They 
are  never  exaggerated.  The  urine  is  increased  in  amount,  and  glycosuria 
is  often  present.  The  secretion  of  siveat  is  also  greatly  increased.  The 
subjective  symptoms  consist  of  severe  intermittent  or  continuous  head- 
ache and  of  a  diminution  of  the  visual  power.  There  may  be  pare- 
sis of  the  third  nerve,  giving  rise  to  external  strabismus,  and  some- 
times to  temporal  hemianopsia  as  a  result  of  pressure  upon  the  central 
part  of  the  chiasm  by  an  enlarged  pituitary  body.  Sometimes  late  in  the 
disease  there  are  occasional  momentary  general  tremors.  The  patients 
often  present  polyphagia  and  polydipsia.  Neuro-retinitis  and  subsequent 
atrophy  of  the  optic  nerve  may  also  occur.  Sexual  power  is  usually 
abolished.  In  women  menstruation  ceases  earW  in  the  disease,  and  the 
breasts  atrophy.  The  mental  condition  is  affected,  and  there  are  usually 
great  apathy  and  diffidence  (perhaps  explicable  by  their  changed  appear- 
ance), loss  of  memory,  and  even,  in  some  cases,  imbecility. 

Diagfnosis. — In  the  later  stages  the  appearance  is  characteristic,  and 
acr(jmegaly  can  then  hardly  be  confounded  with  other  diseases.  The  pe- 
culiar enlargement  of  the  extremities,  the  oval,  prognathous,  and  distorted 
face,  the  deep,  rough  voice,  the  more  or  less  pronounced  pigmentation  of 
the  skin,  the  wasting  of  the  muscles,  and  the  profound  cachexia  give  a  per- 
fect clinical  picture.  In  those  cases  in  which  the  cachexia  has  become  ex- 
treme there  are  from  time  to  time  peculiar  tremors  or  spasms  of  the 
body. 


ASTA  SI  A- ABA  SI  A.  1181 

Differential  Diagnosis. — In  the  earlier  stages  the  disease  is  most  easily 
confounded  with  the  hypertropldc  pulmonary  osteo-arthropathy  of  Marie. 
In  this  both  hands  and  feet  are  greatly  enlarged  ;  but  the  fingers  are  club- 
shaped,  the  face  is  not  involved,  and  there  usually  exists  some  chronic  pul- 
monary complication.  In  a  case  that  I  observed  there  were  bronchiectasis 
and  bronchorrhea.  From  osteitis  deformans  it  may  be  distinguished  bv  the 
fact  that  in  this  condition  chieiiy  the  long  bones  of  the  limbs  and  the  flat 
bones  of  the  skull  are  hypertrophied  and  very  painful.  Elephantiasis 
may  be  distinguished  by  the  fact  that  it  attacks  the  lower  limbs,  does  not 
involve  the  bones,  and  the  skin  presents  a  granular  or  a  nodular  appear- 
ance. From  arthritis  deformans  acromegaly  may  be  distinguished  bv  the 
fact  that  the  disease  develops  late  in  life  and  is  associated  with  orreat  de- 
formity of  the  joints,  the  face  ordinarily  escaping.  The  following  table 
(after  Dercum)  will  serve  to  distinguish  two  diseases  that  are  apt  to  be 
confounded  with  one  another  : 

AcROJfEGALT.  MYXEDEMA. 

Occurs  most  commonly  in  early  adult  life.      A  disease  of  mature  life — forty  to  fifty 

years. 
In  maJ.es  and  females  equally.  Five  times  as  frequent  in  females  as  in 

males. 
Enlargement  of  the  bones  characteristic.       Xo  enlargement  of  the  bones. 
Marked  prognathism  of  jaw  and  flatten-      Face  full-moon-shaped. 

ing  of  cheeks. 
Skin  brownish-yellow  :  hair  coarse  and      Skin  pale,  waxy,  shiny,  and  boggy  ;  hair 

unwieldy  :  nails  short  and  striated.  falls  out :  nails  not  affected. 

Fingers  symmetric  and  sausage-shaped.         Fingers  clubbed  at  the  end. 
Administration  of  thyroid  extract  is  of       ThjToid  treatment  of  the  greatest  benefit. 

the  smallest  benefit. 

The  prognosis  is  hopeless  for  cure  and  doubtful  for  duration.  The 
disease  is  progressive,  although  it  remains  stationary  for  a  longer  or  shorter 
period.  Retrogression  never  occurs.  Ordinarily,  the  patients  die  of  some 
intercurrent  condition ;  although  death  may  be  due  to  the  cachexia  of 
acromegaly  itself.  Life,  however,  may  last  for  twenty  years  after  the 
appearance  of  the  first  symptoms. 

Treatment  of  the  condition  itself  has  proved  unavailing.  Certain 
cases  have  been  reported  in  which  there  was  slight  temporary  improve- 
ment after  the  use  of  extract  of  pituitary  body  or  of  thyroid  gland,  but 
the  results  are  contradictory.  The  cephalalgia  can  be  more  or  kss  com- 
pletely controlled  by  antipyrin  or  caffein.  Phosphorus,  mercurv,  the 
iodids,  and  arsenic  have  been  wholly  useless. 


ASTASIA-ABASIA. 


ASTASIA-ABASIA  is  rather  a  symptom  than  a  disease  sui  generis.  It 
consists  of  an  interference  with  the  power  of  walking,  although  the  limbs 
show  no  trace  of  paralysis  and  are  capable  of  performing  perfectly  other 
complicated  movements.  In  this  respect  it  is  somewhat  allied  to  the 
functional  neuroses.  In  a  case  reported  by  Burr,  complicated  with  severe 
anemia,  changes  were  found  in  the  posterior  and  lateral  columns  of  the 
cord ;  ordinarily,  however,  no  sross  lesions  can  be  discovered.     The  dis- 


1182  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ease  usually  attacks  either  sex  in  early  adult  life,  and  is  sometimes  asso- 
ciated uith  hysteria  and  neurasthenia. 

The  symptoms  consist  either  of  a  tendejicy  to  fall  Avhen  standing  up- 
right or  attempting  to  walk,  or  of  great  difficulty  in  locomotion^  the  feet 
being  dragged  along  the  ground  for  short  steps,  the  body  swaying  or  mak- 
ing various  contortions  to  maintain  the  balance,  whilst  the  patient  grasps 
eagerly  at  any  possible  support  and  exhibits  every  manifestation  of  fear. 
Blocq  recognizes  three  degrees.  In  the  (a)  first  or  most  severe,  the  upright 
posture  and.  above  all,  walking  are  absolutely  impossible.  If  the  patient 
is  lifted  up  and  supported  on  either  side,  the  legs  hang  powerless.  These 
patients,  however,  when  lying  in  bed  show  neither  loss  of  power  nor  inco- 
ordination, and  are  perfectly  able  to  crawl  on  their  hands  and  knees.  In 
the  (6)  second  degree  the  patient  is  able  to  stand  if  supported  on  either 
side ;  if  an  attempt  to  walk  is  made,  the  feet  are  dragged  with  difficulty 
along  the  ground.  In  the  {c)  third  degree  locomotion  is  possible,  but  the 
feet  are  dragged  along  for  short  steps,  often  exhibiting  deviations  such  as 
occur  in  ataxia ;  moreover,  the  patient  is  usually  unable  to  proceed  as 
soon  as  the  eyes  are  closed.  In  this  degree  the  patients  are  able  to  re- 
main standing,  but  from  time  to  time  they  exhibit  sudden  giving  way  of 
the  legs,  followed  by  equally  sudden  recoveries.  Hysteric  stigmata  are 
usually  present,  although  in  some  cases  they  fail  completely ;  in  two  of 
the  cases  that  I  have  observed  there  was  complete  cutaneous  anesthesia. 

The  diagnosis  is  usually  easy,  and,  though  certain  cases  resemble 
the  movements  of  the  more  violent  forms  of  chorea,  they  may  be  distin- 
guished by  the  fact  that  their  limbs  become  quiet  as  soon  as  they  lie  down. 
In  certain  early  forms  of  locomotor  ataxia  also  this  symptom  may  be  pres- 
ent, and  can  then  only  be  distinguished  from  the  true  form  by  the  lack  of 
coordination  in  bed  and  the  presence  of  other  tabetic  symptoms. 

The  prognosis  is  favorable,  although  some  cases  are  quite  obstinate. 

The  treatment  is  chiefly  suggestive.  Cases  complicated  by  neuras- 
thenia are  often  cured  by  the  rest-treatment ;  those  in  Avhom  anemia  is 
present  should  be  treated  for  that  condition.  Hypnotism  also  may  be  of 
use,  but  the  most  important  element  is  to  encourage  the  patient  to  make 
an  efibrt  to  walk  ;  it  is  astonishing  then  to  note  the  rapidity  with  which 
he  will  ordinarily  improve. 


CAISSON  DISEASE. 

{Diver's  Paralysis ;  Paralysis  from  Lessened  Atmospheric  Pressure.) 

Definition. — A  ])aralytic  condition  caused  by  sudden  transference 
from  an  abnormal  atmospheric  pressure  to  one  of  normal  intensity. 

The  pathology  of  the  disease  is  obscure.  Ley  den  has  found  tears 
in  the  substance  of  the  dorsal  region  of  the  spinal  cord  filled  with  white 
blood-cells,  but  without  hemorrhagic  foci.  Other  authors  have  found 
minute  hemorrhages  in  the  substance  of  the  cord  and  the  meninges.  It 
has  been  supposed  by  some  that  as  a  result  of  sudden  reduction  in  pres- 
sure the  nitrogen  gases  that  have  been  forced  into  solution  in  the  blood 


CAISSON  DISEASE.  1183 

are  suddenly  liberated,  with  the  formation  of  air-emboli ;  others  have 
believed  that  the  changes  are  due  to  a  sudden  disturbance  of  the  gaseous 
metabolism.  In  cases  in  which  death  has  occurred  after  a  considerable  in- 
terval the  lesions  of  disseminated  focal  myelitis  have  been  discovered. 

The  etiology  of  the  disease  is  very  clear,  and  certain  predisposing 
factors  are  worthy  of  note.  Divers  are  more  apt  to  suflFer  if  they  have 
been  working  at  extreme  depths,  particularly  if  the  period  of  exposure 
to  great  pressure  has  been  prolonged ;  even  moderate  pressure  will  some- 
times produce  symptoms  if  continued  for  a  sufficient  length  of  time,  and 
short  periods  of  rest  do  not  prevent  the  development  of  the  disease.  Ordi- 
narily, it  can  be  said  that  unless  the  pressure  exceeds  two  and  one  half  or 
three  atmospheres  no  danger  may  be  apprehended. 

The  symptoms  vary  greatly  in  intensity.  In  the  mildest  form  they 
consist  of  neuralgic  pains  in  the  joints,  sometimes  with  slight  articular 
swelling,  headache,  giddiness,  and  a  little  tinnitus.  These  pains  may  be- 
come more  violent,  particularly  in  the  loins,  and  be  followed  by  a  gradual 
loss  of  2301V  er  and  by  anesthesia  in  the  limbs;  these  symptoms  may  disap- 
pear in  a  few  hours  or  become  more  severe,  with  the  development  of  com- 
plete paralysis  and  interference  with  the  action  of  the  sphincters.  This 
paralysis  usually  assumes  the  form  of  paraplegia  ;  monoplegia  d^ndi  hemi- 
plegia also  occur,  and  sometimes  there  are  complete  paralysis  and  anesthesia 
of  all  four  extremities  and  of  the  trunk.  In  the  most  severe  cases  cere- 
bral symptoms  are  also  present,  consisting  of  sudden  loss  of  consciousness, 
profound  coma,  irregular  respiratory  action,  and  finally,  after  a  short  time, 
death  from  cardiac  failure. 

The  diagnosis  is  very  easy.  It  is  possible,  however,  that  an  attack 
of  apoplexy  should  occur  in  a  man  who  has  been  under  water,  and  the 
patient  should  always  be  examined  for  the  presence  of  this  or  some  other 
organic  lesion. 

The  prognosis  varies  with  the  intensity  of  the  symptoms.  The  lighter 
forms  consist  merely  of  joint-pains  and  slight  dizziness  that  usually  pass 
away  in  the  course  of  a  few  hours.  Paraplegias  or  hemiplegias,  develop- 
ing slowly  and  not  assuming  a  severe  form,  are  also  transient  in  character. 
A  more  severe  paraplegia  is  usually  permanent,  although  some  improve- 
ment may  be  expected.  The  apoplectic  forms  are  almost  invariably  fatal 
in  the  course  of  a  few  hours. 

The  treatment  consists,  firstly,  of  prophylactic  measures.  In  all  places 
where  caisson-work  is  carried  on  one  or  more  locks  should  be  provided  in 
which  the  pressure  can  be  gradually  reduced  until  it  is  approximately  that 
of  the  atmosphere.  Divers  should  be  instructed  to  come  slowly  to  the  sur- 
face. If  the  pressure  exceeds  three  atmospheres,  the  maximum  length  of 
the  working-period  should  not  be  more  than  one  hour,  and  several  hours 
should  be  permitted  between  the  descents.  A  chamber  should  also  be 
provided  in  which  a  man  who  exhibits  symptoms  of  the  disease  can  be 
once  more  subjected  to  a  pressure  greater  than  that  of  the  atmosphere,  as 
this  usually  causes  an  arrest  of  the  process.  When,  however,  the  condi- 
tion resembles  that  of  acute  myelitis,  the  treatment  is  purely  symptomatic. 
It  consists  of  rest,  careful  hygiene,  and  a  stimulating  diet.  Potassium 
iodid  may  also  be  administered  in  the  later  stages,  but  its  value  is  very 
doubtful.  In  some  of  the  acute  forms  with  more  or  less  respiratory  fail- 
ure inhalations  of  oxygen  have  been  recommended. 


1184  DISEASES  OF  THE  NERVOUS  SYSTEM. 


V.  VASOMOTOR  AND  TROPHIC   DISORDERS. 
ANGIONEUROTIC  EDEMA. 

{Acute  Circumscribed  Edema  of  the  Skin  ;  Intermittent  Angioneurotic  Edema.) 

Definition. — A  disease  characterized  by  the  appearance  of  an 
edematous  swelling  of  the  skin  or  mucous  membranes.  In  general  it  is 
not  accompanied  by  constitutional  symptoms. 

The  pathology  of  the  disease  is  obscure.  It  is  supposed  to  be  due 
either  to  venous  stasis  or  to  some  nervous  influence  upon  the  lymph- 
channels,  causing  them  to  exude  liquid.  No  lesions  have  as  yet  been 
described. 

Ktiology. — Neuropathic  heredity  appears  to  have  some  influence 
upon  the  disease,  but  nervous  manifestations  in  the  patient  himself  are 
more  important.  Occasionally  the  condition  follows  infectious  diseases  or 
severe  hemorrhage.  The  most  important  exciting  causes  are  cold  and 
emotional  disturbances.  The  disease  occurs  most  frequently  in  males, 
and  almost  exclusively  in  early  adult  life. 

Symptoms. — The  edema  usually  appears  suddenly,  is  sharply  cir- 
cumscribed, and  the  skin  of  the  aifected  area  is  slightly  elevated  and 
reddened,  or  else  somewhat  paler  than  the  surrounding  tissue.  Ordinarily, 
subjective  symptoms  are  absent;  occasionally  there  are  slight  paresthesice. 
The  edema  may  appear  in  any  part  of  the  body,  but  usually  it  is  most 
common  on  the  backs  of  the  hands  or  legs  and  in  the  face,  especially  the 
eyelid.  Occasionally  it  may  appear  upon  the  mucous  membranes  either 
of  the  lips,  tongue,  or  glottis ;  in  the  latter  situation  it  sometimes  pro- 
duces severe  dyspnea,  and  at  least  in  one  case  it  has  caused  death.  Its 
presence  has  also  been  suspected  in  the  mucous  membrane  of  the  gastro- 
intestinal tract.  Ordinarily  the  patient  has  no  symptoms  whatever  of 
disease ;  occasionally,  however,  there  are  severe  colic  and  sometimes 
vomiting.  In  one  case  hematuria  was  observed,  and  in  another  hemor- 
rhage from  the  swollen  gums ;  of  course  in  the  latter  case  the  diagnosis 
was  doubtful.  The  patient  may  exhibit  a  certain  degree  of  anxiety 
during  the  attack.  Ordinarily  the  swelling  persists  a  few  days,  and  then 
disappears,  but  relapses  are  exceedingly  common,  and  may  recur  very 
frequently  for  many  years. 

The  differential  diagnosis  has  to  be  made  from  urticaria,  to  which 
it  bears  a  great  similarity.  According  to  Osier,  giant  urticaria  is  the 
same  disease. 

The  prognosis  is  of  course  favorable  for  life ;  for  cure  it  is  more 
doubtful,  as  the  disease  is  sometimes  exceedingly  obstinate. 

The  treatment  consists  of  rest,  the  use  of  tonics  particularly  directed 
to  the  nervous  system,  and  the  correction  of  any  gastro-intestinal  dis- 
order. Quinin  has  occasionally  proved  very  valuable.  Hypnotism  has 
also  been  suggested. 


RAYNAUD'S  DISEASE.  1185 


HYDROPS  ARTIOULORUM  INTERMITTENS. 

Definition. — A  condition  characterized  by  periodic  effusions  into 
one  or  more  of  the  large  joints,  and  usually  the  knee. 

The  pathologfy  is  unknown,  but  it  is  suspected  that  it  depends  upon 
some  nervous  disturbances  of  the  vessels  or  lymph-channels  in  the  joints. 

The  etiology  is  also  doubtful.  The  disease  occurs  in  nervous  indi- 
viduals, and  has  been  found  associated  with  other  nervous  diseases,  as  ex- 
ophthalmic goiter,  or  in  patients  suffering  from  other  vascular  diseases, 
as  angina  pectoris. 

The  symptoms  consist  of  the  sudden  development  of  a  swelling  in  the 
affected  joint,  which,  however,  does  not  present  any  symptoms  of  inflam- 
mation and  is  rarely  painful.  This  swelling  lasts  from  three  to  eight  days 
and  then  disappears  as  suddenly  as  it  came.  At  regular  intervals  of 
from  one  to  four  weeks  it  is  repeated,  and  this  repetition  may  continue 
for  years. 

The  diagnosis  must  be  made  upon  the  symptoms  and  the  periodicity 
of  the  condition. 

The  prognosis  is  doubtful,  most  cases  being  exceedingly  obstinate. 

Treatment. — Electro-therapy  in  various  forms  has  been  recom- 
mended. Among  the  drugs  that  have  been  suggested  are  salicylic  acid, 
quinin,  arsenic,  and  ergotin.  None,  however,  have  proved  particularly 
valuable. 


RAYNAUD'S  DISEASE. 

{Symmetric  Gangrene.) 

Definition. — A  condition  apparently  of  vasomotor  nature,  affecting 
symmetric  parts  of  the  body,  and  chiefly  the  tips  of  the  extremities. 

The  pathology  is  by  no  means  definitely  made  out.  It  is  supposed 
that  alterations  must  occur  in  the  vasomotor  centers  of  the  medulla  and 
cord,  but  none  have  as  yet  been  found,  partly  because  the  disease  is 
rarely  fatal.  In  some  cases  peripheral  neuritis  has  been  observed  and  in 
others  peripheral  endarteritis.  The  gangrene  is  usually  superficial,  and 
resembles  closely  that  caused  by  cold  ;  rarely  it  causes  an  extended  loss 
of  substance. 

The  etiology  of  the  condition  is  obscure  and  complex,  largely,  no 
doubt,  because  a  number  of  different  conditions  have  been  confounded 
under  this  designation.  The  disease  occurs  in  children  and  in  neurotic 
women,  less  often  in  men.  A  neuropathic  heredity  seems  to  predispose 
to  it,  and  occasionally  it  exists  in  connection  with  other  nervous  dis- 
eases, as  epilepsy,  migrain,  hysteria,  and  mental  disorders.  The  occur- 
rence of  paroxysmal  hemoglobinuria  has  led  to  the  suspicion  that  malaria 
is  an  etiologic  factor.  I  am  not  aware,  however,  that  plasmodia  have 
been  found  in  any  case,  and  the  asserted  good  results  following  the  ad- 
ministration of  quinin  are  insufficient  to  establish  the  contention.  Syph- 
ilis and  various  other  infectious  diseases  have  also  been  mentioned  as 
etiologic  factors,  and  more  recently  a  form  has  been  described  that  is  sup- 

75 


1186  DISEASES  OF  THE  NERVOUS  SYSTEM. 

posed  to  be  purely  hysteric  in  nature.  The  most  important  exciting 
cause  is  exposure  to  cold,  although  attacks  may  also  be  brought  on  by 
severe  emotional  disturbances. 

Symptoms. — The  disease  presents  three  grades  of  severity  :  first, 
anemia  or  local  syncope ;  second,  cyanosis  or  local  asphyxia ;  and  third, 
gangrene.  Local  syncope  consists  in  a  vasomotor  spasm  in  one  or  more 
extremities,  the  fingers  being  most  frequently  affected,  and  rarely  more 
than  one  at  a  time.  They  become  white,  almost  waxy  in  appearance, 
cold,  and  hard  to  the  touch,  and  they  may  be  either  dry  or  covered  with 
a  cold  perspiration.  The  finger  is  perfectly  numb,  but  severe  neuralgic 
pains  may  be  felt  in  the  arm ;  if  the  skin  be  pricked  with  a  pin,  no  blood 
flows.  Ordinarily  this  syncope  disappears  gradually,  the  reaction  being 
accompanied  by  tingling  and  formication  in  the  affected  digit,  which  ulti- 
mately returns  to  a  normal  condition.  Local  asphyxia  is  a  further  stage 
of  this  condition :  in  this  the  finger  is  blue  and  swollen,  and  there  is  a 
sense  of  discomfort  that  is  apparently  due  to  the  stretching  produced  by 
the  engorged  veins.  This  cyanotic  condition  may  also  affect  the  ears, 
toes,  and  the  tip  of  the  nose,  and,  like  the  preceding  stage,  it  may  dis- 
appear without  leaving  any  trace  of  its  existence.  Patients  that  have 
reached  this  stage  seem  to  be  more  liable  to  a  recurrence  upon  slight  ex- 
pcJsure  than  those  who  only  present  local  syncope.  The  attacks  are  more 
likely  to  recur  constantly  in  the  same  digit,  and  not  to  appear  first  in  one 
and  then  in  another.  During  the  existence  of  this  stage  a  not  infrequent 
associated  symptom  is  hemofilohimiria  ;  this  is  especially  apt  to  occur  in 
children,  and  has  led  to  the  suspicion  of  malarial  influence.  In  some 
cases,  when  hemoglobinuria  is  not  found,  the  urine  contains  an  excess 
of  urates.  If  the  attack  lasts  for  several  days,  trophic  changes  take 
place  in  the  finger-nail,  giving  rise  to  a  transverse  ridge,  which  per- 
sists until  that  portion  of  the  nail  has  grown  beyond  the  end  of  the  fin- 
ger. If  local  cyanosis,  however,  continues  sufficiently  long,  gangrenous 
changes  take  place.  These  appear  first  as  small  black  spots  or  vesicles 
filled  with  serum  upon  the  end  of  the  fingers  or  about  the  root  of  the 
nail;  these  gradually  slough  off,  leaving  a  small  ulcer  that  may  slowly 
cicatrize.  Often  patients  subject  to  recurrences  of  the  disease  show  a 
number  of  cicatrices  on  the  ends  of  the  fingers,  or  if  the  ears  are  affected 
there  may  be  slight  shrivelling  of  their  edges.  The  gangrene,  however, 
may  be  more  severe,  in  Avhich  case  the  distal  phalanges  of  the  affected 
fingers  may  become  black  or  dark  red,  covered  with  blebs,  and  finally 
mummified.  The  line  of  demarkation  then  forms,  and  ultimately  the 
gangrenous  portion  falls  off,  leaving  an  ulcerated  stump  that  slowly 
cicatrizes.  This  form  may  not  be  limited  exclusively  to  the  hands  and 
feet  or  ears,  but  symmetric  patches  sometimes  appear  in  the  skin  of  the 
breast.  During  the  time  that  the  gangrene  is  present  the  patients  suffer 
from  excruciating  pains  in  the  limbs  that  interfere  with  sleep,  often  causing 
transient  melancholia,  and  seeming,  more  than  the  gangrene  itself,  to 
depress  the  general  condition.  Fever  is  rarely  present ;  sugar  is  some- 
times found  in  the  urine,  but  not  constantly." 

The  diagnosis  is  necessarily  difficult  when  it  is  remembered  that  all 
clinicians  do  not  agree  that  such  a  disease  exists.  According  to  Raynaud's 
definition,  it  is  a  neurosis  characterized  by  enormous  exaggeration  of  the 
excito-motor  energy  of  the  gray  parts  of  \he  spinal  cord  that  control  the 


PROGRESSIVE  HEMIATROPHY  OF  THE  FACE.  1187 

vasomotor  innervation.  If  this  be  accepted,  then  all  cases  in  Avhich 
lesions  of  the  nerves  and  arteries  have  been  found  are  not  properly  of 
the  same  nature ;  and  there  are  a  number  of  other  conditions  that  may 
produce  gangrene,  often  somewhat  symmetric  in  type  and  perhaps  due  to 
vasomotor  spasms  (particularly  syj-ingomyelia  and  leprosy).  The  so-called 
"dead  finger"  is  a  common  symptom,  and  its  occurrence  is  by  no  means 
sufficient  justification  for  a  diagnosis  of  Raynaud's  disease.  In  fact,  the 
typical  forms  of  this  condition  should  advance  to  slight  superficial  and 
symmetrically  placed  patches  of  gangrene.  Gangrene  may  also  occur  in 
diabetes,  and  hence  the  urine  should  always  be  examined  to  exclude  this 
condition.  Hysteric  gangrene  is  rarely  symmetric,  and  the  patients  pre- 
sent various  hysteric  stigmata. 

The  prognosis  is  very  favorable.  Only  in  marasmic  children  do  the 
attacks  ever  lead  to  death.  Ordinarily  they  become  in  time  less  frequent 
and  ultimately  disappear,  but  in  a  few  cases  the  tendency  to  recurrence 
is  obstinate. 

The  treatment  consists  of  improvement  in  the  general  condition 
during  the  intervals.  During  the  attack  the  most  effective  measures  are 
a  mild  massage,  the  use  of  local  lukewarm  baths,  and  electricity  very 
cautiously  applied,  either  in  a  constant  descending  stream  to  the  spinal 
column  or  by  the  application  of  the  anode  to  the  spine  and  of  the  cathode 
to  a  vessel  containing  water  into  which  the  hand  has  been  plunged.  Amyl 
nitrite,  which  might  be  expected  to  relax  the  vasomotor  spasm,  fails  to 
have  any  effect ;  on  the  other  hand,  pilocarpin  has  been  employed  with 
good  results.  If  the  pains  are  very  severe,  they  must  be  combated  by 
morphin — although  gangrene  may  occur  at  the  site  of  the  injection — 
administered  hypodermically,  if  necessary.  Sleep  should  be  obtained  by 
means  of  narcotics.  The  gangrenous  parts  should  always  be  carefully 
protected  by  a  local  dressing. 


PROGRESSIVE  HEMIATROPHY  OP  THE  FACE. 

{Progressive  Facial  Atrophy.) 

Definition. — A  rare  disease,  characterized,  as  its  name  would  indi- 
cate, by  a  progressive  atrophy  of  one-half  of  the  face,  stopping  sharply  at 
the  middle  line,  and  in  the  severer  forms  involving  the  skin,  muscles, 
and  bones. 

The  pathology  of  the  condition  is  unknown.  Rarely  symptoms 
indicating  inflammation  of  the  cervical  sympathetic,  such  as  dilatation 
of  the  pupil  or  flushing,  have  been  present,  and  symptoms  indicating 
inflammation  of  the  trigeminus  have  been  equally  infrequent.  Mend&l, 
however,  has  reported  a  case  in  which  he  found  chronic  interstitial  neuri- 
tis of  the  branches  of  the  trifacial,  and  other  cases  have  been  reported  in 
which  the  Gasserian  ganglion  was  diseased.  Microscopic  examination 
has  shown  a  disappearance  of  the  subcutaneous  fatty  tissue  and  a  general 
atrophy  of  the  elements  of  the  skin  itself,  often  associated  with  the  pres- 


1188  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ence  of  an  abnormal  quantity  of  pigment.  As  a  rule,  the  vessels  are 
relatively  enlarixed. 

The  etiology  is  unknown.  The  condition  usually  commences  early 
in  life  and  shows  no  predilection  for  either  sex.  An  hereditary  tendency 
does  not  appear  to  exist,  but  the  disease  occurs  frequently  as  a  complica- 
tion of,  or  rather  in  connection  with,  other  neurotic  conditions.  Of  these 
the  most  frequent  are  neuralgia,  migrain,  epilepsy,  and  mental  disorders ; 
less  frequently,  tic  convulsif  and  chorea,  particularly  if  the  latter  affects 
the  muscles  of  the  jaw  and  tongue.  Occasionally  it  has  been  recorded  as 
occurring  in  patients  suffering  from  locomotor  ataxia  or  multiple  sclerosis. 
It  does  not  appear,  however,  that  progressive  facial  atrophy  has  any  ana- 
tomic connection  with  these  conditions.  In  a  few  cases  the  disease  has 
been  preceded  by  an  injury  to  the  skull  or  face,  and  in  others  it  has  fol- 
lowed an  acute  infectious  disease.  Ordinarily  it  occurs  in  early  life — i.  e. 
between  the  tenth  and  fifteenth  years — and  in  these  cases  it  usuall}'  pro- 
gresses to  the  most  severe  type. 

The  earliest  symptom  is  a  flattening  of  the  skin  on  the  affected  side, 
constituting  the  lightest  form  of  the  disease,  which  may  remain  station- 
ary at  this  point ;  if,  however,  it  progresses,  the  muscles  and  bones  also 
become  involved,  so  that  the  affected  half  of  the  face  is  distinctly  smaller 
than  the  healthy  side.  The  objective  changes  that  take  place  in  the  skin 
are  the  development  of  white  spots  in  which  the  pigment  has  disappeared, 
and  Avhich  have  the  appearance  almost  of  scar-tissue,  or,  what  is  more 
commonly  the  case,  of  an  increase  in  pigmentation  with  a  formation  of 
yellowish  or  brownish  blotches,  the  skin  being  depressed  in  these  areas, 
which  usually  lie  along  the  course  of  the  nerve-trunks,  especially  the 
infraorbital.  The  hair  becomes  thinner,  dryer,  and  often  falls  out.  The 
secretion  of  the  sebaceous  glands  is  diminished  and  the  skin  dryer.  Rarer 
phenomena  are  the  distiirhanee  of  hJnshing,  so  that  the  affected  side  of  the 
face  remains  unchanged  in  color  Avhen,  as  a  result  of  some  emotional  dis- 
turbance, the  other  is  distinctly  reddened.  Disturbances  of  sensation  are 
not  common.  In  some  cases  electric  and  tactile  sensibility  have  been 
diminished ;  in  others  the  patients  have  complained  of  slight  paresthesiae. 
The  special  senses  remain  unaffected,  and  even  when  the  atrophy  extends 
to  the  tongue,  taste  remains  perfect  on  the  affected  side.  In  one  case 
there  were  a  slight  disturbance  of  hearing  and  occasional  tinnitus. 

The  diagnosis  of  the  condition  is  easy  both  when  it  is  suspected  and 
when  it  is  far  advanced.  The  only  condition  with  which  it  could  be  con- 
founded is  congenital  facial  asymmetry.  In  facial  hemiatrophy,  however, 
the  skin  is  shrunken  and  wrinkled,  and  the  hair  is  dryer  and  thinner, 
contrasting  markedly  with  the  healthy  side,  and  there  is  usually  a  history 
of  commencement  some  years  after  birth.  In  congenital  asymmetry  the 
difference  between  the  two  sides  is  slight,  and  the  skin  over  the  smaller 
side  is  normal  in  every  respect.  Commonly  in  this  condition  we  also 
find  differences  in  the  development  of  the  extremities.  In  a  case  that  I 
recently  observed  with  marked  facial  asymmetry,  the  left  side  being 
smaller,  the  hand  and  foot  on  the  same  side  were  distinctly  smaller  than 
the  corresponding  members. 

The  prognosis  is  unfavorable  as  regards  cure.  The  disease  itself  is 
not  in  the  least  dangerous,  and  cases  have  been  recorded  that  have  been 
under  observation  for  thirty  years  or  more. 


SCLERODERMA   DIFFUSUM.  1189 

Treatment  is  unsatisfactory.  The  prolonged  use  of  electricity  has 
been  said  to  arrest  the  process,  and  sometimes  this  arrest  occurs  sponta- 
neously ;  it  is  not  certain  that  the  treatment  is  of  any  use. 

An  allied  condition  is  hemihypertrophy  of  the  face.  This  is  an  ex- 
ceedingly rare  condition,  and  is  apparently  always  congenital.  It  involves 
chiefly  the  soft  parts,  the  ear,  skin,  tongue,  and  tonsils  being  all  enlarged. 
There  is  an  increased  secretion  from  the  sebaceous  glands,  which  may 
appear  as  small  elevations  upon  the  skin.  Usually,  as  in  congenital 
asymmetry,  there  is  enlargement  of  the  extremities  on  the  same  side. 
The  only  case  that  has  come  to  autopsy  presented  no  lesions. 

Treatment  is  of  course  unavailing;. 


SCLERODERMA   DIFFUSUM. 

Definition. — A  peculiar  hardening  of  the  skin,  with  areas  of  pig- 
mentation and  depigmentation,  associated  in  the  more  advanced  stages 
with  trophic  lesions,  muscular  atrophies,  and  aifections  of  the  bones. 

Pathology. — The  affected  skin  is  characterized  by  an  increase  of  the 
connective  tissue  and  of  the  elastic  fibers,  and  by  a  narrowing  of  the  ves- 
sels as  a  result  of  perivascular  infiltration. 

The  etiology  is  not  clear.  Some  of  the  cases  are  associated  with 
joint-affections  that  resemble  those  of  chronic  rheumatism  ;  others  follow 
exposure  to  a  very  low  temperature.  The  presence  of  trophic  lesions  in 
the  skin  and  the  development  of  myopathies  lead  to  the  supposition  that 
it  is  properly  classed  with  the  trophic  neuroses.  The  disease  usually 
occurs  in  middle  life,  although  cases  have  been  observed  among  children. 
Women  are  more  frequently  affected  than  men. 

Symptoms. — Three  stages  are  recognized  :  First,  a  rather  dense 
edema.  Second,  a  true  sclerosis,  in  which  the  skin  appears  thicker,  with 
an  absence  of  the  normal  folds  ;  it  becomes  firm  and  hard,  so  that  it  can- 
not be  pinched  between  the  fingers  and  lifted  from  the  flesh.  Moreover, 
there  are  always  pigmentary  changes,  certain  parts  being  darker  than 
normal,  while  others  become  a  dead  white,  appearing  almost  as  if  com- 
posed of  alabaster.  The  disease,  as  a  rule,  attacks  first  the  upper  por- 
tion of  the  body — i.  e.  the  face,  neck,  hands,  and  arms,  or  the  surface 
of  the  thorax,  and  is  most  pronounced  in  those  regions  where  the  bones 
are  subcutaneous.  The  diminished  elasticity  considerably  interferes  with 
the  movements  of  the  body.  If  the  neck  is  affected,  it  is  difiicult  to  turn 
the  head  ;  if  the  skin  over  the  joints  is  involved,  their  normal  flexion  and 
extension  cannot  be  perfectly  performed.  The  subjective  sensations  are 
those  of  tension,  the  patient  complaining  that  the  skin  has  become  "  too 
small  "  for  him.  If  any  forcible  action  is  attempted,  there  is  severe  pain, 
accompanied  by  slight  tears  in  the  skin.  The  skin  is  paler  and  cooler 
than  normal,  and  the  slightest  exposure  to  cold  causes  great  discomfort 
and  cyanosis.  The  secretion  of  sweat  may  be  normal,  but  is  usually  di- 
minished. Tactile  sensibility  is  unimpaired.  The  third  stage  is  that  of 
atrophy  ;  the  skin  becomes  thin  as  paper  ;  the  other  symptoms,  however, 
remain  as  before,  except  that  the  secretion  of  sweat  is  abolished   and 


1190  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ulcerations  appear  that  either  heal  slowly  or  not  at  all.  In  addition,  there 
are  muscular  atrophies  associated  -with  contractures.  Often  there  is  con- 
siderable atrophy  of  the.  hones.,  or  there  may  be  a  development  of  exos- 
toses from  the  periosteum.  Occasionally  the  end-phalanges  of  the  fingers 
undergo  a  process  of  gangrene  that  is  similar,  in  some  respects,  to  that  of 
Raynaud's  disease.  Chronic  joint-ajf'ections  may  also  be  observed  in  this 
stage,  particularly  of  the  fingers. 

The  course  of  the  disease  is  variable.  Usually  it  develops  slowly 
and  lasts  for  many  years. 

The  diagnosis  is  usually  easy,  though  occasionally  it  has  been  con- 
fused with  Addison  s  disease  on  account  of  the  excessive  pigmentation. 
There  is,  of  course,  some  resemblance  to  Raynaud' s  disease,  although 
the  condition  of  the  skin  itself  is  very  different.  In  the  atrophic  stages 
it  may  be  confounded  with  xeroderma  pigmentosum. 

The  prognosis  is  always  doubtful.  In  the  later  stages  the  patients 
become  emaciated,  and  pass  into  a  cachectic  state,  in  which  death  may 
occur.  Pulmonary  complications  may  develop.  Complete  cure  may, 
however,  occur,  and  particularly  in  cases  that  have  a  rapid  course. 

The  treatment  is  unsatisfactory.  The  unpleasant  tension  of  the 
skin  may  be  somewhat  diminished  by  ointments  and  massage  ;  warm 
water  or  steam  baths  may  also  give  considerable  relief.  The  most  import- 
ant thing  is  to  maintain  the  general  condition  of  the  patient  by  tonics 
and  a  change  of  climate.  Sodium  salicylate  has  been  recommended,  but 
is  probably  valueless. 


MORPHEA. 

( Scleroderma  Circumscriptum.) 


This  disease  consists  of  the  development  of  small  areas  of  sclerosis 
that  are  distinctly  related  to  the  distribution  of  the  nerves.  These  areas 
are  round  or  oval,  brownish  or  violet  in  color,  and  as  they  increase  in 
size  there  develops  in  their  centers  more  or  less  sclerosis.  In  these  scle- 
rotic areas  there  are  often  punctiform  collections  of  pigment,  the  hairs  fall 
out,  and  superficial  ulcerations  may  be  present  Occasionally  they  may 
go  on  to  atrophy  of  the  skin.     There  are  no  constitutional  symptoms. 

The  diagnosis  is  usually  easy. 

The  prognosis  as  regards  life  is  favorable ;  as  regards  cure  it  is 
doubtful. 

The  local  treatment  is  the  same  as  for  the  diffuse  form  of  sclero- 
derma. 


AINHUM. 


This  is  a  disease  characterized  by  an  enlargement  of  the  little  toe 
and  the  formation  of  a  line  of  demarkation  at  its  base. 

The  pathology  is  not  known,  but  it  appears  from  a  Rontgen-ray 
picture  that  the  bones  are  absorbed.     There  is  some  dispute  as  to  whether 


EB  YTHR  OMELAL  GIA.  1191 

it  is  one  of  the  manifestations  of  leprosy  or  not.  At  any  rate,  it  does  not 
appear  that  typical  lepra  bacilli  have  been  found. 

Etiology. — The  disease  may  occur  in  childhood  or  early  adult  life, 
and  is  most  common  in  negroes.  It  occurs  almost  exclusively  in  tropical 
regions — e.  g.  Brazil  and  Syria. 

The  symptoms  of  the  condition  consist  in  the  formation  of  Sifurrotv 
at  the  base  of  the  little  toe  of  one  of  the  feet.  This  grows  deeper  and 
deeper  until  spontaneous  amputation  has  occurred.  Rarely  the  other 
toes  on  the  same  foot  become  progressively  involved.  Certain  vasomotor 
disturbances  may  be  observed ;  the  foot  is  usually  swollen,  bluish-red, 
and  cold  ;  sometimes  the  other  foot  may  exhibit  similar  changes  without 
the  formation  of  furrows  at  the  base  of  the  toes.  There  is  some  diminu- 
tion of  sensation  to  touch,  temperature,  and  electricity,  and  ordinarily 
the  patient  complains  of  vague  pains  in  the  limbs. 

The  diagnosis  is  to  be  made  from  leprosy,  with  which,  indeed,  it 
may  be  identical,  and  congenital  amputation :  the  latter  only  occasions 
difficulty  when  the  disease  commences  in  early  life. 

The  prognosis  is  favorable  to  life,  but  the  disease  is  usually  slowly 
progressive. 

No  effective  treatment  has  been  discovered,  but  the  parts  should  be 
protected  against  injury,  and  the  patients  may  be  given  tonics  and  ano- 
dynes as  required. 


ERYTHROMELALGIA  ( Weir  Mitchell). 

{Paralytic   Vaso-motor   Neurosis   of  the   Extremities.) 

Definition. — A  disease  characterized  by  paresthesia,  redness  of  the 
skin,  and  by  pain,  usually  in  the  toes  and  heels,  associated  with  more  or 
less  severe  general  disturbances. 

The  pathology  is  unknown,  but  the  disease  appears  to  be  due  to 
some  disturbance  of  the  vasomotor  centers  or  nerves. 

]^tiology. — The  cause  seems  to  be  exposure  to  cold,  but  a  nervous 
temperament  or  a  previous  attack  of  rheumatism  appears  to  have  some 
predisposing  action.  Men  are  more  frequently  affected,  and  the  disease 
usually  develops  in  early  adult  life. 

Symptoms. — The  earliest  symptom,  as  a  rule,  is  the  occurrence  of 
severe  pains  in  the  feet.  Objectively,  there  are  swelling  and  reddening 
of  the  skin,  and  the  sensitiveness  is  so  severe  that  the  patient  is  unable  to 
walk.  The  general  symptoms  consist  of  headache,  dizziness,  palpitation 
of  the  heart,  or  even  fainting.  The  attacks  occur  more  frequently  during 
the  summer  months,  and  are  always  aggravated  by  exposure  to  heat  or  a 
vertical  position  of  the  limbs. 

The  diagnosis  is  easy,  the  condition  being  really  a  symptom  rather 
than  a  disease.  It  may  occur  in  the  course  of  hemiplegia  and  in  some 
organic  diseases  of  the  spine,  and  these  should  be  excluded. 

The  prognosis  is  favorable ;  often,  however,  the  disease  will  recur 
at  irregular  periods  for  a  number  of  years.  The  attack  can  usually  be 
cut  short  by  plunging  the  limb  into  ice-cold  water. 


1192  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — This  should  always  be  tonic,  and  employed  during  the 
intervals ;  massage,  hot  and  cold  douches,  and  the  faradic  current  may  be 
used  upon  the  affected  extremities.     The  pain  may  call  for  anodynes. 


ACROPARESTHESIA. 

{Spastic  Vasomotor  Xeurosis  of  the  Extremities.) 

Definition. — A  disease  characterized  by  abnormal  sensations  in  the 
hands,  slight  vasomotor  disturbances,  and  slight  stiffness  of  the  fingers. 

The  pathology  and  etiology  are  not  understood.  Possibly  the 
condition  is  due  to  some  disturbance  of  the  peripheral  nervous  system. 
It  occasionally  occurs  after  injury  or  as  a  result  of  prolonged  exposure 
to  cold,  hence  is  common  among  laundresses.  It  is  more  frequent  among 
women  than  men.  and  usually  develops  in  middle  life. 

The  symptoms  consist  in  the  more  or  less  sudden  development  of 
formication  and  tinglbui  or  numbness  in  the  fingers  and  finger-tips,  usu- 
ally bilateral,  but  sometimes  occurring  only  on  one  side.  Less  frequently 
the  toes  are  affected.  These  pains  are  more  severe  in  the  night  and  early 
morning,  and  worse  in  summer  or  after  exposure  to  heat.  The  vaso- 
motor disturbances  are  variable.  Sometimes  nothing  can  be  observed, 
and  sometimes  the  extremities  are  bluish  and  cold,  sometimes  pink  and 
warm.  Sensibility  is  rarely  affected.  In  some  cases,  however,  there  is 
considerable  hyperesthesia ;  in  others  moderate  anesthesia.  In  a  few 
cases  there  is  stiffness  of  the  hands.  Slight  tropJiic  distvrhances  have 
been  re])orto<l  in  a  few  cases.  The  attack.s  may  last  from  a  few  minutes 
to  several  hours,  and  may  recur  fre(juently  or  only  at  considerable  inter- 
vals. Usually  during  the  attack  the  abnormal  sensations  are  continuous, 
but  occasionally  they  are  intermittent  in  character.  The  condition 
known  as  tender  toes,  that  occasionally  occurs  after  an  attack  of  typhoid 
fever,  is  probably  a  form  of  this  disease.  It  is  ascribed  to  the  Brand 
treatment,  but  incorrectly. 

The  diagnosis  is  usually  easy.  Care  should  be  taken,  however,  not 
to  confuse  these  acroparesthesia?  with  commencing  locomotor  ataxia, 
tetany,  or  hysteria.  In  Raynaud's  disease  cold  increases  the  intensity 
of  the  symptoms. 

The  prognosis  is,  in  general,  favorable,  the  disease  usually  disap- 
pearing after  some  months  ;  sometimes,  however,  the  condition  is  ob- 
stinate. 

The  treatment  is  rather  unsatisfactory.  Laundresses  should  be 
advised  to  adopt  some  other  vocation.  Local  stimulation  with  the  faradic 
brush  has  sometimes  been  of  value,  and  hydrotherapy  may  also  be  em- 
ployed. At  the  same  time,  the  patient  should  be  given  tonics,  particu- 
larly if  anemia  is  present.  Alkaline  washes  are  almost  a  specific  for 
the  tender  toes.  Saturated  solutions  of  sodium  or  lithium  carbonate 
should  be  employed. 


MEBALGIA  PARESTHETICA.  1193 

MERALGIA  PARESTHETICA. 

[Bernhardf  s  Disturbance  of  Sensation.') 

Definition. — A  disease  characterized  by  paresthesia  and  disturb- 
ance of  sensation  on  the  outer  side  of  the  thigh,  in  the  region  supplied 
by  the  external  cutaneous  femoral  nerve. 

Pathology. — Nawretsky  has  examined  one  case,  and  found  chronic 
interstitial  neuritis.  There  is  reason  to  believe  that  this  is  not  always 
present. 

Htiology. — This  is  very  various  ;  some  of  the  cases  have  been  pre- 
ceded by  injury,  excessive  exercise,  or  infectious  disease.  Alcoholism, 
constipation,  and  pregnancy  are  also  common  predisposing  causes  ;  cold 
douches  have  been  blamed  in  several  instances.  The  exposed  situation 
of  the  nerve  is  supposed  to  render  it  more  liable  to  this  peculiar  dis- 
turbance. 

Symptoms. — These  are  of  two  varieties:  'P\YBt,t]ieparest}iesice.  There 
may  be  burning,  tingling,  or  stabbing  pains  that  are  severe  enough  to 
disable  the  patient ;  or  there  may  be  only  a  feeling  of  cold  or  numbness. 
Second,  the  sensory  disturbances.  These  vary  from  slight  hyperesthesia 
to  total  anesthesia.  The  different  senses  are  not  always  equally  involved ; 
pain,  temperature,  and  electro-cutaneous  sensibility  being  usually  more 
profoundly  aifected  than  the  others.  Frequently  both  thighs  are  affected. 
There  is  often  a  tender  point  just  inside  the  anterior  superior  spine  of 
the  ilium. 

The  diagnosis  is  easy. 

The  prognosis  is  doubtful.  Some  of  the  cases  recover  rapidly, 
but  the  majority  become  chronic. 

Treatment. — But  little  can  be  done.  Locally,  the  dry  brush  seems 
to  do  good  in  some  cases,  and  the  general  health  should  be  improved  if 
possible.     In  aggravated  cases  a  portion  of  the  nerve  may  be  excised. 


PART   IX. 

DISEASES  OF  THE  MUSCLES. 


MYOSITIS. 


Rheumatic  myositis  and  the  suppurative  form  observed  in  pyemia, 
and  rarely  in  other  acute  infectious  diseases,  have  been  appropriately 
described  in  connection  with  the  diseases  to  which  they  are  secondary 
manifestations.  There  remain  to  be  discussed  two  rare  forms  of  the 
disorder. 

INFECTIOUS    MYOSITIS. 
{Acute  Polymyositis). 

Definition. — A  primary  acute  or  a  subacute  inflammation  of  the 
voluntary  muscles  due  to  an  unknown  microbic  agent. 

Pathologfy. — The  disease  is  a  true  inflammation  of  all  the  volun- 
tary muscles,  involving  chiefly  the  muscular  fibers,  and  to  some  extent, 
also,  the  interstitial  connective  tissue.  Beginning  with  marked  hyper- 
emia, there  next  occurs  an  exudation  of  leukocytes.  The  muscles  are 
firm,  fragile,  and  later  undergo  fatty  degeneration.  Serous  infiltration 
occurs  and  there  is  a  slight  hyperplasia  of  the  intermuscular  connective 
tissues.  Hueppe  records  a  case  that  showed  nothing  definite  beyond  a 
hyaline  degeneration  of  the  muscular  fasciculi. 

!^tiology. — We  are  no  less  ignorant  of  the  predisposing  influences 
than  of  the  specific  exciting  agency,  though,  perhaps,  young  males  are 
most  often  the  victims  of  this  malady. 

Symptoms. — As  a  rule,  first  the  muscles  of  the  extremities,  and 
later  of  the  trunk  also,  become  swollen,  firmer  than  normally,  and  stiif, 
rendering  locomotion  somewhat  difiicult  and  painful. 

The  involved  parts  may  also  be  tender  to  the  pressing  finger,  and  a 
slight  edema  may  be  noticed  that  is  at  first  more  or  less  localized,  but 
finally  becomes  generalized,  and  extends  even  to  the  face.  An  erythem- 
atous eruption  then  appears,  Avhich  is  irregularly  disseminated  over  the 
skin-surface,  and  may  tend  to  more  or  less  pigmentation.  Moderate 
pyrexia  and  splenic  enlargement  are  among  the  early  and  constant 
symptoms.  In  the  advanced  stage  the  muscles  of  deglutition  and  of 
respiration  become  involved,  rendering  the  act  of  swallowing  diflScult, 
and  inducing  marked  dyspnea. 

Among  the  complications  may  be  enumerated  bronchitis  and  broncho- 
pneumonia, the  latter  often  being  a  terminal  condition. 

Diagnosis. — Taken  in  the  aggregate,  the  symptoms  are  of  little 
diagnostic  importance  and  the  previous  history  is  invariably  negative. 

1195 


1196  DISEASES  OF  THE  MUSCLES. 

Trichiniasis  must  be  discriminated,  since  this  disease  produces  an  iden- 
tical clinical  picture.  The  distinction  may  rest  upon  the  examination 
of  an  excised  piece  of  aifected  muscle,  Avhich  "svill  not  only  discover  the 
trichinae,  if  present,  but  also  enable  the  microscopist  to  detect  the  posi- 
tive evidences  of  polymyositis.  In  a  recent  supposititious  case  of  infec- 
tious myositis  of  my  own,  a  portion  of  muscle,  examined  for  me  by  Dr. 
Babcock,  showed  neither  trichina  nor  the  histioid  changes  of  myositis. 
Multiple  neuritis  presents  neither  swelling  nor  edema. 

Course  and  Prognosis. — The  course  of  the  disease  may  either  be 
comparatively  rapid  (two  or  three  months),  or  it  may  be  slow  (chronic) 
and  continue  over  two  or  three  years.  It  usually  terminates  in  death, 
which  is  caused,  in  the  immense  majority  of  cases,  by  paralysis  of  respira- 
tion. Occasionally,  since  the  heart-muscle  has  been  rarely  found  to  be 
implicated,  the  end  may  be  preceded  by  cardiac  failure. 

The  treatment  is  simply  palliative  and  supportive. 

PROGRESSIVE    OSSIFYING   MYOSITIS. 

Definition. — Myositis,  either  general  or  local,  in  which  the  affected 
muscles  undergo  progressive  ossification. 

Pathology. — Following  the  changes  that  ordinarily  characterize 
myositis  (swelling,  leukocytic  exudation,  etc.),  a  calcification  that  is 
often  complete  takes  place.  The  process  may  extend  to  and  involve 
the  heart. 

The  etiology  is  obscure,  though  males  are  especially  the  subjects 
of  the  complaint,  Avhich  usually  begins  about  the  time  of  puberty. 

Diagnosis. — The  muscles  are  represented  by  plates  of  bony  hard- 
ness, leading  to  more  or  less  complete  ankylosis  of  the  joints  and 
vertebrse. 

The  course  of  myositis  ossificans  is  very  slow,  and  treatment 
has  afforded  only  negative  results. 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY. 

{Amyotrophia  Spinalis  Progressiva ;  Type  of  Duchenne-Aran.) 

Definition. — A  disease  of  the  peripheral  motor  neurons  and  the 
muscles  they  supply,  usually  beginning  in  the  cervical  region. 

Pathology. — There  is  atrophy  of  the  anterior  cornua  of  the  cord, 
affecting  chiefly  the  ganglion-cells,  degeneration  of  the  nerve-fibers  and 
of  the  muscles.  Occasionally  there  are  small  areas  of  sclerosis  that 
may  involve  the  pyramidal  columns  for  a  short  distance. 

Ktiology. — The  disease  appears  to  be  hereditary  in  a  few"  cases,  and 
in  these  may  develop  in  childhood.  A  commonly  accepted  predisposing 
cause  is  prolonged  severe  muscular  exertion.  It  is  most  common  in 
males,  and  most  frequently  appears  during  the  third  decade  of  life. 

Symptomatology. — The  first  changes  usually  appear  in  the  thenar 
and  hypothenar  eminences  of  the  hands.  These  become  flat  and  soft ; 
there  are  loss  of  power,  some  stiffness,  and  inability  to  perform  deli- 
cate coordinated  movements;  the  thumb  assumes  a  position  parallel  to 
the  other  fingers  {ape-hand) ;  the  interossei  muscles  waste  and  grooves 
appear  between  the  metacarpal  bones.     The  degenerative  changes  do 


PROGRESSIVE  NEURAL  MUSCULAR  ATROPHY.  1197 

not  ascend  by  continuity ;  the  deltoid  usually  being  affected  immedi- 
ately after  the  muscles  of  the  hand.  If  the  two  hands  have  not  bean 
affected  simultaneously,  the  other  now  begins  to  show  characteristic 
changes.  In  the  lower  limbs  the  quadriceps  femoris  is  usually  the  first 
muscle  attacked.  The  disease  gradually  involves  one  group  of  muscles 
after  another  until  a  large  part  of  the  muscular  system  is  affected.  All 
the  muscles  exhibit  the  fibrillary  twitchings,  the  reactions  of  degenera- 
tion, and  the  wasting.  Hypertrophy  never  occurs,  and  the  paralysis  is 
nearly  always  flaccid.  The  fibrillary  twitchings  are  characteristic,  but 
not  pathognomonic.  They  are  not  constant,  but  may  be  developed  by 
slightly  irritating  the  muscle.  There  is  usually  quantitative  diminution 
to  the  faradic,  and  qualitative  alteration  to  the  galvanic  current.  The 
diplegic  reaction  consists  of  the  development  of  contractures  in  the  op- 
posite arm  when  the  anode  is  placed  in  the  carotid  fossa  and  the  cathode 
over  the  spine.  It  is  most  common  in  this  disease,  but  may  occur  in 
other  conditions.  The  reflexes  diminish  in  proportion  to  the  atrophy 
of  the  muscles,  and  ultimately  disappear  completely  ;  the  patients  grad- 
ually become  almost  incapable  of  voluntary  motion  ;  but  for  a  time  they 
learn  to  overcome  their  disabilities  by  the  compensatory  use  of  other 
groups  of  muscles.  In  the  late  stage  the  diaphragm  becomes  paralyzed 
and  bulbar  symptoms  appear ;  usually  the  patients  die  from  inspira- 
tion-pneumonia. Rare  and  probably  accidental  symptoms  are  disturb- 
ances of  the  pupillary  reflexes  and  increase  in  the  secretion  of  sweat. 

DiflEerential  Diagnosis. — In  chronic  antero-poliomyelitis  groups 
of  muscles  are  affected  without  any  particular  order,  and  total  paralysis 
is  a  very  early  symptom  ;  in  amyotrophic  lateral  sclerosis  the  spastic 
symptoms  are  present ;  in  syringomyelia  and  pachymeningitis  cervicalis 
hypertrophica  disturbance  of  sensation,  pain,  and  trophic  lesions  occur ; 
in  Pott's  disease  affecting  the  lower  cervical  region  there  are  tenderness 
over  the  spine  and  sensory  disturbances ;  in  peripheral  neuritis  the  fin- 
gers are  unequally  affected  and  the  deltoid  does  not  waste ;  in  aj^thritic 
atrophy  joint-symptoms  are  present ;  and  in  the  peculiar  muscle-atrophies 
following  excessive  use  of  certain  groups  of  muscles,  rapid  improve- 
ment occurs  when  the  cause  is  removed. 

Prognosis. — This  is  unfavorable  as  to  cure.  The  course  is  exceed- 
ingly slow,  and  the  patients  often  live  for  a  number  of  years  after  the 
first  symptoms  have  appeared.  They  are,  however,  exceedingly  liable 
to  pulmonary  complications,  particularly  a  fatal  form  of  bronchitis. 

Treatment. — Prophylactic  measures,  such  as  the  avoidance  of  pro- 
longed excessive  work,  are  rarely  possible.  Retardation  may  possibly 
be  obtained  by  the  systematic  use  of  electricity,  massage,  and  gymnas- 
tics. Gowers  advocates  the  hypodermic  injection  of  strychnin  nitrate 
in  ascending  doses,  commencing  with  ywo  S^-  ^^^  rapidly  increasing  to 
-^q',  one  injection  should  be  given  daily. 


PROGRESSIVE  NEURAL  MUSCULAR  ATROPHY. 

(Charcot-Marie-Hoffmann  Type;  Peroneal  Type,  Gowers.) 

Definition. — A  degenerative  process,  apparently  commencing  in 
the  nerves,   and  characterized  by  muscular  degeneration,  with  subse- 


1198  DISEASES  OF  THE  MUSCLES. 

quent  contractures,  marked  sensory  disturbances,  and  a  loss  of  the 
reflexes. 

Pathology. — Degenerations  have  been  found  in  the  muscles,  the 
peripheral  nerves,  and  the  spinal  column.  In  the  former  the  muscle- 
cells  show  degenerative  changes.  The  nerves  exhibit  a  chronic  inter- 
stitial neuritis  with  proliferation  of  the  connective  tissue,  and  destruc- 
tion of  the  myelin-sheaths  and  axis-cylinders.  In  the  spinal  cord  degen- 
eration has  been  found  in  the  posterior  columns.  The  nature  of  the  dis- 
ease seems  to  be  akin  to  that  of  neuritis,  the  changes  in  the  muscles  and 
spinal  cord  being  secondary  to  those  of  the  nerves. 

Htiology. — Heredity  seems  to  play  an  important  part  in  the  causa- 
tion of  the  disease,  which  may  either  occur  in  successive  generations  of 
a  family  or  aifect  several  members  of  the  same  generation.  Sporadic 
cases  occasionally  occur  for  which  it  is  impossible  to  trace  any  ancestral 
influence,  though,  as  the  disease  has  been  known  to  skip  a  generation,  it  is 
not  impossible  that  such  cases  are  still  hereditary.  Males  are  much 
more  frequently  affected  than  females,  and  the  disease  almost  invariably 
commences  between  the  ages  of  ten  and  twenty  years. 

Symptoms. — As  the  name  implies,  muscular  wasting  usually  begins 
in  the  muscles  of  the  feet  or  hands,  either  the  peronei,  the  common  ex- 
tensors of  the  toes,  or  the  small  muscles  of  the  foot  itself,  or  else  in  the 
muscles  of  the  thenar  and  hypothenar  eminences  and  the  interossei. 
Usually  the  atrophy  is  symmetric.  In  the  feet  it  leads  to  an  early 
development  of  club-foot,  which  is  most  pronounced  when  the  extremity 
is  at  rest.  Very  early  the  atrophy  of  the  small  muscles  causes  the  toes 
to  assume  the  claAv  position,  and  the  atrophy  of  the  peroneals  causes 
foot-drop,  so  that  in  walking  the  foot  is  dragged  along  the  ground.  In 
the  later  stages  the  foot  becomes  permanently  fixed  in  a  position  of 
equino-varus  or  valgus.  The  hands  have  the  characteristic  appearance 
given  by  a  flattening  of  the  ball  of  the  thumb  and  middle  finger.  The 
interosseal  grooves  also  become  deeper  and  the  fingers  gradually  assume 
the  claw-like  position  {'■'■main  en  griff e'').  The  disease  extends  slowly 
upward,  involving  the  muscles  of  the  calf  and  thigh  or  the  forearm  and 
arm.  The  affected  muscles  usually  shoAv  distinct  fibrillary  tAvitchings 
that  may  be  so  severe  as  to  give  rise  to  an  irregular  tremor  of  the  fin- 
gers. Spontaneous  spasmodic  contractions  may  also  occur.  When 
electrically  examined  the  muscles  cither  show  a  marked  diminution  in 
reaction  to  the  galvanic  and  faradic  currents,  or  distinct  reactions  of 
degeneration  can  be  elicited.  Similar  electric  changes  are  also  found 
in  the  nerves.  Mechanic  excitability  of  the  muscles  is  considerably 
diminished,  these  changes  being  found  also  in  the  muscles  that  are 
apparently  healthy.  The  tendon-reflexes  are  usually  absent,  although 
in  the  early  stages,  when  the  muscles  of  the  thigh  are  still  unaltered, 
the  knee-jerk  may  be  merely  diminished.  Sensation  is  sometimes  unal- 
tered, but  ordinarily  there  is  considerable  diminution  to  touch.  It  is 
possible  that  some  cases  show  an  alteration  in  the  pain  and  temperature 
sense ;  often  there  are  paresthesias,  and  occasionally,  pains  of  consider- 
able intensity.  The  general  condition  of  the  patient,  however,  remains 
excellent.  The  vegetative  organs  are  unaffected  and  nutrition  is  there- 
fore intact. 

The  diagnosis  can  be  made  from  other  forms  of  progressive  muscu- 


PSEUDO-HYPEBTROPHIG  MUSCULAR   PARALYSIS:  1199 

lar  atrophy  (particularly  the  type  "  Duchenne-Aran  ")  by  the  sensory 
disturbances ;  from  locomotor  ataxia  by  the  absence  of  sphincter  dis- 
turbances ;  and  from  the  cerebral  palsies  of  childJiood  by  the  fact  that 
it  begins  late  in  life  and  is  distinctly  progressive,  showing  also  a  diminu- 
tion of  the  tendon-reflexes  and  reactions  of  degeneration  in  the  muscles. 

The  prognosis  is  good  as  regards  life,  but  unfavorable  as  regards 
cure  or  even  improvement.     The  course  of  the  disease  is  extremely  slow. 

The  treatment  employed  in  the  other  forms  of  amyotrophy  may  be 
tried,  but  so  far  nothing  has  succeeded  in  staying  the  course  of  the 
disease. 

A  type  of  disease  closely  allied  to  the  preceding  has  been  described 
by  D^jerine  under  the  name  of  ^'- iyifantile  hypertrophic  and  progressive 
interstitial  neuritis.''  The  muscular  symptoms  were  the  same,  but 
there  were  in  addition  ataxia,  lancinating  pains  in  the  limbs,  consider- 
able sensory  disturbances,  Romberg's  sign,  myosis,  with  slow  or  absent 
pupillary  reflexes  and  nystagmus.  In  addition  to  these  a  peculiar  symp- 
tom in  his  case  was  the  enormous'  hypertrophy  of  the  nerve-trunks, 
which  could  be  felt  under  the  skin  as  large,  firm  cords.  Pathologically 
the  muscles  showed  degenerative  changes  and  the  nerves  a  pseudo-hyper- 
trophy due  to  the  enormous  proliferation  of  the  connective  tissue  and 
degeneration  in  the  posterior  columns  of  the  spinal  cord.  The  dis- 
ease appears  also  to  be  due  to  old  hereditary  influence,  the  first  2  cases 
described  being  a  brother  and  sister. 


PSEUDO-HYPERTROPHIO  MUSCULAR  PARALYSIS. 

Definition. — A  disease  characterized  by  a  progressive  loss  of  power 
in  the  muscles  without  disturbance  of  their  electric  reaction,  while  at  the 
same  time  one  or  more  of  them  increases  in  size  and  firmness. 

Pathology. — Microscopic  examination  of  the  muscles  shows  that  the 
hypertrophy  has  been  produced  by  the  hyperplasia  of  adipose  tissue  in 
the  perimysium  internum.  The  muscle-fibers  may  either  be  normal, 
atrophied,  or  hypertrophied,  and  there  may  be  a  relative  increase  in  the 
connective  tissue.     The  motor  nerves  are  invariably  intact. 

The  etiology  of  the  disease  is  obscure.  It  appears  to  be  trans- 
mitted by  females  chiefly  to  males.  Occasionally  it  has  been  associated 
with  mental  disturbances  that  appear  to  indicate  that  it  may  be  indirectly 
a  nervous  condition.  Consanguinity,  according  to  Gowers,  may  be  a  pre- 
disposing cause  if  it  continues  through  several  generations.  The  disease 
usually  develops  in  early  life,  and  those  forms  that  occur  after  puberty 
are  more  common  in  females. 

Symptoms. — The  enlargement  usually  affects  the  muscles  of  the 
calves  of  the  legs,  although  various  muscles  in  other  parts  of  the  body 
may  be  involved,  as  the  infraspinatus  and  masseter,  or  the  muscles  of  the 
arms  and  thighs,  giving  the  patient  the  appearance  of  an  unequally  de- 
veloped athlete.  Fibrillary  contractions  may  sometimes  be  seen,  but  are 
not  frequent.  The  electric  reactions  show  no  qualitative  alteration,  but 
are  quantitatively  diminished  in  proportion  to  the  loss  of  power.     This 


1200  DISEASES  OF  THE  MUSCLES. 

loss  of  power  is  manifested  first  in  the  gait,  which  is  uncertain  and 
waddling ;  next,  by  the  difficulty  the  patient  has  in  arising  from  the 
ground.  He  first  gets  on  his  hands  and  knees,  then  lifts  his  knees 
from  the  floor  and,  placing  his  hands  first  on  his  ankles,  climbs  up  his 
legs  until  he  assumes  a  more  or  less  upright  position  (Fig.   78).     In 


Fig.  78. — Mode  of  risin^r  from  the  ground  in  pseudo-hypertrophic  paralysis  (Gowers) 


the  later  stages  of  the  disease  the  volume  of  the  muscles  becomes  less 
than  normal.  At  this  period  contractures  may  occur  leading  to  the  de- 
velopment of  club-foot  or  of  lateral  deviation  of  the  spine.  Lordosis  may 
also  be  produced  by  weakness  of  the  muscles  of  the  back,  and  the  spinal 
column,  being  no  longer  properly  supported,  may  topple  to  one  side  or 
the  other.  Ultimately  the  patient  may  lose  all  power  in  the  affected 
limbs  and  pass  into  a  cachectic  state,  in  which  he  dies.  Few  ever  reach 
adult  life.  Some  of  the  cases,  however,  seem  to  be  milder  in  character, 
and  may  amount  to  nothing  more  than  a  slight  weakness,  which  persists 
throughout  life  but  does  not  seriously  inconvenience  the  patient.  Often 
signs  of  intellectual  disturbance  are  present,  the  patient  learning  more 
slowly  and  showing  an  impaired  intellectual  coordination.  At  other  times 
epilepsy  may  be  present.  A  peculiar  variety  is  known  by  the  French  as 
forme  fruste  ;  this  is  characterized  by  a  rapid  atrophy  of  the  hypertro- 
phied  muscles,  and  consequently  the  course  of  the  disease  is  more  severe. 

The  diagnosis  is  relatively  simple,  a  typical  case  being  easily  recog- 
nized. In  those  cases,  however,  in  which  hypertrophy  is  slight,  the  dis- 
ease may  be  easily  confounded  with  progressive  muscular  dystrophy,  a 
disease  of  which,  perhaps,  this  is  only  a  variety. 

The  prognosis  is  unfavorable,  few  of  the  cases  living  to  adult  life. 

Treatment. — No  tonic  or  alterative  drug  has  exhibited  the  power 
of  arresting  the  progress  of  the  disease,  and  electricity  is  equally  value- 
less. Gowers  believes  that  persistent,  systematic  exercise  and  massage 
sometimes  retards  the  course,  but  never  leads  to  arrest.  This  should  be 
tried  in  every  case. 


DYSTROPHIA  MUSCULORUM  PROGRESSIVA  (Erh). 

[Scapnlo-humeral  Type;  Jucenile  Form  of  Progressive  Muscular  Afrophi/.) 

Definition. — A  primary  myopathy,  commencing  usually  in  the  mus- 
cles of  the  shoulder-blades  and  appearing  about  the  period  of  puberty. 
Pathology. — There  are  irregular  hypertrophy  and  atrophy  of  the 


DYSTROPHIA  MUSCULORUM  PROGRESSIVA.  1201 

muscle-fibers,  disturbances  of  the  striation,  and  multiplication  of  the 
nuclei,  with  a  relative  increase  of  the  entire  fascicular  connective  tissue. 
The  motor  nerves,  even  in  their  finest  terminations  in  the  muscles,  show 
no  alteration,  nor  are  changes  found  in  the  cord. 

Ktiology. — Heredity  plays  an  important  part,  although  occasionally 
the  disease  may  occur  sporadically.  As  in  the  other  forms,  it  sometimes 
develops  from  emotional  disturbances,  exposure  or  fatigue.  The  sexes 
are  aifected  about  equally.  The  first  symptoms  usually  appear  at  puberty, 
or  not  later  than  the  twentieth  year,  although  in  a  few  cases  the  condition 
has  developed  in  early  adult  life. 

Symptoms. — The  muscles  first  aifected  are  usually  the  pectorals  and 
the  latissimus  dorsi.  From  these  the  process  rapidly  extends  to  the 
muscles  in  the  neighborhood — i.  e.  the  serrati  and  the  muscles  of  the 
back.  The  muscles  of  the  arm,  particularly  the  flexors  in  the  lower 
arm  and  the  long  extensors,  are  usually  most  involved.  In  the  thighs, 
the  glutei  and  quadraceps  femoris  are  particularly  subject  to  the  atrophic 
process.  The  muscles  that  are  most  likely  to  escape  are  the  sterno-mastoid, 
the  spinati,  and  the  deltoid  in  the  upper  part  of  the  body ;  and  the  sar- 
torius  and  the  muscles  of  the  calves  of  the  legs  in  the  lower  part.  The 
muscles  gradually  waste,  and  the  wasting  is  accompanied  by  a  correspond- 
ing loss  of  power,  a  diminution  in  the  reflexes  and  of  the  electric  reac- 
tions. Reactions  of  degeneration  are  not  present.  Certain  peculiar 
appearances  are  produced  by  the  atrophy  of  certain  of  the  groups  of 
muscles.  As  the  shoulder-blades  are  no  longer  supported,  they  stand  out 
from  the  back,  giving  rise  to  the  so-called  "winged"  appearance,  and  as 
the  result  of  the  weakness  of  the  muscles  of  the  back  lordosis  is  exceed- 
ingly common.  Finally,  weakness  of  the  muscles  of  the  back,  and  par- 
ticularly of  the  glutei,  causes  the  patient,  when  he  rises  from  the  stooping 
posture,  to  go  through  the  same  actions  that  are  carried  out  by  children 
sufiering  from  pseudo-muscular  hypertrophy — i.  e.  climbing  up  his  own 
legs.  Finally,  if  the  diaphragm  is  involved,  dyspnea  may  develop  to 
a  greater  or  less  extent,  and  may  even  lead  to  death.  In  certain  rare 
cases  the  muscles  of  the  face  also  show  slight  paresis,  manifested  by  an 
inability  to  whistle,  a  disturbance  of  speech,  and  an  imperfect  closure  of 
the  eyelid.  Motion  is  affected  proportionately  with  the  degree  of  atrophy. 
The  gait  is  disturbed  and  becomes  waddling,  due  to  the  alternate  lifting 
of  the  sides  of  the  pelvis  in  order  to  clear  the  foot  of  the  ground.  Sen- 
sation is  never  disturbed.  The  sphincters  are  not  involved  and  bulbar 
symptoms  do  not  appear,  even  late  in  the  disease. 

The  diagnosis  must  of  course  be  made  from  the  other  forms  of 
progressive  muscular  atrophy.  The  differential  diagnosis  is  essentiallv 
the  same  as  that  for  the  infantile  type,  excepting  that  from  the  latter  it 
can  be  distinguished  by  the  different  order  of  invasion  and  the  period  of 
life  at  which  it  occurs.  It  is  exceedingly  difficult,  sometimes,  to  make  a 
differential  diagnosis  if  the  muscles  of  the  face  are  also  involved.  In 
certain  rare  cases,  such  as  one  described  by  Oppenheim,  there  may  be  a 
congenital  absence  or  a  weakness  of  certain  groups  of  muscles,  and  par- 
ticularly of  those  most  likely  to  be  involved  in  this  disease.  In  such 
instances  the  differential  diagnosis  may  be  made  upon  learning  that  the 
weakness  has  existed  since  birth  and  has  not  increased. 

The  prognosis  is  hopeless  as  regards  improvement.  The  course  of 
76 


1202  DISEASES  OF  THE  MUSCLES. 

the  disease  is  slow,  but  pi'ogressive,  though  life  is  usually  not  threatened 
unless  the  diaphragm  is  involved.  The  patient  ordinarily  lives  for 
twenty  or  thirty  years  after  being  first  attacked. 

The  treatment  consists  of  s^-stematic  gymnastics,  massage,  and 
electricity.  At  the  same  time  the  general  health  of  the  patient  must  not 
be  neglected.     Apparent  results  are,  however,  rarely  attained. 


DYSTROPHIA  MUSCULORUM  PROGRESSIVA  {Dejerine- 

Landonzy). 
{Facio-scapulo-humeral  Type;  Infantile  Type  of  Progressive  Muscular  Atrophy.) 

Definition. — This  form  is  characterized  by  the  development  of  mus- 
cular atrophy  of  the  face,  shoulder,  and  arm,  giving  rise  particularly  to 
the  fades  myopathica. 

Pathology. — The  wasted  muscles  show  in  all  respects  the  histologic 
changes  found  in  the  type  of  Erb,  and  essentially  those  found  in  the 
pseudo-hypertrophic  form  of  muscular  paralysis. 

Ktiologfy. — The  disease  is  distinctly  hereditary,  and  occurs  ordinar- 
ily about  the  third  and  fourth  years  with  equal  frequency  in  both  sexes, 
although  a  curious  predisposition  to  one  sex  or  the  other  is  noted  in  cer- 
tain families.  As  many  as  ten  generations  in  a  family  have  been  re- 
corded in  which  one  form  or  other  of  myopathy  developed.  In  a  few 
cases  some  acute  infectious  disease  or  disturbance  of  general  nutrition  has 
preceded  the  muscular  wasting,  but  there  is  no  reason  to  believe  that  the 
connection  is  other  than  accidental. 

Symptoms. — The  disease  usually  begins  in  the  muscles  of  the  face. 
Of  these  the  muscles  of  the  eyelids  and  mouth  first  undergo  degeneration, 
giving  rise  to  a  peculiar  expression  in  which  the  eyes  cannot  be  closed, 
the  upper  lid  covering  only  half  of  the  eyeball  ;  the  under  lip  drops  for- 
ward and  downward  ;  the  upper  lip  is  wasted  and  expressionless  ;  all 
wrinkles  disappear,  and  the  patient  has  a  peculiar  and  strikingly  stupid 
expression.  The  ordinary  movements  of  the  face  are  considerably 
affected.  Whistling  cannot  be  accomplished,  speech  is  imperfect,  and 
when  the  muscles  of  the  eyeballs  are  involved  ocular  fixation  is  impossi- 
ble. The  shoulder-muscles  next  undergo  atrophy.  The  earliest  to  be 
affected  are  usually  the  cuciiUaris,  the  rhomboids,  and  the  pectoral  mus- 
cles ;  finally,  the  disease  extends  to  the  arms,  where  we  find  the  deltoid, 
biceps,  triceps,  and  some  of  the  extensors  involved.  Ordinarily  certain 
groups  of  muscles  seem  to  escape,  among  these  being  the  muscles  of 
mastication  and  the  muscles  of  the  forearm  and  hand.  As  the  result  of 
these  changes,  the  shoulder-blades  become  more  freely  movable  and  stand 
out  from  the  back  and  the  shoulders,  and  when  the  patient  is  lifted  by 
placing  the  hands  under  the  arms,  the  shoulders  show  an  abnormal  degree 
of  upward  movement.  The  nutrition  of  the  muscles  is  only  affected  in 
proportion  to  the  atrophy.  Electric  reactions  remain  normal  qualita- 
tively, but  are  diminished  quantitatively.  Fibrillary  contractions  occur 
with  extreme  rarity  ;  power  is  diminished  in  proportion  to  the  wasting. 
Sensory  disturbances  do  not  occur. 


ARTHRITIC  MUSCULAR  ATROPHY.  1203 

The  diagnosis  is  to  be  made  from  the  spinal  and  neural  forms  of 
muscular  atrophy  and  from  the  congenital  absence  of  certain  groups  of 
muscles.  From  the  two  first-mentioned  forms  it  can  readily  be  distin- 
guished by  the  fact  that  the  hand  becomes  involved,  if  at  all,  in  the  last 
stages  of  the  disease :  also  by  the  absence  of  the  reactions  of  degenera- 
tion and  of  muscular  twitching.  It  is  also  diagnosed  from  the  neural 
type  by  the  absence  of  disturbances  of  sensation.  From  the  congenital 
absence  of  certain  groups  of  muscles  the  diagnosis  is  sometimes  difficult, 
for,  curiously  enough,  the  groups  of  muscles  affected  are  usually  the  same 
as  those  affected  by  the  myopathy.  A  distinction  can  be  made  partly  by 
the  history,  partly  by  the  more  efficient  and  perfect  compensatory  hyper- 
trophy of  the  muscles  that  remain. 

The  course  of  the  disease  is  slowly  progressive,  only  occasionally  ex- 
hibiting a  temporary  arrest. 

The  duration  is  variable,  but  patients  may  live  thirty  or  forty  years 
after  the  first  symptoms  appear. 

The  prognosis  is  of  course  hopeless  as  regards  cure  or  improvement. 
As  regards  existence,  however,  it  is  the  most  favorable  of  all  the  forms 
of  progressive  muscular  atrophy — a  fact  that  is  probably  due  to  the  ability 
of  the  patients  to  walk  until  the  very  last  stages  of  the  disease,  so  that 
they  are  able  to  maintain  a  better  physical  condition. 

The  treatment  is  the  same  as  that  for  other  forms,  and  consists  of 
electricity,  massage,  and  especially  of  systematic  gymnastics. 


HEREDITARY  MUSCULAR  PARALYSIS   {Leyden). 

This  commences  in  children,  and  usually  between  eight  and  ten  years 
of  age.  It  affects  the  muscles  very  much  as  they  are  affected  in  the 
pseudo-hypertrophic  form,  except  that  there  is  no  increase  in  size.  The 
disease  is  markedly  hereditary  in  type. 


ARTHRITIC  MUSCULAR  ATROPHY. 

Pathology. — It  has  frequently  been  observed  that  after  inflamma- 
tion of  a  joint  the  muscles  that  move  it  have  undergone  a  certain  degree 
of  atrophy.  This  usually  occurs  in  the  extensors,  and  is  severe  in  pro- 
portion to  the  duration  of  the  inflammation.  Microscopic  examination 
of  the  muscles  shows  a  rather  uniform  diminution  in  the  breadth  of  the 
fibers,  as  well  as  a  slight  proliferation  of  the  nuclei  and  occasionally  an 
indistinctness  of  the  striation.  The  nerve-trunks  and  cord  have  been  re- 
ported to  be  normal. 

The  etiology  of  the  condition  is  not  clearly  determined.  It  has 
been  supposed  to  be  due  to  disuse,  but  if  such  were  the  case  all  the  mus- ' 
cles  moving  the  joint  would  be  equally  affected.  Moreover,  it  sometimes 
occurs  too  rapidly  to  render  this  explanation  acceptable.  It  has  also 
been  supposed  to  be  due  to  the  extension  of  the  inflammation  either  to 
the  nerves  or  directly  to  the  muscles,  but  the  other  symptoms  of  neuritis 
are  rarely  present.  Finally,  Yulpian  has  suggested  that  it  is  of  reflex 
origin,  and  this  hypothesis  is  most  generally  accepted. 


1204  DISEASES  OF  THE  MUSCLES. 

Symptoms. — The  wasting  usually  occurs  very  rapidly  after  the 
onset  of  the  joint-affection.  The  muscles  show  a  diminished  contrac- 
tility to  faradism  and  galvanism,  but  the  reactions  of  degeneration  do 
not  occur.  Occasionally  there  is  fibrillary  twitching.  The  mechanic 
irritability  of  the  muscles  is  greatly  increased,  and  the  reflexes  show 
a  corresponding  exaggeration,  ankle-clonus  being  frequently  observed 
when  the  knee-  or  ankle-joints  are  aifected. 

The  diagnosis  may  be  readily  made  upon  the  existence  of  the  joint 
aifection,  the  local  character  of  the  muscular  atrophy,  and  the  absence  of 
degenerative  reactions  with  increased  mechanical  irritability. 

Prognosis. — Ordinarily,  as  soon  as  the  joint  has  recovered,  improve- 
ment commences  in  the  muscles  and  progresses  rapidly  to  complete  resto- 
ration of  function.  In  some  cases,  however,  atrophy  persists,  and  in  a 
few  instances  secondary  contractures  take  place. 

The  treatment  consists,  first,  in  the  removal  of  the  cause  by  the  cure 
of  the  articular  condition  ;  secondly,  in  gentle  massage  and  electric  stimu- 
lation of  the  muscles.  As  a  rule  this  should  not  be  commenced  until  the 
joint  is  well. 

MUSCULAR    ATROPHIES. 

These  may  also  occur  as  a  result  of  other  conditions,  such  as  direct 
injury,  fracture  of  the  bones,  or  prolonged  work  with  a  single  group  of 
muscles,  but  they  scarcely  demand  separate  description. 

MUSCULAR    HYPERTROPHY. 

This  occasionally  occurs  as  an  idiopathic  affection.  In  these  cases 
microscopic  examination  shows  an  increase  in  the  size  of  the  fibers, 
although  sometimes  there  are  slight  degenerative  alterations,  such  as  the 
presence  of  vacuoles  or  indistinctness  of  the  striation.  The  cause  of  the 
disease  is  unknown.  It  occasionally  appears  in  those  of  a  neuropathic 
heredity,  and  one  case  is  recorded  that  developed  in  an  idiot.  The  symp- 
toms consist  of  enlargement  of  the  muscles,  which  usually  exhibit  in- 
creased power,  but,  at  the  same  time,  great  susceptibility  to  fatigue. 
Occasionally  the  power  is  diminished. 

The  diagiwsis  from  pseudo-muscular  hypertrophy  is  sometimes  difficult. 
The  prognosis  is  unfavorable  for  any  improvement  in  the  condition.  No 
treatment  that  has  any  influence  upon  it  is  known. 


THOMSEN'S  DISEASE. 

[Myotonia  Congenita.) 

Definition. — An  hereditary  disease  of  the  muscles  in  which  the 
groups  that  have  been  contracted  by  a  voluntary  influence  remain  for 
a  short  time  in  a  state  of  contraction,  and  then  relax  slowly. 

Pathology. — Certain  authors  have  described  alterations  in  the  ter- 
minal nerve-plates  in  the  muscles,  but  it  is  difficult  to  determine  whether 
these  alterations  are  artificial  or  an  actual  part  of  the  disease.  The  pe- 
ripheral nerves  are  normal.     The  muscles  themselves  exhibit  the  follow- 


THOMSEN'S  DISEASE.  1205 

ing  alterations :  The  muscle-fibers  are,  on  the  average,  of  an  increased 
transverse  diameter — ^.  e.  the  smallest  are  the  size  of  ordinary  muscle- 
fibers  and  the  largest  about  twice  the  size.  There  is  also  a  distinct  and 
considerable  increase  in  the  number  of  nuclei.  The  protoplasm  is  not 
so  clear  as  in  normal  muscles,  but  shows  a  fine  granular  cloudiness, 
rendering  the  striation  less  distinct.  Occasionally,  the  muscle-fibers  are 
vacuolated.     The  connective  tissue  between  the  muscle-fibers  is  normal. 

etiology. — Hereditary  influence  is  the  most  important  factor  in  the 
causation  of  the  disease.  Thomsen,  who  was  himself  a  victim,  has  been 
able  to  trace  the  disease  for  five  generations  in  his  own  family.  Occa- 
sionally a  generation  is  skipped.  Other  factors  that  have  been  supposed 
to  act  as  predisposing  or  exciting  causes  are  prolonged  exertion  (1  case 
having  developed  in  a  man  without  myotonic  antecedents  after  two  years 
of  severe  exertion)  and  emotional  disturbance  of  the  mother  during  preg- 
nancy. Exposure  to  cold,  and  fright,  and  a  neurotic  temperament  have 
also  been  accused  of  exerting  a  predisposing  or  exciting  influence.  The 
disease  is  somewhat  more  frequent  in  males  than  in  females,  usually  de- 
velops in  early  life,  is  often  associated  with  manifestations  of  mental  dis- 
turbance, and  occasionally  occurs  in  those  whose  ancestors  have  exhib- 
ited lesions  of  the  nervous  system  other  than  myotonia. 

Symptoms. — The  chief  symptom  of  the  disease  is  the  so-called  myo- 
tonic contraction.  If  the  patient,  after  a  period  of  rest,  attempts  to  set  a 
certain  group  of  muscles  in  action,  the  first  contraction  is  made,  but  is  not 
followed  by  relaxation  for  a  considerable  interval — sometimes  as  much  as 
a  half  minute ;  during  this  period  the  muscles  remain  in  a  state  of  tonic 
contraction.  Thus,  if  the  patient  attempts  to  shake  hands,  he  clasps  the 
other  hand  strongly,  and  the  clasp  persists.  When  he  lets  go,  it  is  seen 
that  a  slight  degree  of  tonic  contraction  still  exists,  for  it  is  impossible 
for  him  to  straighten  out  his  fingers  immediately.  Upon  a  repetition  of 
the  movement  the  tonic  contraction  recurs,  but  not  so  strongly,  and  if  the 
repetition  is  continued,  it  disappears  entirely,  so  that  the  muscular  system 
of  the  patient  behaves  in  all  respects  like  that  of  a  normal  person,  and 
long  walks  or  other  severe  muscular  exertion  may  be  undertaken.  In 
some  cases  practically  the  whole  muscular  system  is  affected,  although, 
excepting  the  muscles  of  mastication,  the  muscles  of  the  face  usually 
escape.  In  others  the  disease  is  limited  perhaps  to  the  upper,  perhaps  to 
the  lower,  extremities.  In  the  former  condition  the  patient  may,  upon  an 
attempt  to  make  a  vigorous  motion  after  resting,  suddenly  become  rigid 
and  fall  to  the  earth  with  considerable  force,  often  injuring  himself  se- 
verely. He  will  then  lie  upon  the  ground  perfectly  conscious,  but  in- 
capable of  relaxing  his  muscles.  When  the  disease,  as  is  more  frequently 
the  case,  is  limited  to  the  lower  extremities,  the  chief  disturbances  ob- 
served are  in  walking.  The  first  step  is  accomplished,  whereupon  the 
patient  halts,  both  legs  having  become  fixed ;  after  a  time  they  relax  and 
another  step  is  taken.  The  period  of  delay  is  now  much  shorter,  and 
after  a  few  more  steps  disappears  entirely.  The  severity  of  the  contrac- 
tion is  diminished  by  moderate  exercise,  heat,  and  tranquillity  of  the 
spirits,  and  is  increased  by  excitement,  cold,  and  fatigue.  The  muscles 
of  deglutition  and  the  sphincters  and  the  muscles  belonging  to  the  non- 
striated  muscular  system  are  never  involved.  Pain  is  not  present,  except 
perhaps  a  slight  sensation  of  cramp,  nor  are  there  disturbances  of  sensa- 


1206  DISEASES  OF  THE  MUSCLES. 

tion.  Mental  disturbances  are  frequent,  and  have  been  ascribed  to  the 
anxiety  occasioned  the  patient  by  the  disease.  They  consist  of  irrita- 
bility, the  avoidance  of  society,  and  sometimes  of  melancholia.  The 
reflexes  show  various  modifications ;  the  knee-jerks  may  be  either  nor- 
mal, increased,  diminished,  or  absent.  The  most  important  pathogno- 
monic symptoms  are  the  alterations  in  the  electric  reactions  of  the 
muscles.  The  changes  are  as  follows  :  Mechanic  irritation  of  the  motor 
nerves  is  normal  or  diminished ;  the  mechanic  irritation  of  the  muscles  is 
increased,  and  so  modified  that  the  contraction  instead  of  being  sudden 
is  slow,  with  a  long  tonic  after-contraction.  The  faradic  irritability  of 
the  nerves  is  normal,  and  faradic  excitation  of  the  muscles  pi'oduces  a 
tonic  contraction  of  long  duration.  The  galvanic  irritability  is  quantita- 
tively increased  and  qualitatively  altered  ;  that  is  to  say,  ACC  is  equal 
to  and  sometimes  even  greater  than  KCC.  All  the  contractions  are  slow, 
tonic,  and  of  long  duration.  Finally,  the  application  of  the  constant  gal- 
vanic stream  gives  rise  to  rhythmic  contractions  that  pass  along  the  body 
of  the  muscles  in  slowly  moving  waves  at  the  rate  of  about  one  to  three  per 
second.  Occasionally  qualitative  galvanic  alterations  have  been  observed 
in  the  nerves.  Finally,  the  appearance  of  the  patient  is  of  some  value. 
The  muscles  are  developed  almost  as  much  as  those  of  an  athlete,  with- 
out a  corresponding  increase  of  power. 

The  diagnosis  is  usually  easy,  and  particularly  if  it  be  possible  to 
examine  the  electric  reactions.  The  condition  might  possibly  be  con- 
founded with  pseudo-hypertrophic  muscular  paralysis,  in  which  the  mus- 
cles are  also  considerably  developed ;  but  instead  of  being  normal  they 
manifest  greatly  diminished  power  and  fail  to  give  a  myotonic  reaction. 
From  tetany  the  condition  may  be  distinguished  by  the  absence  of  Trous- 
seau's sign,  by  a  briefer  period  of  tonic  contracture,  and  an  absence  of 
severe  pains.  From  spastic  paraplegia  and  Little's  disease  it  may  be 
distinguished  by  the  fact  that  in  these  diseases  the  spastic  conditions  are 
permanent  and  do  not  disappear  after  exercise.  From  occupation-neur- 
oses it  may  be  distinguished  by  the  fact  that  the  cramps  only  appear 
upon  the  performance  of  a  certain  peculiarly  coordinated  movement. 
From  hysteria  it  is  diflFerentiated  by  the  absence  of  stigmata  and  the  care 
an  hysteric  patient  exhibits  to  avoid  injury  to  himself,  and  by  the  pecu- 
liar electric  reaction. 

The  prognosis  is  hopeless.  The  disease  commences  in  early  life  and 
continues  until  death,  with  more  or  less  frequent  remissions  and  exacer- 
bations. It  is  possible  that  these  remissions  may  be  permanent,  and  one 
case  has  been  reported  of  a  young  woman  whom  marriage  greatly  bene- 
fited. The  disease  is  rarely  dangerous  to  life,  excepting  in  so  far  that 
those  who  suffer  from  it  are  much  more  liable  to  injury. 

Treatment  is  exceedingly  unsatisfiictory.  Practically  nothing  can 
be  done,  although  in  a  few  cases  systematic  stimulation  of  the  muscles 
has  produced  some  mitigation.  The  patients  often  learn  methods  by 
which  they  can  at  least  diminish  the  unpleasant  symptoms.  Certain 
movements  seem  to  prevent  or  shorten  the  period  of  tonic  contraction. 
Of  course  exposure  to  cold  or  emotional  disturbance  should  be  avoided  as 
far  as  possible. 


PART  X. 

THE  INTOXICATIONS;   OBESITY;    HEAT- 
STROKE. 


THE  INTOXICATIONS. 

ALCOHOLISM. 

{Alcoholic  Inebriety.) 

Definition. — An  acute  or  chronic  intoxication  due  to  the  abuse  of 
alcohol.  It  is  a  general  degenerative  condition,  particularly  of  the 
brain  and  nervous  system,  characterized  by  a  moderate  (often  progress- 
ively increasing)  or  excessive,  continuous  or  periodic,  craving  for  alcohol, 
leading  to  drunkenness.  Alcoholism  is  often  simply  a  variety  of  in- 
ebriety or  narcomania,  a  congenital  or  acquired  brain-  and  nervous  dis- 
ease, characterized  by  a  resistless,  permanent  desire  for  alcohol  (alco- 
holic inebriety/).  Mania-a-potu,  or  "crazy  drunkenness,"  is  an  acute 
maniacal  condition  occurring  in  an  alcoholic  drinker  of  a  neurotic  con- 
stitution. Delirium  tremens  is  an  hallucinatory  manifestation  that 
occurs  in  habitual  drinkers  of  alcohol,  either  as  the  direct  consequence 
of  the  long-continued  action  of  alcohol  on  the  brain,  or  because  of  its 
sudden  withdrawal  in  an  inebriate.  Dipsomania  is  an  alcoholic  insanity 
in  which  an  intense  maniacal  "drink-impulse"  occurs  in  a  periodic 
drinker  (usually  of  spirits). 

Pathology. — In  cases  of  death  from  acute  alcoholism  the  brain  and 
kidneys  are  found  to  be  greatly  engorged  with  blood.  The  gastro- 
duodenal  mucous  membrane  is  also  markedly  congested,  injected,  and 
covered  Avith  a  thick,  sticky,  blood-tinged  mucus. 

Chronic  Alcoholism. — Since  alcohol  is  physiologically  a  poison,  and 
not  a  food,  and  essentially  a  drug,  and  not  a  drink,  the  effects  of  its 
habitual  ingestion  are  directly  to  produce  degeneration  of  nearly  all  of 
the  bodily  tissues,  and  indirectly  to  increase  the  liability  to  many  dis- 
eases by  lessening  the  systemic  powers  of  resistance,  thus  favoring 
fatality  from  such  disease.  The  degree  of  pathologic  change  depends 
upon  the  innate  vigor  of  the  tissues,  the  age  at  which  indulgence  in 
alcohol  is  commenced,  and  upon  the  kind,  degree  of  concentration,  and' 
the  quantity  of  alcohol  habitually  taken.  Ethylic  alcohol  is  less  dele- 
terious than  the  "  fusel  oil  "  that  is  sometimes  used  as  an  adulterant  in 
spirits. 

The  chief  effects  of  chronic  alcohol-poisoning  are  seen  in  the  ner- 
vous and  digestive  systems,  and  in  the  kidneys.    Fatty  changes  are  prom- 

i2or 


1208  THE  INTOXICATIONS ;   OBESITY;   HEAT-STROKE. 

inent  in  the  malt-liquor  intemperates,  while  a  connective-tissue  over- 
growth predominates  in  spirit-drinkers.  The  mucosa  of  the  stomach 
presents  the  appearance  of  chronic  gastric  catarrh.  Dilatation  of  the 
stomach  is  common  in  free  drinkers  of  beer,  ale,  and  porter.  The  liver 
shows  the  changes  of  chronic  congestion,  of  fatty  infiltration  or  degen- 
eration, or  of  cirrhosis  and  contraction.  The  renal  chancres  are  analo- 
gous  to  those  of  the  liver,  the  chronic  congested  ("pig-backed")  and 
fatty  kidneys  occurring  mostly  in  those  who  have  drunk  excessively  of 
malt  liquors,  while  the  small,  sclerosed,  and  fibrous  kidneys  (chronic 
interstitial  nephritis)  are  seen  in  those  who  have  been  spirit-habitues. 
The  heart  is  often  loaded  with  fat.  and  the  muscular  structure  may  re- 
veal fatty  degeneration,  being  pale,  flabby,  friable,  and  dilated.  The 
blood-vessels  are  atheromatous,  thickened,  tortuous,  and  sometimes  vari- 
cose, and  sudden  death  has  been  caused  in  inebriates  by  the  rupture  of 
small  aneurysms  of  the  middle  cerebral  artery.  In  the  brain  the  vari- 
ous stages  of  sclerosis,  with  shrunken,  narrow,  and  flattened  convolu- 
tions, often  appear.  Chronic  pachymeningitis,  with  slight  hemorrhages, 
is  not  infrequent.  The  pia-arachnoid  membrane  also  may  be  opaque 
and  thickened,  and  serous  eflfusions  into  the  subarachnoid  space  and  into 
the  ventricles  have  been  noted.  The  nerve-cells,  nerve-centers,  and 
nerve-fibers  show  degeneration,  hardening,  and  atrophy.  Alcoholic 
neuritis  is  especially  prominent  in  many  cases. 

Ktiology. — An  impaired  personal  health  and  vigor,  as  well  as  the 
"  personal  equation  '"  and  a  deficiency  of  will-power,  self-control,  con- 
science, and  conviction,  are  among  the  predisposing  causes.  Drunken 
or  inebriate  parents  frequently  transmit  to  their  offspring  a  morbid  im- 
pulse or  desire  for  alcohol,  and  an  environment  of  depraved  morality  and 
of  depressing  and  corrupting  social  influences  are  usually  potent  dis- 
posing influences,  particularly  in  those  who  are  illy  prepared,  by  hered- 
ity or  training,  to  resist  the  temptation  and  insidious  activities  of  such 
evil  surroundings.  Although  some  assert  that  poverty  predisposes  to 
intemperance,  it  is  more  likely  that,  in  a  great  majority  of  instances  at 
least,  intemperance  is  the  cause  rather  than  the  consequence  of  poverty, 
both  of  individuals  and  communities.  The  exciting  cause  is  the  persist- 
ent misuse  of  alcohol  as  a  beverage,  in  the  form  of  distilled  liquors  or 
spirits,  wines,  and  fermented  or  malt  liquors. 

Symptoms. — The  ."iymptoms  of  acute  alcoholism  range  from  mild 
intoxication  to  an  acute  delirium  or  a  profound  stupor  and  coma.  It 
begins  with  the  stage  of  vascular  relaxation  and  of  feelings  of 
warmth  and  exhilaration,  due  to  the  depressing  and  paralyzing  effects 
of  the  alcohol  upon  the  vasomotor  tone.  The  second  stage  is  one  of 
partial  functional  paralysis  of  t/ie  nerve-centers,  marked  disturbance  of 
the  faculties,  muscular  incoordination,  and  delirious  speech.  In  the 
third  stage,  of  "  dead-drunkenness,"  there  are  acute  coma,  stertorous 
breathing,  a  bloated  and  congested  face,  a  slow  and  full,  but  weak, 
pulse,  a  cold  and  clammy  skin,  a  heavy  alcoholic  odor  of  the  breath, 
and,  sometimes,  incontinence  of  urine  and  feces.  It  frequently  hap- 
pens that  unconsciousness  is  not  so  profound  but  that  the  patient  may 
be  aroused,  though  replies  to  questioning  are  stupid  and  incoherent. 
Ordinary  acute  alcoholism  seldom  passes  beyond  a  stage  of  exhilaration, 


ALCOHOLISM.  1209 

ending  in  mild  narcosis.  Sometimes,  however,  the  irritant  action  of  the 
alcohol  predominates  over  its  narcotic  action,  giving  rise  to  acute  alco- 
holic gastritis  or  nephritis. 

Acute  mental  disorders  ('■'acute  alcoholic  insanity'')  are  not  infre- 
quently met  with.  Mania-a-potu  may  come  on  quite  suddenly  in  de- 
bauchees, or  in  those  who  have  drunk  hard  durincr  a  short  time,  as  in  a 
night's  carousal.  The  mental  excitability  increases  until  a  violent  mani- 
acal storm  not  unlike  the  mania  of  epilepsy  possesses  the  drinker.  While 
in  this  state  of  infuriated  delirium  homicide  may  be  committed.  Tremors 
are  absent.  Acute  alcoholic  melancholia  develops  suddenly  in  some 
cases,  with  a  suicidal  tendency.  Delirium  tremens  is  more  common 
in  alcoholic  inebriates,  and  is  also  seen  at  times  in  those  who  drink 
greatly  to  excess,  but  are  not  habitues.  Convulsive  seizures  have 
been  noted  in  some  cases,  interrupting  the  coma  ("acute  alcoholic 
epilepsy");  these  may  or  may  not  be  accompanied  by  mania.  An 
acute  alcoholic  paralysis  from  multiple  neuritis  (occasionally  with  ataxic 
symptoms)  may  attack  hard  drinkers,  and  may  last  for  several  weeks  or 
months. 

Chronic  alcoholism  (alcoholic  inebriety)  I  consider  a  true  disease. 
While  acute  alcoholism  may  also  be  an  occasional  manifestation  of  the 
chronic  affection,  it  is  often  a  vice  which,  if  indulged  in  to  an  excessive 
degree,  or  if  too  frequently  repeated,  becomes  a  disease,  though  it  is 
difficult  to  determine  at  what  point  the  transition  occurs.  Again,  it  is 
not  always  easy  to  learn  whether  the  early  acute  alcoholic  excesses  are 
really  vices  or  morbid,  diseased  cravings  for  alcohol  in  hereditary  narco- 
maniacs. The  disease  of  inebriety  (alcoholic)  is  a  condition  in  which,  as 
some  one  has  said,  it  is  not  whether  one  "cannot ""  or  "will  not:"'  but 
in  which  one  "  cannot  will  "  to  resist  the  desire  for  alcohol. 

The  steady,  so-called  '-moderate  drinker""  who  saturates  his  blood 
and  tissues  every  day  for  years  is  much  more  apt  to  suifer  from  chronic 
alcoholic  poisoning  with  its  attendant  degenerations  than  one  who  goes 
on  a  '•  spree  "  once  a  month  for  a  day  or  two,  and  during  the  intervals 
is  free  from  the  toxic  influence  of  alcohol.  The  syrnptow.s  develop  very 
gradually,  and  are  usually  marked  for  some  time  by  the, deceptive  sensa- 
tion of  stimulation,  warmth,  and  well-being,  due  to  the  vasomotor  pare- 
sis and  the  anesthetic  effects  of  the  alcohol.  Impairment  of  digestion 
is  early  noted.  There  are  a  coated  tongue,  foul  breath,  vomiting  before 
breakfast,  and  gastric  distress  after  eating.  Constipation  alternating 
with  diarrhea  is  common.  Muscular  tremors  gradually  develop  and  often 
progress  into  an  ataxic  gait.  Insomnia,  mental  impairment,  and  blunt- 
ing of  the  moral  sense  come  on.  "Alcohol  dims  the  perception,  con- 
fuses the  judgment,  paralyzes  the  vrill.  and  deadens  the  conscience  " 
(Kerr).  In  his  distress  and  degradation  the  inebriate  seeks  to  relieve 
himself  by  taking  more  of  the  alcohol,  only  to  find,  on  awakening  from 
his  narcosis,  that  body,  intellect,  will,  and  emotion  are  still  more  de- 
praved. In  fact,  the  brain-  and  nerve-disorders  are  more  grave,  perma- 
nent, and  extensive  in  the  majority  of  instances  than  those  of  the  viscera. 
This  is  owing  to  the  delicacy  of  the  nervous  mechanism  and  to  the  ready 
degeneration  under  the  influence  of  the  altered  blood,  and  the  conse- 
quent impaired  cellular  nutrition,  directly  due  to  the  toxic  action  and 


1210  THE  INTOXICATIONS;    OBESITY;   HEAT-STROKE. 

deficient  normal  pabulum,  and  indirectly  to  the  lessened  elimination  of 
waste-products. 

Dementia  is  often  the  terminal  state  of  the  chronic  inebriate.  Delu- 
sions of  persecution  are  quite  masked  in  alcoholic  insanity.  The  depu- 
rative  organs  manifest  various  symptoms  due  to  the  long-continued 
irritating  action  of  alcohol.  The  liver  is  either  fatty  and  enlarged,  or 
cirrhotic  and  contracted,  and  jaundice,  dropsy,  and  hemorrhoids,  along 
with  physical  hepatic  signs,  are  correspondingly  observed.  The  watery 
eye,  the  injected  conjunctivae,  the  swollen  eyelids,  the  bloated  and 
flabby  or  pallid  and  shrunken  face,  the  dilated  capillaries  of  the  nose 
{acne  rosacea)  and  cheeks,  may  now  be  seen.  The  urinary  examination 
will  show  in  many  cases  the  deranged  function  of  the  kidneys  and  point 
to  the  nature  of  structural  impairment.  On  account  of  the  Aveak  and 
flabby  heart  there  are  palpitations,  dyspnea,  and  precordial  distress,  and 
occasionally  sharp  pains.  Chronic  valvular  endocarditis  may  be  discov- 
ered. The  pulse  is  soft  and  weak  in  beginning  fatty  degeneration  of 
the  vessels.  Thickened  arteries  are  common  in  old  cases,  and  the  pul- 
sations are  often  increased  in  tension  and  usually  rapid.  Muscular 
capacity  and  endurance  are  greatly  diminished. 

Delirium  tremens  occurs  in  the  majority  of  cases  in  inebriates  or 
chronic  drinkers  during  or  after  a  debauch,  and  particularly  from  the 
use  of  spirituous  licjuors.  It  may  occur,  also,  during  abstinence  from 
alcohol,  on  account  of  some  mental  perturbation,  or  fright,  acci- 
dental shock,  or  acute  inflammatory  illness.  It  may  either  come  on 
suddenly,  or  be  preceded  (often  for  a  day)  by  some  slight  premonitory 
symptom,  as  anorexia,  restlessness,  or  depression  of  spirits.  The 
patient  usually  awakens  at  night  with  a  tremor,  becomes  sleepless, 
wants  to  get  out  of  bed  to  do  some  imaginary  thing,  talks  constantly 
and  incoherently,  looks  about  uneasily  and  fearfully,  and  breaks  gradu- 
ally into  a  cool  perspiration.  Hallucinations  of  sight,  hearing,  and 
smell  develop.  The  patient  sees  terrifying  and  loathsome  reptiles,  and 
tries  to  escape  from  them,  or  to  clutch  them  in  order  to  cast  them  aAvay. 
The  "  horrors  "  may  become  so  great  that  suicide  may  be  attempted,  as 
by  falling  out  of  the  window.  Auditory  hallucinations  may  take  the 
form  of  enemies,  policemen,  or  the  roar  of  wild  animals.  The  mus- 
cular tremors  increase,  the  pulse  becomes  frequent  and  weak,  and  the 
tongue  coated  with  a  thick  white  fur.  There  is  moderate  fever,  which, 
if  the  delirium  is  prolonged,  takes  on  a  typhoid  character,  the  tongue 
becoming  tremulous,  dry,  brown,  and  fissui'ed,  with  the  onset  of  sub- 
sultus  tendinum,  carphologia,  coma-vigil,  and  muttering  delirium.  In 
favorable  cases  improvement  begins  on  the  third  or  fourth  day,  from 
which  time  the  symptoms  gradually  subside.  Convalescence  may  be 
said  to  be  established  when  restful  sleep  can  be  obtained ;  this  is  fol- 
lowed by  a  desire  for  food.  In  unfavorable  cases  the  patient  may  pass 
from  a  typhoid  state  into  exhaustion  and  death,  or  may  die  suddenly 
either  during  a  paroxysm  of  cardiac  failure  or  from  some  complication, 
as  cerebral  hemorrhage  or  pneumonia. 

Diagnosis. — The  condition  of  persons  found  dead-drunk  is  seldom 
mistaken  for  any  other.  The  reverse  more  often  happens,  and  in  this 
way  apoplectic  and  uremic  comas  may  be  diagnosed  as  alcoholic  coma. 
Cases  picked  up  in  the  street  in  a  state  of  apparent  unconsciousness 


ALCOHOLISM.  1211 

should  be  carefully  tested  in  this  regard.  Instances  in  which,  as  the 
postmortem  examination  subsequently  has  shown,  cerebral  hemorrhage 
has  followed  a  drinking-bout,  render  the  diagnosis  more  difficult ;  in 
such  the  patient  should  be  given  the  benefit  of  the  doubt  and  handled 
as  though  the  case  Avere  one  of  apoplexy.  An  important  early  step  is 
to  ascertain  whether  the  coma  is  complete,  or  whether  the  patient  can 
be  roused  by  shouting  in  the  ear,  by  applying  ammonia  to  the  nostrils, 
or,  better  still,  by  pressing,  with  gradually  increasing  firmness,  over 
a  sensitive  spot,  as  the  supraorbital  notch ;  if  the  unconsciousness 
is  alcoholic,  he  will  come  to  his  senses,  if  only  for  a  moment.  Ab- 
stemious apoplectics  have  been  known  to  stagger  and  talk  thickly, 
like  drunken  men  (Kerr),  and  have  been  arrested  and  taken  to  a  police- 
station  instead  of  to  a  hospital.  Congestion  and  lobar  pneumonia 
affecting  the  bases  of  the  lungs  should  be  looked  for,  as  they  are  com- 
mon causes  of  death  in  drunkards.  A  table  giving  the  principal  points 
in  the  differential  diagnosis  will  be  found  under  Uremia  (vide  p.  965). 

The  diagnosis  of  chronic  alcoholism  is  made  from  the  history,  and 
from  the  muscular  tremors  (worse  in  the  morning),  vomiting,  mental 
restlessness,  "mendacity,"  and  involuntary  "lying"  (Kerr).  The  con- 
dition may  resemble  general  paralysis,  and  if  the  habits  of  the  patient  are 
kept  secret  it  may  be  very  difficult  to  differentiate  these  affections.  A 
prominence  of  disorder  of  the  digestive  tract  usually  points  to  alcohol- 
ism. Nervous  excitement,  tremors,  fear,  wakefulness,  and  the  distinctive 
physiognomy  are  more  evident  in  chronic  alcoholism,  even  when  general 
paralysis  has  been  caused  by  alcohol,  which  is  apparently  the  case. 
Paralysis  agitans,  locomotor  ataxia,  epileysy,  and  nervous  dyspepsia  may 
also  be  mistaken  for  chronic  alcoholism  by  the  unwary. 

Delirium  tremens  is  distinguished  by  the  history,  by  the  restlessness, 
delirium,  hallucinations,  tremors,  and  terrors.  Mania-a-potu  differs  from 
the  preceding  mainly  in  its  usual  association  with  acute  alcoholism  in 
neurotics,  in  the  muscular  contractions,  the  furious  mania,  and  convul- 
sive movements.  The  delirium  of  apical  pneumonia  that  obtains  in 
some  cases  (as  Avell  as  in  meningitis)  must  be  thought  of  in  the  diag- 
nosis of  delirium  tremens.  The  diagnosis  of  alcoholic  neuritis  from 
other  conditions  simulating  it  will  be  found  elsewhere  {vide  p.  1029). 

Prognosis. — In  acute  alcoholism  the  prognosis  is  favorable  in  pri- 
vate, manageable  cases.  Many  of  the  cases  brought  into  hospitals  are 
affected  also  with  pneumonia,  and  usually  die.  The  tissue-changes  in 
chronic  alcoholism  are  so  profound,  and  they  affect  such  delicate  and 
vital  tissues,  that  when  the  alcohol-habit  thus  becomes  fixed  permanent 
recovery  never  takes  place.  The  treatment  appropriate  for  the  inebriate 
and  forced  abstinence  from  alcohol  relieve  many  of  the  symptoms  and 
some  of  the  debility,  but  relapses  are  all  too  common  and  are  almost 
certain  to  occur.  Insanity  and  paresis  are  not  infrequent  terminations 
of  chronic  alcoholism.  Many  complications  are  apt  to  supervene,  as 
Bright's  disease,  epilepsy,  melancholia,  fatty  heart,  pneumonia,  and 
thrombosis.  Alcoholic  neuritis  often  clears  up  upon  withholding  alco- 
hol and  stimulating  the  peripheral  nerves  both  by  appropriate  drugs 
and  external  remedial  measures.  Recovery  from  delirium  tremens  is 
dubious  in  cases  of  severe  injury,  inflammatory  troubles,  or  infections. 

Treatment. — In  cases  of  acute  drunkenness,  which   are  onlv  too 


1212  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

commonly  met  with,  nothing  special  is  i^equired  except  to  prevent  the 
ingestion  of  any  more  alcohol  and  to  allow  the  patient  to  sleep  until  the 
elimination  of  the  poison  is  more  or  less  complete.  The  effects  of  the 
intoxication,  in  the  general  depression,  headache,  anxious  and  irritable 
stomach,  and  various  functional  visceral  and  nervous  disorders,  may  need 
careful  corrective  and  sustaining  treatment  for  a  week  or  more.  The 
diet  should  be  light  and  nutritious.  Aperient  waters,  hot  baths,  with 
liquor  ammonii  acetatis  frequently  repeated,  and  a  combination  of  dilute 
mineral  acid  and  bitter  tonics  (uux  vomica,  gentian),  are  also  indicated. 
In  profound  cases  of  alcoholic  coma,  convulsions,  or  mania-a-potu 
no  alcohol  should  be  given.  Trite  though  this  injunction  may  seem,  it 
is  important  to  emphasize  this  statement,  so  that  the  physician  may  be 
sure  to  counteract  a  popular  impression  that  the  giving  of  more  alcohol 
will  cause  a  mania  to  subside  permanently.,  and  to  guard  against  the 
smuggling  of  liquor  to  the  patient  by  his  misguided  friends.  It  is  often 
necessary  to  empty  the  stomach  at  once  when  collapse  is  imminent  by 
the  use  of  the  stomach-tube  or  -pump,  washing  out  the  organ  with  hot 
water,  to  which  ginger  or  cinnamon  has  been  added.  To  this  end 
emetics  may  be  used — viz.  ipecac  or  apomorphin,  hypodermically  (gr.  -|- 
to  i-  —  0.008-0.0108).  The  external  application  of  warmth,  friction, 
artificial  respiration,  faradism  to  the  phrenic  nerve,  ammonia-  or  amyl- 
nitrite-inhalations,  and  hypodermics  of  atropin,  strychnin,  and  digitalis, 
may  all  be  tried.  Hot  rectal  enemata  or  a  calomel  purge  if  the  stomach 
will  tolerate  the  drug  should  be  used  early.  The  maniacal  attacks  may 
be  treated  by  hypodermics  of  morphin  and  hyoscin,  and  by  such  seda- 
tives as  chloral,  bromids  in  large  (3j — 4.0)  doses,  and  rarely  such  hyp- 
notics as  paraldehyde,  trional,  chloralamid,  and  the  like.  Indeed,  it  is 
very  important  to  secure  sleep  as  soon  as  possible.  An  excellent  for- 
mula in  cases  of  medium  severity  is : 

^.  Sodii  bromid.,  ^j    (32.0); 

Tr.  capsici,  3j    (4.0); 

Tr.  digitalis,  3ss  (2.0) ; 

Elix.  simplicis,  q.  s.  ad  sij  (64.0). — M. 

Sig.  3J  (4.0)  every  two  or  three  hours,  in  water. 

As  soon  as  some  quietude  and  sleep  have  been  obtained,  it  is  in  order 
to  administer  concentrated  food  in  an  easily  assimilable  form. 

The  treatment  of  chronic  alcoholism  is  more  often  best  conducted  in 
"homes"  for  inebriates,  in  hospitals,  and  similar  institutions.  At  the 
outset  there  must  be  an  "unconditional  surrender"  in  the  use  of  alco- 
hol. Its  withdrawal  should  be  enforced  at  once  in  many  cases,  and  very 
rapidly  in  all  others,  according  to  the  judgment  of  the  physican  as  to 
the  psychic  and  physical  condition  of  the  patient.  Substitutes  for 
alcohol  are  the  strong  fruit-juices,  as  hot  lemonade  or  hot  ginger, 
and  cardamom  tea  often  is  useful.  Coffee,  milk,  cocoa,  and  hot  broths 
are  also  to  be  recommended.  The  diet  should  be  carefully  increased 
in  nutritive  strength  as  the  gastric  irritability  diminishes.  Some- 
times such  sedatives  to  the  stomach  as  the  bismuth-preparations,  effer- 
vescent alkaline  drinks,  and  lime-water  may  be  indicated.  Peptonized 
food  is  often  well  borne  at  first  in  cases  in  Avhich  gastric  distress  is 
marked.     Nutrient  enemata  are  seldom  required,  but  should  be  resorted 


ALCOHOLISM.  1213 

to  in  the  gravest  cases,  particularly  during  the  states  of  alcoholic 
dementia.  The  general  health  must  be  looked  after  by  placing  the 
patient  in  the  best  of  fresh  air,  exercise,  cold  and  warm  bathing,  by 
mental  and  social  occupation,  and  by  diversion.  When  the  craving  for 
alcohol  is  hereditary  and  intense,  seclusion  in  an  inebriate-house  or 
some  similar  institution  is  often  necessary  for  a  long  time,  inasmuch  as 
the  danger  of  lapsing  into  the  former  drink-habit  is  so  common  in 
these  cases. 

The  insomnia  of  chronic  alcoholism  may  be  met  temporarily  by  the 
use  of  large  doses  of  bromids,  chloral,  hyoscin,  or  sulfonal.  Morphin 
may  be  indicated  at  times,  but  should  be  used  with  great  caution  in 
order  to  avoid  adding  the  morphin-habit  to  that  of  alcohol.  Perhaps 
the  best  single  agent  to  use  in  counteracting  the  symptoms  of  chronic 
alcoholism  is  strychnin,  either  as  the  nitrate  or  sulphate,  hypodermically 
and  by  the  mouth  ;  iron,  arsenic,  the  hypophosphites,  dilute  phosphoric 
acid,  quinin,  gold  and  sodium  chloride,  avena  sativa,  and  the  like 
are  often  useful  adjuvants  in  the  tonic  treatment.  Atropin,  hypodermic- 
ally,  may  also  be  recommended  when  vascular  dilatation  and  weakness 
are  prominent.  A  "  substitute "  for  alcohol,  both  for  its  local  and 
mental  effects,  may  be  prescribed  to  meet  the  occasional  cravings.  Tart 
fruits  (as  oranges  and  lemons),  coifee,  hot  malted  milk,  ginger,  gentian, 
and  capsicum  infusions  may  be  tried.  Tinctures  should  not  be  given  in 
this  form  for  obvious  reasons.  Sweating  and  purging  the  patient,  and 
the  administration  of  bromids,  chloral,  and  gelsemium  for  a  day  or  two 
in  advance,  may  avert  a  "  drink-storm  "  or  the  periodic  cravings  for  al- 
cohol that  may  be  expected  by  prodromal  manifestations.  Sometimes, 
however,  as  in  the  sudden  outbursts  of  dipsomaniacs,  there  is  no  time  to 
institute  their  treatment.  It  is  claimed  that  hypnotic  suggestion  will 
abolish  effectually  the  ardent  desire  for  alcohol  in  a  certain  number  of 
neurotic  cases  of  alcoholic  inebriety.  Temperance  revivals  may  be  said 
to  do  permanent  good  only  in  those  similar  neurotic  cases  that  are 
fortunately  impressionable  to  appeals  by  total-abstinence  orators,  but, 
in  order  to  maintain  the  reformed  drunkard's  pledge,  it  is  often  necessary 
that  interested  persons  continue  to  watch,  guide,  and  inspire  him,  in 
order  that  a  weakened  will  may  not  precipitate  a  cyclic  lapse  into  his 
old  habits. 

In  all  cases  the  treatment  will  be  incomplete  unless  the  highest  part 
of  the  patient's  nature  receives  due  attention  throughout.  The  reason 
must  be  enlisted  in  the  treatment,  and  this  is  best  attempted  by  sound 
teaching  concerning  the  fallacy  of  the  prevalent  belief  in  the  virtues 
of  alcohol  as  a  beverage. 

No  pains  should  be  spared  to  impress  upon  the  patient  the  need  of  a 
persistent  abstinence  from  all  intoxicants  as  long  as  he  lives.  All  the 
influence  of  culture,  music,  and  the  fine  arts,  of  high-toned  morality  and 
pure,  undefiled  religion,  should  be  enlisted  to  strengthen  self-respect 
and  to  fortify  volition  and  inhibition.  Moral  regeneration  may  thus  in 
certain  cases  check  indirectly  the  physical  and  mental  degeneration, 
but  it  cannot  efface  the  consequences  of  the  alcoholic  poisoning  which  it 
represents. 

Delirium  tremens  requires  firm  but  tactful  isolation  and  vigilant 
nursing.  All  alcohol  should  be  withheld.  If  stimulation  is  needed, 
aromatic  spirits  of  ammonia,  strychnin,  and  atropin,  with  bland  hot 


1214  THE  INTOXICATIONS;    OBESITY;  HEAT-STROKE. 

drinks  and  broths,  may  be  administered.  Easily  digested  and  nutri- 
tious food  should  be  given  to  support  the  strength.  Sleep  must  be 
procured  by  such  means  as  are  mentioned  above  in  the  treatment  for 
mania-a-potu.  The  dosage  required,  however,  is  usually  not  as  great, 
but  must  be  kept  up  longer  than  in  the  maniacal  condition.  Cardiac 
weakness  may  need  such  stimulants  as  digitalis,  strophanthus,  and  the 
ammonium  salts.  After  the  attack  subsides,  tonic  doses  of  strychnin, 
chirata,  gentian,  asafetida,  calumbo,  and  iron,  together  with  graduated 
exercise  out  of  doors,  are  to  be  employed.  Turkish  baths,  industrial 
occupations,  and  the  like  are  indicated  to  conserve  the  patient's  strength 
and  thus  fortify  him  against  yielding  to  temptation  and  a  morbid 
appetite. 

GINGER   AND    COLOGNE-WATER   INEBRIETY. 

Habitual  drinkers  of  alcoholic  ginger,  capsicum,  and  lavender  prepa- 
rations, and  eau-de-Cologne  are  practically  alcohol-habituds  or  inebri- 
ates. They  drink  these  liquids  for  the  alcohol  that  is  in  them. 
The  so-called  essence  of  ginger  (Jamaica  ginger),  which  contains 
considerable  alcohol  in  some  of  its  preparations,  is  often  used  primarily 
for  relieving  an  attack  of  "  ci*amps  "  or  "  colic,"  and  if  frequently  re- 
peated, can  readily  induce  a  morbid  habit  of  "ginger-drinking."  In 
other  cases  the  craving  for  alcoholic  indulgence  (often  hereditary),  may 
have  been  aroused  by  a  social  glass  of  wine,  but,  from  a  sense  of  shame 
the  desire  has  been  kept  secret,  and  gratified  by  drinking  eau-de-Cologne, 
lavender  essence,  or  even  tincture  of  capsicum.  Perhaps  many  more 
such  cases  exist,  and  especially  among  neurotic  women  in  good  circum- 
stances, than  are  usually  recognized. 

MORPHINISM. 
( Opium-inebriety.) 

Definition. — A  chronic  intoxication,  due  to  the  habitual  use  of 
morpliin  or  of  opium  in  some  other  form  (opiumism). 

Pathology. — In  cases  of  death  from  acute  or  chronic  opium-  or 
morphin-poisoniiig  there  is  nothing  distinctive  in  the  pathologic  appear- 
ances. In  acute  cases  vascular  congestion  of  the  brain  and  membranes 
has  been  noted ;  but  even  in  chronic  cases  the  tissue-degeneration  and 
fatty  and  connective-tissue  proliferations  that  are  characteristic  of 
alcoholism,  are  practically  absent.  Decided  lesions  are  usually  trace- 
able to  associated  affections.  The  principal  anatomic  changes  are  those 
due  simply  to  malnutrition.  Thus,  we  have  the  emaciation  and  the 
shrunken  appearance  of  cerebral  anemia,  and  pallor  and  atrophy  of  the 
cardiac  muscle  and  of  the  vascular  walls.  The  dried  and  wasted  struc- 
tures, due  to  tissue-starvation,  are  quite  a  contrast  to  the  fat-infiltrated 
or  degenerated,  cirrhotic,  and  inflamed  tissue  of  alcoholic  inebriety. 
Direct  destruction  of  parenchymatous  cells  is  more  evident  in  the  later. 

!Etiologfy. — The  climate,  country,  and  nationality  have  a  certain 
disposing  influence  in  the  development  of  opiumism  and  morphinism. 
In  the  opium-growing  parts  of  Asia,  as  in  China,  India,  and  Persia, 
where  the  climate  is  warm,  enervating,  and  conducive  to  physical  and 


MORPHINISM.  1215 

moral  abandonment  during  the  greater  part  of  the  year,  and  in  Turkey 
also,  opium-eating-and-smoking  habitues  are  as  numerous  as  alcohol- 
habitues  are  in  Europe  and  America  among  the  Caucasians.  Morphin- 
ism is  more  common  here  than  is  opiumism,  except  among  the  poverty- 
stricken. 

'  Women  are  more  commonly  the  victims  of  morphinism  than  men, 
except  physicians  and  druggists  as  a  class.  Mattison  has  found  70  per 
cent,  of  his  opiate  patients  to  be  medical  practitioners.  Many  con- 
tracted the  habit  by  using  morphin  for  severe  chronic  neuralgia,  in- 
somnia, and  the  like.  Indeed,  pain  and  sleeplessness  have  been  the 
principal  source  of  this  drug-habit. 

Ennui  and  an  idle  spirit  of  irritation  and  adventure  among  the  sen- 
sation-loving and  luxurious  sometimes  sow  the  seeds  of  an  indulgence 
in  narcotics  that  bring  forth  fruitage  in  the  form  of  a  fixed,  morbid,  and 
uncontrollable  craving  for  constant  satisfaction,  and  a  consequent  phys- 
ical, mental,  and  moral  decline. 

The  incautious  prescribing  of  morphin  and  the  too  ready  hypodermic 
use  of  the  alkaloid  by  physicians  in  treating  various  cases  of  pain  are 
not  infrequently  the  cause  of  morphinism.  OverAvork  of  the  brain, 
great  business  or  social  strains,  prolonged  "worry  and  anxiety  either 
with  or  without  work,  insomnia,  remorse,  idleness,  and  secret  vices,  are 
the  most  common  predisposing  agents  of  the  morphin-habit. 

Paregoric,  laudanum,  chlorodyne,  and  "soothing-syrup"  are  drunk 
to  a  frightful  extent  in  large  cities  among  the  poor  and  miserable,  and 
cause  great  disturbance  of  the  health  of  the  habitues. 

Symptoms. — These  may  be  in  abeyance  for  some  time,  while  the 
habit  is  forming  and  the  doses  are  still  slight.  As  the  craving  increases, 
the  dose  and  its  frequency  increase  to  keep  pace  with  the  desire. 
Anemia  gradually  develops,  with  sallowness  of  the  skin,  wasting  of 
the  features  and  body,  languor,  weakness,  functional  deterioration, 
mental  depression,  anorexia,  restlessness,  insomnia,  tremors,  irritability, 
shyness,  dilatation  of  the  pupils  (except  when  under  the  influence  of 
the  drug),  and  a  characteristic  propensity  to  lying.  Cardialgia  is  often 
complained  of  by  those  who  use  opium  pretty  constantly.  The  asso- 
ciated vices  of  opiumism  are  less  violent  and  inflammatory  than  those 
of  alcoholism,  and  more  secretive  and  speculative,  such  as  gambling  and 
sexual  perversions.  Itching  is  frequent,  and  especially  after  taking  the 
opium  or  morphin.  Attacks  of  chills,  followed  by  pyrexia,  with  de- 
lirium and  transient  albuminuria  (renal  congestion)  occur  in  some  cases. 
Diarrhea  and  dysentery  have  been  observed  in  some  instances.  There 
may  be  also  disturbances  of  the  visual  muscular  apparatus.  Sufferers 
from  painful  carcinoma  in  whom  opium  or  morphin  is  required  for  steady 
use  do  not  become,   except  in  rare  cases,   true  morphinomaniacs. 

The  course  of  morphinism  is  that  of  a  progressive  asthenia,  in  which 
cardiac  palpitation,  dyspnea,  abdominal  and  muscular  cramps,  trembling,, 
fear,  sleeplessness,  mental  confusion,  melancholy,  slovenliness,  and  moral 
obtuseness  come  on.  Some  women,  known  to  be  kleptomaniacs,  have 
been  found  to  be  secret  opiumists.  Sexual  impotence  in  the  male,  and 
amenorrhea  and  abortion  in  the  female,  are  common  results.  The  skin 
is  wrinkled,  dry,  and  harsh,  and  may  show  numerous  needle-scars  and 
abscesses  in  those  addicted  to  the  hypodermic  use  of  the  drug.     The 


1216  THE  INTOXICATIONS;   OBESITY;  HEAT-STROKE. 

termination  is  the  direct  result  of  the  extreme  debility  or  marasmus  or 
of  some  intercurrent  affection. 

The  diagnosis  must  be  made  from  the  history.  When  the  latter 
is  wanting  because  of  a  lack  of  veracity  or  deception,  chronic  alcohol- 
ism may  have  to  be  differentiated  from  opiumism.  The  more  open  and 
often  periodic  habits  of  the  alcoholic  habitue,  and  the  general  aspect  of 
the  physical  and  mental  and  complicating  conditions,  usually  show 
marked  differences  between  the  two  drug-intoxications. 

Prognosis. — The  likelihood  of  a  cure  is  exceedingly  remote.  On 
the  other  hand,  under  proper  conditions  much  relief  may  be  given  the 
morphinomaniac,  and  although  the  habit  may  be  suspended  only  for  a 
time,  life  may  thus  be  prolonged  for  years. 

The  treatment  is  manifestly  difficult  and  unpromising.  Institu- 
tional isolation,  rest,  diversion,  Avatchful  care,  regular  and  studied  feed- 
ing, baths,  and  graduated  exercise  in  the  open  air  as  far  as  possible,  but 
under  surveillance  in  order  to  prevent  the  smuggling  of  opium,  morphin, 
or  compound  pre})arations  containing  either,  are  the  most  efficient 
measures.  As  to  the  manner  of  withdrawing  the  narcotic,  much  care, 
judgment,  and  tact  form  a  sine  qua  non  in  the  treatment.  A  sudden 
and  absolute  stoppage  of  the  use  of  the  drug  sometimes  leads  to  great 
distress,  and  even  to  collapse  ("  abstinence  phenomena  "") :  it  is,  therefore, 
not  to  be  recommended,  as  in  chronic  alcoholism.  On  the  other  hand, 
the  too  gradual  withdrawal  is  torturing.  A  middle  course,  the  "rapid- 
gradual  method  "  of  Erlenmeyer,  is  usually  resorted  to,  in  which  the 
reduction  of  the  quantity  of  morphin  or  opium  to  nothing  occupies  but 
a  week  or  ten  days.  Various  substitutes  have  been  recommended  that 
generally  prove  not  to  be  substitutes  at  all,  but  simply  act  in  a  symp- 
tomatic way,  and  may  lead  to  another  habit  as  bad  if  not  Avorse.  Such 
drugs  as  cocain,  hyoscyamus,  belladonna,  bromids.  and  chloral  have 
thus  been  used. 

In  the  symptomatic  treatment  of  the  morphin-habit  moderate  doses 
of  bromids,  with  cannabis  indica  and  some  such  vegetable  bitter  as  gen- 
tian, may  prove  useful  in  allaying  the  nervous  irritability  and  restless- 
ness at  night.  Sulfonal  is  a  good  hypnotic  in  these  cases.  Cathartics, 
stomach  sedatives  alternating  with  tonics,  concentrated  foods,  massage, 
hot  and  cold  bathing,  electricity  (general  galvanization),  and  "  complete 
control  over  the  patient"  are  usually  indispensable  adjuncts  in  the 
treatment  after  the  withdrawal  of  the  opium  or  morphin.  Cardiac 
stimulants,  strychnin  and  physostigmin  salicylate  (gr.  ywo — 0.0006) 
hypodermically,  have  been  recommended  recently  as  important  in 
counteracting  the  functional  depression  of  these  habitues.  Industrial 
activity,  and  mental  and  social  diversion,  aid  in  maintaining  any  im- 
provement made  and  in  rendering  the  patient  less  liable  to  a  relapse. 

PLUMBISM. 
(Chronic  Lead-poisoninf/ ;   Saturnism.) 

Definition. — A  chronic  intoxication  due  to  the  slow  absorption  of 
lead,  either  industrially  or  accidentally. 

Pathology. — The  principal  lesions  are  found  in  the  muscles,  periph- 
eral nerves,  liver,  kidneys,  and  mucous  membranes.     The  affected  mus- 


PLUMBISM.  1217 

cles  are  wasted,  pale-yellow  in  color,  and,  in  advanced  cases,  show  a 
marked  fibroid  growth.  The  vessels  in  the  muscles  also  reveal  arterio- 
sclerosis. The  peripheral  nerves  are  affected  with  a  parenchymatous 
neuritis,  and  are  especially  involved,  with  degenerative  changes  in 
the  nerve-endings  in  the  muscles.  The  nearer  we  approach  the  spi- 
nal cord  along  the  course  of  an  affected  motor  nerve,  the  less 
marked  are  the  changes,  although  in  some  cases  a  very  slight  in- 
volvement of  the  anterior  nerve-i'oot  cells  has  been  noted.  The  cord  is 
usually  normal. 

In  the  brain,  the  pathologic  changes  scarcely  warrant  us  in  attribut- 
ing lead  encephalopathy  to  them.  Aside  from  a  slight  meningitis  and 
arteriosclerosis  of  the  cerebral  blood-vessels  here  and  there,  with  a  cor- 
responding connective-tissue  growth  and  capillary  hemorrhages,  the 
evidences  of  lead-poisoning  are  practically  7nl.  Cerebral  symptoms  are 
most  probably  the  outcome  of  functional  disturbances.  The  liver  and 
kidney  show  parenchymatous  atrophy  and  cirrhosis. 

etiology. — (a)  Personal  susceptibility/  to  lead-poisoning  is  greater 
in  some  people  than  in  others,  all  other  things  being  equal,  (b)  Plumb- 
ism  is  more  common  in  adults  than  in  children,  because  of  greater  ex- 
posure. ((?)  Sex. — Women  are  more  susceptible  than  men.  (d)  Occupa- 
tion is  the  most  frequent  cause  of  lead-intoxication.  Workers  in  white 
lead  (plumbic  carbonate),  red  lead,  and  litharge,  all  of  which  substances 
are  used  as  paints,  are  especially  to  be  mentioned  as  liable  to  saturnism. 
Among  the  most  common  industrial  causes  are  the  following :  painting, 
plumbing,  lead-mining,  rolling  sheet-lead,  pottery-glazing,  type-found- 
ing and  setting,  shot-making,  dress-making  (in  which  lead-dyed  silk 
thread  is  used  and  the  ends  bitten  off),  lace-making,  glass-grinding,  and 
calico-printing.  (e)  An  accidental  source  of  lead-poisoning  is  found 
in  the  contamination  of  food  and  drink.  Men  employed  in  the  manu- 
facture of  white  lead  and  eating  lunches  in  dusty  work-rooms  may  also 
suffer  from  plumbism  in  this  way.  Drinking-water  stored  in  lead-lined 
cisterns  and  passed  through  lead  pipes  is  frequently  contaminated,  espe- 
cially if  the  water  contains  a  slight  amount  of  acid.  Flour,  bread,  bis- 
cuit, candy,  butter,  and  milk  may  cause  poisoning  by  adulteration  with 
lead  chromate,  used  to  give  a  rich,  yellow  tint  to  these  articles ;  and  to- 
bacco wrapped  in  lead- foil  has,  less  commonly,  resulted  in  symptoms  of 
saturnism. 

The  absorption  of  the  lead  takes  place  mainly  through  the  gastro- 
intestinal tract,  especially  through  the  lungs,  and  much  less  through  the 
skin.  It  may  be  deposited  in  most  of  the  soft  tissues  and  viscera,  but 
especially  in  the  nerves,  muscles,  and  liver.  Elimination  takes  place 
through  the  kidneys,  and  probably,  though  in  very  slight  quantities, 
with  the  bile  and  saliva,  and  through  the  skin. 

Symptoms. — Depending  upon  individual  susceptibility,  it  may  be 
months  or  years  before  the  first  manifestations  appear.  Ayiemia  is  an 
early  and  marked  symptom  {saturniyie  cachexia).  There  is  a  moderate 
reduction  of  the  corpuscles  and  of  hemoglobin.  The  general  nutrition 
is  poor. 

The  characteristic  blue  line  at  the  borders  of  the  gums  is  rarely  ab- 
sent, especially  in  those  who  are  not  scrupulous  in  their  attention  to 
the  teeth.     It  is,  as  a  rule,  most  distinct  at  the  roots  of  the  lower  ca- 

77 


1218  THE  INTOXICATIONS ;   OBESITY;  HEAT-STROKE. 

nines  and  incisors,  and  is  formed  by  a  deposition  of  lead  sulphid.  Bluish 
patches  may  also  be  met  -with. 

Colic  is  very  common  and  is  also  characteristic.  The  pains  center 
around  the  navel,  and  are  quite  severe  and  griping.  They  are  associated 
Avith  retraction  and  rigidity  of  the  abdominal  Avails,  and  with  obstinate 
constipation.  The  pains  are  paroxysmal,  may  be  referred  at  times  to 
the  epigastrium,  and  may  be  accompanied  by  vomiting.  Between  the 
paroxysms  a  dull  pain  usually  exists  over  the  whole  abdomen.  During 
the  attacks  of  colic  the  pulse-tension  is  increased  and  cardiac  action 
lessened. 

Paralyses  are  common  symptoms,  and  may  either  be  acute,  subacute, 
or  chronic  in  nature.  Although  usually  localized  palsies,  they  are  some- 
times generalized.  The  most  characteristic  lead-palsy  is  that  known  as 
wrist-drop  (see  also  Multiple  Neuritis,  p.  1029). 

Both  fine  and  coarse  tremors  occur,  though  not  so  commonly  as  in 
chronic  mercurial  poisoning.  They  usually  begin  in  the  hands  and 
arms,  are  rather  constant,  and  are  aggravated  by  voluntary  effort  and 
emotional  excitement. 

Cramps  in  the  affected  muscles  and  about  the  joints  ilead-artJir algid) 
are  occasionally  noted.  Slight  anesthesia,  especially  in  cases  of  wrist- 
drop, is  sometimes  detected  here  and  there,  but  may  in  certain  instances 
be  due  to  saturnine  hysteria. 

The  cerebral  symptoms  are  important.  The  phrase  "  lead  encephal- 
opathy "  includes  such  manifestation  as  delirium  and  coma,  neuro-retini- 
tis,  aphasia,  convulsions,  hemiplegia,  amaurosis,  hysteria,  and  insanity. 
The  delirium  and  coma  are  the  commonest  brain-symptoms,  and  may 
come  on  suddenly  with  tremors  and  hallucination.  Epileptic  convul- 
sions are  often  severe.  Hemianopsia  has  been  observed.  Mania  and 
melancholia  occur  in  cases  of  mental  unbalancing,  and  hysteric  out- 
breaks are  seen  in  girls.  Intense  headache  is  not  uncommon.  "  Sat- 
urnine gout,"  so  called,  is  described  as  a  result  of  chronic  plumbism. 
The  kidneys  are  contracted,  the  heart  is  hyportrophied,  and  arterio- 
sclerosis is  marked,  Avith  a  diminution  in  the  excretion  of  urea  and  uric 
acid.  The  pulse-tension  is  increased.  These  evidences  shoA\"  a  simi- 
larity to  gout,  and  favor  the  development  of  uratic  deposits  in  the 
joints,  but  they  are  the  effects  of  *' mineral,"  and  not  of  essential  or 
true  gout.  Lead  may  be  discovered  in  the  urine  by  laying  a  strip  of 
magnesium  in  it  and  noting  the  deposit  of  metallic  lead  if  present 
(Von  Jaksch).  Abram  asserts  that  the  addition  of  a  solution  of  ammo- 
nium oxalate  (1  gm.  to  150  c.c.  of  A\ater)  facilitates  the  test. 

Diagnosis. — The  history  of  exposure  to  lead-poisoning  is  usually 
clear  in  those  Avorking  the  metal  in  its  various  forms.  Accidental  origins 
of  saturnism  are  often  obscure  and  very  difficult  to  trace,  although  if 
the  characteristic  Avrist-drop,  the  blue  gingival  line,  colic,  and  cachexia 
be  present,  the  diagnosis  is  readily  made. 

Alcoholic  paralysis  of  the  loAver  extremities  may  be  differentiated  by 
the  history,  the  greater  prominence  of  sensory  symptoms,  and  by  the  ab- 
sence of  the  blue  line  on  the  gums. 

Prognosis. — In  the  absence  of  the  graAer  nervous,  arterial,  and 
renal  symptoms,  the  prognosis  is  good.  Wiien  there  is  profound 
paralysis,   A\-ith  reactions  of   degeneration,   and    especially  in  primary 


ABSENICISM.  1219 

atrophy  of  the  muscles,  the  prognosis  is  generally  bad.  In  the  severe 
encephalopathic  forms,  and  in  cases  in  which  marked  arteriosclerosis  and 
renal  cirrhosis  are  manifested,  the  prognosis  is  unfavorable,  but  depends 
upon  the  extent  of  damage  done. 

Treatment. — The  prevention  of  plumbism  is  difficult  in  lead-work- 
ing establishments,  owing  to  the  carelessness  and  indifference  of  both 
employers  and  employees,  and  to  the  lack  of  any  adequate  antidote 
during  exposure.  Rigid  cleanliness  is  absolutely  necessary,  especially 
of  the  hands  and  nails  and  before  eating.  Means  to  allay  dust  should 
be  regularly  and  constantly  employed.  Milk  and  sulphuric-acid  lemon- 
ade have  been  recommended  for  use  by  workers  in  lead,  for  their  sup- 
posed antidotal  effects.  As  perfect  ventilation  as  possible  should  be 
secured,  and  respirators  are  in  use  in  some  lead-works,  being  worn  as 
"snouts."  Potassium  iodid  ffhould  be  given  in  chronic  plumbism, 
beginning  with  small  doses  (gr.  iii-v — 0.1944-0.324),  given  preferably 
in  milk,  after  meals. 

In  lead  colio  hot  applications  to  the  abdomen  and  hypodermic  injec- 
tions of  morphin  and  atropin  are  often  indicated.  Efficient  doses  of 
Epsom  or  Glauber's  salts  are  used  to  combat  the  constipation.  Given 
in  combination  with  dilute  sulphuric  acid  (in  order  to  form  an  insoluble 
lead  sulphate)  and  with  belladonna,  the  best  and  speediest  benefits  may 
be  obtained  thereby. 

Iron  for  the  anemia,  strychnin  and  galvanism  for  the*  paralysis, 
lithia-water  for  the  renal  deterioration,  and  nitroglycerin  or  sodium 
nitrite  for  the  arteriosclerosis  (enough  to  relieve  increasing  tension)  are 
the  symptomatic  items  of  treatment  that  are  usually  indicated.  Rarely, 
hopeless  cases  of  saturnine  encephalopathy  need  to  be  sent  to  asylums 
for  the  insane. 

ABSENICISM. 

( Chronic  Arsenic-poisoning.) 

Definition. — A  chronic  intoxication  resulting  from  the  gradual 
absorption  of  arsenic. 

Pathology. — The  peripheral  nerves  show  a  degenerative  neuritis, 
and  the  anterior  horns  of^the  spinal  cord  may  be  similarly  affected. 

Ktiology. — The  causes  of  arsenicism  may  be  habitual,  industrial, 
medicinal,  or  accidental.  The  individual  predisposition  to  arsenic-in- 
toxication varies  in  different  persons.  A  neurotic  diathesis  usually 
underlies  the  habit  of  "arsenic-eating"  in  those  who  crave  the  drug 
for  its  alleged  exhilarant  or  narcotic  effects  {arsenic  inebriety).  Not  a 
few  women  suffer  from  chronic  arsenicism  as  the  result  of  the  ingestion 
of  arsenic  "to  improve  the  complexion  and  brilliancy  of  the  eye." 
Men  employed  in  arsenic-works  of  various  kinds  often  suffer  from  the 
chronic  poisoning.  For  example,  miners  and  smelters  of  arsenic  pyrites, 
dyers  and  wall-paper  workers  using  Scheele's  or  Schweinfurth's  green,  _ 
artificial-flower  makers,  shot-makers,  glass-workers,  and  taxidermists, 
are  all  liable  on  account  of  their  occupations.  Sometimes  the  medicinal 
use  of  moderate  doses  of  arsenic,  as  in  Fowler's  solution,  even  for  a 
short  time,  may  in  very  susceptible  persons  induce  arsenical  paralysis 
(Putnam ;  Osier).  Accidental  arsenicism  may  come  from  living  in 
rooms  where   wall-paper,    carpets,    colored    paper   ornaments,    toys,    or 


1220  THE  INTOXICATIONS ;   OBESITY;  HEAT-STROKE. 

curtains  are  contaminated  with  arsenic  anilin  dyes ;  this  does  not  oc- 
cur so  frequently  as  years  ago. 

Symptoms. — There  are  anemia,  loss  of  flesh  and  strength,  dryness 
and  irritation  of  the  mucosae,  of  the  eyes,  nose,  throat,  and  upper 
respiratory  tract.  Anorexia,  nausea,  and  diarrhea  indicate  the  pres- 
ence of  a  gastro-intestinal  catarrh.  In  some  cases,  milder  than  others, 
the  fat  is  well  preserved.  Slight  puffiness  of  the  eyelids  or  eyebrows 
may  occur,  and  some  epigastric  distress  may  be  complained  of  Marked 
conjunctivitis,  occasional  dysenteric  attacks,  loss  of  the  hair,  and  numb- 
ness and  tingling  in  the  extremities  form  a  commonly  observed  symptom- 
group.  Cutaneous  symptoms  may  appear,  as  pigmentation  ("arsenic- 
bronzing"),  and  eczematous,  herpetic,  urticarial,  and  pemphigoid  mani- 
festations. Albuminuria  with  casts  and  blood  mark  the  renal  irritation 
that  sometimes  occurs. 

The  most  characteristic  evidence  of  chronic  arsenic-poisoning  is  seen 
in  the  gradual  increasing  diffuse  or  multiple  neuritis.  Differing  from 
lead-palsy,  the  leg-extensors  and  the  peroneal  group  of  muscles  are  in- 
volved first,  although  the  arms  may  also  become  affected  later  {vide  Mul- 
tiple Neuritis,  p.  1030).  Contractions  in  the  lower  and  a  fine  tremor  of 
the  upper  extremities  are  apt  to  occur.  Arsenic-poisoning  may  also 
cause  headache,  vertigo,  melancholia,  and  hysteria.®  The  drug  is  elimi- 
nated by  tl^e  kidneys  and  may  be  found  in  the  urine.  Sometimes  a 
great  toleration  of  arsenic  is  observed  in  workmen  and  habitues,  the 
only  evidences  being  a  clear,  sallow,  waxy  complexion,  a  gloomy  ex- 
pression, and  some  dyspepsia,  perhaps,  as  in  the  well-known  Styrians. 

Diagnosis. — This  is  not  difficult,  when  once  the  source  of  the  pois- 
oning is  determined.  The  clinical  appearances  are  distinct  from  lead- 
intoxicatio7i,  especially  in  the  mode  of  progress  of  the  paralysis,  and  in 
the  more  marked  sensory  s^^mptoms  combined  with  the  motor-disturb- 
ances of  arsenicism. 

The  prognosis  is  favorable  in  most  cases  in  which  removal  from 
the  exposure  to  the  influence  of  arsenic  is  possible.  A  few  cases  die 
from  tlie  great  general  debility. 

Treatment. — Abstention  from  the  use  of  arsenic  for  cosmetic  pur- 
poses, avoidance  of  its  influence  in  the  arts,  care  in  its  medicinal  ad- 
ministration, and  prophylaxis  as  regards  the  possible  or  discovered 
sources  of  contamination,  form  the  first  considerations  in  the  treatment. 
Elimination  of  the  arsenic  may  be  promoted  by  the  use  of  potassium 
iodid  and  purgatives.  Gastro-intestinal  and  other  irritations  must  be 
met  by  appropriate  sedative  remedies.  The  neuritis  and  palsies  require 
— as  soon  as  the  tenderness  and  pain  subside — massage  and  electricity. 
Judicious  and  wholesome  alimentation  and  tonics  are  indicated. 

MERCURIALISM. 
( Chronic  Mercurial  Poisoning.) 

Definition. — A  chronic  intoxication  caused  by  the  habitual  inges- 
tion, or  combined  industrial  absorption  of  mercury,  in  susceptible 
individuals. 

Pathology. — No  marked  pathologic  changes  have  been  noted  in 
human  beings,  aside  from  the  evidences  of  oral,  gastro-intestinal,  and 


MEBCUBIALISM.  1221 

renal  irritation  and  inflammation.  It  is  not  improbable  that  the  cere- 
bral cortical  areas  suifer  more  from  metallic  irritation  than  do  the 
spinal  or  peripheral  nerve-tissues. 

!^tiology. — Some  persons  are  much  more  easily  mercurialized  than 
others,  (a)  Salivation  and  stomatitis  from  the  therapeutic  use  of  mer- 
cury form  a  variety  that  is  not  infrequent  in  these  days.  (5)  Indus- 
trial origin.  The  chief  cause  of  chronic  mercurialism  is  the  inhalation 
of  the  vapor  of  the  metal  by  artisans  in  the  industries  in  which  it  is 
used.  Thus  miners  and  smelters  and  those  engaged  in  making  mirrors, 
barometers,  thermometers,  amalgams,  felt  hats,  vermilion-pigment,  and 
artificial  teeth  sometimes  suffer  from  chronic  mercurial  poisoning.  It 
should  be  pointed  out  here  that  mercury  is  volatile  at  ordinary  tempera- 
tures, and  is  absorbed  into  the  blood  through  the  lungs,  digestive  tract, 
and  skin.  Calomel  vapor-baths  have  caused  poisoning  in  a  few  cases, 
(c)  Purely  accidental  mercurialization  also  occurs,  {d)  Women  and  children 
are  more  susceptible  to  the  action  of  mercury  than  men.  In  all  cases 
the  mercury  exists  in  the  tissues  as  an  albuminate. 

Symptoms. — There  are  anemia,  emaciation,  gastro-intestinal  dis- 
orders, stomatitis,  salivation,  maxillary  necrosis,  ulceration  of  the  gums, 
loosening  of  the  teeth,  fetor  of  the  breath,  marked  tremors,  and  paraly- 
sis. The  oral  symptoms  are  not  as  prominent,  however,  as  in  acute 
mercurial  poisoning.  The  hair  falls  out,  the  nails  become  brittle,  and 
pigmentation  of  the  skin  is  seen. 

The  tremor  is  characteristic.  It  is  first  felt  or  noticed  in  the  tongue 
and  lips,  is  usually  fine,  later  coarse  and  choreiform,  and  spreads  grad- 
ually throughout  the  muscular  system.  It  is  aggravated  by  voluntary 
efibrt,  and  may  cease  during  sleep  in  mild  cases.  Speech  is  altered. 
Hysteric  tremors  may  also  exist.  Great  irritability  and  restlessness  are 
€ommon.  Aphasia,  hemiplegia,  hemianesthesia,  and  peripheral  neuritis 
with  palsies,  occur.  There  is  no  atrophy,  nor  are  the  reactions  of  de- 
generation present  in  the  paralyzed  muscles.  Severe  pains  may  be 
present  in  the  extremities,  including  the  joints,  and  grave  cerebral 
symptoms  occasionally  develop  (stupidity,  headache,  loss  of  memory, 
insomnia,  hallucinations,  delirium,  coma,  convulsions,  and  confusional 
insanity).  Albuminuria  with  anasarca  may  occur.  The  effects  of 
chronic  hydrargyrism  in  women  upon  their  offspring  are  also  important, 
the  children  being  rachitic,  weak,  sickly,  and  prone  to  tuberculosis. 

Diagfnosis. — The  history,  the  characteristic  tremors,  paresis,  and 
mental  irritability  are  significant.  In  the  absence  of  a  history  of  ex- 
posure to  mercury,  the  differentiation  from  progressive  genercd  paresis, 
disseminated  sclerosis,  or  jjaralgsis  agitans  may  be  more  or  less  difficult. 

Prognosis. — Recovery  is  common  upon  the  removal  of  the  source 
or  on  removing  the  patient  from  the  source  of  the  poisoning.  Fatal 
terminations  rarely  ensue,  and  then  in  cases  of  mercurial  encephalop- 
athy of  a  grave  type  and  with  a  tendency  to  idiocy. 

Treatment. — Prevention  of  further  poisoning  is  imperative,  elimi- 
nation is  to  be  promoted,  and  the  symptoms  are  to  be  met  as  they  arise. 
Potassium  chlorate,  Avith  the  tincture  of  myrrh,  and  astringents  are  use- 
ful for  the  occasional  stomatitis  and  salivation.  Potassium  iodid,  and 
also  sulphur  baths,  may  be  used  to  aid  in  the  elimination  of  the  mer- 
cury.    Iron,  cod-liver  oil,  good  food  and  fresh  air,  and  a  free  activity 


1222  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

of  the  emunctories  are  of  positive  value.     Electricity  may  be  resorted 
to  for  the   paresis. 

FOOD-INFECTION    AND    PTOMAIN-POISONING. 

In  recent  years  there  have  been  reported  an  increasing  number  of 
cases  of  serious  illness  that  have  been  traced  to  infected  and  contami- 
nated food.  Undoubtedly  many  such  instances  are  now  brought  to 
notice  that  in  former  times  were  attributed  to  other  causes,  or  that  were 
not  diagnosticated  because  of  a  lack  of  knowledge.  On  the  other  hand, 
the  increased  consumption  of  canned  and  preserved  meats  has  cer- 
tainly augmented  the  liability  to  poisoning  from  these  products,  as  the 
reports  of  cases  show.  Lack  of  care  in  the  inspection  and  selection  of  the 
meats,  uncleanliness,  and  sometimes  unscrupulousness,  in  their  handling 
and  preparation,  must  result  in  infection,  putrefaction,  and  toxicity. 
The  infection  of  the  food  may  be  due  to  (1)  disease  of  the  animal  or 
plant  from  which  the  food  is  derived ;  (2)  microbic  inoculation  of  the 
food  after  derivation  and  before  ingestion  by  human  beings ;  (3)  infec- 
tion by  toxicogenic  bacteria,  and  the  presence  of  ptomains  or  toxalbu- 
moses.  The  transmission  to  man  of  such  aftections  in  animals  as  tuber- 
culosis, anthrax,  glanders,  and  pleuro-pneumonia,  by  eating  the  infected 
meat,  has  been  sufficiently  proved.  Again,  meat  and  milk  may  become 
infected,  before  being  ingested  by  the  patient,  by  pathogenic  micro- 
organisms, as  of  typhoid  fever  and  diphtheria,  or  from  the  production 
of  toxins  owing  to  the  action  of  non-pathogenic  putrefactive  micro- 
organisms. A  great  many  instances  of  food-infection,  particularly  of 
meat  and  milk,  have  been  shown  to  be  due  to  the  presence  of  sapro- 
phytic germs,  this  happening  even  when  the  articles  of  food  have  been 
obtained  from  healthy  stock  and  have  been  kept  free  from  specific  path- 
ogenic bacteria.  It  is  not,  however,  the  saprophytes  themselves  in  all 
cases,  but  the  poison  develoj)ed  in  the  food  before  it  is  eaten  or  formed 
in  the  body  afterward,  that  produce  the  symptoms  and  sometimes  death. 
According  to  Novy,  some  of  the  saprophytic  bacteria  with  which  food  is 
infected  outside  of  the  body,  under  certain  conditions,  are  capable  of 
living  in  the  body  as  parasites,  especially  on  dead  matter,  and  there 
become  toxicogenic. 

The  chronic  poisons  or  ptomains  resulting  from  the  action  of  the 
saprophytes  in  foods  are  called  ''  putrefactive  alkaloids  ;"  those  bacterial 
products  of  a  proteid  nature  are  called  "  toxalbumins  "  or  "  toxalbu- 
moses."  The  latter,  according  to'Vaughan,  are  more  frecjuently  present 
in  infected  foods.      They  are  all  absorbed  from  the  digestive  canal. 

Poisoning  by  Infected  Milk  and  Milk-products. — It  is  now  well  known 
that  the  cause  of  the  liigli  iiioi-tality-rate  among  infants  in  hot  weather 
is  traceable  directly  or  indirectly  to  the '"summer  diarrheas'  in  chil- 
dren fed  artificially,  wholly  or  partially,  with  milk  infected  by  numerous 
varieties  of  saprophytic  germs  and  thus  poisoned  by  ptomains,  such  as 
tyrotoxicon.  This  special  chemical  poison  has  been  isolated  by 
Vaughan,  and  discovered  by  him  in  cheese.  It  has  also  been  found 
in  ice-cream,  frozen  custards,  and  cream-puff's,  and  lias  caused  poison- 
ing-symptoms mainly  of  acute  gastro-intestinal  inflammation,  "con- 
striction of  the  fauces,"  nausea  and  vomiting,  sharp,  griping  intestinal 


FOOD-INFECTION  AND  PTOMAIN-POISONING.  1223 

pains,  headache,  thoracic  oppression,  chilliness,  dizziness,  and  sometimes 
purging,  follo'wed  by  relief  in  mild  cases.  In  the  severe  and  long-con- 
tinued forms,  however,  exhaustion  may  supervene,  with  subnormal  tem- 
perature, coma,  collapse,  and  death  in  the  graver  cases.  Xo  chemical 
or  physiologic  antidote  is  known.  Elimination  may  be  assisted,  and 
stimulation  is  needed.  Irrigation  may  be  employed  for  the  former  in 
both  stomach  and  bowels.  Strychnin,  nitroglycerin,  atropin,  and  the 
aromatic  spirits  of  ammonia  are  most  effective  as  stimulants. 

Meat-poisoning. — Various  tainted  meats,  as  mince-meat  "  w^armed 
over,"  veal  pie,  carelessly-kept  chicken  salad,  badly-preserved  and 
canned  meats,  partially-decayed  sausages  (botuUsmus)  have  caused 
violent  symptoms  of  poisoning.  Diseased  raw  and  partially-cooked 
meat  has  also  been  eaten  with  disastrous  results.  It  should  be  borne  in 
mind  that  even  prolonged  cooking  fails  to  destroy  the  toxic  action  of 
certain  ptomains  in  infected  meats  ;  also,  that  meat  that  has  been  cooked 
and  kept  under  certain  conditions  may  become  infected  with  bacteria  as 
well  as  when  it  is  raw.  On  the  other  hand,  bad,  putrid  meat  has  been 
known  not  to  cause  toxic  symptoms. 

The  symptoms  caused  by  the  poisoning  are — "  (1)  those  due  to  a  true 
infection;  (2)  those  due  to  simple  poisoning"  (Mann).  Cases  of  the 
former  group  run  the  usual  course  of  an  infectious  disease,  often  simu- 
lating typhoid  fever.  Those  under  the  second  division  manifest  the 
symptoms  of  a  violent  gastro-enteritis,  with  vomiting,  intense  colicky 
pains,  purging,  fever,  accelerated  pulse,  nervous  prostration,  great  mus- 
cular W'Cakness,  and  cramps  in  the  calves  of  the  legs.  Often  a  subse- 
quent subnormal  temperature,  extreme  depression,  convulsive  movement, 
vertigo,  dimness  of  vision,  dyspnea,  somnolence,  great  soreness  of  the 
mouth,  collapse,  and  sometimes  death  supervene.  The  mortality-rate 
varies  from  15  to  55  per  cent,  of  all  the  cases. 

Differential  Diagnosis. — Arsenic-poisoning  may  have  symptoms 
similar  to  those  of  ptomain-poisoning.  But,  as  Harrington^  points  out, 
there  are  three  chief  points  of  difference :  in  arsenic-poisoning  there  is 
swallowing  because  of  pain ;  in  ptomain-poisoning  the  pupils  are  us- 
ually dilated  and  the  muscular  prostration  is  almost  as  extreme  as  a  palsy. 

The  treatment  is  largely  eliminative.  symptomatic,  and  supportive. 
The  prophylactic  measures,  private  and  public,  are  generally  obvious. 

Poisoning  by  Fish  (Ichthi/smus)  and  Shell-fish. — Many  instances  of 
this  serious  form  of  intoxication  have  been  produced.  The  fish  may 
contain  certain  poison-glands,  ovaries,  etc.  Especially  is  this  true  of 
certain  species  known  in  Japan,  one  of  which  is  believed  to  cause  the 
disease  called  "  Kakke."  Avhich  prevails  during  the  summer  months  in 
Tokio.  A  certain  species  offish  {^Clupea  venenosa)  inhabiting  the  West 
Indian  waters  is  supposed  to  be  always  poisonous,  although  the  source 
or  true  character  of  the  poison  is  doubtful.  In  Russia,  many  cases  of 
ichthyismus  have  resulted  from  eating  both  the  fresh  and  preserved 
sturgeon  and  salmon  meat  that  are  affected  with  an  infectious  disease 

CI 

peculiar  to  the  fish.  In  Germany  and  other  parts  of  middle  Europe 
a  severe  form  of  gastritis  called  '' Barbencholera  "  follows  the  eating 
of  sick  barbels. 

The  use  of  tainted  preserved  and  canned  fish,  eels,  oysters,  mussels, 

Boston  Medical  and  Surgical  Journal,  Dec.  14,  1899. 


1224  THE  INTOXICATIONS ;    OBESITY;  HEAT-STROKE. 

crabs,  lobsters,  and  the  like,  is  more  frequently  the  cause  of  symptoms  of 
poisoning,  however.  Brieger's  mytilotoxhi,  the  active  poison  formed  in 
some  mussels,  and  the  eating  of  which  at  Wilhelmshaven  caused  several 
epidemics,  is  probably  developed  only  under  certain  favorable  conditions 
of  saprophytic  infection.  Devilled  crabs,  lobsters,  and  salad  have  also 
caused  severe  gastro-enteritis  because  of  contamination  with  germs  pro- 
ducing ptomains.  Oysters  have  been  accused  of  conveying  typhoid  in- 
fection (vide  p.  26).  The  symptoms  of  fish-  and  shellfish-poisoning  are 
variable.  Sometimes  marked  cerebro-spinal  manifestations  predominate, 
with  convulsions  and  paralysis.  Dryness  and  constriction  of  the  throat, 
dizziness,  labored  respiration,  disturbed  vision,  jerky  speech  or  aphonia, 
perhaps  rapid  pulse,  loss  of  coordination,  numbness,  coldness  of  the 
extremities,  dilated  pupils,  paresis,  collapse,  and  death  within  a  few 
hours,  may  ensue. 

Other  cases  have  a  pronounced  gastro-intestinal  or  choleraic  group 
of  symptoms,  Avith  nausea  and  vomiting,  pain,  tenesmus,  and  mucous  and 
bloody  stools.  In  some  of  them  marked  cutaneous  irritation  is  shown 
by  erythema,  great  heat  and  itching,  urticaria,  and  swelling.  Dyspnea, 
lividity,  and  sometimes  delirium,  have  also  been  noted.  The  progno- 
sis is  grave  in  many  instances.  The  treatment  is  similar  to  the 
above — namely,  emetics,  purgatives,  enemata,  and  lavage.  The  indica- 
tions are  to  be  provided  for  as  they  arise. 

GRAIN-    AND   VEGETABLE-POISONING. 

Ergotismus. — Epidemics  of  ergotism  have  resulted  from  the  con- 
tinued use  of  meal  made  from  contaminated  grains  grown  on  virgin  soil. 
The  parasite  {daviceps  purpurea)  is  a  fungus  that  infests  rye  and  other 
grains;  it  does  not,  however,  grow  readily  where  the  soil  is  well  culti- 
vated, and  epidemics  of  ergot-poisoning  are  much  less  frequent  than 
formerly,  if  we  except  certain  places  in  Spain  and  Russia.  According 
to  Kobert,  three  poisonous  substances  are  found  in  the  ergot :  ergotinic 
acid,  sphacelinic  acid,  and  cornutin.  The  first  of  these  is  not  poisonous 
Avhen  taken  into  the  stomach  ;  the  second  is  supposed  to  cause  gangrene  ; 
and  the  last  produces  grave  effects  on  the  nervous  system,  and  is  found 
only  in  fresh  ergot,  hence  the  greater  prevalence  of  nervous  manifesta- 
tions in  sickness  that  breaks  out  soon  after  harvest. 

The  nervous  symptoms  are  remarkable  for  their  convulsive  character- 
istics {ergotismus  convuhivus).  Prodromes  of  weakness,  tingling  in  the 
extremities,  and  headache  may  exist  for  several  weeks  before  the  spasms 
come  on.  The  formication  increases,  and  cramps  and  contractures,  with 
flexed  wrists  and  extended  feet  and  toes,  seize  the  patient.  In  severe 
cases  epileptoid  convulsions  occur  and  may  prove  fatal.  Delirium  and, 
in  very  chronic  cases,  dementia  may  supervene.  Recovery  is  slow,  and 
the  contractures  may  persist  for  some  time,  with  muscular  atrophy  and 
anesthesia.  In  some  interesting  instances  there  may  appear  nervous 
symptoms  resembling  locomotor  ataxia  (''ergot  tabes"),  owing  to  poste- 
rior spinal  sclerosis.     Abortion  results  in  pregnant  women. 

Gangrenous  ergotism  {ergotismus  gangra>nosus)  is  characterized  by 
dry  gangrene  of  the  hands  and  feet,  usually  of  the  fingers  and  toes. 
Before  the  gradual  blackening  appears,  there  may  be  formication,  pain. 


GRAIX-   AXD    VEGETABLE-POISONING.  1225 

spasm,  num'bness,  and  coldness.  As  mortification  and  the  line  of  de- 
markation  progress,  the  parts  drop  off  bit  bv  bit,  and  fever  may  attend 
the  sphacelation.  Pneumonia  (septic)  may  sometimes  complicate  this 
malady.  The  fatality  has  been  considerable  in  some  epidemics.  The 
treatment  of  ergotism  is  entirely  symptomatic. 

Maidismus  or  Pellagra. — This  is  a  chronic  nutritional  disturbance 
due  to  poisoning  from  eating  contaminated  corn-meal  bread.  The  dis- 
ease prevails  extensively  among  the  poorer  classes  in  Lombardy,  Spain, 
and  southern  France.  The  origin  of  the  infection  of  the  maize  is 
said  to  be  bacillary,  the  latter  causing  putrefactive  or  fermentative 
changes  in  the  fresh,  moist  corn-meal,  with  the  production  of  ptomains. 

The  symptoms  at  the  beginning  are  languor,  debility,  indigestion, 
anorexia,  restlessness,  and  occasionally  diarrhea.  This  is  soon  followed 
by  erythema,  pain,  and  roughness  of  the  skin.  Exfoliation  of  the  latter 
reveals  a  suppurating  surface.  In  severe  cases,  paresthesi^e,  spasms, 
paraplegia,  headache,  backache,  delirium,  and  a  suicidal  mania  may 
occur.     Idiocy  and  profound  cachexia  may  result  from  numerous  attacks. 

Structural  changes  have  been  found  in  the  cord,  and  fatty  degenera- 
tion and  ulceration  in  the  viscera. 

Prophylaxis  by  thorough  drying  and  careful  storing  of  the  meal  is 
to  be  aimed  at.      The  symptoms  are  to  be  met  as  rationally  as  possible. 

Lathyrismus  is  an  intoxication  caused  by  the  seed  (used  in  the  form 
of  meal)  of  three  varieties  of  vetch  or  chicken-pea,  viz.  Lathyrus  cicera, 
L.  sativus,  and  L.  clymenum.  or,  respectively,  red,  German,  and  Span- 
ish vetch.  The  meal  is  generally  mixed  with  that  obtained  from  other 
cereals.  Its  use  for  several  hundred  years  has  been  observed  to  cause 
leg-stiffness,  passing  into  a  transverse  myelitis,  with  sensory  and  motor 
paraplegia.  Spasticity  and  exaggerated  tendon-reflexes  may  remain 
for  some  time  after  the  paralysis  subsides.  Slight  fatty  degeneration 
was  noted  by  Cautain  in  excised  bits  of  muscle.  Very  chronic  cases 
may  die  in  paralysis,  from  the  toxic  effects  of  the  poison,  which,  thus 
far,   has  not  been  separated. 

Muskroom-poisoning. — Though  not  so  common  as  formerly,  poisoning 
from  eating  non-edible  mushrooms  occurs  now  and  then,  owing  to  ignor- 
ance or  carelessness  in  gathering,  keeping,  and  cooking  them.  Fresh 
morels  are  poisonous,  while  those  that  have  been  dried  and  boiled  are 
not  so,  because  of  evaporation  or  solution  of  the  contained  poison. 

The  red  agaric  (arnanita  m.uscarid),  on  account  of  the  poisonous 
alkaloid  muscarin  that  it  contains,  may  cause  very  severe  symptoms. 
These  are  nausea,  vomiting,  diarrhea,  hemoglobinemia.  hemoglobinuria, 
and  jaundice  {probably  hepatogenous)  in  the  case  of  fresh  morel-poisoning 
(Striimpell).  Tetanic  and  epileptiform  convulsions  give  a  slow  pulse, 
dilated  pupil,  disturbed  vision,  salivation,  coma,  and  death  in  the  gravest 
cases  of  red-agaric  intoxication,  in  addition  to  the  symptoms  of  gastro- 
intestinal irritation. 

The  treatment  is  symptomatic.  Emetics,  purgatives,  stimulants,  and, 
in  red-agaric  poisoning,  atropin,  for  its  physiologic  antidotal  efiect,  are 
usually  indicated. 


1226  THE  INTOXICATIONS;   OBESITY;   HEAT-STROKE. 

OBESITY. 

{Polysarcia  Adiposa  :  Lipomatosis  Universalis.) 

Definition. — Corpulence,  or  the  presence  of  an  excessive  amount  of 
bodily  fat,  may  be  said  to  begin  to  take  the  form  of  a  disease  when  it 
becomes  an  inconvenience  or  impairs  the  bodily  functions. 

Pathology. — The  chief  alteration  is  the  marked  and,  in  some  in- 
stances, colossal  increase  in  the  fat  deposit  throughout  the  body.  Not 
only  is  the  adipose  tissue  greatly  increased  in  localities  where  it  is  nor- 
mally found  or  '•  preformed,"  as  under  the  skin,  but  the  various  internal 
organs  and  tissues  that  are  normally  quite  or  nearly  free  from  fat,  may  in 
obesity  show  a  decided  fatty  infiltration. 

The  round,  fat  face,  ''double  chin,"  broad  and  deep  chest,  lavge  waist, 
thick  and  prominent,  sometimes  overhanging,  abdominal  panniculus  adi- 
posus,  and  bulky,  cylindric,  and  apparently  shortened  extremities,  are 
familiar  appearances  postmortem  as  well  as  antemortem. 

There  may  be  differences  in  the  number  and  size  of  the  fat-globules  in 
the  histologic  elements.  Thus,  in  the  plethoric  form  of  obesity  the  cel- 
lular fat-globules  are  larger  than  those  of  the  anemic  or  hydremic  form. 
Qualitative  differences  in  the  fat  may  also  occur. 

The  Mood  in  cases  of  obesity  is  increased  in  specific  gravity  to  as  much 
as  1065  or  1070.  In  a  majority  of  cases  the  hemoglobin-percentage  is 
also  increased  (plethora). 

The  heart  is  overlaid  with  fat,  and  the  intermuscular  tissue  shows  a 
decided  fatty  infiltration.      Hypertrophic  dilatation  is  frequently  present. 

The  arteries  may  show  fatty  changes  in  the  intima  and  media,  and  in 
the  older  cases  chronic  endarteritis  with  thickening  and  sclerosis  of  the 
vessels.     The  veins  are  often  affected  with  varicosities. 

Passive  congestion  and  edema  of  the  /m?///.S'  are  secondary  to  the  car- 
diac weakness  that  is  so  common  in  advanced  cases.  The  liver,  lungs, 
and  kidneys  may  be  enlarged  owing  to  fatty  infiltration.  Chronic  in- 
terstitial nephritis  may  form  a  late  complication  of  obesity. 

The  stomach  may  be  dilated,  and  often  shows  a  catarrh  of  the  mucosa. 
Catarrhal  enteritis  of  mild  type  also  occurs  sometimes. 

Pathogenesis. — Obesity  is  probably  dependent  on  a  disturbance 
of  cell-activity,  and  this  disturbance  of  metabolism  may  be  transmitted 
through  heredity  {vide  infra).  The  overuse  of  carbohydrates  leads  directly 
to  fat-increase.  The  consumption  of  proteids  may  also  result  in  a  fat- 
forming  non-nitrogenous  residue,  Avhich  if  not  oxidized  may  produce 
fatness  (see  also  Etiology). 

Etiology. — Among  the  chief  }iredisposiny  conditions  are  heredity, 
climate,  iiabit,  occupation,  temperament,  age.  and  sex.  Among  202  of 
my  cases,  in  which  the  family  history  was  noted,  heredity  was  distinctly 
traceable  in  60  per  cent.  Gout  was  either  in  association  or  occurred 
among  the  antecedents  in  45  per  cent,  of  these  cases  and  the  same  was 
true  of  ''rheumatism"  in  30  per  cent.  It  followed  typhoid  fever  in 
6  per  cent,  of  the  totality  of  cases.  The  disease  dated  from  child-birth 
in  14  per  cent,  of  the  cases  and  from  marriage  (apart  from  child-birth) 
in  7.3  per  cent,  among  151  females.  The  menopause  has  little  if  any 
influence.  Corpulence  is  much  more  frequent  among  the  inliabitants 
of  hot,  moist  climates,  and  of  low  countries  of  the  temperate  and  arctic 


OBESITY.  1 227 

regions.  Thus  it  is  commonly  observed  among  Orientals,  Dutchmen, 
South  Pacific  Islanders,  Southern  Italians,  and  certain  African  races. 
Sedentary  habits  and  occupations  form  common  predisposing  factors. 
The  sluggish,  luxury-  and  rest-loving,  phlegmatic  temperament  also 
favors  an  abnormal  fat-deposition.  As  regards  the  age,  polysarcia  gen- 
erally makes  its  appearance  in  persons  of  advanced  middle  life,  between 
forty  and  fifty  years,  while  hereditary  obesity  dates  from  infancy  and 
early  childhood ;  in  women,  it  may  appear  at  puberty  and  between 
thirty  and  forty  years  of  age.  Women,  and  especially  Jewesses,  seem 
to  be  more  subject  to  corpulence  than  men.  Congenital  anomalies  and 
monstrosities  (idiots,  cretins,  acephali),  also  anemics  and  hemiplegics, 
are  often  excessively  fat. 

The  exciting  causes  of  obesity  are  especially  the  ingestion  of  too  much 
fat-making  food,  the  intemperate  use  of  alcoholic  beverages,  especially 
beer,  ale,  and  porter,  with  or  Avithout  deficient  exercise.  The  fat  may 
be  derived  from  an  excess  of  albumin,  fat,  or  carbohydrates  in  excess. 
An  excessive  diet  of  starches  and  sugars  acts  indirectly  as  a  fat-producer 
by  lessening  the  oxidation  of  the  ingested  fat  and  of  the  fat  formed  from 
proteids,  because  the  carbohydrates  themselves  are  so  readily  oxidized. 

Syttlptoms. — Obesity  is  not  accompanied  by  any  bodily  symptoms 
at  first.  Except  some  inconvenience,  and  a  sense  of  burdensomeness 
during  walking  or  working,  nothing  may  be  complained  of  for  years. 
With  the  progressive  development  of  the  disease,  however,  and  particu- 
larly with  the  involvement  of  the  viscera,  subjective  manifestations 
increase  in  number  and  intensity.  Usually  the  earliest  troublesome 
symptom  is  breathlesHness  on  exertion,  due  to  a  weak  heart  and  to  the 
hampering  of  respiration  by  heavy  chest-walls  and  the  upward-crowded 
diaphragm.  In  plethoric  individuals  the  face  is  red  and  congested,  as 
are  also  the  mucous  membranes  (conjunctivae,  labise).  In  anemic  subjects 
(usually  women)  the  skin  is  pale,  the  muscles  are  flabby  and  weak;  the 
pulse  is  small  and  compressible,  and  dyspnea,  palpitation,  inclination  to 
rest  often  and  sleep  much,  and  dizziness  (symptoms  of  anemia  and  chloro- 
sis) are  manifested.  On  the  other  hand,  in  plethoric,  corpulent  subjects 
(usually  men)  the  muscles  are  firm  and  strong,  and  the  pulse  and  heart- 
beats vigorous ;  later,  however,  the  latter  becomes  weak  and  irregular. 
Brachycardia  is  not  infrequent.  The  signs  of  fatty  heart  {vide  p.  656) 
are  obtained  on  physical  examination.  Muscular  power  may  diminish 
very  rapidly,  the  appetite  often  fails,  and,  oddly  enough,  great,  fat  men 
may  consume  very  small  quantities  of  food.  Intercurrent  acute  infec- 
tions (typhoid  fever,  pneumonia)  are  badly  borne,  and  hyperpyrexia  is 
usually  associated  with  them. 

The  liver  may  show  enlargement.  The  passive  congestion  of  the 
respiratory  mucous  membr^me  is  often  signalled  by  cough  and  distressing 
dyspnea  and  attacks  of  asthma.  Profuse  sweating  is  common.  There 
may  be  polyuria  or  oliguria^  according  to  the  activity  of  the  skin  and 
kidneys  at  the  same  time.  Uric  acid  and  the  urates  are  usually  found 
to  be  increased. 

Symptoms  of  gastric  catarrJt  and  gastrectasia  may  occur.  Great 
thirst  and  bulimia  are  noted  in  some  instances.  Constipation  may  be 
followed  by  chronic  diarrhea.  Sexual  desire  is  often  abated,  and  azo- 
ospermia is  not  rare.  Corpulent  women  often  suffer  from  uterine  dis- 
placement and  prolapse.     Amenorrhea,  sterility,  endometritis  (conges- 


1228  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

tive),  leukorrhea,  and  an  aggravated  climacteric  are  seen  in  obese  women 
also.  The  skin  is  often  irritated  (intertrigo)  by  the  excessive  sweating, 
and  by  the  friction  of  cutaneous  surfaces  in  the  folds  of  fat.  as  under  the 
breast,  at  the  abdominal  and  inguinal  folds,  and  around  the  scrotum 
and  labia.  This  may  be  followed  by  eczema.  Painful  excoriations, 
pruritus,  acne  rosacea  (in  alcoholics),  and  alopecia,  are  also  not  un- 
common. 

Complications. — Hernia,  cardiac  asthma,  bronchitis,  pulmonary 
congestion,  edema,  arteriosclerosis,  albuminuria,  glycosuria,  anginal 
attacks.  Cheyne-Stokes  respiration,  cerebral  hemorrhage,  and  coma  may 
manifest  themselves  as  the  precursors  of  the  final  stage. 

Diagnosis. — This  is  not  difficult  in  most  cases.  Care  must  be  exer- 
cised in  detecting  associated  conditions,  complications,  and  sequelae. 

The  prognosis  will  depend  upon  the  peculiar  features  of  each  indi- 
vidual case,  the  cause  and  its  removability,  and  upon  the  variety,  degree, 
symptoms,  and  prevailing  complications. 

Treatment. — Prophylaxis  is  important  in  the  earlier  years  of  those 
showing  an  hereditary  predisposition  to  corpulence.  The  fat-forming 
(farinaceous)  substances  must  be  diminished  in  the  dietary.  The  propor- 
tions of  fat  and  proteid  in  the  food  must  be  regulated  according  to  the 
amount  of  muscular  activity,  and  the  latter  should  be  encouraged  in  fresh 
air,  along  with  cool  bathing.  At  middle  life,  in  those  predisposed  to 
polysarcia,  all  imprudences  in  eating  and  drinking  should  be  cautioned 
against,  and  the  quantities  of  various  articles  of  food  and  the  time  of  eat- 
ing regulated.  Outdoor  sports  and  gymnastics  should  be  also  gauged 
accordingly. 

The  dietetic  treatment  of  confirmed  obesity  is  all-important.  Insep- 
arable from  this  is  the  stimulation  of  the  bodily  forces  that  oxidize  and 
destroy  the  fat.  These  two  means  are  utilized  in  the  principal  methods 
of  treating  obesity,  and  that  method  must  be  selected  which  invigorates, 
while  at  the  same  time  it  involves  neither  injury  nor  weakening  of  the 
patient. 

The  principal  systems  of  dietary  are  those  known  by  the  names  of 
Banting,  Ebstein,  and  Oertel. 

In  "  Bantingism,"  sugars,  fats,  and  starches  are  greatly  reduced  in 
the  diet-list;  water,  however,  is  not  restricted,  and  vinous  and  spirituous 
liquors  are  permitted.  In  those  of  a  rheumatic  or  gouty  diathesis 
Banting's  heavy  proteid  and  alcohol  dietary  is  not  to  be  recommended. 
It  is  best,  I  think,  to  exclude  alcohol  in  most  cases,  owing  to  its  eflfect 
in  diminishing  tissue-oxidation  and  in  retarding  cell-metabolism.  This 
method  fails  to  secure  elimination  of  waste  products. 

In  Ebstein's  diet-list  more  than  double  the  amount  of  fat  and  car- 
bohydrates is  permitted  as  compared  with  Banting's  list,  whilst  the 
albuminous  substances  are  diminished.  Fal  is  freely  allowed,  as  this 
does  not  increase  stored  fat  (?),  but  tends  to  impair  the  appetite,  while 
sugar  and  potatoes  only  are  strictly  forbidden. 

Oertel  of  Munich  also  allows  more  fat  than  Banting,  but  less  fat  and 
more  (about  double  the  quantity)  proteids  and  carbohydrates  than 
Ebstein.  The  amount  of  free  water  permitted  daily  is  only  one  pint; 
about  one  pint  additional  in  other  food  is  allowable. 

Oertel '  writes  :  "  The  body  stores  up  fat  if  more  than  118  grams  of 

^  Twentieth  Cent.  Praci.  of  Med.,  vol.  ii.  pp.  698,  699. 


Fat. 

Carbohydrates. 

Calories. 

25 

75 

1180 

45 

120 

1608 

OBESITY.  1229 

albumin  and  259  grams  of  fat,  a  total  of  277  grams  (2894  calories),  are 
taken  in.  On  the  other  hand,  110  grams  of  albumin  and  600  grams 
of  starch,  a  total  of  710  grams  (2944  calories),  may  be  given  without 
producing  a  deposit  of  fat.  With  a  mixed  diet  the  limit  lies  near  118 
grams  of  albumin,  100  grams  of  fat,  and  368  grams  of  starch,  a  total 
of  586  grams  (2923  Calories)."     His  diet-table  for  obesity  is  appended: 

Albumin. 

Minimum   .    .    .    .  ^ 156 

Maximum 170 

Oertel  gives  a  special  diet-list  in  circulatory  disturbances. 

On  the  basis  of  Voit's  laws,  Strlimpell  recommends  in  the  average 
cases  125  gm.  (4  oz.)  or  more  of  albumin,  40  gm.  (IJ  oz.)  of  fat,  and 
150  gm.  (462  oz.)  of  starch.  Schwenniger's  rule  difiers  from  Oertel's 
merely  in  the  forbidding  of  liquids  with  the  meals  and  in  permitting 
their  use  only  after  two  hours  have  elapsed.  Yeo's  diet-list  is  also  a 
useful  guide. 

In  plethoric  obesity  a  judicious  rearrangement  of  the  food  (some  in- 
crease of  the  albuminoid  substances),  coupled  with  sufficient  muscular 
exercise  (walking,  horseback-riding,  bicycling,  rowing,  swimming,  gym- 
nastics) accomplish  successful  reduction,  as  a  rule. 

Increasing  weakness  of  the  heart  with  an  impeded  circulation  natur- 
ally diminishes  the  excretion  of  water  by  the  cutaneous  and  renal  routes. 
In  such  cases  the  circulatory  system  must  receive  unusually  careful 
attention  and  the  consumption  of  fluid  must  be  limited.  If  evidences 
of  anemia  be  present,  the  amount  of  liquid  may  be  also  much  restricted 
and  the  fat-forming  dishes  rigidly  excluded.  "  The  hydremic  form 
must  be  opposed  by  the  ingestion  of  an  abundance  of  albuminoid 
material,  of  fat-producing  substance,   and  the  hydrocarbons"  (Oertel), 

Under  any  system  of  dietetic  treatment  the  patient  should  be  weighed 
accurately  and  frequently,  and  the  food-limit  be  diminished  or  modified 
according  to  the  results.  The  food  may  be  weighed  and  measured  at 
first,  but  the  patient  soon  learns  to  estimate  by  bulk  the  requisite  quan- 
tity of  each  substance. 

The  following  dietary  illustrates  Avhat  may  be  ordered  in  some  cases  : 

Mog-ning  Meal. — Fine  wheat-bread,  1\  ounces  (40.0);  a  soft-boiled 
egg;  milk,  1  ounce  (32.0);  sugar,  77  grains  (4.9);  coffee,  4|-  ounces 
(136.0). 

Noon  Meal. — Soup,  3  ounces  (96.0);  fish,  3  ounces  (96.0);  roast  or 
boiled  beef,  veal,  or  game  or  poultry,  6  to  8  ounces  (192.0-256.0) ;  green 
vegetables,  1^  ounces  (48.0) ;  bread,  1  ounce  (32.0) ;  fruit,  3  or  4  ounces 
(96.0-128.0)";  no  liquid  (or  only  4  or  5  ounces— 120.0-148.0  cc— of 
very  light  wine). 

Afternoon  Meal. — Sugar,  77  grains  (4.9);  coffee,  4  ounces  (128.0); 
milk,  1  ounce  (32.0);  occasionally  bread,  1  ounce  (32.0). 

Evening  Meal. — Caviare,  ^  ounce  (10.6) ;  one  or  two  soft-boiled 
eggs;  beefsteak,  fowl,  or  game,  5  ounces  (160.0) ;  salad,  1  ounce  (32.0); 
cheese,  1  dram  (4.0) ;  bread,  rye  or  bran,  ^  ounce  (16.0)  ;  fruit  or  water, 
4  to  5  ounces  (120.0-148.0). 

The  mechanical  treatment  (to  increase  oxidation),  by  exercise,  is  to  be 
used  in  conjunction  with  the  dietetic.  The  form  of  the  exercise,  and 
also  the  time  and  frequency,  must  be  adjudged  for  each  case  {vide  supra). 


1230  THE  INTOXICATIONS ;   OBESITY;   HEAT-STROKE. 

When  cardiac  dilatation  and  myocardial  degeneration  (fatty)  are  the 
cause  of  symptoms  of  precordial  distress,  dyspnea,  and  palpitation, 
resort  may  be  had  to  Oertel's  system  of  graduated  ^valking  on  the  level 
or  climbing  along  "health  paths"  {vide  Fatty  Overgrowth,  p.  657). 
Or,  the  well-known  Nauheim  or  Schott  treatment  may  be  used.  Great 
care  must  be  exercised  in  prescribing  the  mechanical  treatment  in  obese 
persons  who  have  atheromatous  vessels. 

The  medicinal  treatment  is  neither  satisfactory  nor  successful.  Caus- 
ative or  associated  conditions — e.  g.  gout — may  present  special  thera- 
peutic indications.  The  juice  of  the  phytolacca  berry  may  reduce  the 
weight,  but  is  harmful. 

Recently,  the  use  of  thyroid  extract  has  come  into  favor.  Leichten- 
stern,  Wendelstadt,  Ewald,  and  others  have  reported  success  in  a  number 
of  cases,  especially  in  those  exhibiting  the  anemic,  flabby,  "  myxede- 
matoid  "  form  of  obesity.  The  loss  of  weight  Avas  from  2  to  3  pounds 
(1-1.5  kgms.)  in  one  week,  and  as  high  as  20  pounds  in  two  to  four 
weeks.  In  two  of  my  own  cases  belonging  to  this  category  the  use  of 
thyroid  extract  (desiccated)  in  small  doses  (gr.  j — 0.0648,  t.  i.  d.)  caused 
a  progressive  loss  of  weight  at  the  rate  of  4  and  6  pounds  per  week  re- 
spectively, without  injury  to  the  general  health.  Thyroidin,  the  active 
principle  of  the  thyroid  gland,  as  shown  b}'  Baumann  and  Ross,  and  iodo- 
thArin  give  results  that  are  perhaps  as  good  as  those  of  thyroid-feeding. 
Jeozykowski  treated  10  cases  of  corpulence  by  thyroidin  in  doses  from 
5  to  8  grains  (0.324-0.518)  per  diem.  In  1  case  more  than  40  pounds 
(18.1  kgms.)  were  lost  in  two  months,  and  in  another  30  pounds  (13.6 
kgms.)  in  three  months.  Symptoms  of  thyroidism  are  the  signal  for  a 
reduction  in  the  dosage  of  thyroid  extract  {vide  Myxedema,  p.  464). 
Hematinics  are  indicated  in  the  anemic  variety  of  obesity. 


HEAT-STROKE. 

(Sunstroke;  Insolation;    Thermic  Fever ;  Heat-exhaustion:  Heat-prostration ?f 

Definition. — A  diseased  condition  the  effect  of  exposure  to  exces- 
sive heat. 

Pathology. — Rigor  mortis  is  marked  and  comes  on  early.  The  high 
temperature  of  the  cadaver  accelerates  the  putrefactive  changes,  which 
also  appear  eaidy.  There  is  considerable  venous  engorgement  of  the 
brain  and  of  the  cerebral  and  spinal  membranes ;  also  of  the  lungs, 
spleen,  and  conjunctiva.  The  blood  is  fluid  and  dark,  and  the  corpus- 
cles are  crenated  and  do  not  tend  to  form  rouleaux.  Ecchymoses  and 
extravasations  of  blood  are  found  in  the  skin,  the  serous  membranes, 
and  the  cavities,  around  the  superior  (cervical)  sympathetic  ganglia  and 
the  vagus  and  phrenic  nerves.  Parenchymatous  changes  in  the  liver 
and  kidneys  may  be  found.  Rigid  contraction  of  the  left  ventricle  is  a 
notable  feature,  while  the  right  ventricle  is  usually  dilated  with  blood. 
Van  Gieson's  recent  report  of  the  cellular  pathology  of  the  cerebro-spinal 
system  in  3  cases  of  sunstroke  in  New  York  shows  an  acute  parenchym- 
atous degeneration  of  the  neurons  of  the  whole  neural  axis  similar  to 
that  of,  and,  Van  Gieson  thinks,  here  actually  due  to,  "  a  species  of  auto- 
intoxication." He  found  the  chromopliilic  placjues  in  the  cortical  cere- 
bral and  cerebellar  (Purkinje's)  cells  and  also  in  the  cells  of  the  anterior 


HEAT-STROKE.  1231 

horns  of  the  spinal  cord,  diminished  in  number,  changed  in  shape  and 
position,  sometimes  finally  broken  up,  and  even  entirely  absent.  The 
nuclei  stain  more  deeply  than  normally. 

IBtiology. — Anything  that  lessens  bodily  resistance  to  external  high 
heat  predisposes  to  heat-stroke.  Thus,  privation,  unsanitary  surround- 
ings, fatigue  of  body  or  mind,  emotional  excitement,  worry,  and  exces- 
sive fretfulness,  overeating,  indulgence  in  alcoholics  (especially),  and 
previous  attacks  of  sunstroke,  are  all  conducive  to  heat-stroke  on  expos- 
ure to  high  temperature.     Males  are  affected  more  often  than  females. 

Sunstroke  occurs  in  persons  (on  land)  working  hard  under  the  direct 
rays  of  the  sun,  in  an  atmosphere  that  is  very  hot  and  humid,  still,  and 
sultry.  Soldiers  on  the  march  and  heavily  accoutered,  masons,  brick- 
layers, hod-carriers,  roofers,  drivers,  farmers,  and  other  out-door  labor- 
ers are  particularly  subject  to  insolation. 

Heat-stroke  and  thermic  fever  are  terms  more  appropriately  applied 
to  those  similarly  affected  in  midsummer  while  working  in  places  not 
exposed  to  the  sun,  but  yet  close,  confined,  and  excessively  hot,  such  as 
glass-works,  foundries,  ocean  steamers,  stoke-holes,  boiler-rooms,  steam 
laundries,  sugar-refineries,  kitchens,  and  the  like. 

Heat-exhaustion  [prostratio  thermica)  is  caused  under  similar  condi- 
tions as  the  preceding,  but  manifests  dissimilar,  and  sometimes  almost 
opposite,  effects. 

The  majority  of  the  cases  of  sunstroke  occur  between  2  and  5  p.  m., 
although  heat-stroke  and  heat-exhaustion  may  occur  at  night  as  late  as 
10  or  11  P.  M.,  as  among  bakers,  night  engineers,  and  hotel  cooks. 

It  seems  to  be  the  consensus  of  opinion  that  the  direct  cause  of  the 
symptoms  of  sunstroke,  heat-stroke,  or  heat-prostration  is  the  action  of 
the  excessive  heat  upon  the  heat-centers,  or  upon  the  vasomotor  center 
or  nerves  (H.  C.  Wood),  the  former  of  which,  if  paralyzed,  produces 
^''thermic''  or  '•'■heat-fever"  while  the  latter,  if  paralyzed,  produces 
lieat-exhau8tion. 

It  should  be  stated,  however,  that  Lambert  and  Van  Gieson,^  after  a 
clinical  and  pathologic  study  of  805  cases  of  sunstroke  occurring  in 
New  York  City  during  1896,  hold  to  the  not  improbable  view  that  the 
immediate  basis  of  sunstroke  is  autotoxic,  Avith  heat  only  as  a  contrib- 
uting cause. 

Symptoms. — Two  forms  of  heat-  or  sunstroke  are  usually  met  with  : 
(1)  The  asphyxial  or  apoplectic  form  ;  (2)  the  hyperpyrexial  form.  Flint 
believes  that  the  majority  of  the  cases  of  sunstroke  are  combinations  of 
apoplexy  and  exhaustion.  Vallin  puts  all  cases  of  insolation  into  tAvo 
classes :  the  first,  sthenic  or  asphyxial,  corresponding  to  our  hyperpy- 
rexial or  congestive  variety;  the  second,  asthenic  or  syncopal,  corre- 
sponding to  our  heat-exhaustion.  Mixed  forms  may  occur  quite  fre- 
quently, the  most  prominent  symptoms  being  referable  to  the  organs 
suffering  the  most,  as  the  cerebro-spinal  system,  heart,  lungs. 

Heat-apoplexy  {aspthyxial  sunstroke)  is  probably  the  least  frequent 
form.  There  may  be  sudden  premonitions,  or  dizziness,  chromatopsia, 
throbbing  headache,  cessation  of  sweating,  or  d3^spnea.  Sometimes 
the  patient,  while  at  work  in  the  sun,  suddenly  falls  unconscious,  a  few 
convulsions  may  occur,  and  in  this  state  he  may  die  with  symptoms  of 
cardiac  failure.     More  often,  insensibility  is  not  so  profound  as  complete 

1  Med.  News,  July  24,  1897. 


1232 


THE  INTOXICATIONS;   OBESITY;  HEAT-STROKE. 


C. 


coma,  there  is  much  restlessness,  epigastric  "  cramp  "  may  be  complained 
of,  also  a  sense  of  thoracic  oppression,  and  occasionally  there  are  nausea 
and  vomiting.  The  headache  may  be  intense,  the  face  is  flushed,  the 
pulse  is  rapid  and  full,  the  temporal  and  carotid  arteries  are  bounding, 
the  breathing  may  be  labored  and  stertorous,  the  pupils  are  contracted 
(except  in  grave  cases),  and  urination  is  often  frequent.  The  skin  is 
hot  and  dry,  and  may  show  petechiae.     The  tongue  is  coated  with  a 

whitish  fur.  A  wild  delirium  has 
been  observed  in  some  cases.  The 
temperature  may  be  subnormal, 
and  is  not  higher  than  102°  F. 
(38.8°  C.)  in  many  instances.  In 
others,  a  mild  degree  of  thermic 
fever  may  be  associated  with  the 
apoplectic  condition,  the  ther- 
mometer registering  104°-106° 
F.(40°-41.1°C.).  In  fatal  cases 
the  coma  becomes  deeper  and 
deeper,  the  pulse  more  rapid  and 
feeble,  and  Cheyne-Stokes  respi- 
ration may  precede  the  termina- 
tion. A  "mousey"  odor  about 
the  body  has  been  noted.  In 
favorable  cases  the  temperature 
falls  to  normal  by  lysis  in  three 
or  four  days,  consciousness  being 
rapidly  regained  at  the  same  time. 
The  hyperpyrexial  variety 
comprises  the  numerous  cases 
of  marked  sunstroke  that  re- 
semble the  preceding  type,  Avith 
the  addition  of  an  intensely  high 
temperature  (thermic  fever).  The 
patient  may  suddenly  become 
comatose  and  die  in  an  asphyxi- 
ated condition,  with  a  tempera- 
ture as  high  as  110°-115°  F. 
(43.3°-46.1°  C.)  or  even  higher. 
Sometimes  prodromes,  as  an- 
orexia, progressively  increasing 
physical  weakness,  cramp-like 
abdominal  pains,  irritability  and 
restlessness,  vertigo,  colored  and 
blurred  vision,  lack  of  sweating, 
a  "bursting"  headache,  and  an  irritable  bladder  may  exist  for  several 
days.  A  subconscious  (automatic)  state,  in  which  the  patient  may  be 
unaw^are  of  his  surroundings,  although  walking  or  even  working,  may 
be  noted  for  hours  before  he  is  stricken  down.  The  onset  is  marked  by 
hyperpyrexia;  the  skin  is  hot,  burning,  dry,  sometimes  flushed  and  red, 
and  sometimes  cyanotic  and  clammy ;  the  eyes  are  suffused  or  "  staring 
-"''   filling,"  with  pin-point  pupils.      There  is  a  full,  rapid,   and  non- 


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Fig.  79.— Chart  of  a  case  of  sunstroke.    J.  D.,  aged 
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and 


HEAT-STROKE. 


1233 


compressible  pulse,  and  coma  may  be  present.  Clonic  spasms  may 
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frequently  incontinence  of  both  feces  and  urine.  The  temperature  is 
very  high  in  most  of  the  cases,  varying  from  105°  to  112°  F.  (40.5— 
44.4°  C.).^  The  pulse-rate  varies  Avith  the  temperature,  from  90  to 
160  beats  per  minute.  The  respirations  are  also  increased  to  24-50 
per  minute.  Many  of  the  alarming  symptoms,  including  the  high  fever 
\vide  accompanying  chart.  Fig.  79).  unconsciousness,  cyanosis,  dyspnea, 
and  convulsions,  may  greatly  subside  during  and  after  the  use  of  the 
cold  bath.  Secondary  exacerbations  occur  for  a  few  days  before  con- 
valescence is  established  in  the  favorable  cases  [vide  chart,  Fig.   80). 

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Fig.  80.— Chart  of  a  case  of  sunstroke.    C.  B.,  aged  twenty-nine  years.    Kecovery. 

Some  patients  never  rally,  and  die  in  a  state  of  asphyxia.  Ketention 
of  urine  (suppression)  is  observed  at  times,  and  particularly  in  those 
accustomed  to  the  use  of  alcohol.  Leukocytosis  is  noted,  besides  the^ 
crenation  of  the  erythrocytes  (degeneration  of  the  red  cells). 

Fatal  complications  of  sunstroke  are  pneumonia,  meningitis,  uremia, 
and  cardio-respiratory  paralysis. 

Heat-prostration  or  heat-exJiaustion  may  come  on  gradually  or  sud- 
denly, with  prodromal  symptoms  (dizziness,  faintness,  headache,  nausea, 

1  Lambert  {he.  cit),  reports  a  ca.se  in  the  X.  Y.  Hosp.  of  117.8°  F.  (47.6°  C). 
78 


1234  THE  INTOXICATIONS ;    OBESITY;   HEAT-STROKE. 

thirst,  drowsiness,  yawning,  epigastric  or  lumbar  pains,  numbness  and 
tingling  of  the  hands  and  feet).  These  are  followed  by  coldness,  clam- 
miness, and  pallor  of  the  surface,  marked  muscular  weakness  and  pros- 
tration, a  small,  febrile,  rapid  pulse,  sighing  breathing,  syncope,  and  col- 
lapse in  the  graver  cases.  The  temperature  at  first  is  subnormal  (95°  to 
970  F._35o  to  36.1°  C),  though  mild  thermic  fever  of  from  100°  to 
102.5°  F.  (37.7°— 39.1°  C.)  may  be  present.  Consciousness  is  rarely 
completely  absent  and  is  regained  early.  Recovery  usually  takes  place 
within  one  or  two  days,  and  in  milder  cases,  under  prompt  and  appro- 
priate treatment  the  patient  may  be  ready  to  go  about  in  a  fcAv  hours. 
In  a  few  cases  of  extreme  prostration  in  weakly  persons  death  may 
ensue  from  cardiac  failure. 

The  sequelne  of  heat-stroke  are  quite  interesting  and  peculiar  in 
some  instances.  Osier  relates  the  case  of  a  patient  who  "  was  subse- 
quently so  sensitive  to  temperatures  in  the  neighborhood  of  75°  F. 
(23.8°  C.)  (italics  mine)  that  at  such  times  he  lived  comfortably  only  in 
the  cellar,  and  finally  sought  refuge  in  Alaska." 

Chromatopsia,  severe  headaches,  irritability  and  ugliness  of  temper, 
or  delirium  may  occur  in  some  patients  as  soon  as  Avarm  weather  sets 
in,  and  may  be  due  occasionally  to  chronic  meningitis  (Wood). 

Diagnosis. — Bearing  in  mind  the  characteristic  differences  that  are 
outlined  above  between  sunstroke  (including  the  asphyxia!  and  hyper- 
pyrexial  forms)  and  heat-exhaustion,  the  diagnosis  is  not  difficult.  The 
history  and  circumstances  attending  the  seizure  are  also  important  in 
making  the  diagnosis.  From  other  affections,  as  acute  alcoholism,  men- 
ingitu,  uremia,  and  cerebral  apoplexjj,  the  differentiation  is  readily  made 
by  noting  the  previous  history,  mode  of  attack,  presence  or  absence  of 
thermic  fever,  state  of  consciousness,  urine,  skin,  pupils,  pulse,  respira- 
tion, and  nervo-muscular  apparatus. 

Prognosis. — This  is  usually  favorable  in  cases  of  heat-prostration. 
It  is  less  so  in  sunstroke,  but  in  all  cases  it  depends  on  the  severity  of 
the  stroke,  the  previous  health  and  habits  of  the  patient,  the  complica- 
tions, and  the  promptness  and  fai^ility  of  the  treatment.  The  mortality- 
rate  during  a  prolonged  period  of  excessively  hot  and  humid  weather 
may  be  very  high,  ranging  from  15  to  50  per  cent.  In  New  York  City, 
during  the  week  ending  August  15,  1896,  out  of  a  total  number  of  1810 
deaths,  648  were  reported  as  due  to  sunstroke  (Lambert).' 

Treatment. — Prophylaxis. — This  is  highly  imperative  in  hot,  sultry 
weather,  particularly  in  cities,  in  which  persons  must  work  in  the  sun 
or  in  poorly-ventilated  and  highly-heated,  closed  places.  Workmen 
should  be  taught  and  warned  privately  and  publicly,  as  through  the 
medium  of  the  press  and  Health  Board  circulars,  to  take  extra  pre- 
cautions during  hot  Aveather,  to  work  and  sleep  in  as  well-ventilated 
rooms  as  possible,  and  to  secure  artificial  ventilation,  if  necessary. 
They  should  live  regular  and  temperate  lives,  avoiding  alcohol  and 
heavy  eating ;  oat-meal  Avater  should  be  drunk,  light-Aveight  and  light- 
colored  clothing  should  be  Avorn,  and  the  direct  rays  of  the  sun  should 
be  avoided  as  much  as  possible.  The  condition  of  the  skin  should  be 
Avatched  and  care  taken  that  SAveating  continues  freely.  Shelter  or  rest 
should  be  sought  at  once  if  sav eating  stops.      Cool  Avet  cloths  or  green 

'  Loc.  oil. 


HEAT-STROKE.  1235 

leaves  should  be  worn  inside  a  light  straw  hat,  and  sometimes  it  may 
be  necessary  for  employers  to  shorten  the  hours  of  labor  during  the  hot- 
test part  of  the  day. 

Treatment  of  the  Attack. — Cases  of  ordinary  heat-prostration  seldom 
require  much  treatment  beyond  the  removal  of  the  patient  to  the  shade 
of  a  comparatively  cool  place,  loosening  all  constricting  clothing,  spray- 
ing with  cool  Avater,  the  use  of  ammonia-  or  amyl-nitrite-inhalations,  and 
of  the  aromatic  spirits  of  ammonia  or  spiritus  glonomi  by  the  mouth. 
If  the  temperature  is  subnormal  and  collapse  threatens,  a  hot  bath  is 
advisable.  Strychnin  and  digitalis  may  be  used  for  a  day  or  two  to 
combat  the  nervo-muscular  weakness. 

Heat-stroke,  especially  the  hyperpyrexial  cases,  must  be  promptly 
treated  by  the  application  of  the  ice-bath  (ice  floating  in  a  tub  of  water), 
temperature  about  40°  F.  (4.4°  C),  or  by  rubbing,  by  the  cold  pack, 
or  by  the  needle-spray  with  iced  water. 

In  the  aspliyxial  cases  venesection  is  frequently  indicated.  The 
subcutaneous  or  intravenous  injection  of  physiologic  salt  solution  (F. 
A.  Packard)  may  be  a  valuable  procedure  in  many  cases.  External 
stimulation  should  be  applied  to  the  precordium  by  mustard  and  to 
the  feet  by  hot  bottles,  and  hypodermic  injections  of  nitroglycerin, 
strychnin,  atropin,  brandy,  camphor,  or  ether  are  useful.  Ice  should 
be  rubbed  over  the  head  constantly.  Care  should,  however,  be  taken 
to  see  that  the  temperature  is  not  reduced  too  far.  A  temperature  of 
about  102°  F.  (38.8°  C.)  should  be  the  signal  for  cessation  of  the  ice- 
bath,  and  for  the  removal  of  the  patient  to  a  cot,  where  he  is  to  be  rubbed 
dry  and  allowed  to  rest  until  an  exacerbation  of  fever  indicates  the 
reapplication  of  the  cooling  measures.  Ice-water  enemata.  with  or  with- 
out brandy,  are  often  useful  adjuvants.  The  needle-spray  of  cold  water 
is  an  excellent  nervous  stimulant  as  well  as  antipyretic.  It  is  given 
while  the  patient  lies  on  a  Kibbee  or  netting  cot,  or  on  a  cot  covered 
with  a  rubber  sheet  so  arranged  as  to  drain  into  a  pail  or  trough.  In- 
ternal antipyretics  are  seldom  well  absorbed,  and  their  depressant  action 
is  so  well  known  as  to  discourage  their  use  in  place  of  hydrotherapy. 
Hutchinson,  Coplin,  and  Bevan  recommend  highly  the  use  of  morphin 
to  control  the  convulsions  of  heat-stroke.  Artificial  respiration  in  the 
asphyxial  cases,  kept  up  until  other  measures  and  stimulants  have  time 
to  act,  may  be  the  means  of  saving  life. 

After  the  reduction  of  the  hyperpyrexia  the  patient  should  be  lightly 
covered  on  a  cot  placed  in  a  cool  place.  An  ice-cap  should  be  applied 
to  his  head,  and  small  pieces  of  cracked  ice  may  be  given  to  allay  gas- 
tric irritability,  with  calomel  to  open  the  bowels  if  necessary.  Albumin- 
water,  skimmed  milk,  buttermilk,  unfermented  grape-juice,  junket,  and 
the  like  may  be  given  for  several  days  preparatory  to  the  ingestion  of 
heavier  food.  If,  as  sometimes  happens,  free  diaphoresis  does  not  come 
on  after  the  reduction  of  most  of  the  fever  and  the  stimulating  treatment, 
a  hot  bath  may  be  given,  and  perhaps  aided  by  the  hypodermic  injec- 
tion of  pilocarpin  in  urgent  cases.  Sequelce  must  be  treated  on  general 
principles. 

The  increased  susceptibility  to  repeated  attacks  of  insolation  (after  the 
first  attack)  makes  it  necessary  to  avoid  exposure  to  heat  ever  after, 
and,  if  possible,  to  seek  a  cooler  climate  during  the  hot  months. 


PART  XI. 

ANIMAL  PARASITIC  DISEASES. 


PSOROSPERMIASIS. 

Psorosperms  belong  to  the  lowest  form  of  protozoa.  They  are  also 
known  as  sporozoa,  and,  because  of  their  parasitic  relation  to  cells,  as 
cT/tozoa. 

The  amoeba  coli  of  amebic  dysentery  belongs  to  the  protozoa.  Blood 
parasites  (hematozoa),  as  the  plasmodium  malaria,  are  likewise  closely 
related  to  the  sporozoa. 

Various  coccidia  may  occur  in  man  to  produce  the  disease  indicated 
by  this  beading.  The  coccidium  oviforme  of  the  rabbit  is  the  commonest 
variety,  being  found  also  in  rats  and  mice.  It  escapes  from  the  livers  of 
the  latter  animals  and  passes  into  the  dejecta;  it  produces  an  hepatic 
disease  in  which  there  are  numerous  whitish  nodules  studding  the  liver. 
These  range  in  size  from  a  pinhead  to  a  split  pea.  and  on  section  dis- 
close a  bile-duct,  the  dilated  portion  of  which  forms  the  nodule.  The 
ovoid  coccidia  are  found  in  the  epithelial  cells  of  the  walls  of  these 
biliary  expansions. 

The  coccidium  perforans  and  coccidium  higeminum  are  found  in  the 
cells  of  the  intestinal  villi  instead  of  in  the  liver  of  the  hosts  mentioned 
above.  Among  veterinarians  a  common  form  of  sickle-shaped  organism 
is  known  that  is  found  witliin  an  ovoid  body  in  the  sarcolemma  of  the 
pig's  muscle — (?'.  e.  the  so-called  Rainey's  tube). 

In  man,  hepatic  disease  similar  to  that  found  in  the  rabbit  is  pro- 
duced by  the  coccidium  oviforme.  The  tumors  formed  by  the  coccidia 
may  be  palpable,  and  the  liver  may  be  quite  tender.  Some  chilliness 
and  fever,  malaise,  and  stupor  ])assing  into  coma  have  been  observed. 
Death  was  caused  on  the  fourteenth  day  in  a  case  admitted  to  St. 
Thomas's  Hospital  (Osier).  The  necropsy  showed  whitish  neoplasms  in 
the  peritoneum,  omentum,  and  kidneys. 

In  the  intestinal  variety  of  internal  psorospcrmiasis  nausea  and 
vomiting,  diarrhea,  and  the  typhoid  state  may  be  manifested.  Involve- 
ment of  the  kidneys  has  caused  hematuria  and  frequency  of  urination. 

External  or  cutaneous  psorospermiasis,  one  form  of  which  was  for- 
merly called  keratosis  follicularis,  is  characterized  by  lesions  at  first  of 
a  hard,  crusty,  papular  type,  later  becoming  confluent,  and  situated  on 
the  face,  lumbo-abdominal,  and  inguinal  regions.  These  papillomatous 
growths  contain  numerous  parasitic  sporozoa. 

In  carcinoma,  epithelioma,  and  Paget's  disease  of  the  nipple  coc- 
cidia are  readily  found  in  and  between  the  pathologic  epithelial   cells, 

1236 


DISTOMIASIS.  1237 

but  whether  they  have  an  etiologic  bearing  upon  these  malignant  affec- 
tions is  still  a  matter  of  uncertainty. 

PropJiylaxis  consists  in  cleanliness  and  care  in  preparing  such  food 
vegetables  as  spinach,  lettuce,  cabbage,  and  other  greens  that  may  pos- 
sibly be  contaminated  by  the  excreta  of  the  lower  animals  liable  to 
psorosperm-infection.  The  treatment  of  psorospermiasis  is  symptom- 
atic, though  rectal  injections  of  a  solution  of  quinin  (1 :  5000  to  1 :  1000) 
may  be  tried. 


DISTOMIASIS. 

( Trematodiasis.) 


Various  forms  of  trematodes,  including  the  distomata,  may  become 
parasitic  in  man. 

Distoma  Hepatictim  (Liver-fluke). — Among  the  more  common  va- 
rieties of  trematodes  or  flukes,  is  the  distoma  hepaticum  or  liver-fluke, 
a  parasite  found  in  animals  (horse,  goat,  ass,  sheep,  rabbit)  and  acci- 
dentally ingested  by  man. 

It  is  almost  30  millimeters  (1.1  inches)  in  length,  and  inhabits  the 
biliary  passages  of  the  animal,  and  from  them  is  discharged  into  the 
intestinal  tract  and  evacuated  with  the  feces.  Under  certain  conditions 
of  temperature  and  moisture,  a  ciliated  embryo  escapes  from  the  egg, 
and  is  ingested  by  a  gasteropod  or  snail  {limncea  truncatula),  in  which 
it  undergoes  development  into  a  sporocyst,  that  in  turn  gives  origin  to 
radice  or  parent  nurses.  These  give  birth  to  daughter-radige  or  cercarioe, 
which  leave  the  gasteropod  or  snail  and  attach  themselves  to  aquatic 
plants,  where  they  are  in  turn  eaten  by  animals. 

Symptoms. — When  present  in  sufiicient  numbers  in  the  bile-passages 
the  liver  becomes  greatly  enlarged,  with  the  occurrence  of  jaundice  and 
ascites  that  may  prove  fatal.  Other  symptoms  may  also  be  present; 
thus  pain  was  prominent  in  41  out  of  100  cases  reported  by  Kurimato 
in  Japan,  and  heart-murmurs  were  present  in  42  of  those  cases. 

Late  in  the  disease  the  liver  may  become  nodulated  and  terminate 
in  atrophy. 

On  inspection  in  well-marked  cases,  a  peculiar  barrel-shaped  bulging 
is  sometimes  seen,  extending  over  the  hepatic  area,  with  tense  abdom- 
inal walls  over  the  enlarged  liver.  This  is  a  pathognomonic  symptom 
of  hepatic  distoma.  An  endemic  form  occurring  in  Japan  has  been  de- 
scribed ;  it  is  characterized  by  marked  emaciation,  diarrhea,  hepatic 
enlargement,  and  often  by  ascites. 

The  prognosis  of  distoma  hepaticum  is  absolutely  fatal  and  the  treat- 
ment is  merely  palliative. 

Among  other  trematodes  may  be  mentioned  (a)  distoma  lanceolatunt 
(found  also  in  cattle) ;  (b)  distoma  erassum,  which  is  larger  in  size  than 
the  preceding ;  (c)  distoma  sibiricum ;  {d)  distoma  'pulmonale  {J).  Rin- 
geri) ;  {e)  distoma  spatulatum  {endemieum)  ;  (/)  amphistomum  liominis  ; 
(g)  distoma  hematohium  (Bilharz).  Two  of  these  deserve  extra,  though 
brief,  mention. 


1238  ANIMAL  PARASITIC  DISEASES. 

Distoma  Pulmonale  (D.  Ringeri)  {Bronchial-fluhe ;  Parasitic  He- 
moptysis).— This  parasite  is  very  common  in  Japan.  It  finds  lodgement 
primarily  in  the  lung,  and  its  ova  sometimes  form  emboli  in  the  brain, 
liver,  and  other  tissues,  and  may  also  be  found  in  the  form  of  little  cysts 
throughout  the  body.  The  symptoms  are  a  cough,  a  reddish-brown 
bloody  sputum,  and  the  presence  of  the  flukes  in  the  expectoration. 
The  latter  are  club-shaped,  and  are  about  8-10  mm.  (^  in.)  long. 

Distoma  Hematobium  {Bilharzia  hematohia  ;  Blood-flukes). — 
This  hematode  is  a  narrow  worm  with  anterior  abdominal  sucking-disks. 
The  male  is  shorter  and  thicker  than  the  female ;  the  former  being  4—15 
mm.  (^— I  in.)  long ;  the  latter,  about  20  mm.  (4  in.).  It  prevails 
mostly  in  Egypt,  Cape  Colony,  and  other  parts  of  Africa,  and  its  en- 
trance into  the  human  body  is  now  believed  to  be  through  the  skin  of 
those  who  bathe  frequently  in  the  African  rivers,  in  many  of  which  it 
abounds.  It  is  not  unlikely  that,  as  formerly  held,  infection  may  also 
occur  in  many  cases  from  drinking  the  impure  water  of  the  rivers.  The 
parasites  or  their  ova  are  found  in  the  bladder,  the  pelvis  of  the  kidney, 
and  the  veins  (especially  the  portal  and  mesenteric). 

The  symptoms  are  hematuria,  with  some  pain  during  urination.  Pus, 
and  some  of  the  ova  of  the  parasites,  may  also  be  found  in  the  urine. 
No  serious  systemic  disturbances  occur  in  bilharziosis.  Prophylaxis  as 
regards  drinking  and  bathing  in  African  waters  should  be  exercised. 
Fouquet  affirms  the  value  of  the  extract  of  male-fern  internally  in  this 
form  of  distomiasis. 


NEMATODES. 


Helmixthologists  include  in  this  class  the  cylindric  worms,  certain 
varieties  of  which  are  among  the  most  common  entozoa  that  infest  the 
human  body  and  inhabit  the  intestines. 

ASCARIASIS. 

Ascaris  I^umbricoides  {Round-worm). — Natural  History. — This 
species  resembles  the  common  earth-worm,  and  is  the  most  frequent 
in  occurrence  of  all  the  parasites.  It  usually  appears  in  children  be- 
tween the  ages  of  three  and  ten  years.  The  round-worm  inhabits  the 
upper  portion  of  the  small  intestine,  and  occurs  singly  or  in  numbers. 
Its  body  is  round,  fusiform,  and  marked  with  fine  transverse  strife.  It 
has  a  yellowish  or  reddish-brown  color,  and  measures  in  the  female  from 
7  to  14  inches  in  length  (17.5-35  cm.),  and  from  4  to  8  inches  in  the 
male  (about  20  cm.),  its  thickness  being  about  that  of  an  ordinary 
goose-quill.  The  cephalic  extremit}^  of  the  worm  has  three  oval  papillae, 
furnished  with  fine  teeth  ;  the  caudal  extremity  is  straight  in  the  female 
and  curved  in  the  male. 

Lumbricoid  worms  develop  from  ova,  which  are  about  .05  to  .06  mm. 
long,  elliptic,  dark-reddish  in  color,  and  have  a  thick,  resisting  envelope. 
There  may  be  sixty  million  of  them  in  a  single  female  worm,  and 
they  sometimes  occur  in  the  feces  in  vast  numbers.      The  development 


ASCARIASIS.  1239 

of  the  embryo  and  worm  external  to  the  body  is  not  accurately  known. 
The  eggs  obtain  entrance  into  the  human  intestine  most  probably  through 
drinking-water,  and  it  has  been  held  that  abundant  mucus,  and  the  pre- 
dominating starchy  and  saccharine  diet  of  which  children  so  often  par- 
take, offer  a  favorable  nidus  for  the  development  of  the  ingested  asca- 
ridian  eggs. 

The  round- worm  sometimes,  though  rarely,  migrates  from  the  small 
intestine.  It  has  been  vomited  up,  and  it  has  also  crawled  into  the  pha- 
rynx, mouth,  and  nares,  and  has  been  withdrawn  thence  by  the  patient's 
fingers.  It  has  even  passed  into  the  larynx  and  trachea,  causing  fatal 
asphyxia  or  pulmonary  gangrene.  The  Eustachian  tube  and  biliary  ducts 
may  be  invaded  with  such  serious  symptoms  as  perforation  of  the  mem- 
branum  tympani  and  hepatic  abscess.  The  ascarides  have  also  been  found 
in  the  peritoneal  cavity,  'postmortem,  with  intestinal  perforation,  due, 
most  likely,  to  other  causes.  They  may  penetrate  the  pancreatic  duct 
and  enter  fistulse  connected  with  the  intestine. 

Symptoms  may  be  absent,  and  yet  the  worms  be  found  repeatedly  in 
the  stools.  Existing  symptoms  are  indefinite,  and  point  simply  to  an 
irritative  condition  of  the  bowel.  Serious  symptoms  may,  however, 
result  from  the  migration  of  the  worm,  as  into  the  biliary  passages, 
Eustachian  tube,  or  larynx.  Fever  is  not  a  necessary  concomitant. 
Lumbricoid  worms  may  give  rise  to  any  or  all  of  the  following  symp- 
toms :  colicky  pains,  iiausea,  vomiting,  indigestion,  diarrhea  (sometimes), 
restlessness,  irritability,  anorexia,  itching  of  and  picking  at  the  nose, 
disturbed  sleep  with  grinding  of  the  teeth,  salivation,  and  nervous 
twitchings.  The  child's  abdomen  and  face  may  be  swollen.  Very  ner- 
vous children  may  manifest  epileptiform  convulsions,  choreic  movements, 
dilated  pupils,  vertigo,  cephalalgia,  mental  disturbances,  and  even  con- 
tractures. 

Complications. — The  development  of  jaundice  will  indicate  obstruc- 
tion of  the  bile-duct,  in  cases  in  which  the  worms  have  been  found  in 
the  feces.  Intestinal  obstruction  from  coiled  worms  has  occurred.  So 
also,  suffocative  symptoms  coming  on,  especially  at  night,  in  a  child 
with  worms,  may  be  due  to  a  migrating  lumbricoid.  Perineal  abscesses 
and  inflamed  hernige  that  have  perforated  externally  sometimes  discharge 
the  ascaris  lumbricoides. 

Diagnosis. — This  is  positively  determined  only  by  discovering  the 
worm  or  ova  in  the  stools.  In  doubtful  cases,  judged  symptomatically, 
the  administration  of  a  suitable  purgative  and  inspection  of  the  resultant 
passages  will  enable  the  physician  to  arrive  at  a  diagnosis. 

The  prognosis  is  good,  unless  serious  complications  arise  {vide  supra), 
when  the  case  should  be  guarded  accordingly. 

Treatment. — Prophylaxis. — The  water  used  for  drinking-purposes 
should  be  obtained  from  the  purest  sources.  That  from  small  streams, 
shallow  wells,  and  the  like  is  most  likely  to  contain  the  ova  of  the  lum- 
bricoides, and  should  be  avoided.  The  use  of  filtered  water  should  be 
encouraged. 

Before  giving  an  anthelmintic,  it  should  be  borne  in  mind  that  no 
good  result  can  be  certainly  obtained  unless  the  gastro-intestinal  tract 
be  nearly  deprived  of  food  for  from  twelve  to  thirty-six  hours,  so  that 
the  toxic  action  of  the  drug  used  may  be  exerted  directly  upon  the  un- 
protected worm. 


1240  ANIMAL  PARASITIC  DISEASES. 

Santonin  is  at  once  the  most  efficient  and  the  most  easily  administered 
remedy.  It  may  be  given  in  doses  of  gr.  :|^  to  1  (0.0162-0.0648)  of  the 
crystals  to  a  child,  or  from  gr.  ij  to  iv  (0.1296-0.2592)  to  an  adult,  in 
the  form  of  a  troche,  before  breakfast.  A  little  milk  or  other  light 
nourishment  may  be  alloAved,  the  troches  being  continued  once  or  twice 
daily  for  two  or  three  days.  This  treatment  is  to  be  followed  by  a  brisk 
purge,  preferably  gr.  j  to  iij  (0.0648-0.1944)  of  calomel.  I  have 
sometimes  combined  small  doses  of  calomel  with  the  santonin  in  a 
troche,  and  with  good  effect.  Xanthopsia  or  yellow  vision,  spasms,  and 
even  convulsions,  and  saffron-colored  urine  may  follow  the  use  of  san- 
tonin in  cases  of  idiosyncrasy  or  overdose  of  the  drug.  Oil  of  worm- 
seed  (chenopodium)  in  doses  of  five  to  ten  drops,  in  emulsion,  capsules, 
or  on  sugar,  may  also  be  used  with  benefit.  Another  favorite  remedy 
with  some  is  the  unofficial  fluid  extract  of  spigelia  and  senna,  to  be  given 
in  from  1-  to  3-dram  (4.0-12.0)  doses.  Finally,  the  fluid  extract  of  spi- 
gelia alone  (1  to  2  drams — 4.0-8.0),  followed  by  a  brisk  purge,  may 
bring  away  dead  worms. 

Oxyuris  Vermicularis  (Seat-,  Fin-,  Thread-,  or  3Iaiv-ivorm). — 
Natural  History. — The  asearis  vermicularis^  as  this  worm  is  also  called, 
inhabits  the  colon  and  especially  the  rectum.  It  is  a  small  worm,  as 
several  of  the  commonly-used  terms  signify,  and  frequently  it  occurs  in 
great  numbers,  sometimes  agglutinated  with  mucus  into  feculent  balls. 
It  is  most  common  in  children,  though  found  not  rarely  at  any  period  of 
life.  The  female  oxyuris  is  whitish  in  color  and  about  ten  or  twelve 
millimeters  (one-half  inch)  long,  the  male  being  about  three  or  four 
millimeters  (about  one-sixth  of  an  inch)  in  length.  Oxyures  develop 
from  ova  in  about  two  weeks  after  the  ingestion  of  the  latter.  The 
eggs  are  irregularly  ovoid,  about  ^-^  in.  (0.05  mm.)  in  length,  and  tena- 
cious of  life.  By  the  time  the  embryos  have  reached  the  cecum,  they 
are  sexually  mature,  and  when  the  female  arrives  in  the  rectum,  im- 
mense numbers  of  eggs  are  deposited  that  mature  into  great  numbers 
of  worms,  the  latter  being  discharged  Avith  the  feces.  Sometimes  the 
worms  crawl  out  of  the  anus. 

Infection  with  the  ova  may  take  place  through  water  and  food 
(green,  uncooked  vegetables  and  fruit)  that  have  come  in  contact  with 
the  hands  of  infected  persons.  Scratching  the  anus  will  permit  of  the 
reception  of  oxyuris  eggs  under  the  finger-nails  (Zenker  and  Heller), 
and  in  careless,  ignorant,  and  uncleanly  persons  the  possibility  of  such 
an  auto-  or  re-infection  should  be  recognized  and  avoided. 

Symptoms. — Pruritus  ani  (itching  of  the  anus),  sometimes  burning 
pain,  and  tenesmus,  with  restlessness  and  disturbed  sleep,  are  the  com- 
monest symptoms  of  the  presence  of  this  parasite.  The  itching  is 
always  worse  at  night,  and  may  be  paroxysmal.  An  herpetic  or  eczem- 
atous  eruption  around  the  anus  should  arouse  suspicion,  particularly 
in  children,  of  the  presence  of  the  oxyuris  in  the  rectum,  and  it  ac- 
counts for  the  intense  itching  (Flint).  Anorexia  and  anemia,  rectal 
irritability,  and  "  nervousness  "  may  be  associated.  It  is  believed  that 
the  migration  of  the  worms  into  the  vagina  of  girls  may  set  up  pruritus 
and  leukorrhea,  and  that  habits  of  masturbation  may  be  induced  in  both 
girls  and  boys  by  the  sexual  irritation  caused  by  the  worm.  Inspection  of 
the  stools  will  reveal,  in  positive  cases,  the  whitish,  thread-like  parasites. 


ASCABIASIS.  1241 

Diagnosis. — The  pruritus,  indicating  rectal  trouble,  will  direct  the 
physician's  attention  to  the  anus,  where  the  oxyures  may  be  seen ;  if 
not  found,  their  discovery  in  the  feces  or  the  discovery  of  the  eggs  by 
microscopic  examination  will  suffice. 

The  prognosis  is  good,  and  proper  treatment  is  always  effective. 

Treatment. — The  exhibition  of  anthelmintics  and  purgatives,  such  as 
recommended  for  destroying  and  removing  the  lumbricoid  worm,  may  be 
effective  against  seat-worms  also,  but  mainly  in  reaching  those  lodged  in 
the  bowel  above  the  rectum.  Attacking  the  oxyures  directly,  however, 
by  means  of  enemata  is  the  most  useful  and  rational  treatment. 

The  rectum  should  be  well  emptied  of  feces,  so  that  the  worms  may 
be  exposed  to  the  action  of  the  medicament  injected,  and  for  this  pur- 
pose enemata  of  cold  water,  either  simple  or  with  salt  or  soap,  may  be 
resorted  to.  Injections  containing  the  decoction  of  quassia  (1  or  2 
ounces — 32.0  to  64.0 — of  the  powder  or  chips  to  the  pint — half  liter — 
of  water)  are  nearly  always  curative.  Other  useful  remedies  are  carbolic 
acid,  turpentine,  tannin,  vinegar,  camphor,  potassium  sulphid,  and  the 
oil  of  eucalyptus.  The  injections  should  be  repeated  once  or  twice  daily 
for  at  least  ten  days.  It  sometimes  happens  that  killing  the  worms  as 
directed  above  affords  only  temporary  relief  The  reason  for  this  is 
obviously  to  be  found  in  the  fact  that  the  oxyuris  breeds  in  the  cecum, 
and  that  only  grown  forms  descend,  reaching  the  rectum. 

Rectal  irritation  may  be  allayed  by  injections  of  laudanum  and 
starch-water  (gtt.  iij— v  to  the  ounce — 32.0).  Anal  itching  is  often 
amenable  to  carbolized  vaselin,  applied  at  bed-time,  or  to  belladonna 
ointment,  or  the  following,  which  has  been  highly  recommended : 

Ty^.  Hydrarg.  chloridi  mitis,  9ij  (2.592); 

Petrolati,  Sss  (16.0). 

M.  et  ft.  ung. 
Sig. — Apply  at  bedtime. 

Ascaris  Alata. — This  is  another  name  for  the  ascaris  mi/stax,  a 
species  of  worm  found  in  the  intestines  of  the  dog  and  cat,  and  occa- 
sionally in  man.  It  is  a  slender  worm,  with  a  closely-rolled  spiral  tail 
and  a  wing-like  projection  on  either  side  of  the  head.  The  female  is 
about  6-7  centimeters  (2.7  inches),  the  male  about  4  centimeters  (1.75 
in.)  in  length.  Scarcely  ten  instances,  however,  have  been  recorded 
in  which  this  parasite  has  occurred  in  man. 

Trichoceplialus  Dispar  (Ascaris  trichiura). — Natural  History. — 
This  worm  measures  about  four  or  five  centimeters  (2  inches)  in  length, 
and  is  characterized  by  the  very  slender,  hair-like  appearance  of  the 
anterior  two-thirds  of  its  body,  in  contrast  to  the  thick  posterior  por- 
tion, which  is  more  or  less  straight  and  blunt-pointed  in  the  female,  but 
rolled  into  a  spiral  in  the  male.  Its  particular  habitat  seems  to  be  the 
cecum,  though  sometimes  it  is  also  found  in  the  colon.  It  may  exist  in 
great  numbers.  Europeans  appear  to  be  infected  with  the  parasite 
more  commonly  than  Americans.  The  trichocephalus  has  been  found 
postmortem  in  many  subjects  dying  with  various  diseases,  as  typhoid 
fever  (Flint),  meningitis  (Earth),  profound  anemia  (Osier),  and  beri-beri. 

Propagation  is  effected  by  the  microscopic  eggs,  which  are  ovoid, 
hard,  nodular,  brownish,  and  about  0.05  mm.  (-g-g-g-  in.)  in  lengtk. 


1242  ANIMAL  PARASITIC  DISEASES. 

Symptoms. — It  is  not  certain  that  the  parasite  causes  any  symptoms, 
nor  even  that  it  aggravates  those  of  an  associated  disease  (vide  sujjra). 
When  occurring  in  great  numbers  the  possibility  of  fecal  accumulation 
may  be  mentioned. 

The  diagnosis  may  be  made  by  microscopy.  The  ova  may  be  de- 
tected in  the  feces. 

The  prognosis  and  treatment  are  not  called  for. 

ANKYLOSTOMIASIS . 

Ankylostomum  Duodenale  {Bochmius  duodenalis). — Natural 
History. — This  parasite  belongs  to  the  family  of  strong ylidce  of  the 
nematoid  worms.  It  was  discovered  in  Milan,  in  1838,  by  Dubini. 
The  length  of  the  female  is  from  8  to  18  mm.  (^  inch),  and  of  the  male 
from  6  to  10  mm.  (^  inch).  Its  body  is  thread-like,  with  a  conical- 
shaped  head,  and  a  large,  bell-shaped  mouth  surrounded  by  a  horny 
capsule,  and  possessing  four  hook-like  teeth,  ventrally  situated,  and  two 
smaller,  vertical  teeth  on  the  dorsal  side,  by  which  the  worm  fixes  itself 
to  the  mucous  membrane.  A  bulbous-like  swelling  exists  at  the  tail  end 
of  the  male  worm.  It  inhabits  the  jejunum  and  duodenum.  The  eggs 
are  found  in  muddy  water,  and  there  liberate  the  embryos.  These  de- 
velop into  larvae,  which,  when  taken  into  the  human  bowel  through 
drinking-water  develop  into  mature  worms.  They  do  not  multiply 
within  the  intestine. 

Pathology. — The  ankylostomum  is  nourished  by  the  blood  it  sucks 
from  the  intestinal  vessels.  It  is  found  postmortem,  sometimes,  in  the 
mucous  or  even  submucous  coat,  rolled  up  in  a  little  blood-cavity.  Ec- 
chymoses,  containing  a  central  opening  through  which  blood  can  ooze, 
are  the  usual  result  of  the  worm's  action.  Chronic  catarrhal  enteritis 
is  usually  associated.     Hypertrophic  dilatation  of  the  heart  is  observed. 

Symptoms. — The  chief  symptom  of  the  condition  is  anemia  (second- 
ary). When  the  number  of  ankylostoma  embryos  introduced  into  the 
intestine  is  large,  the  anemia  may  develop  acutely ;  when  but  a  few  are 
introduced,  the  withdrawal  of  blood  is  more  gradual,  and  chronic  anemia 
develops.  I  think,  however,  it  may  be  safely  affirmed  that  the  anemia 
is  not  wholly  due  to  blood-sucking.  In  some  cases  the  impoverishment 
of  the  blood  has  been  so  profound  as  to  simulate  a  pernicious  anemia. 

This  parasite  has  been  found  to  be  the  cause  of  the  disease  known  as 
"Egyptian  chlorosis,"  first  described  by  Griesinger.  Ankylostomiasis 
is  not  uncommon  in  tropical  countries  (Italy,  Brazil).  In  Italy  it  has 
been  termed  tunnel  or  mountain  anemia;  in  Belgium  it  is  known  as 
brickmaker's  anemia  ;  again,  it  occurs  among  workers  in  coal-mines — 
miner  s  cachexia.  In  this  country  it  is  rare,  though  alleged  to  have 
been  seen  in  the  Southern  States.  The  importation  of  infected  Italian, 
Hungarian,  and  Polish  laborers  may,  at  some  future  time,  cause  the 
propagation  of  the  ankylostoma  parasite  in  the  United  States.  The 
anemia  of  ankylostomiasis  is  progressive,  and  it  is  noteworthy  that  no 
organic  cause  for  it  can  be  discovered.  There  may  be  in  addition, 
slight  gastro-intestinal  disorder  (anorexia,  colicky  pains,  nausea  and 
vomiting,  and  constipation  alternating  with  diarrhea).  In  cases  marked 
by  an  acute  development  of  anemia   considerable   general  weakness. 


TRICHINIASIS.  1243 

dyspnea  and  sometimes  dropsy  may  ensue.  The  areas  of  the  apical 
cardiac  impulse  and  of  cardiac  dulness  are  increased  downward  and 
laterally.  Various  murmurs — hemic — may  be  heard,  and  the  pulmonic 
sound  may  be  accentuated  {vide  Pernicious  Anemia,  p.  429). 

Diagnosis. — This  is  made  by  finding  the  eggs  or  mature  worms  in  the 
feces.  The  former  are  oval- shaped,  about  0.05  mm.  (^-^  inch)  in 
length,  and  have  a  much  thinner  shell  than  the  ova  of  the  round-worm. 
They  do  not  segment  except  within  the  intestine.  In  any  case  of  pro- 
nounced anemia  in  which  the  cause  is  obscure  the  patient's  dejections 
should  be  carefully  examined  for  the  ankylostoma  parasite  or  its  eggs. 

Duration. — The  disease  may  last  for  months  or  for  several  years. 

Prognosis. — If  left  untreated,  the  affection  may  end  fatally.  Intense 
anemia,  obstinate  diarrhea,  and  profound  nutritive  disturbances  con- 
stitute symptoms  of  grave  import.  Properly  treated,  the  prognosis  is 
quite  favorable.     A  spontaneous  cure  may  occur  in  some  cases. 

Treatment. — PropJiylactic. — Workmen  in  mines,  tunnels,  and  brick- 
yards, and  in  tropical  localities  especially,  should  be  warned  not  to  drink 
the  water  close  at  hand  Avithout  previous  boiling  and  then  cooling. 

Medicinal. — Anthelmintics  to  kill  the  ankylostoma  and  purgatives 
to  remove  it  from  the  intestine  are  indicated  as  for  other  intestinal  para- 
sites. The  oleoresin  of  male  fern  in  J-  to  1-dram  (2.0-4.0)  doses,  san- 
tonin, and  thymol  are  very  useful  for  the  first-named  object. 

Cathartics  or  enemata  are  used  to  bring  away  the  dead  parasites, 
after  which  nourishing  food,  iron,  and  tonics  are  to  be  given. 

TRICHINIASIS. 

[Trichinosis.) 

The  parasite  that  gives  rise  to  this  afiection  is  the  trichina  spiralis. 

Natural  History. — The  mature  male  worm  is  0.8  to  1.5  mm.  (^ 
in.)  long  and  the  female  2  to  4  mm.  (^^--g-  in.).  The  head  is  pointed  and 
unarmed,  and  the  neck  is  long  and  more  slender  than  the  body,  which 
has  a  round  blunt  end.  The  worm  is  viviparous.  It  inhabits  the  intes- 
tines of  such  animals  as  the  rat,  dog,  cat,  hog,  and  man. 

The  embryo  or  muscle  trichina  is  about  0.6  to  1  mm.  (^  in.)  long,  and 
lies  coiled  up  in  a  spiral  form  within  an  ovoid  capsule  in  the  sarcolemma- 
sheath  of  muscle-fiber.  The  life-history  begins  with  the  larval  state  of 
the  trichinae  encysted  in  the  muscles.  When  this  flesh  is  eaten  by  another 
animal,  or  by  man,  the  larvae  are  liberated  during  the  digestive  process. 
Passing  into  the  intestines,  they  reach  the  adult  stage  in  from  two  to  four 
days,  being  then  sexually  mature,  and  in  five  to  seven  days  more  they 
produce  hundreds  of  living  embryos. 

The  intestinal  trichinae  become  fully  grown,  and  then  usually  die  in 
from  four  to  five  weeks.  The  female  trichina  may  bring  forth  several 
broods  of  embryos  dui'ing  her  life-period  in  the  intestine.  The  living 
embryos  leave  the  intestine  at  once,  and  invade  the  muscles  through 
various  channels — principally  along  the  connective-tissue  routes — so  that 
the  symptoms  of  muscular  irritation  develop  in  from  seven  to  ten  days 
after  eating  the  trichinous  meat.  The  embryos  attain  to  maturity  (larval 
form)  in  about  two  weeks  after  entering  the  muscular  tissues.  Their 
presence  causes  a  mechanical  irritation  that  results  in  the  formation  of  a 


1244 


AXLMAL  PARASITIC  DISEASES. 


Fig.  81. — Trichina  spiralis  from  the  head  of 
the  right  gastrocnemius  muscle  three  weeks  after 
the  first  symptoms  appeared  (Queen  obj.  |;  eye 
piece  Xo.  II). 


fibrous  capsule  in  from  four  to  six  weeks.     In  man  it  probably  becomes 

encysted  at  a  later  period  than 
in  the  lower  animals,  as  shown 
bv  the  accompanying  illustration, 
taken  from  a  case  under  the  im- 
mediate observation  of  Dr.  L.  Na- 
poleon Boston  (Fig.  81).  Usually 
but  a  single  worm  is  found  within 
one  capsule,  though  occasionally 
three  or  four  are  seen.  Leuckart 
found  numbers  of  embryos  free 
in  the  abdominal  cavity  of  in- 
fected animals;  they  have  also 
been  found  in  the  mesentery. 
The  encapsulated  trichinse  may 
live  many  years  in  the  muscles. 
With  increasing  age  the  capsules 
become  thicker  and  may  be  the  seat  finally  of  calcareous  infiltration. 
Pathology. — The  diaphragm  is  most  thickly  infested  with  the  larval 
trichina?.  Next  in  order  are  such  trunk-muscles  as  the  intercostals  and 
abdominals,  then  the  muscles  of  the  neck,  including  the  larynx,  head, 
eyes,  and  extremities.  Up  to  the  seventh  week  of  the  disease  the  intes- 
tinal trichinae  may  be  very  numerous,  as  many  as  a  dozen  being  found  in 
a  drop  of  intestinal  mucus.  There  may  be  some  intestinal  inflammation 
(cataiTh)  and  the  mesenteric  glands  may  also  be  swollen  and  appear  like 
those  of  typhoid  fever.  In  cases  that  proved  fatal  during  the  second 
month,  Cohnheim  noted  an  abundance  of  fat  in  the  liver,  a  granular  state 
of  the  renal  epithelium  and  of  the  heart-muscle,  broncho-pneumonic  areas 
(occasionally),  and  hypostatic  pneumonia  (frequently).  Microscopically, 
the  muscles  show  '•  the  changes  characteristic  of  acute  myositis  "  (Fitz) 
after  the  fifth  week.  The  trichinous  cysts  in  the  muscles  may  be  seen 
with  the  naked  eye  as  small,  grayish-white,  opaque,  "  oat-shaped  "  specks, 
longitudinally  disposed  in  the  meat-fibers. 

Sources  of  the  Trichina. — The  trichina  was  first  found  in  pork — 
the  usual  source  of  trichiniasis  in  man — by  the  late  Joseph  Leidy.  It 
should  be  noted  that  some  individuals  may  be  dangerously  infested  with 
trichinae  and  yet  give  no  symptomatic  evidence  of  the  presence  of  the 
parasite.  Recent  investigations  show  that  the  live  trichinae  may  be  found 
in  the  fatty  as  well  as  the  fleshy  portion  of  pork.  The  pig  is  infested  by 
eating  trichinous  rats,  trichinous  pork,  or  human  or  porcine  excre- 
ment containing  the  embryos  of  propagating  intestinal  trichinae.  The 
rat  may  be  the  original  host  of  the  parasites,  or  it  may  itself  become  in- 
fected by  older  rodents  eating  their  fellows,  or  by  eating  trichinous  pork 
or  human  or  porcine  excrement  voided  during  the  stage  of  intestinal 
infection. 

As  to  the  frequency  of  the  infection  of  hogs,  it  may  be  said  that  about 
2  per  cent,  were  found  to  be  trichinous,  according  to  Salmon's  report 
(1884),  of  nearly  three  hundred  thousand  examinations  of  American  pork. 
Other  examinations,  however,  show  a  variation  of  infection  of  from  .05 
to  6  per  cent,  of  hogs.  In  Prussia,  according  to  Eulenberg's  statistics, 
the  ratio  is  decidedly  less  varying — from  1  to  2160  hogs  (1876)  to  1  to 


TRICHINIASIS.  1 245 

1817  (1889).  "The  dissecting-room  and  postmortem  statistics  show 
that  from  one-half  to  two  per  cent,  of  all  bodies  contain  trichinae  "  (Osier). 

Of  course,  man,  as  a  rule,  becomes  infected  by  eating  raw  or  partially 
cooked  pork  containing  living  muscle-trichinse  (larvae).  Eating  raw  ham 
and  sausages,  a  habit  common  among  the  Germans  of  Prussia  (particu- 
larly during  picnics),  and  in  some  parts  of  the  United  States  where 
German  emigrants  have  settled  in  large  numbers,  explains  the  compara- 
tive frequency  of  this  disease  in  such  localities.  Trichiniasis  has  occurred 
in  epidemic  form  in  North  Germany,  France,  Spain,  Russia,  the  Scan- 
dinavian countries,  and  in  several  of  the  northwestern  United  States. 

Symptoms. — Postmortem,  examination  often  reveals  the  presence 
of  muscle-trichinae,  whereas  no  history  of  trichiniasis  or  of  any  disease 
resembling  it  has  been  obtainable.  It  is  to  be  recollected  that  to  the 
migration  of  the  parasites  the  principle  symptoms  of  trichinosis  are  due. 

In  well-marked  cases  of  infection  g astro-intestinal  disturhances  appear 
on  the  second  or  third  day  after  the  ingestion  of  the  affected  meat.  Vom- 
iting, diarrhea,  and  colicky  pains  in  the  abdomen  may  be  present.  The 
diarrhea  sometimes  takes  on  the  characteristics  of  a  choleraic  attack  or 
may  be  followed  by  obstinate  constipation. 

Extreme  "muscular  weariness"  and  bodily  fatigue  often-  occur  for 
several  days  before  the  embryonic  parasites  can  have  begun  to  wander 
into  the  muscles.  On  about  the  tenth  to  the  fifteenth  day,  when  migra- 
tion usually  commences,  cMHs,  followed  by  a  temperature  of  101.5°  to 
104°  (38.6°  to  40°  C.)  and  marked  myositis,  come  on.  The  muscles  are 
stiff,  tense,  painful  on  pressure  and  motion,  and  someAvhat  swollen.  The 
flexors  of  the  extremities  are  particularly  sore  and  often  firmly  con- 
tracted, causing  the  knees  and  elbows  to  be  acutely  bent.  Mastication, 
deglutition,  and  j:>Ao?^a^^o?^  may  be  difficult  and  painful  because  of  the 
involvement  of  the  muscles  of  the  jaws,  pharynx,  and  larynx.  Intense 
dyspnea  is  frequent  on  account  of  the  involvement  of  the  cliaphragm  and 
intestinal  muscles.  The  temjyerature  shows  marked  remissions  in  most 
cases,  and  may  even  be  subnormal.    The  pulse  varies  Avith  the  temperature. 

Edema  is  characteristic  in  nearly  all  of  the  cases.  It  appears  on 
about  the  seventh  day  after  the  infection,  and  begins  in  the  face,  usually 
being  noted  first  in  the  eyelids,  and  extending  thence  to  the  extremities 
and  trunk  during  the  height  of  the  muscular  symptoms.  It  may  last  for 
several  days,  then  disappear  for  several  days  or  a  week,  and  reappear. 
Ascites  even  has  been  observed.  Edema  of  the  larynx  and  bronchial 
catarrh,  the  latter  rarely  leading  to  broncho-jDneumonia,  may  also  super- 
vene and  add  to  the  gravity  of  the  dyspnea.  Profuse  SAveating  may  last 
for  several  weeks.  Miliaria,  urticaria,  acne,  furunculosis,  herpes,  and 
pruritus  may  occur  as  skin-manifestations.  Insomnia,  headache,  a  tem- 
porary loss  of  the  tendon-reflexes,  and  dilatation  of  the  pupils  (Rup- 
precht)  have  been  noted  among  the  nervous  symptoms.  Prolonged  cases 
show  a  marked  degree  of  emaciation  and  anemia.  T.  R.  BroAvn  ^  found 
a  decided  increase  of  the  eosinophiles  in  the  blood,  amounting  to  37  per 
cent.  This  discovery  has  been  confirmed  by  Cabot,  Gwyn,  Atkinson, 
Stump,  Osier,  and  others.  W.  T.  Howard,  Jr.,^  was  able  to  confirm 
Brown's  observation  on  the  presence  of  eosinophiles  in  the  muscle-lesions, 
but  failed  to  find  an  increase  of  these  cells  in  the  circulating  blood. 

^  Johns  Hopkins  Bulletin,  1897,  vol.  viii. 

'■'  Philadelphia  Medical  Journal,  December  2,  1899. 


1246  ANIMAL  PARASITIC  DISEASES. 

Complications,  as  a  typhoid  state,  hypostatic  pneumonia,  and  pleurisy 
may  appear.  Albumin,  with  casts,  and  occasionally  red  and  white  cor- 
puscles are  found  in  the  urine. 

Recovery  is  effected  in  mild  cases  within  two  weeks  ;  in  the  severe 
cases  of  infection  from  six  weeks  to  several  months  may  be  occupied 
before  convalescence  begins. 

Diagnosis. — The  following  symptoms  ai-e  regarded  as  pathogno- 
monic :  sudden  swelling  of  the  face,  coming  on  after  the  patient  has 
suffered  for  several  days  from  muscular  soreness ;  loss  of  appetite,  fever, 
and  profuse  sweats  (Bohler) ;  painful,  tender,  and  "rubber-like"  hard- 
ness of  the  muscles,  with  difficulty  in  movement ;  semiflexed  extremities ; 
gastro-intestinal  catarrh,  with  a  red,  dry,  coated  tongue ;  dyspnea,  diar- 
rhea, and  edema  of  the  extremities  following  the  subsidence  of  that  first 
noticed  in  the  face.  Friedreich  emphasizes  hoarseness,  and  Packard 
rapidity  of  respiration  without  evident  cause,  as  diagnostic  symptoms. 

Meat-  and  saumge-poisoning  may  be  distinguished  from  trichiniasis 
by  the  more  ra))id  course  of  the  former,  the  dry  throat  and  skin,  jaundice, 
visual  disturbances,  and  the  absence  of  edema  and  muscular  symptoms. 

Direct  examination  of  the  passages  and  of  the  muscles  may  be  resorted 
to.  The  discovery  of  the  parasites  in  the  pork  a  portion  of  Avhich  has 
been  eaten  by  the  sick  of  course  establishes  the  diagnosis.  A  low-power 
microscope  should  be  used  to  examine  the  intestinal  mucus  for  the  trichinge. 
Light  purgation  should  precede  this  endeavor.  Harpooning  such  muscles 
as  the  biceps  for  the  purpose  of  removing  some  muscle-fiber,  or  directly 
incising  a  small  portion  under  Schleich's  method  of  infiltration-anes- 
thesia, may  permit  of  a  positive  diagnosis  in  some  cases. 

Acute  rheumatism.,  cholera,  typhoid  fever,  and  acute  polymyositis 
(pseudo-trichiniasis)  may  at  times  resemble  trichiniasis.  Epidemics  of 
the  parasitic  disease  are  more  readily  diagnosed  than  an  isolated  case. 

Prognosis. — This  depends  upon  the  number  of  parasites  ingested 
with  the  infected  meat  or  sausage,  and  upon  the  number  of  embryos  gen- 
erated in  the  intestines  by  the  matured  Avorms.  Marked  early  diarrhea 
is  favorable.  The  prognosis  should  be  guarded,  as  death  may  occur  as 
late  as  from  the  fourth  to  the  sixth  week.  Uf  357  cases  collected  by 
Packard  the  mortality  was  24.07  per  cent. 

Treatment. — Prophylaxis  is  of  supreme  importance,  both  as  to  the 
infection  of  the  hog  and  the  danger  of  eating  infected  pork.  Care  should 
be  exercised  in  the  feeding  of  swine,  and  the  destruction  of  rats  should 
be  made  as  complete  as  possible  in  and  about  the  styes.  Pig-excrement 
should  be  removed  and  burned,  and  feeding  with  milk,  bran,  grain,  and 
vegetables  should  be  forced  upon  all  keepers  of  swine. 

Rigid  inspection  of  the  meat-supply,  as  is  done  in  Germany,  should 
be  carried  out  by  sanitary  officers  employed  by  the  government.  It  is 
held  to  be  an  impracticable  measure  where  immense  quantities  of  meat 
are  handled  daily  to  examine  microscopicalh'  simply  a  minute  fragment 
of  pork  taken  from  each  hog  slaughtered.  Decidedly  the  safest  and 
most  efficient  way  to  prevent  trichinosis  is  to  thoroughly  salt,  smoke,  and 
cook  the  pork  that  is  to  be  used.  Roasting  should  be  particularly  well 
done,  in  order  that  the  heat  may  effectively  reach  the  central  portions  of 
the  meat.     Putrefaction  does  not  kill  the  parasites. 

The  treatment  of  those  who  have  eaten  trichinous  meat  should  be  by 


FILARIASIS.  1247 

a  prompt  evacuation  of  the  bowel,  especially  within  the  first  twenty-four 
hours,  as  after  the  embryo  young  have  been  brought  forth  and  have 
passed  into  the  muscles  no  known  treatment  is  successful  in  attacking 
them.  Calomel  is  one  of  the  best  drugs,  and  active  purgation  usually 
follows  its  use  in  large  doses,  succeeded  by  salines ;  rhubarb,  senna,  sul- 
phur, aloin,  and  large  doses  of  oil  or  glycerin  may  also  be  tried.  In 
combination  with  the  purgatives  some  anthelmintic  (male  fern,  santonin, 
thymol)  should  be  used.  The  encysted  or  larval  parasites  are  not  acces- 
sible to  treatment,  although  picric  acid  has  been  recommended.  The 
symptoms  to  be  met  are  the  great  muscular  pains,  insomnia,  and  weak- 
ness, which  is  often  severe  in  protracted  cases.  Prolonged  hot  baths, 
anodyne  embrocations,  with  hypodermics  occasionally,  may  prove  useful 
for  the  first ;  bromids,  chloralamid,  and  the  like  for  the  second  symptom ; 
and  a  concentrated  liquid  diet,  strychnin,  peptonoids,  and  the  like  for  the 
last.  Massage,  electricity,  and  stimulating  applications,  as  chloroform 
liniment,  may  be  required  during  convalescence  and  for  some  time  there- 
after to  combat  the  muscular  weakness,  soreness,  and  stiffness. 

FILARIASIS. 
{Filaria  Sanguinis  Hominis.) 

There  are  several  varieties  of  filarise  that  may  be  found  in  human 
blood.  The  two  principal  ones  are  the  filaria  sanguinis  hominis  nocturna 
and  filaria  sanguinis  hominis  diurna.  The  first  is  a  white,  opaline, 
thread-like  worm,  tapering  toward  the  ends,  which  latter,  however,  are 
blunt.  The  male  is  83  mm.  (3.2  inches)  long ;  the  female  155  mm. 
(6.1  inches).  The  second  worm  is  known  only  in  embryonic  form,  and 
is  distinguished  by  granulations  in  the  axis  of  the  body.  Manson  found 
them  in  the  blood  of  Congo  negroes,  but  only  during  the  daytime.  On  the 
other  hand,  the  nocturnal  filaria  is  found  only  at  night,  or,  if  the  host  be 
either  by  habit,  necessity,  or  choice,  a  day-sleeper,  during  this  time, 
showing,  then,  that  there  is  some  condition  of  the  body  during  quietude 
that  is  conducive  to  the  appearance  of  the  filaria  in  the  blood  (blood  and 
chyle  flow,  Granville).  This  "  filarial  periodicity  "  is  a  curious  and  strik- 
ing characteristic  of  these  parasites. 

The  embryos  are  produced  by  the  female  in  great  numbers,  and  are  so 
small  that  they  readily  pass  through  the  capillaries.  According  to  Man- 
son,  who,  in  1877,  found  the  larvae  of  filaria  sanguinis  hominis  in  the 
stomach  of  a  female  mosquito,  it  is  probable  that  after  filling  itself  with 
the  blood  of  an  infested  man  during  sleep,  the  mosquito  seeks  stagnant 
water,  dies,  and  the  larvae  are  set  free.  In  this  way  it  may  happen  that 
man  takes  in  the  embiyos  through  the  drinking-water.  They  find  a 
permanent  seat  in  the  lymphatics  of  the  human  host,  mature,  and  bring 
forth  young,  which  may  again  infest  the  blood  by  passing  through  the 
lymph-ducts  into  the  thoracic  duct  and  general  circulation. 

The  geographic  distribution  of  the  filaria  is  limited  mainly  to  the 
tropics  and  sub-tropics.  Filariasis  is  most  common  in  Brazil,  the  West 
Indies,  Mexico,  the  Southern  States,  Southern  China,  India,  Egypt,  a 
part  of  Australia,  and  the  southern  Pacific  islands,  where  it  is  quite 
endemic. 

The  symptoms  of  filariasis  are  in  abeyance  until  some  obstruction 


1248 


ANIMAL  PARASITIC  DISEASES. 


of  the  lymph-channels  is  caused  by  the  parasite.  There  are  several  con- 
ditions or  endemic  diseases  produced.  Elephantiasis  arabum  is  believed 
by  Manson  to  be  the  effect  of  these  parasites  in  a  certain  proportion  of 
cases  at  least.      In  -|ie(inM'ii~  ■  f  night-blood  fro?r  88  Cochin  Chinese  he 


Fig.  82.— Th-  -ir^v.-ii..:.'  •  .-;:,/.■  :..,;:  :i  :.'; '.j  ;.-■  ';vs 
of  four  successive  instanianeuus  cxi."'SurL-s.  The-  k-ugth  of 
each  exposure  was  one-fifth  of  a  second,  the  entire  series 
occupying  less  than  five  seconds.  The  magnification  is  to 
eight  hundred  diameters,  with  a  Zeiss  one-twelfth  homoge- 
neous immersion  lens  (F.  P.  Henry). 


Fig.  sS. — Filaria  aliv.-  in  the 
blood.  Instantaneous  photomi- 
crograph. Four  hundred  diam- 
eters magnification.  Four  milli- 
meters Zeiss  apochromatic  (F.  P. 
Henry). 


found  filariae  in  21 :  14  specimens  came  from  patients  with  elephantiasis, 
and  only  1  showed  filariae.  This  latter  fact,  he  explains,  is  to  be  expected, 
since,  in  order  to  give  rise  to  elephantiasis  (due  to  an  infarction  of  the 
lymphatic  glands  connected  with  the  diseased  areas),  the  adult  filariae 
mu.st  lie  on  the  distal  side  of  the  glands,  which  makes  it  impossible  for  the 
young  filariae  to  pass  into  the  general  circulation.  "  Therefore  the  person 
least  likely,  in  a  filarial  district,  to  have  filariae  in  his  blood  is  one  who  is 
the  subject  of  elephantiasis."' ' 

Hematochyluria  and  Chyluria. — The  patient  passes  a  white,  opaque, 
milky  urine,  occasionally  bloody,  with  a  clotty  sediment.  This  may  be 
intermittent,  and  normal  urine  may  be  passed  for  many  weeks  before 
chyluria  or  hematochyluria  reappears.  There  may  be  at  the  same  time  a 
slight  degree  of  polyuria.  Under  the  microscope,  fat  granules  and  white 
and  red  corpuscles  are  seen.  The  lively,  wriggling  embryo  filarise  may 
also  be  discovered  in  the  urine,  as  well  as  in  the  blood  at  night.  There 
is  a  dilatation  of  the  lymph-vessels  in  the  kidneys  alongside  of  the 
tubules,  and  in  the  abdominal  lymph-plexuses.  Sometimes  a  little  vesical 
irritation  and  straining  during  urination  may  be  caused  by  the  endeavor 
to  pass  chylous  blood-clots.  The  thoracic  duct  above  the  diaphragm  has 
been  found  impervious  (Stephen  Mackenzie). 

1  British  Med.  Jour.,  June  2,  1894. 


DBACONTIASIS.  1249 

Lymph-scrotum  and  lymph-vulva  have  been  caused  by  the  filarige.  The 
parts  are  greatly  swollen,  thickened,  and  contain  distended  lymphatics 
filled  with  a  turbid  and  either  milk-white,  salmon-colored,  or  blood-red 
coagulable  liquid  that  is  discharged  upon  puncturing  the  varices.  The 
filaria  is  not  always  found  in  the  exuded  lymph.  The  inguinal  and 
femoral  regions  are  often  enlarged  and  doughy.  An  erysipelatous  inflam- 
mation of  the  parts  is  not  infrequent  in  these  cases,  and  may  be  ushered 
m  by  a  chill  and  high  fever,  lasting  a  day  or  two,  and  ending  with  a  pro- 
fuse sweat. 

The  filarise  have  also  been  found  in  a  case  of  ascites  (Winckel),  in  one 
of  hemoptysis  (Yamane,  Japan),  and,  by  the  same  observer,  they  were 
found  in  the  feces  (chylous  diarrhea). 

Treatment. — Prophylaxis  in  regard  to  the  drinking-water  is  essen- 
tial in  order  to  avoid  filariasis.  Filtering,  boiling,  and  storing  the  water 
in  mosquito-proof  receptacles  is  sufficient.  Thymol  in  from  1-  to  5-grain 
(0.0648-0.324)  doses,  given  for  from  two  to  eight  weeks,  has  caused  the 
disappearance  of  the  larval  filariae  in  several  cases.  Methylene-blue 
appears  also  to  have  produced  a  cure  in  a  case  of  chyluria  reported  by 
Flint,  although  Laveran  and  Henry  believe  that  it  is  of  little  value. 
The  latter  states  that  he  has  "  given  this  drug  in  larger  doses  than  were 
used  in  the  case  reported  by  Flint,  and  for  a  much  longer  period,  with- 
out the  slightest  effect  upon  the  parasite."^  The  adult  filaria  seems  to  be 
beyond  the  reach  of  any  known  medication  that  will  not  prove  dangerous, 
either  directly  or  indirectly,  to  its  human  host. 

DRACONTIASIS. 

( Gruinea-ivorm  Disease.) 

The  parasite  is  the  filaria  or  dracunculus  medinensis  or  persarum, 
common  in  the  tropics  of  Asia,  Africa,  and  America.  It  is  only  recently 
that  the  male  guinea-worm  has  been  found.  It  is  usually  solitary,  and 
measures  from  50  to  100  cm.  (20  to  40  in.)  in  length  and  about  2  mm. 
(-^  in.)  in  diameter.  It  is  cylindric,  whitish,  with  blunt  papillated  head, 
and  a  sharp,  curved  tail.  The  body  is  nearly  filled  by  the  uterus,  which 
contains  innumerable  embryos.  The  live  young  dracunculus  escapes 
from  the  intestines  of  an  infested  man,  ox,  horse,  dog,  or  jackal,  enters 
the  body  of  a  cyclops  or  small  cray-fish,  and  there  becomes  a  fully-devel- 
oped larva.  It  is  then  taken  into  the  stomach  and  intestines  of  man 
through  the  contaminated  drinking-water.  The  female  enters  the  intes- 
tines by  way  of  the  mesentery,  and  the  male  worm,  after  fulfilling  its 
sexual  functions  there,  probably  dies,  while  the  female  brings  forth  its 
young,  which  pass  into  the  connective  tissues  of  its  human  host.  The 
worm  has  an  inexplicable  affinity  for  the  subcutaneous  and  intermuscular 
tissues  of  the  feet  and  legs,  where  it  attains  full  development. 

Symptoms. — Wherever  the  parasite  is  situated,  it  may  often  be  felt' 
coiled  up  under  the  skin,  which  at  that  point  becomes  red,  sore,  and  fluc- 
tuating like  an  abscess.  When  opened,  either  surgically  or  naturally  by 
the  worm,  the  head  appears  through  the  aperture.  The  favorite  spot  for 
perforation  is  the  dorsum  of  the  foot,  though  sometimes  it  extrudes  from 

1  Med.  News,  Mav  2,  1896. 
79 


1250  ANIMAL   PARASITIC  DISEASES. 

the  legs,  occasionally  from  the  thighs,  and  very  rarely  from  the  thorax 
and  abdomen. 

Treatment. — Prophylaxis  in  regard  to  the  drinking-water  and  as  to 
bathing  where  the  intermediary  host  of  the  dracunculus — the  cyclops — 
has  its  habitat  is  essential  for  safety. 

The  active  treatment  embraces  the  surgical  measures  necessary  to  re- 
move the  worm  entire  and  to  promote  the  healing  of  the  irritated  tissues. 
The  burrow  should  be  opened,  and  the  worm  gradually  coiled  around  a 
quill  or  a  smooth,  cylindric  piece  of  wood  until  it  can  be  withdrawn  with- 
out being  torn  and  allowing  any  embryos  to  escape  into  the  tissues.  Roth 
claims  that  after  incision  the  application  of  compresses  of  carbolic  acid 
(1  to  15)  over  the  wound  causes  the  worm  to  be  removed  in  tMO  or  three 
days.  Native  Indian  physicians  commend  highly  the  local  application  of 
the  leaves  of  the  "  amarpattee  "  plant.  Asafetida  and  sulphur  have  been 
recommended  internally,  but  without  any  definite  result. 

OTHER   PILARIS. 

Among  other  filarife  that  have  been  found  in  man  are  the  following  : 
The  filaria  immitis,  which  causes  hematuria  and  has  been  found  in  the  por- 
tal vein,  whilst  the  ova  were  discovered  in  the  ureteral  and  vesical  walls ; 
filaria  labialis,  found  in  a  lip  pustule ;  filaria  ientis.  found  in  a  cataract ; 
filaria  trachealis  and  bronehialis,  seen  in  the  trachea,  bronchioles,  and 
lungs  ;  filaria  hominis  oris,  observed  by  Leidy  in  the  mouth  of  a  child; 
filaria  loa,  noticed  in  the  tropics  among  negroes,  its  habitat  being  beneath 
the  conjunctiva. 

OTHER  AND  UNCOMMON  NEMATODES. 

Eustrongylus  Gigas. — This  parasite  is  exceedingly  rare  in  man,  but 
has  been  found  in  many  of  the  carnivora  and  in  some  herbivora.  It  is 
supposed  that  fish  act  as  the  intermediate  host  for  the  larvae.  The  worm 
is  enormous  in  size,  the  female  being  from  25  to  100  cm.  (10  to  40  in.) 
in  length  and  from  5  to  12  mm.  (1-  to  ^  in.)  long.  It  is  a  red,  cylindric 
parasite  with  blunt-pointed  ends.  Its  most  common  seat  is  the  kidney, 
which  it  may  destroy,  causing  hematuria  and,  perhaps,  the  presence  of  the 
eustrongylus  ova. 

Strongylus  paradoxus  has  been  found  in  the  respiratory  organs  of  the 
pig  and  in  the  dejecta  of  a  pork-dealer. 

Anguillula  stercoralis  or  intestinalis  occurs  in  the  stools  of  certain 
tropical  endemic  diarrheas.  The  parasites  are  oviparous,  and  the  eggs 
may  be  taken  through  the  drinking-water.  They  have  been  found  in  the 
biliary  and  pancreatic  ducts,  as  well  as  in  various  parts  of  the  intestines. 
Boiling  the  water  as  a  prophylactic  measure  and  the  administration  of 
thymol  or  male-fern  are  to  be  recommended. 

Ecliinorhyncus  gigas  belongs  to  the  Aeanthoce])Jiala  (thorn-headed 
worms)  and  infests  the  intestines  of  the  pig.  The  larval  host  is  the 
cockchafer  or  floral  beetle  grub.  In  the  only  case  reported,  that  of  a 
boy  (Lanibl).  a  small  echinorhyncus  was  found  in  the  intestines. 

Ecliinorhyncus  moniliformis  occurs  in  rats,  and  one  case,  that  of  a 
Sicilian,  has  been  reported  by  Calandruccio,  in  which  the  ova  were  found 


ECHINOCOCCUS  DISEASE.  1251 

in  the  feces.      The  larval  host  is  probably  the  Blaps  micronata.     The 
ethereal  extract  of  male-fern  causes  the  expulsion  of  the  parasite. 


CESTODES. 

ECHINOCOCCUS   DISEASE. 
[Hydatid  or  Bladder-worm  Disease.) 

The  taenia  echinococcus  is  also  called  tcenia  nana  by  Van  Beneden,  but 
should  not  be  confounded  with  the  tenia  nana  of  v.  Siebold,  a  brief  de- 
scription of  which  follows  this  article.  It  is  the  smallest  tape-worm  of 
our  domestic  animals,  and  lives  between  the  villi  in  the  small  intestine, 
especially  in  the  larger  breeds  of  dogs,  as  the  mastiff  and  Newfoundland. 
It  has  a  length  of  from  4  to  9  mm.  (^  to  J  in.),  and  consists  of  only  three 
or  four  sections,  the  last  one  of  which  is  mature.  The  rostellum  project- 
ing from  the  small  head  has  thirty  or  forty  booklets  arranged  in  a  double 
row.  Hundreds  and  sometimes  thousands  of  eggs  are  contained  in  the 
mature  segment.  The  intermediary  hosts  for  the  larvae  are  rarely  man, 
the  horse,  and  the  sheep,  and  more  often  the  hog  and  ox. 

I<ife  History. — The  ova,  embryos,  or  the  proglottides  even,  of  the 
adult  tenia  are  voided  by  the  dog,  and  in  various  ways,  to  be  pointed  out 
later,  are  ingested  by  man.  The  dog  first  becomes  infected  by  eating 
the  bladders  or  echinococcus  cysts  of  some  animal  that  harbors  the  larval 
form  of  the  tenia,  and  the  matured  teniae  appear  in  from  eight  to  ten 
weeks.  The  liberated  six-hooked  embryos  burrow  through  the  intestinal 
wall  or  enter  the  portal  vein ;  they  then  pass  into  the  solid  viscera,  as  the 
liver,  into  the  peritoneal  cavity,  the  muscles,  lungs,  brain,  etc.  There 
they  develop  into  the  larval  form  and  cause  the  formation  of  hydatid  or 
echinococcus  cysts.     During  the  latter  process  the  booklets  disappear. 

In  the  development  of  echinococcus  cysts,  about  four  weeks  after  the 
ingestion  of  the  bladder-worm  eggs,  small  nodules  appear,  about  1  mm. 
(2^  in.)  in  size.  In  about  five  months  the  cyst-walls  consist  of  two 
layers,  an  external  layer  and  an  inner,  granular,  parenchymatous  layer 
(or  endocyst),  containing  a  clear  liquid.  As  the  reaction  to  the  irritation 
caused  by  the  parasite  and  its  cyst  increases,  a  fibrous  investment  forms 
around  them.  At  this  time,  also,  small  daughter-cysts,  or  vesicular  buds, 
form  the  minor  granular  layer  of  the  mother-cyst,  and  contain  the  heads 
of  the  larv^.  They  are  soon  set  free,  and  may  themselves  give  rise  to 
other  or  granddaughter-cysts  in  a  similar  way.  These  really  become  the 
breeding  capsules  of  little  cellular  outgrowths  that  form  the  scolices  or 
heads  of  future  teniae.  They  show  the  four  sucking  disks  and  a  circle  of 
booklets.  Each  scolex,  when  taken  into  the  intestine  of  the  dog,  de-. 
velops  into  an  adult  bladder-worm  or  taenia  echinococcus.  This  endogenous 
mode  of  cystic  growth  is  common  in  man  (E.  hydatidosus) ;  but  in  some 
of  the  lower  animals,  and  rarely  in  man,  the  daughter-  and  grand- 
daughter-cysts may  develop  between  the  two  layers  of  the  primary  or 
mother-cyst,  and  then  extrude  {exogenous  variety ;  E.  granulosus).  A 
third    variety    is    the    multilocular    echinococcus    (E.    alveolaris.   Buhl), 


1252  ANIMAL  PARASITIC  DISEASES. 

affecting  principally  the  liver.  A  large,  hard  tumor  is  seen  that  on  sec- 
tion shows  a  firm  connective-tissue  framework  surrounding  alveoli  that 
average  a  small  pea  in  size.  These  alveoli  contain  small  echinococcus 
cysts  with  thick,  laminated  walls.  They  may  contain  scolices  or  hooklets, 
and  sometimes  they  are  quite  sterile.  The  echinococci  may  be  situated 
in  the  lymph- channels  and  bile-ducts  (Zenker). 

The  pure  hydatid  fluid  is  colorless,  odorless,  limpid,  neutral  in  reaction, 
and  has  a  specific  gravity  of  1005  to  1012.  About  96  to  98  per  cent,  is 
water,  and  sodium  chlorid,  carbonate,  and  sulphate,  traces  of  sugar 
(dextrose),   and  uric   acid   are   found   among   the   constituents. 

Among  the  changes  that  an  echinococcus  cyst  may  undergo  the  com- 
monest is  that  of  the  death  of  the  echinococci,  as  from  diminished  nour- 
ishment due  to  intense  proliferation  of  daughter-  and  granddaughter- 
cysts.  The  contents  become  thickened,  putty-like,  or  granular,  and  even 
calcified.  Remnants  of  these  obsolete  cysts,  such  as  the  chitinous  sub- 
stance of  the  old  and  outer  wall-layer  and  hooklets,  may  be  found. 
Traumatism  or  chemical  irritation  may  also  cause  the  death  of  the 
echinococcus  and  obliteration  of  the  cysts.  Sometimes  rupture  of  the 
cyst  occurs,  with  serious  consequences  to  the  patient ;  on  the  perito- 
neum daughter-cysts  or  free  scolices  may  be  disseminated  and  grow.  Or 
perforation  into  the  respiratory,  digestive,  or  urinary  tracts  and  dis- 
charge of  daughter-cysts  and  hydatid  fluid  may  take  place.  Lastly,  sup- 
puration and  the  formation  of  large  hepatic  abscesses  may  ensue,  eithei- 
spontaneously  or  on  account  of  septic  instruments  used  for  tapping  the 
cysts. 

Ktiology. — Carelessness  in  the  feeding  and  the  keeping  of  dogs  is 
the  primary  source  of  hydatid  disease,  and  the  preparing  of  food  where 
dogs  are  allowed  to  roam  about,  to  be  petted,  and  so  on,  accounts  for  the 
majority  of  cases.  Females  are  more  often  affected  than  males,  and  chil- 
dren and  young  adults  seem  to  be  oftener  affected  than  those  older  id 
years. 

As  regards  the  geographic  distribution,  echinococcus  disease  prevails 
most  extensively  in  Iceland,  where  man  and  dog  live  closely  together. 
In  Australia,  also,  many  persons  are  affected.  It  is  not  so  common  in 
Europe,  Asia,  or  Africa,  and  in  America  it  is  rare. 

Organs  Affected. — The  tenia  echinococcus  has  an  undoubted  predi- 
lection for  the  liver.  Next  in  order  of  frequency  are  the  lungs,  intes- 
tines, perhaps  the  urinary  organs,  brain,  and  spinal  cord.  The  spleen, 
bones,  muscles,  the  heart,  and  blood-vessels  are  involved  with  uncertain 
fre((uency. 

Symptoms. — Hydatids  of  the  Liver. — Unless  the  cystic  tumors  com- 
press the  portal  area  or  the  biliary  passages,  or  invade  the  neighboring 
viscera,  subjective  symptoms  may  be  entirely  wanting.  Not  infrequently 
echinococcus  sacs,  partly  calcified,  have  been  found  postmortem,  not 
having  produced  any  symptoms  during  life.  Gradual  but  progressive 
loss  of  flesh  and  strength  with  the  presence  of  a  fluctuating  tumor  may 
be  the  only  symptoms  present  until  late  in  the  disease.  If  the  cysts 
attain  a  large  size,  a  sensation  of  dragging,  and  of  pain  even,  is  often 
present ;  as  a  rule,  however,  pain  is  absent  throughout  the  course  of  the 
disease.  If  the  tumor  displaces  the  diaphragm  upward  and  compresses 
the  lung,  cough  and  dyspnea  result.     In  some  cases  the  sac  has  ruptured 


EOHINOGOGCUS  DISEASE.  1253 

into  the  bronchi,  and  given  rise  to  cough  and  to  expectoration  of  the 
fluid  and  vesicles. 

If  the  portal  veins  and  bile-duct  are  compressed,  splenic  enlargement 
from  passive  congestion,  ascites,  and  jaundice  will  occur,  these  symptoms 
being  more  common  when  the  cysts  are  multilocular.  Rupture  may 
occur  into  the  intestines  (colon),  into  the  pleura  or  pericardium,  causing 
pyothorax  or  pyo-pericai'dium,  or  into  the  inferior  vena  cava,  causing 
fatal  pulmonary  embolism. 

Fever  is  usually  absent  throughout,  unless  the  contents  of  the  sac 
become  converted  into  an  abscess ;  then  rigors  or  chills,  fever  (hectic  in 
type),  and  sweatings  occur,  with  jaundice  (more  or  less  intense)  and  rapid 
emaciation. 

Not  infrequently  the  cyst-wall  becomes  partly  calcified  and  the  con- 
tents are  reabsorbed,  with  an  entire  absence  of  symptoms,  the  patient 
dying  in  after  years  of  some  intercurrent  disease. 

When  rupture  occurs,  unless  the  contents  be  evacuated  through  the 
respiratory  or  alimentary  tract  or  externally,  symptoms  of  collapse 
develop  and  are  followed  by  death. 

The  physical  signs  give  on  inspection  fulness  or  bulging  in  the  right 
hypochondriac  region,  especially  if  the  cyst  be  single,  of  large  size,  and 
situated  anteriorly. 

Palpation  confirms  inspection  and  shows  a  fluctuating  mass  or  masses. 
A  trembling  impulse  is  felt  sometimes  on  deep  palpation,  aided  by  light 
percussion  over  the  opposite  side  of  the  cyst,  constituting  the  so-called 
"  hydatid  thrill."  This  sign  cannot  always  be  elicited,  but  when  present 
is  pathognomonic  of  the  disease.  The  remainder  of  the  liver  shows  uni- 
form enlargement.  The  spleen  is  often  palpably  increased  in  size  from 
passive  congestion. 

Percussion  reveals,  in  addition  to  the  hydatid  fremitus,  an  increased 
area  of  dulness  to  the  left  or  posteriorly,  depending  on  the  location  and 
extent  of  the  growths.  If  the  left  lobe  be  involved,  the  line  of  flatness 
may  extend  across  the  sternum  to  the  left  hypochondriac  region.  If  the 
cysts  are  multiple  and  on  the  antero-inferior  surface,  the  stomach  may  be 
displaced  toward  the  left  and  dulness  may  extend  across  the  epigastrium ; 
if  posteriorly,  the  pleural  cavity  may  be  encroached  upon,  causing  an 
increased  area  of  flatness  upward  in  the  postero-axillary  line.  Frerichs 
claims  the  line  of  dulness  posteriorly  in  hydatid  disease  to  be  a  curved 
one,  whose  convexity  is  upward. 

Auscultation  gives,  according  to  Santoni  and  others,  a  short  sharp 
booming  sound  when  the  tumor  is  percussed,  that  may  be  likened  to  one 
produced  by  striking  a  membrane  stretched  over  a  metallic  frame. 

Diagnosis. — In  the  entire  absence  of  subjective,  symptoms  and  of 
characteristic  physical  signs,  the  diagnosis  is  impossible.  If,  however, 
the  cyst  be  of  sufiicient  size  to  give  fluctuation  and  the  liver  be  irregu- 
larly enlarged,  with  an  absence  of  fever,  pain,  and  marked  emaciation, 
the  disease  may  be  strongly  suspected.  The  only  certain  demonstration 
of  the  condition  is  the  discovery  of  the  characteristic  booklets  in  the  as- 
pirated or  discharging  contents  of  the  cyst.  Among  the  conditions  that 
may  be  misdiagnosed  for  hydatid  disease  are — («)  Dilatation  of  the  gall- 
bladder, (5)  hydronephrosis,  (c)  right-sided  pleurisy  with  effusion,  {d) 
syphilis  of  the  liver,  {e)  carcinoma,  (/)  abscess,  and  {g)  cirrhosis. 


1254 


ANIMAL  PARASITIC  DISEASES. 


Hydatid  Cyst. 

Previous  history  negative,  except  the  com- 
panionship of  dogs. 
Pain  and  jaundice  usually  absent. 


Enlargement  in  any  direction,  depending 

upon  the  location  of  the  cysts. 
Hydatid  thrill  may  be  present. 

Less  so. 

Hydatid  Cyst. 

The  history  is  negative  {vide  supra). 

Urinalysis  is  negative. 

The  tumor  is  most  prominent  over  the 
hepatic  area,  and  is  associated  with 
enlargement  of  the  liver. 

The  duration  is  indefinite  and  uremia 
rare. 

Hydatid  Cyst. 

The  onset  is  sIovf  ;  pain  and  fever  are 
absent. 

The  presence  of  a  fluctuating  mass  in  the 
hepatic  area,  7wt  chancfimj  with  the  po- 
sition of  the  patient.  Hydatid  fremitus 
is  present,  but  no  bulging  of  the  inter- 
costal spaces. 

Aspiration  reveals  a  clear  yellow  liquid 
of  low  specific  gravity,  containing  no 
albumin,  but  chlorids  and  booklets. 

The  disease  invariably  runs  a  chronic 
course. 


Dilatation  of  the  Gall-bladder. 


A   previous    history    of    having 
biliary  calculi  is  often  present. 

Attacks  of  biliary  colic  followed  by  jaun- 
dice either  are  present  or  enter  into 
the  previous  history. 

Enlargement  is  always  in  one  direction — 
downward  and  posteriorly. 

"Hydatid  fremitus"  never  present. 

The  tumor  is  somewhat  movable. 

Hydronephrosis. 

There  is  a  history  of  renal  calculi  or  of 

vesical  inflammation. 
Urinalysis   reveals    evidences    of    renal 

disease. 
The    tumor   is   most   prominent   in    the 

flank  and  iliac  fossa.     If  extending  to 

the  right  hypochondriac  region,  it  does 

not  move  with  the  liver. 
The  duration  is  short ;  a  termination  in 

uremia  is  common. 

Pleurisy  with  Effusion. 

The  onset  is  sudden,  and  violent  pain  is 
present,  with  fever  and  dyspnea. 

The  presence  of  effusion,  beginning  at 
the  base  of  the  chest  and  gradually 
extending  upward — changing  loith  the 
po.titiou  of  the  patient  and  accompanied 
by  bulging  of  the  intercostal  spaces. 

Aspiration  gives  a  cloudy,  turbid  liquid, 
containing  albumin  and  flakes  of  lymph 
with  high  specific  gravity. 

The  disease  generally  runs  an  acute 
course. 


For  a  diflferential  diagnosis  from  (d),  (e),  (/),  and  (g)  I  would  refer 
the  reader  to  the  discussion  of  the  several  diseases  [vide  Diseases  of  the 
Liver). 

EcMnococcus  of  the  Respiratory  Organs. — The  lung  has  been  the  seat 
of  the  larvse  quite  frequently,  and  instances  have  been  noted  especially 
in  North  Germany  and  Austi'alia.  The  right  lower  lobe  has  been  the 
seat  of  predilection,  though  sometimes  the  pleura  is  the  primary  source 
of  trouble.  There  are  pain  in  the  chest,  cough,  dypsnea,  perhaps  arching 
of  the  overhanging  thoracic  region,  signs  of  a  pleural  effusion,  a  tym- 
panitic note  above  the  prominence,  hemoptysis,  and  the  pathognomonic 
expectoration  of  hydatid  disease.  The  general  condition  may  not  be  seri- 
ously affected.  Perforation  into  the  pleural  sac  b}^  pulmonary  echino- 
cocci  may  be  followed  by  empyema,  and,  later,  by  perforation  of  the  chest 
wall.  The  heart  may  be  dislocated.  Compression  of  the  lung  may  pro- 
duce gangrene. 

The  diagnosis,  in  the  absence  of  the  characteristic  sputum,  is  to  be 
made  from  phthisis  and  a  pleural  effusion.  Their  location  at  the  base  of 
the  chest  may  serve  to  differentiate  hydatid  cysts  from  phthisis,  as  well 
as  the  absence  of  marked  emaciation.      The  characteristic  curved  upper 


ECHINOCOCCUS  DISEASE.  1255 

boundary  of  dulness  in  pleural  effusion  and  the  change  of  the  boundary 
upon  changing  the  patient's  position  will  serve  to  distinguish  this  affec- 
tion. Puncture  of  any  bulging  area  will  determine  the  character  of  the 
liquid.  Pleural  echinococci  sometimes  cause  great  compression  of  the 
lung  and  a  barrelling  of  the  chest  on  one  or  both  sides.  The  pain  may  be 
quite  sharp,  and  the  respiratory  murmur  either  distant  or  altogether  absent. 

Echinococcus  of  tlie  Mediastinum. — Hare  has  collected  6  cases  of 
hydatid  disease  among  520  cases  of  mediastinal  tumors. 

Echinococcus  of  tlie  Heart. — Since  most  of  the  cases  have  shown  in- 
volvement principally  of  the  right  side  of  the  heart,  the  instances  of  sud- 
den death  that  have  been  reported  may  be  readily  understood. 

EcMnococcus  of  the  brain  and  spinal  cord  should  not  be  confounded 
with  cystic  degeneration  of  the  choroid  plexuses.  The  symptoms  of  cere- 
bral hydatids  are  those  of  tumor,  peristent  and  intense  cephalalgia,  vom- 
iting, psychical  disturbances,  convulsions,  amblyopia,  and  "choked 
disk,"  and  sometimes  paralysis.  Hydatid  disease  may  develop  inside  the 
dura  mater,  or  it  may  penetrate  from  without  and  destroy  the  vertebi'Ee 
before  they  compress  the  cord  to  a  great  degree.  The  symptoms  are  those 
of  a  compression  myelitis. 

Echinococcus  of  the  Spleen. — About  40  cases  of  involvement  of  the 
spleen  have  been  described.  The  organ  may  become  greatly  enlarged 
and  be  mistaken  for  that  due  to  malaria,  leukemia,  etc.  The  hydatid 
thrill  may  be  detected. 

Echinococcus  of  the  Kidneys. — More  than  100  cases  have  been  ob- 
served, mostly  in  Germany  and  France.  The  cyst  may  be  as  large  as  in 
hydronephrosis.  Many  of  the  cysts  are  of  the  exogenous  form  of  growth. 
As  a  rule,  one  kidney  only  is  affected,  and  generally  the  left  one.  Ab- 
dominal and  thoracic  compression  symptoms  may  be  caused,  and  bulging 
is  often  present  in  the  lumbar  region  in  marked  cases.  This  may  be 
punctured  as  an  aid  in  the  diagnosis.  Rupture  into  the  pelvis  of  the 
kidney  and  the  discharge  of  the  smaller  cysts  may  give  rise  to  renal  colic 
and  to  the  discharge  of  the  cysts  with  the  urine.  More  rarely,  rupture 
of  a  suppurating  cyst  may  take  place  in  the  loin. 

Echinococcus  of  the  peritoneum  is  rare  as  a  primary  condition. 
Echinococci  have  also  been  located  in  the  bladder,  prostate,  testicle, 
ovary,  uterus,  great  omentum,  mesentery,  pancreas,  arteries,  lymphatics, 
thyroid  gland,  inuscles,  bones,  joints,  parotid  gland,  orbit,  and  mamma. 

A  multilocular  echinococcus  cyst  may  give  rise  to  a  very  large,  fluc- 
tuating, bossellated  tumor  below  the  liver ;  this  may  simulate  colloid 
cancer,  either  of  the  liver  or  the  gall-bladder.  Icterus,  marked  and 
obstinate,  with  or  without  ascites,  an  enlarged  spleen,  and  a  long  course 
without  decided  loss  of  flesh,  are  indicative  of  this  form  of  hydatid. 
Fatal  hemorrhage  may  supervene. 

A  peculiar  complication  of  echinococcus  cysts  is  the  occasional 
development  of  urticaria.  It  has  been  noted  especially  shortly  after 
the  puncture  of  a  cyst,  and  this  is  somewhat  diagnostic  when  it  appears. 

The  prognosis  is  generally  grave  both  as  to  life  and  cure,  although 
some  cases  of  hydatid  disease  of  the  liver  have  lasted  for  more  than  ten 
years. 

The  character  of  the  changes  in  the  cysts  and  their  mode  of  termi- 
nation influence  the  prognosis.     Thus,  the  occurrence  of  suppuration 


1256  ANIMAL  PARASITIC  DISEASES. 

is  to  be  dreaded.  Spontaneous  cures  have  been  noted  in  a  few  in- 
stances. 

Treatment. — As  in  most  of  the  other  parasitic  diseases,  prevention 
is  more  or  less  effectual,  and  a  cure  is  difficult  or  impossible.  Infection 
of  the  dog  should  be  avoided  by  preventing  its  gaining  access  to  possible 
sources  of  hydatid  disease,  as  the  raAv  flesh  of  animals,  especially  in  the 
form  of  meat-scraps  around  slaughter-houses.  In  order  that  human 
beings  may  not  be  affected,  dogs  should  not  be  carelessly  handled  or 
allowed  to  be  where  they  may  come  in  contact  with  food  and  drink  in 
any  Avay,  whether  meat  or  eggs,  vegetables,  fruits,  or  cereals.  Cleanli- 
ness in  keeping  dogs  and  in  the  proper  preparation  of  food  are  essential 
in  regions  where  hydatid  disease  is  prevalent. 

Medicines  cannot  reach  the  parasites  in  man,  situated  as' they  are  in 
larval  form  encysted  in  the  various  tissues  and  organs  of  the  body. 
Whenever  the  cyst  becomes  large,  accessible,  and  the  cause  of  trouble- 
some symptoms,  surgical  measures  may  be  resorted  to.  Among  these 
are,  simple  tapping,  tapping  with  aspiration,  and  with  the  subsequent 
injection  of  various  substances  (as  iodin  and  zinc-chlorid  electrolysis), 
and  incision  with  drainage.  Excision  of  the  liver  cysts  has  been  practised 
by  Raggi,  Pozzi,  Tansini,  and  others,  but  its  practical  value  is  still 
undetermined. 

T^aSNI^   OR   TAPE-WORMS. 

Natural  History. — Tape-worms  are  found  in  the  intestine  of  man, 
and  are  the  matured  or  completely  developed  larvse  or  cysticerci  from  the 
muscles  and  solid  viscera  of  animals.  Different  varieties  of  cysticerci 
develop  from  the  ova  of  the  respective  varieties  of  teni^.  These  tape- 
worm eggs,  after  having  passed  out  of  the  bowel,  may  be  taken  into  the 
systems  of  various  animals  by  various  modes,  entering  the  circulation, 
it  may  be,  and  becoming  fixed  Avithin  the  solid  tissues,  especially  the 
muscles.  In  about  two  or  three  months  pea-sized  cysts  develop,  and 
from  the  cyst-walls  there  gradually  forms  a  new  tenia-head,  called  a 
scolex,  or  nurse.  The  worm-cysts,  popularly  termed  "measles,"  con- 
stitute the  cysticerci.  Remaining  in  the  tissues,  they  die  and  become 
calcified  in  from  three  to  six  years  (Striimpell).  But,  if  taken  into  the 
stomach  by  the  eating  of  raw  or  partially-cooked  meat,  a  tape-worm  de- 
velops from  the  scolex.  The  maturation  of  the  segments  of  the  tape- 
Avorm  commences  several  months  after  the  fixation  of  the  scolex  in  the 
intestine.  In  the  natural  life-cycle  of  a  tape-worm  the  usual  order  of 
lodgement  may  be  reversed.  Thus  man  instead  of  a  lower  animal  may 
become  the  host  of  the  tenia  eggs,  Avhich  in  turn  may  find  their  way  into 
the  solid  viscera  and  muscles  to  develop  into  cysticerci.  Again,  this 
same  order  may  in  some  way  be  brought  about  by  "auto-infection." 
The  tape-worm,  as  its  name  indicates,  has  a  ribbon-like  form  ;  although 
it  has  a  number  of  segments  and  joints,  giving  it  a  link-belt  appearance. 
When  matured,  these  segments,  or  proglottides,  develop  male  and  female 
generative  organs. 

Varieties. — Taenia  Solium  [Pork  Tape-tvorm). — This  Avorm  is  seen 
much  loss  frequently  here  than  in  Europe.  It  develops  in  the  small 
intestine  after  the  ingestion  of  raAv  or  underdone  "measly"  pork. 
This  worm  does  not  necessarily  exist  singly,  as  its  name  Avould  indicate, 


TAPE-WOBMS.  1257 

although  such  is  usually  the  case.  It  ranges  from  2  to  4  meters 
(6  to  13  feet)  in  length.  The  head  is  rounded,  pin-head  in  size,  and  is 
succeeded  by  a  thread-like  neck  and  by  gradually  shortening  and  -widen- 
ing segments.  Four  suckers  and  a  projecting  circle  of  twenty -six  long 
and  short  booklets  arm  the  head  of  the  tenia.  There  may  be  as  many 
as  800  segments.  The  mature  ones  become  detached  continuously,  and 
are  passed  with  the  feces,  several,  as  a  rule,  occurring  together,  and  not 
singly,  as  in  the  case  of  taenia  saginata.  They  are  about  1  centimeter 
(f  in.)  in  length  and  from  6  to  8  millimeters  {\-\  in.)  in  breadth,  and 
about  1  meter  (39.36  in.)  from  the  head  they  are  "  approximately  quad- 
rilateral"  in  shape.  These  proglottides  are  bisexual.  The  female  mat- 
rix occupies  the  middle  of  each  proglottis,  and  is  provided  with  from 
eight  to  fourteen  irregular,  tree-like  branches  on  each  side.  The  male 
generative  organs  are  small  vesicles  in  the  anterior  portion  of  the  seg- 
ment. The  sexual  opening  is  situated  on  one  side,  near  the  middle. 
The  ovarian  or  uterine  apparatus  of  a  mature  segment  contains  myriads 
of  thick-shelled  eggs,  each  one  of  which  has  an  embryo  with  six  booklets. 

Taenia  Mediocanellata  {Saginata). — The  beef  tape-worm  is  some- 
times called  the  "'unarmed  tape-worm," ^ince  the  head  possesses  suck- 
ing disks,  but  no  booklets.  It  is  more  common  in  this  country  and  even 
in  some  of  the  European  nations,  as  England.  Longer  than  the  tenia 
solium,  being  4  to  6  meters  (12  to  20  feet)  in  length,  its  segments  are 
also  thicker  and  larger,  measuring  from  16  to  18  mm.  (|-  in.)  long,  and 
from  8  to  10  mm.  {^  in.)  broad.  The  head  of  the  worm  as  well  as  the 
ripe  ovum  is  also  slightly  larger  and  proportionately  thicker.  The  ova- 
rian branches  are  more  numerous  (eighteen  to  thirty  in  number)  and  di- 
vide more  dichotomously  than  those  of  tenia  solium.  Proglottides  are 
also  found  in  the  stools,  where  they  sometimes  exhibit  a  crawling  motion 
that  has  caused  them  to  be  mistaken  for  individual  parasites.  Cysti- 
cercus  saginata  has  never  been  observed  in  man. 

Bothrioceplialus  latus  (Fish  tafje-ioorm.,  Tcenia  lata)  occurs  most  com- 
monly in  Russia,  Switzerland,  Holland,  and  the  German  Baltic  prov- 
inces. It  is  the  loncjest  cestode.  measuring  from  6  to  10  meters  (20  to 
30  feet).  The  head  is  club-shaped,  unarmed,  and  has  tAvo  lateral  longi- 
tudinal grooves  as  suckers.  The  segments  may  be  distinguished  from 
those  of  the  preceding  varieties  named  by  their  marked  breadth  and 
shortness,  also  by  the  centrally  situated,  tortuous  ovarian  rosette,  and 
the  sexual  orifice  near  the  center  of  the  abdominal  surface  of  each  pro- 
glottis. The  ova  are  larger  than  those  of  the  pork  and  beef  tape-worms, 
though  thinner-shelled  and  with  a  sort  of  lid  at  one  end.  They  develop 
only  in  fresh  water.  From  them  is  formed  an  embryo  with  vibrating 
cilia  and  six  booklets.  Pike  and  other  fish  swallow  these  embryos, 
which  develop  into  cysticerci  in  the  muscles,  peritoneum,  and  solid  vis- 
cera. The  eating  of  measly  fish,  raw  or  partially  cooked,  thus  favors 
the  development  of  this  tape-worm  in  the  human  intestine. 

Symptoms. — Contrary  to  what  has  been  supposed  in  days  gone  by, 
there  are  no  absolutely  diagnostic  symptoms  of  the  presence  of  tape-worm 
that  can  be  relied  upon.  Indeed,  the  existence  of  a  tape-worm  in  the 
bowel  may  not  be  suspected  even  because  of  the  total  absence  of  indica- 
tive, subjective  sensations.  On  the  other  hand,  teniae  may  cause  consid- 
erable local  distress  and  impairment  of  the  general  health.     Because  of 


1258  ANIMAL  PARASITIC  DISEASES. 

this  fact  a  knowledge  of  the  existence  of  tape-worm  in  certain  neurotic 
subjects  leads  to  an  inordinate  description  of  symptoms  that  exist  mainly 
in  the  workings  of  a  morbid  imagination. 

Alimentai'y  symptoms  of  tape-worm  may  be  as  folloAvs :  anorexia  alter- 
nating with  a  voracious  appetite,  constipation  alternating  with  diarrhea, 
colicky  pains  in  the  abdomen,  indigestion,  nausea,  and  vomiting,  and 
sometimes  salivation. 

G-eneral  st/mjytoms  of  the  teniae  may  be  added,  as  lassitude,  inappe- 
tence,  mental  uneasiness,  worry  and  irritability,  depression  of  spirits, 
some  physical  prostration,  and  even  emaciation.  Various  refiex  symptoms, 
such  as  pruritus  of  the  nose  and  anus,  vertigo,  migrain,  tinnitus  aurium, 
palpitation,  visual  disturbances  (even  temporary  amaurosis),  dilatation  of 
the  pupils,  choreic  movements,  and  epileptiform  convulsions  have  been 
attributed  to  these  parasites.  But,  on  careful  inquiry,  adequate  causes 
for  some  of  these  symptoms  may  be  found  in  other  associated  morbid 
conditions. 

Diagnosis. — This  is  always  to  be  made  by  the  discovery  of  tenia 
segments  or  ova  in  the  underclothing  or  stools.  The  doubtful  presence 
of  suspected  tape-worm  may  be  cleared  by  the  administration  of  a  suitable 
purgative,  which  will  usually  suffice  to  bring  away  portions  of  the  worm 
in  the  dejections.  I  would  here  add  a  special  warning  lest  mucous  casts 
or  shreds  or  vegetable  structures  (as  of  onion)  be  mistaken  for  tape-worm. 

The  diagnosis  of  the  variety  of  the  tape-worm  may  also  be  made  by 
a  careful  scrutiny  of  the  segments.  Those  of  the  tenia  saginata  are  larger 
and  fatter  than,  and  their  generative  apparatus  is  unlike  that,  of  tenia 
solium  {vide  supra). 

Hypochondriasis  can  be  excluded  by  repeated  examinations  of  the 
stools,  especially  after  the  exhibition  of  cathartics,  and  by  the  uniform 
failure  to  detect  portions  of  tape-worm  or  tenia  eggs. 

The  prognosis  is  favorable.  Indeed,  teniae  may  exist  at  all  ages 
and  for  years  without  any  danger  to  the  patient. 

Treatment. — Prophylaxis. — The  way  to  avoid  acquiring  a  tape- 
worm is  to  use  none  but  Avell-cooked  meats ;  this  applies  to  beef  and 
pork  in  particular.  The  use  of  pure  drinking-water  is  of  no  little  im- 
portance also.  The  proglottides  of  the  tenia  should  ahvays  be  burned, 
and  not  throAvn  where  they  may  be  taken  into  the  bodies  of  other  ani- 
mals, as  the  cow  or  hog,  and  then  be  allowed  to  propagate.  Govern- 
mental inspection  of  the  meat-supply  in  abattoirs  should  be  rigidly  carried 
out  in  all  parts  of  the  country. 

Curative. — Before  administering  the  chosen  anthelmintic,  the  patient 
needs  to  undergo  a  "preparatory  treatment."  This  has  for  its  object 
the  starvation  of  the  parasite,  so  as  to  weaken,  if  possible,  its  hold  upon 
the  intestinal  mucosa.  This  is  specially  necessary  in  the  case  of  tenia 
solium,  in  which  the  cephalic  booklets  are  obstinately  and  firmly  fixed  to 
the  membrane,  and  since  a  cure  cannot  be  said  to  have  been  effected 
unless  the  head  be  dislodged  with  the  dejecta.  For  about  two  days  prior 
to  giving  the  remedy  the  patient  should  be  restricted  in  diet  to  milk, 
light  soups,  a  little  white  bread,  and  the  like.  Meanwhile,  the  bowels 
should  be  purged  gently  once  or  tAvice,  after  a  simple  enema,  to  clear 
away  accumulated  fecal  masses  that  might  prevent  the  easy  discharge 
of  the  worm. 


TAPE-WORMS.  1259 

In  the  evening  preceding  the  day  on  which  the  drug  is  to  be  exhibited, 
a  saline  cathartic  should  be  given  to  empty  the  bowel  of  fecal  matter  as 
completely  as  possible.  The  following  morning  no  breakfast  should  be 
allowed,  and  before  noon  the  selected  anthelmintic  should  then  be  ad- 
ministered. Some  authors  assert  that  if  the  worm  does  not  come  away 
in  a  few  hours,  and  an  intense  sense  of  pressure  is  felt  in  the  abdomen,  a 
brisk  purge  is  indicated.  To  make  assurance  doubly  sure,  and  if  the 
patient  be  not  too  weak,  it  might  be  well  to  order  a  cathartic  as  routine 
practice,  within  a  few  hours  at  the  latest. 

There  are  several  very  efficacious  anthelmintic  drugs  to  choose  from. 
Prominent  among  them  is  male  fern.     Given  to  an  adult  in  doses  of  ^  to 

1  dram  (2.0-4.0)  of  the  ethereal  extract,  and  followed  in  several  hours 
by  a  calomel  and  a  saline  purge,  it  usually  succeeds  in  bringing  away  the 
tenia.  Another  valuable  remedy  is  pelletierin,  the  active  principle  of 
pomegranate;  the  tannate  may  be  prescribed,  dose  1  to  1.5  gm,  in  cap- 
sules ;  or,  a  decoction  of  the  pomegranate  bark  may  be  used,  in  combi- 
nation with  male  fern,  as  in  the  Leipsic  formula  (Striimpell) : 

^.   Granati  radicis  corticis,  |iv-v  (128.0-160.0); 

Aquae,  Oij  (1  liter). 

Mix  and  macerate  for  twenty-four  hours, 

and  boil  until  reduced  to  f  gv  (148.0). 

Add  :  Oleoresinae  aspidii,  3j  (4.0). 

Sig.  To  be  taken  in  three  or  four  doses,  at  short  intervals. 

Pepo  in  emulsion  or  in  a  sugary  paste  (about  two  ounces — 64.0 — and 
deprived  of  the  envelopes)  is  at  once  a  useful  and  harmless  remedy. 

Another  effective  vermifuge  is  kousso  (Brayera  anthelmintica).  An 
infusion  of  half  an  ounce  (16.0)  of  the  flowers  to  one  pint  of  water  and 
mucilage  of  acacia  is  made,  a  wineglassful  of  which  may  be  taken  every 
half  hour.  The  Germans  recommend  sometimes  the  agreeable,  though 
more  expensive,  Rosenthal's  "  kousso  tablets."  Enough  of  these  to 
make  15  grains  (0.972)  may  be  taken  within  one  hour,  with  cafe  noir  or 
lemonade.  Koussin  (the  active  f)rinciple)  in  doses  of  30  to  40  grains 
(1.94-2.592)  has  also  been  recommended,  but  should  not  be  given  to 
pregnant  women,  as  abortion  may  be  produced.  Among  other  remedies 
of  value  as  vermifuges  may  be  mentioned  kamala  (1  to  3  drams — 4.0— 
12.0 — of  the  powder  and  hairs,  in  wine  or  water),  oil  of  turpentine  (J  to' 

2  ounces — 16.0—64.0 — in  emulsion  or  milk),  and  thymol.  The  combined 
use  of  such  drastics  as  croton  oil  renders  the  action  of  the  anthelmintic 
drug  more  certain  at  times. 

Although  the  head  of  the  tenia  may  not  be  detected  in  the  stools 
along  with  the  body  of  the  worm  (and  such  is  usually  the  case),  a  cure 
usually  follows  nevertheless,  since,  on  account  of  its  smallness,  it  may 
easily  escape  notice,  and  also  from  the  fact  that  the  head  often  dies  and 
thus  loses  its  hold  upon  the  membrane,  being  carried  away  with  the  feces. 
On  the  other  hand,  if  after  the  lapse  of  several  months  from  the  removal 
of  a  tape-worm,  segments  again  appear  in  the  stools,  it  may  be  inferred 
that  the  head  was  not  dislodged  or  that  another  worm  has  developed.  In 
cases  where  the  tenia  seems  to  redevelop  with  remarkable  frequency  and 


1260  ANIMAL  PARASITIC  DISEASES. 

obstinacy  it  may  happen  that  the    head    and  neck   are  well  protected 
beneath  one  of  the  valvulse  conniventes. 

After  the  removal  of  the  tape-worm — a  weakening  procedure,  as  a 
rule — the  condition  calls  for  supportive  measures.  The  diet  should  not 
be  too  heavy  for  a  time,  but  nutritious  and  easily  digestible. 

T^NIA   NANA. 

This  is  the  smallest  tape-worm  in  man  (v.  Siebold).  It  varies  from 
8  to  20  mm.  (|--f  in.)  in  length  and  from  0.5  to  0.7  mm.  {-^^  in.)  in 
width.  The  head  has  four  suckers,  a  rostellum,  and  booklets.  The  seg- 
ments are  yellowish,  short,  and  broad.  It  is  believed  b}-  some  observers 
that,  occurring  in  children,  as  it  commonly  does,  this  parasite  is  the  cause 
of  epileptiform  convulsions  and  enuresis  nocturtia.  Thousands  of  ova 
may  be  found  within  a  cubic  centimeter  of  fecal  matter. 

T^NIA   CUCUMERINA. 
{Elliptica;   Canina.) 

A  small  reddish  tape-worm  found  frequently  in  the  intestines  of  the 
dog.  It  is  10  to  40  cm.  (4—16  in.)  in  length.  The  larvae  or  cysticerci 
develop  in  the  louse  or  flea  of  the  dog  or  cat.  The  parasite  is  more  com- 
mon in  children  than  in  adults,  owing  to  the  intimate  relation  of  the 
former  with  the  last-named  pet  animals. 

T^NIA   FLAVOPUNCTATA. 
[TcEiiia  Diminuta  ;   Tcenia  Leptocephala.) 

Taenia  diminuta  is  a  very  small  cestode,  20  to  60  mm.  (1—21  in.)  in 
length,  with  a  small  club-shaped  head  and  nearly  a  thousand  segments. 
The  cysticerci  inhabit  such  insects  as  the  asopia  famialis  (caterpillar  and 
cocoon) ;  the  anisolabis  annuli  (belonging  to  the  orthoptera) ;  and  the 
coleoptera  axis  spinosa  and  scaurus  striatus.  Man  has  been  infected 
a  number  of  times,  probably  by  taking  food  containing  these  infested 
insects. 

Taenia  Madagascariensis  and  Tcenia  serrata  are  other  forms  rarely 
found  in  man. 


PARASITIC  ARACHNIDA. 

Pentastoma  Tenioides. — This  parasite  in  its  adult  form  is  an  inhabitant 
of  the  nasal  foss»  of  the  dog  or  horse,  though  it  may  also  occur  in  man 
both  in  this  and  in  the  larval  form.  The  ova  are  ejected  during  sneezing, 
and  are  then  ingested  by  man.  The  larvae  are  found  in  the  liver,  lungs, 
and  kidneys. 

Sarcoptes  (Aca7'us  Scabiei).-^T\i\s  insect  produces  the  skin  affection 
known  as  "the  itch,"  or  scabies,  an  affection  more  common  in  Europe 
than  in  America,  whei'e  it  constitutes  only  about  4  or  5  per  cent,  of  all 


OTHER  PARASITIC  INSECTS.  1261 

cases  of  skin  disease.  It  is  most  prevalent  among  the  poor  and  the  un- 
clean. The  female  is  visible  to  the  naked  eye,  and  is  about  0.5  mm. 
(^  in.)  in  length  ;  the  male  is  about  0.25  mm.  (^-l-g-  in.).  Both  are 
nearly  as  broad  as  they  are  long. 

The  parasite  penetrates  the  skin  and  lives  in  a  burrow  or  cuniculus 
that  it  makes  for  itself.  The  female  lives  in  the  end  of  the  burrow,  which 
may  contain  a  number  of  ova,  and  appears  as  a  minute,  brownish-black, 
dotted,  sinuous  line,  situated  chiefly  in  the  cutaneous  folds,  where  the  skin 
is  mostly  delicate,  as  between  the  fingers.  Secondary  skin  lesions,  due  to 
scratching,  are  common.  Sulphur  ointment,  well  rubbed  in  after  hot 
bathing,  is  usually  quite  efficacious. 

Sarcoptes  scabiei  hominis  is  a  variety  of  the  preceding  that  infests 
other  animals  (cat,  dog,  cow,  horse,  wolf,  goat,  camel,  etc.).  Occasionally 
it  may  gain  an  entrance  into  man's  skin,  but  dies  simultaneously  in  the 
human  host,  although  many  invasions  may  occur. 

Leptus  Autumnalis  [Harvest  Bug). — The  most  common  of  several  va- 
rieties is  a  mite  of  a  reddish  color,  having  six  legs  armed  Avith  claws  and 
sharp  mandibles.  It  arises  among  low  bushes  and  thus  appears  about  the 
ankles  and  legs.  It  partially  penetrates  the  skin,  boring  only  far  enough 
with  its  short,  thick  head  to  procure  nourishment.  Artificial  dermatitis 
may  be  produced  by  the  irritation  of  scratching.  Mercury,  sulphur,  and 
naphthol  ointments  suffice  to  destroy  the  parasite. 

Demodex  Foliculorum  [Comedo  Mite). — This  minute  parasite  may 
be  expressed  from  swollen  sebaceous  follicles  of  the  nose,  cheek,  and 
other  parts  of  the  face.  It  has  a  worm-like  body  with  very  short  legs, 
and  is  only  about  0.2  to  0.4  mm.  [-^  in.)  in  length.  It  is  not  known  to 
produce  acne,  as  was  formerly  supposed. 


OTHER  PARASITIC  INSECTS. 

PEDICULOSIS. 
{PMTiiriasis.) 

Lice  or  pediculi  live  on  and  attack  the  skin.  Three  forms  are  found 
on  man  :  pediculus  capitis,  jjedieulus  co7'j)oris,  and  pediculus  puhis. 

The  pjediculus  capitis  is  whitish  or  grayish  in  color,  about  1  mm.  [-^ 
in.)  long  (male),  and  has  six  legs  under  the  front  part  of  the  body.  The 
oviparous  female  is  nearly  twice  as  long  as  the  male,  and  lays  from  fifty 
to  eighty  eggs  on  the  hairs  within  a  week.  These  ova,  or  "nits,"  ma- 
ture in  from  three  to  eight  days.  Itching  is  the  most  prominent  symp- 
tom, and  an  eczematous  eruption  above  and  behind  the  ears  and  in  the 
neck  is  often  associated.  "Plica  polonica  "  was  a  phrase  once  used  to' 
designate  the  matted  condition  of  the  hair  in  extremely  dirty,  crusty, 
and  long-neglected  cases  of  head-lice. 

Pediculus  Vestimentorum  [Corporis). — This  louse  inhabits  more  often 
the  clothing  than  the  body  itself.  It  is  larger  than  the  head  louse,  and, 
like  the  latter,  moves  slowly.      The  nits  are  found  with  difficulty  on  the 


1262  ANIMAL  PARASITIC  DISEASES. 

fibers  of  the  underclothing.  It  sucks  blood  through  a  proboscis  inserted 
into  the  sweat  poi'es,  and  after  withdrawing  leaves  a  minute  hemorrhagic 
speck.  Irritation  of  the  skin  is  produced,  and  in  old  cases,  as  in  filthy 
tramps  (the  great  unwashed  class),  the  skin  becomes  scaly  and  quite  pig- 
mented (vagabond's  disease).  The  efforts  at  scratching  are  almost  frantic, 
and  after  a  cure  is  effected  parallel  white  lines,  the  remains  of  scratch- 
marks,  followed  by  atrophic  changes,  may  be  visible,  as  in  a  case  that  I 
reported.^ 

Pediculus  or  Phthiriasis  Pubis  (Crab-louse). — This  parasite  is  not  limited 
to  the  pubis,  but  attacks  also  the  hairy  region  in  the  axilla,  on  the  chest, 
and  may  even  reach  the  beard  and  eyebrows.  It  clings  firmly  to  one  or 
two  hairs  close  to  the  skin.  Its  six  legs  with  strong  claws  are  placed 
closely  together  at  the  anterior  part  of  the  ovoid  body. 

Treatment. — The  hair  should  be  cut  short  where  the  head-lice  and 
nits  are  abundant.  Saturating  the  hair  and  scalp  with  kerosene  oil  for 
twenty-four  hours  usually  kills  the  parasites.  Body-lice  may  be  destroyed 
by  scalding  the  underclothing  and  hot-ironing  carefully  about  the  seams. 
A  hot  soap-and-water  bath  is  sufficient  for  the  body,  and  sedative  and 
antiseptic  ointments  may  be  useful  adjuvants.  Mercurial  and  beta- 
naphthol  unguents  usually  suffice  in  treating  for  2)ediei(lus  pubis.  Prof. 
J.  V.  Shoemaker  ^  affirms  that  naphthol  is  a  remedy  that  seems  to  meet 
the  indications  presented  by  the  three  forms  of  the  disease ;  he  prepares 
it  as  follows  : 

I^.  Beta-naphtol,  3]  (-l-O) ; 

Cologne  water,  fs"iv-vi  (120.0-178.0).— M. 

Cimex  Lectularius  or  Bed-bug. — This  too  well-known  parasite  is  flat, 
brownish-red  in  color,  and  from  2  to  5  mm.  (-jV ~t  ^^•)  ^^  length.  It  in- 
fests beds  and  public  vehicles,  emitting  a  disagreeable  odor.  It  is  a 
blood-sucker,  and  causes  considerable  itching,  local  irritation,  and  urti- 
caria even  in  some  persons,  while  others  arc  unmindful  of  their  attacks. 
Sulphur  fumigation  and  mercuric  chlorid  applications  to  the  harboring 
places  of  the  bed-bugs  are  effectual  destructive  agents.  Saturated  sodium 
bicarbonate  solution  will  relieve  the  burning  and  itching. 

Pulex  Irritans  ((7o?»7>/on  Flea). — This  "  ubiquitous  "  parasite  is  from 
2  to  4  mm.  (yV"!  i"-)  ^'^  length,  black  or  (when  filled  with  blood)  brown- 
ish-red in  color,  having  six  legs,  the  liind  ones  of  which  are  relatively 
very  large  and  poAverful,  enabling  it  to  jump  many  times  its  own  height. 
A  flea's  bite  causes  a  sharp  sting,  and  leaves  a  slightly  raised  red  spot. 
Treatment  is  the  same  as  for  the  preceding  insect. 

Pulex  Penetrans  ("  J?////t'r  "). — This  parasite,  also  called  "sand-flea," 
is  indigenous  to  the  West  Indies,  South  America,  and  the  Southern 
States.  The  impregnated  female  penetrates  the  skin,  and  especially  that 
of  the  feet,  for  purposes  of  ovulation.  As  the  distention  with  the  eggs 
occurs,  swelling,  pain,  and  even  ulceration  may  appear.  The  sand-flea 
is  a  small,  egg-shaped  insect,  about  half  the  size  of  an  ordinary  flea, 
brownish  in  color,  and  exceedingly  resistant  to  crushing  force.  Prophy- 
laxis in  I'egard  to  foot-wear  is  necessary.  Essential  and  antiseptic  oils 
may  also  be  put  on  the  feet  or  stockings. 

^  International  Clinics,  vol.  iii.  third  series,  p.  76. 
*  A  Practical  Treatise  on  Diseases  of  the  Skin,  p.  849. 


OTHER  PARASITIC  INSECTS.  1263 

Ixodes  ( Wood-tick). — There  are  several  varieties  of  tick-  or  wood- 
louse  that  may  attack  the  human  skin,  among  which  ixodes  albijnctus  is 
supposed  to  be  the  most  common.  Ixodes  ricinus  and  ixodes  bovis  are 
found  on  horses  and  cattle.  They  are  blood-suckers,  adhering  to  the 
skin  very  firmly,  and  wheals  may  be  produced  by  them.  A  drop  of  tur- 
pentine, or  of  some  such  essential  oil  as  anise  or  rosemary,  will  cause 
them  to  loosen  their  hold. 

Dermanyssus  Avium  at  G-allinae. — These  bird-  and  fowl-insects  are 
small  and  grayish-white  in  color,  and  may  attack  the  human  skin  and 
cause  eczematous  eruptions,  owing  to  the  scratching  induced  by  the 
irritation. 

Culicidse  [Mosquitoes  and  Gf-nats). — The  blood-sucking  mosquito  (culex 
auxifer),  so  Avell  known,  may  also  transfer  to  human  beings  the  filaria 
sanguinis  hominis  and  perhaps  the  plasmodium  malarias. 

The  gnat  {eulex  pipiens)  is  very  troublesome  during  certain  seasons, 
particularly  along  water-courses  and  in  wooded  districts.  Its  bite  is 
quick,  sharp,  and  stinging. 

The  hirudo  (leech)  is  a  parasite  that  sometimes  attaches  itself  to 
bathers.  In  the  tropics  it  has  been  known  to  cause  severe  bites  and 
inflammation. 

The  bites  and  stings  of  bees,  wasps,  spiders,  and  ants  have  been 
known  to  cause  considerable  inflammation,  edema,  and  blood-poisoning. 

CEstridae  {Bot-flies). — These  may  become  parasitic  in  man  in  the  larval 
form.  Species  of  the  hydoxerma  and  dermatobia,  that  infest  the  skin 
of  the  horse,  ox,  goat,  etc.,  have  also  been  observed  among  the  Central 
and  South  American  Indians.  They  burrow  beneath  the  skin  of  the 
abdomen,  scrotum,  and  other  regions. 

Muscidse  {Common  Flies). — Common  flies  affect  the  skin  of  man  by 
depositing  eggs  in  wounds.  The  ova  hatch  within  twenty-four  hours 
sometimes,  and  the  dipterous  larvae  may  swarm  to  make  the  so-called 
"living"  wound  or  sore  {myiasis  vulnerum).  The  larvae  or  maggots  do 
not  penetrate  the  tissues,  however.  The  principal  flies  that  infest  wounds 
are  the  flesh-fly  {sarcophila  camaria),  the  blow-fly  {calliphora  vomitoria), 
the  screw-worm  fly  {compsomyia  macellaria),  and  the  ordinary  house-fly 
{musca  domestica). 

Internal  myiasis  may  also  be  caused  by  swallowing  the  ova  of  these 
flies.     The  larvae  may  thus  be  vomited  or  defecated. 

Epidemic  urticaria  is  often  caused  by  the  migration  of  the  caterpillar 
{cuetJiocampa).  Among  other  parasites  that  attack  man  and  inhabit  par- 
ticular regions  are  the  following :  The  simulium  7^eptans,  or  creeping 
gnat  of  Sweden  ;  the  seroot-fly  {zimbj  of  Abyssinia  ;  the  ixodes  carapato, 
a  virulent  bed-bug  in  Brazil ;  the  Jicematopota  pluvialis  (Clegg)  of  the 
West  Highlands. 


INDEX. 


Abscess,  atheromatous,  678 
hepatic,  878 
of  brain,  1113 
of  liver,  878 

complications  and  sequelae,  880 
diagnosis,  881 
etiology,  878 
pathology,  878 
physical  signs,  880 
prognosis  and  treatment,  883 
symptoms,  879 
of  lungs,  534 
etiology,  534 
pathology,  534 
prognosis,  233 

symptoms  and  diagnosis,  433 
treatment,  535 
of  spinal  cord,  1078 
perinephritic,  1000 
retropharyngeal,  724 
Acarus  scabiei,  1260 
Acetonuria,  952 
Achalme's  bacillus,  203 
Achylia  gastrica,  783 
Acid,  lactic,  in  gastric  contents,  737 
Acromegaly,  1179 
Acroparesthesia,  1192 
Actinoniycosis,  350 
bacteriology,  350 
course  and  prognosis,  352 
cutaneous,  351 
intestinal,  351 

method  of  detecting  actinomyces,  352 
modes  of  infection,  351 
oral,  351 
pulmonary,  351 
Acute  articular  rheumatism,  202 
ascending  paralysis,  1065 
cause,  1066 
definition,  1065 
diagnosis,  1066 
etiology,  1066 
pathology,  1065 
prognosis  and  treatment,  1066 
reflexes  in,  1066 
symptoms,  1066 
Bright's  disease,  974 
catarrhal  gastritis,  749 

laryngitis,  473 
chorea,  1144 
cystitis,  1006 
delirium,  1135 

fatty  degeneration  of  the  new-horn,  418 
febrile  jaundice,  367.      (See  Weil's  Dis- 
ease. ) 
gastro-intestinal  catarrh,  800 
hemorrhagic  encephalitis,  1115 
myelitis,  1072 
nephritis,  974 
pancreatitis,  905 


Acute  perihepatitis,  875 
phthisis,  282 
poliencephalitis,  1115 
rhinitis,  467 
spinal  meningitis,  1068 
suppurative  gastritis,  753 
yellow  atrophy,  883 
Addison's  disease,  451 
blood  in,  453 
definition,  451 
diagnosis,  454 
etiology,  452 
extract  of   suprarenal    capsules   in 

treatment,  455 
pathogenesis,  452 
pathology,  451 
prognosis,  454 
skin  in,  453 
symptoms,  454 
treatment,  454 
urine  in,  454 
Adenia,  444.     (See  Pseudo-leukemia.) 
Afebrile  typhoid,  32 
Ainhum,  1190 
Albumin,  tests  for,  943 
Albuminuria,  942 
causes,  942 
functional,  943 
senile,  940 
Alcoholism,  1208 
chronic,  1210 
Alimentary  or  lipogenic  glycosuria,  382 

tract,  tuberculosis  of,  304 
AUorrhythmia,  669 
Amblyopia,  toxic,  1039 
Amceba  coli.     (See  Dysentery.) 

dysenterise,  100 
Amyloid  degeneration  of  heart,  659 
kidney,  definition,  966 
diagnosis,  968 
etiology,  967 
pathology,  966 

prognosis  and  treatment,  968 
symptoms,  967 
urine  in,  967 
Anemia,  419 

blood  in  simple,  420 
definition,  419 
diagnosis,  417 
etiology,  416 
idiopathic,  426 

infantum  pseudo-leuksemica,  449 
pathology,  449 
symptoms,  449 
of  simple,  419 
primary  or  essential,  420 
prognosis,  417 
progressive  pernicious,  426 
secondary,  433 
simple  or  benign,  420 

]2fi5 


1266 


INDEX. 


Anemia,  splenic,  450 
symptoms,  416 
treatment,  417 
Aneurysm,  682 

avterio-venous,  694 

axial,  682 

cardiac,  660 

congenital,  694 

definition,  682 

diffei-ential  diagnosis,  689 

dissecting,  682 

false,  682 

fusiform,  682 

miliary,  682 

of  abdominal  aorta,  692 

of  celiac  axis,  693 

of  hepatic  artery,  693 

of  ])ulmonary  artery,  693 

of  splenic  artery,  693 

of  the  heart,  660 

of  thoracic  aorta,  683 

pathology  and  etiology,  682 

peripheral,  682 

arteries  in,  687 
physical  signs,  686 
prognosis,  690 
pulse  in,  687 
sacculated,  682 

spliygmographic  tracing  in,  687 
symptoms,  683 
tracheal  tugging  in,  688 
treatment,  690 
varieties,  682 
Angina  Ludovici,  709 
maligna,  179 
pectoris,  671 

diagnosis  from  pseudo-angina,  672 
etiology,  672 
pathology,  672 

prognosis  and  treatment,  673 
symptoms,  672 
vasomotoria,  672 
Angioneurotic  edema,  1183 
Anhydremia,  419.     (^ee  Anemia.) 
Animal  parasitic  diseases,  1237 
Ankylostomum  duodenale,  1242 
Anorexia,  787 

Anterior  poliomyelitis,  definition,  1076 
etiology.  1076 

prognosis  and  treatment,  1077 
reflexes  in,  1077 
symptoms,  1077 
Anthracosis,  535.     (See  Pneumonokoniosis.) 
Anthrax,  .'!52 
bacillus,  352 
diagnosis,  354 
edema,  354 
external,  353 
immunity  in,  353 
internal,  354 
manner  of  infection,  353 
pathology,  352 
prognosis,  355 
treatment,  355 
Antipueumococcic  .serum,  156 
Antistreptococcic  serum,  177 
Antitetanic  serum,  362 
Aortic  incompetency  or  insufficiency,  599 
regurgitation,  599 

blood-count  in,  602 

Corrigan  or  water-hammer  pulse  in, 

603 
murmur  in,  604 


Aortic  regurgitation,  pulse-tracing  in,  604 
Quincke's  capillary  pulse  in.  603 
stenosis,  605 

murmur  in,  607 
Aphasia,  1120 
motor,  1120 
sensory,  1122 
Aphtha  cachectica,  697 
Aphthongia,  1061 

Aphthous   fever,   372.      (See   Foot-and-mouth 
Disease. ) 
stomatitis,  696 
diagnosis,  697 

prognosis  and  treatment,  697 
symptoms.  697 
Apoplexy,  cerebral.  1115 
ingravescent,  1117 
serous,  1117 
Appendicitis,  812 

anatomical  aspect,  813 
bacteriology,  817 
chronic,  824 
clinical  history,  817 
consequences  of  perforation,  815 
definition,  812 
diagnosis,  821 

from  acute    intestinal    obstruction, 

823 
from   acute    tubercular    peritonitis. 

823 
from  extra-uterine  pregnancy,  823 
from  indigestion,  822 
from  perinephritic  abscess,  822 
from  renal  colic,  822 
from  typhoid  fever,  823 
local  measures  in  treatment,  827 
pathology  of  catarrhal.  813 
of  interstitial,  814 
of  ulcerative,  814 
physical  signs,  820 
recurrent  or  relapsing,  825 
surgical  aspect  in  treatment  of,  826 
temperature-chart,  821 
treatment,  827 
Apraxia,  1121 
Arsenicism,  1219 
Arterial  .sclerosis,  678 

clinical  history,  680 
definition,  678 
diagnosis,  681 
etiology,  679 
pathology,  678 
prognosis  and  treatment,  682 
Arteries,  aneurysm  of,  682 

atheroma  of.  678.    (See  Arterial  Sclerosis.) 
diseases  of,  677 
Arthritic  muscular  atrophy,  1203 
Arthritis  deformans,  387 
acute  form,  391 
bacteriology  of,  389 
causes,  388 
diagnosis,  391 
pathology,  388 

symjjtoms  of  chronic  form.  389 
treatment,  391 
varieties.  390 
gonorrlieal,  213 
Arthropathies  in  locomotor  ataxia,  1084 
Ascaris  alata.  1241 

lumbricoides,  1238 
Ascites,  926 

adiposus,  926 

character  of  fluid  in,  929 


INDEX. 


1267 


Ascites,  detinition,  926 

diagnosis  from  chronic  peritonitis,  929 

from  ovarian  cyst,  928 
etiology,  926 
fluid  in,  926 
patlaology,  926 
physical  signs,  927 
prognosis,  929 
symptoms,  929 
treatment,  929 
Asiatic  cholera,  109 
Astasia-abasia,  1181 
Asthma,  493 

bronchial,  493 
cardiac,  657 
clinical  history,  494 
course  and  prognosis,  496 
Cursehmann's  spirals  in,  495 
definition,  493 
diagnosis,  496 
duration  of  attack,  495 
etiology,  493 
hay-,  471 
pathology,  493 

reflex  causes  of  bronchial,  493 
renal,  964 
treatment,  496 
Ataxic  paraplegia,  1089 
Atelectasis,  pulmonary,  521 
Atheroma,  778 
Athetosis,  1150 
Atrophy,  acute  yellow,  883 
deflnition,  883 
diagnosis,  885 
etiology,  883 
liver  in,  883 
pathology,  883 
physical  signs,  884 
prognosis.  885 

symptoms    and  physical   signs, 
"  884 

treatment,  8S5 
urine  in,  884 
Autumnal  catarrh,  471 

Bacillus,  Achalme's,  203 

comma.  111 

icteroides,  120 

of  anthrax,  352 

of  diphtheria,  181 

diagnostic  value  of,  187 
manner  of  staining,  181 

of  Eberth.  22 

of  glanders,  348 

of  hydrophobia,  356 

of  influenza,  158 

of  leprosy,  346 

of  syphilis,  327 

of  tetanus,  359 

of  the  plague,  169 

of  tuberculosis,  263 
distribution  of.  264 

of  typhoid  fever,  22 

of  typhus,  68 

of  yellow  fever,  120 

pestis  bubonicfe,  169 

tussis  convulsivse,  253 
Bacterium  coli  commune,  111 

of  cerebro-spinal  meningitis,  125 
Barrel-shaped  chest  of  emphysema,  530 
Basedow's    disease,    458.     (See  Exophthalmic 

Goiter.) 
Baths  in  scarlet  fever,  243 


Baths  in  typhoid  fever,  55 

Beaded  ribs  in  rickets,  405 

Bed-bug,  1262 

Bed-sores  in  typhoid  fever,  66 

Beef  tape-worm,  1256 

Bell's  palsy,  1050 

Beri-beri,  1031    (See  Endemic  Neuritis.) 

Bernhardt' s  disturbance  of  sensation,  1193 

Bile-ducts,  carcinoma  of,  862 

stenosis,  863 
Black  death,  169.     {See  Bubonic  Plague.) 

vomit,  121 
Bladder,  diseases  of,  1006 

hemorrhage  of,  1011 

neoplasms  of,  1011 

neuroses  of,  1012 
Bleeders'  disease,  415.     (See  Hemophilia.) 
Blood,  diseases  of,  416 

in  anaemia  infantum  pseudo-leuksemica, 
449 

in  chlorosis,  424 

in  leukemia,  440 

in  progressive  pernicious  anemia,  430 

in  pseudo-leukemia,  447 

in  purpura,  414 

in  scurvy,  408 

in  secondary  anemia,  433 

in  simple  anemia,  419 

in  typhoid.  22,  40 
Boiled-ham  appearance,  904 
Bothriocephalus  latus,  1257 
Brachycardia.  667 

associated  with  neurosis,  668 

diagnosis,  671 

etiology,  670 

pathology  and  etiology,  667 

physical  signs,  671 

prognosis,  671 

symptoms,  670 

treatment,  671 
Brain,  abscess  of,  1113 

and  meninges,  diseases  of,  1104 

anemia  of,  1108 

disturbances  of  circulation  of,  1107 

edema  of,  1108 

emboli  and  thrombosis,  1109 

hyperemia  of,  1107 

inflammation  of,  1113 

sclerosis  of,  1130 

softening  of.  1109-1111 

tuberculosis  of,  315 

vascular  degeneration  of,  1112 
Break-bone  fever,  167.     (See  Dengue.) 
Breast-pang,  671 
Bronchial  asthma,  493 
diagnosis,  493 

pathology  and  etiology,  492 
physical  signs.  492 
prognosis  and  treatment,  493 
symptoms,  492 

stenosis,  493 
Bronchiectasis,  489 

diagnosis  from  tuberculosis,  491 

etiology,  490 

histology,  490 

physical  signs,  491 

prognosis,  491 

symptoms,  490 

treatment,  491 
Bronchitis,  acute,  481 

capillary,  514 

catarrhal.  480 

physical  signs,  484 


1268 


INDEX. 


Bronchitis,  chronic,  485 

clinical  varieties,  486 

diagnosis  from  pulmonary  tuberculosis, 
486 
from  pneumonia,  483 

eosinophilic,  487 

fibrinous,  498 

plastic,  498 

treatment,  498 
Bronchocele,  456.     (See  Goiter.) 
Broucho-pneumonia,  514 

atelectasis  in,  514 

blood  in,  515 

cerebral  type,  517 

diagnosis  from  lobar  pneumonia,  518 

duration,  517 

etiology,  515 

general,  518 

morbid  anatomy,  515 

pathology,  514 

physical  signs.  516 

prognosis,  519 

sputa  in,  516 

treatment,  520 

tubercular,  518 
Brouchorrhea,  486 
Brown  atrophy  of  heart,  659 
Brown-Sequard's  spinal  paralysis,  1080 
Bruit  de  diable,  A>.', 
Bubonic  plague,  169 

Buhl's  disease,  416.      (See  Acute  Fatty  Degen- 
eration of  the  New-born.) 
Bulbar  paralysis,  1094 

Cachexia  in  cancer  of  stomach,  774 
malarial,  91 

pachydermique,  462.     (See  Myxedema,  i 
saturnine,  1217 
syphilitic,  332 
Caisson  disease,  1182 
Calculi,  biliary,  854.     (See  Cholelithiasis.) 
pancreatic,  913 

renal,  968.     (See  Xi'phroUthiasis.) 
Camp-fever,  67.     (See  Typhus  Fever.) 
Capillary    bronchitis,    514.       (See    Broncho- 
pneumonia.) 
Carcinoma  of  esophagus,  726 
of  intestines,  835 
of  liver,  895 
of  lungs,  538 
of  pancreas,  910 
of  stomach,  771 
Cardiac  aneurysm,  660 
dilatation,  645 
diseases,  585 
hypertrophy,  633 
insufficiency.  785 

murmurs,  hemic,  in  acute  chorea,  1144 
in  chlorosis.  423 
in  pernicious  anemia,  429 
in  aortic  regurgitation,  599 
in  aortic  stenosis.  605 
in  mitral  regurgitation,  607 
in  mitral  stenosis,  611 
in  pulmonary  regurgitation,  621 
in  pulmonary  stenosis,  622 
in  tricuspid  regurgitation,  617 
in  tricuspid  stenosis,  620 
thrombosis,  636 
Cardialgia,  785 
Cardiospasm,  784 
Catarrh,  intestinal,  793 
Catarrhal  bronchitis,  480 
laryngitis,  473 


(See  Muscular  BheiimO' 


129 
132 


I  Celiac  disease,  805 
'  Cephalodynia,  364. 
tism. ) 
Cerebral  hemorrhage,  1115 

palsies  of  childhood,  1133 
Cerebro-spiual  fever,  or  meningitis,  124 
meningitis,  abortive  form,  129 
complications,  129 
cutaneous  symptoms,  128 
differential  diagnosis,  1.30 
duration  and  prognosis,  131 
fulminant  or  ajfoplectic  form,  130 
history,  124 
immunity  in,  131 
incubation,  126 
intermittent  form 
local  remedies  in, 
lumbar  puncture  in.  130 
micro-organism  of,  125 
mild  or  rudimentary  form,  129 
modes  of  conveyance,  126 
mortalitj-,  131 
nervous  symptoms,  127 
pathology,  124 
predisposing  causes,  126 
sequela-,  131 
symptoms,  126 
treatment,  131 
typhoid  form,  129 
Cestodes,  1251 

Chalicosis.  535.     (See  Pneumonokoniosis.) 
Charcot's  disease,  1095 
Chicken-pox,  231.     (See  \'ariceUa.) 
Chills  and  fever,  79.     (See  Malaria.) 
Chloroma,  451 
Chlorosis,  421 
blood  in.  424 
complexion  in,  422 
heart-murmurs  in,  423 
malaise  in,  422 
pica  in.  422 
rubra,  422 
Choked  disk,  1040 
Cholelithiasis.  854 

acute  obstruction  in,  854 
chronic  obstruction  in,  8.56 
composition    and  appearance    of  biliary 

calculi,  6.54 
definition,  854 
difl"erential  diagnosis,  856 
etiology,  854 
prognosis,  8.5,5 

rupture  of  the  duct  from,  855 
symptoms,  ^.54 
Cholera  Asiatica,  109 

algid  stage,  114 

bacillus  of.  111 

causes.  111 

clinical  types,  115 

complications,  115 

contagiousness,  112 

diet  in,  116 

ditferential  diagnosis,  115 

enteroclysis  in  treatment,  118 

epidemic,  109 

mortality  of,  115 

history,  109 

hypodermoclysis  in  treatment,  117 

immunity  in,  113 

incubation  period.  113 

intravenous  injections  in  treatment, 

118 
lavage  in  treatment,  117 


INDEX. 


1269 


Cholera  Asiatica,  modes  of  infection,  112 
preventive  inoculations  in,  116 
prognosis,  115 
prophylaxis  in,  116 
serous  diarrhea  in,  113 
sicca,  113 

stage  of  reaction,  114 
symptoms,  113 
temperature  in,  114 
treatment  of  attack,  117 
urine  in,  114 
visceral  lesions,  109 
infantum,  800,  802 
morbus,  807 
nostras,  806 
sporadic,  806 
Choluria,  948 
Chorea,  acute,  1144 

chronic  progressive,  1147 
electrica,  1149 
fibrillary,  1150 
major,  1154 
rhythmic,  1148 
Choreiform  disorders,  1148 
Chronic  arsenical  poisoning,  1220 
cystitis,  1009 
hydrocephalus,  1128 
interstitial  nephritis,  985 
laryngitis,  475 
lead-poisoning,  1217 
mercurial  poisoning,  1221 
myelitis,  1074 

parenchymatous  nephritis,  981 
pericarditis,  584 
progressive  chorea,  1147 
tuberculosis,  286 
Chyluria,  947 

Cimex  lectularius,  or  bed-bug,  1262 
Cirrhosis,  atrophic,  888,  889 
biliary,  888,  891 
Glissonian,  889 
hypertrophic,  888,  889,  891 
Laennec's,  838 
of  liver,  887 
of  lung,  512 
Colic,  renal,  968 
Colitis,  797 

simple  ulcerative,  811 
Collapse  of  the  luugs,  521.     (See  Pulmonary 

Atelectasis.) 
Colon,  dilatation  of,  842 
,  Comma  bacillus.  111.     (See  Cholera.) 
Congestion  of  lungs,  500 
Constipation,  838-846 

hygienic  treatment,  840 
Convulsions,  infantile,  1159 
Corradi's  method  of  treating  aneurysm,  690 
Cow-pox,  229.     (See  Vaccinin.) 
Cranial  nerves,  diseases  of,  1037 
Croup,  diphtheritic,  179 

membranous,  185.     (See  Laryngeal  Diph- 
theria.) 
Croupous  or  fibrinous  pneumonia,  132. 
Culicidiffi,  1263 
Cvstic  kidnev,  1002 
Cystitis,  1006 

acute  infectious,  852 
catarrhal,  1006 
chronic,  1009 
mycotic,  1008 
septic,  1006 
toxic,  1007 
traumatic,  1007 


Degeneeatioxs  of  the  heart,  656 
amyloid,  659 
brown  atrophy,  659 
calcareous,  6.59 
fatty,  656 

fatty  overgrowth,  658 
hyaline,  659 
Delirium,  acute,  1135 

tremens,  1211 
Dementia,  alcoholic,  1211 
Demodex  folliculorum,  1261 
Dengue,  causes,  167 
complications,  168 
differential  diagnosis  from  yellow  fever, 

168 
symptoms,  167 
treatment,  168 
Dermanyssus  avium  et  gallinse,  1263 
Diabetes  insipidus,  385 
treatment,  887 
mellitus,  374 

acetone  in,  378 
acute,  377 
blood  in,  376 
blood-test  in,  382 
causes,  377 
chronic,  377 
coma  in,  379 

cutaneous  symptoms,  379 
diagnosis,  382 
diet  in,  382 

hygienic  treatment,  384 
infantile,  381 
medicinal  treatment,  384 
microbic  theory  of,  375 
mortality,  382 
nervous  symptoms,  379 
pancreatic,  381 
pathogenesis,  374 
pathology,  375 
Pavy's  view  of,  375 
prognosis,  382 
sexual  symptoms,  381 
special  etiology,  377 
sugar  in,  378 
symptoms,  378 
test  for  acetones,  378 
treatment,  382 
uric  acid  and  urea  in,  378 
urine  in,  378 
Diabetic  coma,  379 
Diarrhoea  alba,  805 
nervous,  845 
of  children,  800 
Dilatation  of  heart,  645 

of  stomach,  744 
Diphtheria,  179 

albuminuria  in,  186 

antitoxin  treatment,  192 

bacillus,  181 

blood  in,  180 

causes  of  death  in,  189 

complications,  186 

diagnosis,  187 

external  applications  in,  192 

hygienic  treatment,  190 

immunity  in,  183 

incubation  of,  183 

intubation  in,  192 

laryngeal,  185 

local  treatment,  191 

malignant,  184 


1270 


INDEX. 


Diphtheria,  modes  of  infection,  182 

mortality,  188 

nasal,  185 

paralysis  in,  186 

pathology,  179 

of  pseudo-membrane,  179 

pharyngeal,  183 

predisposing  factors,  183 

prognosis,  188 

prophylaxis  against,  189 

pseudo-diphtheria,  179 

sequelae,  186 

serum-therapy  in,  192 

skin-rashes  in,  186 

tonsillar,  183 

toxins,  1S2 

tracheotomy  in,  192 

treatment,  189 

use  of  cultures  in  diagnosis  of,  187 
Diphtheritic  dysentery,  103 
Disease,  Addison's,  451 

caisson,  1182 

celiac,  804 

Charcot's,  1095 

of  the  coronary  arteries,  655 
Diseases,  combined  forms  of  cardiac,  622 

of  arteries,  677 

of  auditory  nerve,  1051 

of  bladder,  1006 

of  brain  and  its  meninges,  1104 

of  bronchial  plexus,  1062 

of  cervical  plexus,  1062 

of  circulatory  system,  575 

of  cranial  nerves,  1037 

of  dura  mater.  1104 

of  esophagus,  724 

of  fifth  nerve,  1047 

of  glosso-pharyngeal  nerve,  1054 

of  hypoglossal  nerve,  1060 

of  intestines,  788 

methods  of  diagnosis,  788 

of  kidneys,  933 

of  liver,  847 

of  lumbar  and  sacral  plexuses,  1064 

of  mediastinum,  571 

of  meninges,  1067 

of  motor  nerves  of  eyeball,  1043 

of  muscles,  1196 

of  nervous  system, 1017 

of  pancreas.  905 

of  peripheral  nerves,  1028 

of  peritoneum,  914 

of  pharynx, 720 

of  pia  mater,  1105 

of  pneumogastric  nerve,  1054 

of  portal  vein,  867 

of  salivary  glands,  709 

of  seventh  nerve,  1048 

of  spinal  accessory  nerve,  1058 

of  spinal  nerves,  1062 

of  spleen,  901 

of  stomach,  735 

methods  of  diagnosis,  735 

of  the  blood.  419 

of  the  bronchi,  480 

of  the  ductless  glands,  451 

of  the  heart,  588 

of  the  larynx. 473 
of  the  lungs,  .501 
of  the  nose.  467 

of  the  pleura,  541 

of  the  respiratory  system,  467 

of  the  suprarenal  capsules,  451 


Diseases  of  the  thyroid  gland,  455 

of  the  tonsils,  711 

of  the  urinary  system,  933 
I  of  unknown  pathology,  1137 

Dislocated  kidney,  933 
Distomiasis,  1238 

Dorsodynia,  364.    {Sue  Muscular  Rheumatism.) 
Dracontiasis,  1249 
Ductless  glands,  diseases  of,  418 
Duodenal  ulcer,  809 
Duodenitis,  795 
Dura  mater,  diseases  of,  1104 
Dysentery,  97 

amceba  coli  in,  100 

amebic  or  tropical  form,  100 

catarrhal  form,  99 

causes,  98 

chronic  catarrhal,  107 

intestinal  irrigation  in,  108 

complications,  102 

dietetic  treatment,  108 

diphtheritic,  prophylactic  treatment  of, 
105 
sequels?,  105 

hepatic  abscess  in,  101 

history  of,  98 

intestinal  ulceration  in,  101 
Dyspepsia,  atonic,  785 

chronic  catarrhal,  754 

nervous,  779 
Dystrophia  musculorum  progressiva,  1201 

Ear,  care  of.  in  scarlet  fever,  244 

complications  of,  in  scarlet  fever,  239 

condition  of,  in  syphilis,  332 
Eberth's  bacillus,  22 
Ebstein's  method  in  obesity,  1228 
Eburnation  of  cartilages,  388 
Echirococcus  disease,  1251 
endogenous,  1251 
exogenous,  1251 
fluid,  1252 
tnultilocular,  1251 
Echinorhyncus  gigas,  1250 

moniliformis,  1250 
Echokinesis,  1153 
Echolalia,  11.53 
Eclampsia  infantilis,  1159 
Ectopia  cordis,  (J75 
Edema,  angio-neurotic,  1183 

of  brain,  1108 

of  larynx, 480 

of  lungs,  .502 
Ehrlich's  reaction  in  typhoid  fever,  43 
Elastic  tissue  in  tubercular  sputum,  292 
Electrical  reaction  in  facial  palsy,  1050 
Electrolysis  in  aneurysm,  690 
Electrothermogen,  212 
Elephantiasis,  1248 

arabum,  1248 
Emaciation  in  acute  tuberculosis,  276 

in  anorexia  nervosa,  1170 

in  carcinoma  of  esophagus,  727 
of  stiinuu'h,  774 

in  chronic  tuberculosis,  299 
Embolism  in  a-iieurysm,  683 

in  chorea.  1144 

in  typhoid  fever.  39 

of  cerebral  arteries,  diagnosis  of,  1119 
Embrocardia,  670 
Emphysema,  524 

compensating,  525 

complications,  530 


INDEX. 


1271 


Emphysema,  cough  in,  527 

diagnosis  from  pneumothorax,  529 

dyspnea  in,  527 

hypertrophic,  525 
cyanosis  in,  527 
etiology,  526 

hereditary  character  of,  527 
pathology,  526 
physical  signs,  528 

interlobular,  524 

nature  of,  525 

senile,  531 

vesicular,  524 
Emprosthotonos  in  tetanus,  360 
Empyema,  558 

diagnosis  from  pleurisy  with   effusion, 
560 

differential  diagnosis,  560 

method  of  James  in  treatment,  560 

micro-organisms  in,  558 

necessitatis,  560,  689 

of  pericardium,  583.     (See  Purulent  Peri- 
carditis.) 

paracentesis  in,  561 

peptonuria  in,  559 

pulsating,  560 

rupture  of  air-cells  in,  559 
Encephalitis,  acute  hemorrhagic,  1115 

chronic  diflfuse,  1114 

focal,  1113 

optic  neuritis  in,  1114 
Encephalopathy,  lead,  1217 
Endocarditis,  588 

cerebral  variety  of  ulcerative,  594 

chronic  interstitial,  596 

diagnosis    of   ulcerative,  from    typhoid 
fever,  495  . 

etiology  of  simple  acute,  589 

of  ulcerative  or  malignant,  593 

malignant  or  infectious  form,  592 

micro-organisms  in  etiology  of,  590 

recurrent  malignant,  594 

simple  acute,  488 

syphilitic,  339 

tuberculous,  289 

ulcerative,  592 
mural,  592 
valvular,  592 

varieties,  588 
Enteralgia,  843 

Enteric  fever,  17.     (See  Typhoid  Fever.) 
Enteritis,  catarrhal,  793 

croupous  or  diphtheritic,  805 

membranous,  842 

phlegmonous,  805 

ulcerative,  811 
Enteroclysis,  117 

Enteroliths  as  a  cause  of  appendicitis,  816 
Enteroptosis,  792 
Enterospasm,  845 
Enuresis,  1014 
Environment  in  phthisis,  318 

in  tuberculosis,  266 
Ephemeral  fever,  .369.     (See  Fehricula.) 
Epidemic   catarrhal    fever,  158.     (See   Influ- 
enza.) 

hemoglobinuria,  418 

stomatitis,  372.  (See  Foot-and-mouth  Dis- 
ease.) 
Epilepsy,  11.37 

diasrnosis  from  hysteria.  1141 

etiology,  1138 

grand  or  haut  mal,  1139 


Epilepsy  in  plumbism,  1219 

Jacksonian,  1140 

in  brain-tumor,  1125 

nocturnal,  1140 

paroxysmal  period,  1140 

pathology,  1137 

petit  mal,  1139 

post-epileptic  phenomena,  1140 

prognosis,  1141 

symptoms,  11.39 

treatment,  1141 
Epistaxis,  472 

in  hemophilia,  416 

in  scorbutus,  409 

in  typhoid  fever,  27 
Erysipelas,  172 

bacteriology,  172 

causes,  172 

complications  and  varieties,  175 

diagnosis  from  acute  eczema,  176 

from  chronic  erythematous  eczema, 

176 
from  eczema  nodosum,  176 
from  erythema,  176 
from  urticaria,  176 

duration,  176 

facial,  174 

gangraenosum,  174 

incubation,  173 

local  treatment,  178 

method  of  conveyance,  173 

migrans,  174 

mortality,  176 

''nephro-,"  175 

occurring  in  typhoid  fever,  44 

pathology,  172 

phlegmonous,  175 

''  pneumo-,"  175 

prognosis,  176 

pustulosum,  174 

relapsing,  175 

sequelae,  175 

symptoms,  173 

treatment,  176 

vesiculosum,  174 
Erythromelalgia,  1191 
Esophagismus,  729 
Esophagitis,  acute,  724 

chronic,  726 
Esophagus,  carcinoma  of,  726 

dilatation  of,  730 

diseases  of,  724 

diverticulum  of,  731 

neuroses  of,  729 

paralysis  of,  729 

rupture  of,  728 

stricture  of,  732 

ulcer  of,  726 
EstridfB,  1263 
Ether-pneumonia,  149 

treatment,  157 
Exophthalmic  goiter,  458 
acute,  459 

cardiac,  physical  signs  in,  459 
chronic,  459 
etiology,  459 

muscular  tremors  in,  460 
treatment,  461 
Experimental  typhoid,  23 
Eyes  in  cerebro-spinal  meningitis,  128 

in  hemiplegia,  1117 

in  intracranial  growths,  1125,  1126 

in  syphilis,  332 


1272 


INDEX. 


Eyes,   oculo-motor    paralysis    of,    in    brain- 
tumor,  1126 

Face  in  apoplexy,  1116 
in  Bell's  palsy,  1050 
in  bulbo-paralysis,  1095 
in  disease  of  seventh  nerve,  1048 
in  epilepsy,  1139 
in  hemiplegia,  1117 

in  progressive  muscular  dystrophy,  1202 
in  syphilis,  332 
in  torticollis,  1059 
progressive  hemiatrophy  of,  1187 
Facial  expression  in  chronic  tonsillitis,  718 
in  paralysis  agitans,  1155 
nerve,  1048 

spasm  or  paralysis,  1047 
Facies  in  cholera,  114 
in  jaundice,  850 
leontina  in  leprosy,  345 
Factitious  purpura,  414 
Fallopian  tubes,  tuberculosis  of.  314 
False    croup,    477.     (See    Spasmodic    Laryn- 

(iitis.) 
Farcy,  348.     (See  Glanders.) 
Fat-embolism  in  diabetes,  376 
Fat-necrosis,  915 

Fatty  degeneration  in  acute  yellow  ati'ophy, 
883 
in  cirrhosis  of  liver,  888 
in  idiopathic  anemia,  427 
of  heart,  652 
of  kidneys  in  diabetes,  376 

in  phosphorus-poisoning,  886 
of  liver,  874 

in  phosphorus-poisoning,  886 
infiltration  of  liver,  873 
kidney,  981 

overgrowths  of  heart,  differential  diag- 
nosis, 654 
Febricula,  369 
Febris  flava,  119.     (See  Yellow  Fever.) 

recurrens,  73.     (See  Relapsintj  Fever.) 
Fecal  concretions  as  a  cause  of  appendicitis, 
816 
impaction,  829 
vomiting,  831 
Fehling's  test  for  sugar,  950 
Fermentation-test  for  sugar,  951 
Fetal  heart-rhythm,  670 
Fetus,  endocarditis  in,  .599 
Fever  and  ague,  79.     (See  Malayia.) 
cerebro-spinal,  124 
dengue,  167 
gastric,  7.50 
glandular,  372 
hysteric,  1171 
in  abscess  of  liver,  879 
in  acute  pneumonic  phthisis,  283 
in  appendicitis,  817 
in  cholera,  115 
in  chronic  obstruction  of  bile-passages, 

837 
in  chronic  tuberculosis,  290 
in  general  miliary  tuberculosis,  276 
in  Hcxlgkin's  disease,  447 
in  infhuMiZii,  1.58 
in  intermittent  fever,  86 
in  meningitic  tuberculosis,  279 
in  pneumonia,  516 
in  pyelitis,  995 
in  pyemia.  200 
in  pylephlebitis,  suppurative,  869 


Fever  in  relapsing  fever,  75 

in  remittent  fever,  90 

in  scarlet  fever,  236 

in  secondary  syj)hilis,  329 

in  septicemia,  197 

in  small-pox,  223 

in  sun-stroke,  1232 

in  tuberculosis  of  lymph-glands,  274 

in  typhoid  fever,  29 

jail-,  67.     (See  Typhus  Fever.) 

lung,  132 

malarial,  79 

Malta,  368 

Mediterranean,  368 

miliary,  371 

mountain-,  67 

pernicious  malarial,  89 

relapsing,  73 

ship-,  67.     (See  Typhus  Fever.) 

splenic,  352 

spotted,  124 

typhoid,  17 

typhus,  67 

yellow,  119 
Fibrinous  bronchitis,  493 

pleurisy,  544 
Fibroid  induration  of  lung,  512 

of  pancreas  in  diabetes,  375 
Fifth  nerve,  diseases  of,  1047 
paralysis  of,  1047 

trophic  changes  in  paralysis  of,  1047 
Filaria  brouchialis,  1250 

hominis  oris,  1250 

immitis,  1250 

labialis  oris,  1250 

lentis,  1250 

loa,  12.50 

sanguinis  hominis,  1248 

distribution  of,  1248 

trachealis,  1250 
Filariasis,  1248 

Fire,  St.  Anthony's,  172.     (See  Erysipelas.) 
Flatulence  in  hysteria,  1170 
Flint's  murmur  in  heart  disease,  605 
Floating  kidney,  933 
Florid  phthi.sis,"  282.     (See  Acute  Phthisis.) 
Fluke,  blood-,  1238 

bronchial,  1238 

liver-,  1237 

varieties  of,  1237 
Folic  brightique,  964 
Follicular  stomatitis,  696 
Food-infection  and  ptomain-poisoning,  1223 
Foot-and-mouth  disease,  372 
Foot-drop.  1029 

Foreign  l)odies  in  intestinal  obstruction,  830 
Fourth  nerve,  1045 

paralysis  of,  1045 
Fremitus,  hydatid,  12.53 

tactile,  in  chronic  tuberculosis,  296 
in  pneumonia,  518 
French  measles,  248.     (See  Rubella.) 
Friction-rub  in  acute  peritonitis,  917 
Friction-sound  in  ])leurisy,  543 

in  sero-fihrinous  pericarditis,  580 
Friedreich's  disease,  i0S6 

sign  in  adherent  pericardium,  585 
Frontal  convolution,  speech-center  in,  1025 

Gait,  ataxic,  1031 
in  beri-heri.  1032 

in   dittevential    diagnosis   of   locomotot 
ataxia,  1084 


II^DEX. 


127? 


Gait  in  pseudo-hypertrophic  muscular  paral- 
ysis, 1200 
in  pseudo-tabes,  1031 
in  spastic  paraplegia,  108S,  1GS9 
Grall-bladder,  distention  or  dropsy  of,  857 
empyema  of,  85S 
fistulous  communications  of,  859 
phlegmonous  inflammation  of,  858 
Gralloping    consumption,    232.       (See    Acute 

Phthisis.) 
Gallop-rhythm    in    fatty    degeneration    of 

heart,  657 
Grall-stones,  854.     (See  Calculi,  Biliary.) 
remote  effects  of,  858 
treatment  for  removal  of,  861 
Galvano-puncture  in  aneurysm,  691 
Granglion,  basal  tumors  in  or  about,  1125 
Gangrene,  expectoration  in,  533 
in  diabetes,  379 
in  ergotism,  1224 
in  lobar  pneumonia,  150 
in  Eaynaud's  disease,  1186 
in  typhoid  fever,  40 
in  typhus  fever,  71 
of  lungs,  531 
Gangrenous  pancreatitis,  908 

stomatitis,  703 
Gastralgia,  786 
Grastrectasis,  744 

Grastric  contents,  examination  of,  736 
crisis,  1083 
fever,  749 

juice,  hyperacidity  of,  782 
subacidity,  783 
ulcer,  763 

clinical  forms,  767 
complications  of,  767 
diagnosis  from  gastralgia,  763 
differential  diagnosis,  768 
hematemesis  in,  766 
Gastritis.     (See  Stomach.) 
acute  catarrhal,  649 
suppurative,  753 
chronic  catarrhal,  754 
diphtheritic,  753 
toxic,  7.52 
Grastrodynia,  786 
Grastro-enteritis,  800 
Gastroptosis,  743.     (See  Malposition  of  Stora- 

ach.) 
Gastroxynsis,  783 
Gelbfieber.     (See  Yellow  Fever.) 
General  lymphadenoma,  444.     (See    Pseudo- 
leukemia.) 
miliary  tuberculosis,  275 
paresis,  1131 

of  insane,  1131 

diagnosis  from  cerebral  syphilis, 

11.32 
stage  of  mania  in,  1132 
tic,  1152.     (See  Tic.) 
Genito-urinary  system,  tuberculosis  of,  312 
German  measles,  248.     i.See  Rubella.) 
Giant  cells  in  tuberculosis,  261 
Gligantoblasts     in     progressive     pernicious 

anemia,  430 
Gin-drinkers'  liver,  887.     (See  Cirrhosis.) 
Glanders,  343 
acute,  348 
bacillus  mallei,  348 
chronic,  349 
diagnosis.  -349 
immunity  in,  348 


Glanders,  lesions  of,  348 

modes  of  infection,  348 

period  of  incubation,  348 

prognosis  and  treatment,  350 
Glandular  fever,  372 
diagnosis,  373 
etiology,  373 
historv,  373 
pathology,  373 
prognosis,  373 
symptoms,  373 
treatment,  373 
Glassblowers'  mouth,  710 
Glioma  of  brain,  1124 
Globus  hystericus,  1167 
Glomerulo-nephritis,  974 
Glossitis,  706 

desiccans,  708 
Glosso-labio-laryngeal  paralysis,  1094 
Glosso-pharyngeal  nerve,  1054 

diseases  of,  1054 
Glossy  skin  in  arthritis  deformans,  390 
Glottis,  edema  of,  in  small-pox,  221 

in  typhoid  fever,  38 
Glycosuria,  949 

alimentary,  382 

salts  for,  950 
Gmelin's  test  for  bile,  948 
Goiter,  456 

exophthalmic,  458 

phvsical  cardiac  signs  of  exophthalmic, 
459 

simple,  456 

symptoms  of  exophthalmic,  457 

thymus  gland  in  treatment  of  simple,  453 

treatment  of  exophthalmic,  461 
Gonorrheal  arthritis,  213 

endocarditis  in,  214 
pathology  of,  213 
Gout,  392 

causes,  394 

dietetic  treatment,  399 

differential  diagnosis,  398 

irregular,  396 

morbid  anatomy,  393 

nervous  manifestations  in,  397 

pathogenesis.  392 

prophylactic  treatment,  398 

retrocedent,  395 

rheumatic,  387 

symptoms  of  acute,  395 
of  chronic,  396 

treatment,  .398 

urine  in,  397 
Graefe's  signs,  459 
Grain-poisoning,  1222 
Grand  mal,  1139 
Granular  kidney,  985 
Graves'     disease,     458.       (See    Exophthalmic 

Goiter.) 
Green  sickness,  421.     (See  Chlorosis.) 
Grippe,  la,  153 

Ground-soil,  Pettenkofer's  theory  of,  24 
Guaiacum-test  for  blood,  939 
Gummata  in  acquired  syphilis,  330 

in  congenital  svphilis,  332 

of  arteries.  .33.5'.  339 

of  brain  and  spinal  cord,  333 

of  heart,  338 

of  liver,  335 

of  lung,  337 

of  pharynx,  336 

of  rectum,  337 


1274 


INDEX. 


Gummata  of  testicles,  340 

of  tougue,  336 

structure  of,  327 
Gums,  blue  line  iu  lead-poisoniug,  1217 
Gustatory  nerve,  1048 

Habit-chorea,  718 
Habit-siiasm,  1152 
Hair  in  typhoid  fever,  33 
Hallucinations  iu  hysteria,  1168 
Handwriting  in  general  paresis,  1131 
Harrison's  groove  in  rickets,  405 
Hay-asthma.  471.     (See  Autumnal  Catarrh.) 
Hay-fever,  471.     (Sec  Autumnal  Catarrh.) 
Headache  in  intracranial  growths,  1125 

in  syphilis,  334 

iu  typhoid  fever,  41 

in  uremia,  963 

sick,  1142.     (See  Migraine.) 
Heart,  amyloid  degeneration  of,  659 

aneurysm  of,  560 

arrhythmia  of,  669 

brown  atrophy  of,  659 

calcareous  degeneration  of,  6.59 

canter-rliythm  iu  dilatation  of,  648 

congenital  aflections  of,  674 

degenerations  of,  656 

dilatation  of,  645 

displacement  of,  in  pleurisy,  548 

fatty,  656 

floating,  663 

hyaline  degeneration  of,  659 

hypertrophy  of  638 

in  pneumothorax,  567 

irregular,  669 

minor  aftectious  of,  662 

misplacement  of,  663 

new  growths  of,  662 

organic,  murmurs  of,  599.    (See  Cardiac 
Murmur.^.) 

palpitation  of,  663 

parasites  of,  662 

rapid.  665 

rupture  of,  661 

shape  of,  in  hypertrophy,  638 

slow.  667 

thrombosis  of,  636 

tuberculosis  of,  315 
Heart-failure  in  diphtheria,  187 

in  lobar  pneumonia,  treatment,  154 
Heat-apoplexy,  1232 
Heat-exhaustion,  1230 
Heat-stroke,  1230 

temperature  in,  1234 

treatment,  1234 
Heberdeu's  nodules,  390.     (See  Arthritis  De- 
formans.) 
Heller's  test,  944 
Hematemesis,  778 

diagnosis  from  liemoptysis,  779 

in  acute  yellow  atroi)hy,  884 

in  cirrhosis  of  liver,  890 

in  hysteria,  1170 

in  leukocythemia,  440 
Hematobium  distoma,  1238 
Hematomyelia.  1072 
Hematorrachis.  1072 
Hematozoa  of  malaria,  82 
Hematuria,  9.'W 

in  acute  cystitis.  1007 

in  acute  nei)hritis.  977 

in  acute  vellow  atrophv,  884 

in  blood-flukes,  1238 


Hematuria  in  chronic  tuberculosis,  300 

in  chyluria,  948 

in  malaria,  89,  92 

in  nephrolithiasis,  971 

in  renal  calculus,  971 

in  scorbutus,  409 

in  tuberculosis  of  kiduey,  313 
Hemeralopia.  1040 
Hemianopia  in  brain-tumors,  1126 
Hemic  murmur  in  chlorosis,  429 
Hemicrania,  1142.     (See  Migraine.) 
Hemiplegia,  1117 

anesthesia  in.  1117 

atrophy  in,  1118 

crossed,  1117 

diagnosis,  1118 

in  brain-tumors,  1126 

iu  chronic  nephritis,  990 

in  hysteria,  1168 

of  childhood,  1133 

reflexes  in,  1117 

spastica  cerebralis,  11.34 
Hemoglobin  in  anemia,  424 
Hemoglobinuria,  940 

diagno.sis,  941 

etiology,  940 

in  Eaynauds  disease,  1186 

paroxysmal,  941 

treatment,  941 
Hemolysis,  causes  of,  940 

in  toxic  hemoglobinuria,  940 
Hemopericardium,  587 
Hemophilia,  415 
Hemoptysis,  504 

etiology,  505 

in  acute  pneumonic  phthisis,  29 

iu  emphy.sema,  530 

in  gangrene  of  lung,  533 

in  hysteria,  1170 

in  mitral  incompetency,  609 

in  mitral  stenosis,  514 

in  onset  of  phthisis,  290 

in  scorbutus,  409 

in  tuberculosis,  293 

parasitic,  1234 

pathology,  .505 

symptoms,  506 

treatment,  508 

vicarious,  506 
Hemorrhage,  broncho-pulmonary,  504 

cerebral,  1115 

extra-meningeal.  1069 

in  acute  yellow  atrophy,  884 

in  anemia,  429 

in  cirrhosis  of  liver,  890 

in  hemo])hilia,  416 

in  infantile  scorbutus,  411 

in  intussusception,  833 

in  leukocythemia,  440 

in  malaria,  91 

in  i)urpura,  413 

iu  scarlet  fever,  842 

in  scorbutus,  409 

in  tuberculosis  of  kidney,  313 

in  typhoid  fever,  34 
in  yellow  fever.  119 

into  .spinal  cord.  1071 

into  si)inal  meninges,  1069 

intra-meningeal.  1069 

pulmonary,  293 

retinal,  in  chronic  nephritis,  990 

vesical,  1011 
Hemorrhagic  diathesis,  415 


INDEX. 


1275 


Hemorrhagic  diseases  of  the  new-born,  418 

nephritis,  982 

in  variola,  221 

pleurisy,  552 

purpura,  412 

scarlet  fever,  238 
Hemorrhoids  in  cirrhosis  of  liver,  890 
Hepatic  abscess,  878 

blood-vessels,  diseases  of,  870 

colic,  854 

iniiltrations  and  degenerations,  871 
Hepatitis,  diffuse  syphilitic,  334 

interstitial,  887 

suppurative,  878 
Hepatization,  gray,  134 

red,  133 

white,  of  fetus,  338 
Hepatogenous  jaundice,  852 
Hereditary  ataxia,  1086 

muscular  paralysis,  1204 
Heredity  in  tuberculosis,  268,  269 
Herpes  in  cerebro-spinal  meningitis,  128 

in  febricula,  370 

in  malaria,  87 

in  neuralgia,  1035 

in  pneumonia,  143 
Hirudo,  1263 

Hodgkin's   disease,  444.      (See  Pseudo-leuke- 
mia.) 
Huntingdon's  chorea,  1147 
Hutchinson's  teeth,  632 

triad,  332 
Hyaline  casts  in  urine,  983,  989 
Hydatid  disease,  1251 

thrill,  1253 
Hydrarthrosis,  214 
Hydrocephalus,  chronic,  1128 
Hydrochloric  acid,  test  for,  in  gastric  juice, 

736 
Hydromyelia,  1097 
Hydronephrosis,  997 

intermittent,  999 
Hydropericardium,  586 

in  nephritis,  977 
Hydrophobia,  356 

bacteriology,  356 

diagnosis,  358 

incubation,  356 

morbid  anatomy,  355 

paralytic  stage,  357 

preventive  inoculation  in,  358 

prodromal  symptoms,  356 

stage  of  excitement,  356 

temperature  in,  357 

treatment  by  attenuated  virus,  359 

virus  of,  356 
Hydrops  articulorum  intermittens,  1185 

peritonsei,  926 
Hydrothorax,  569 

in  nephritis,  977 
Hypernephroma,  1003 
Hyperorexia,  783 
Hyperpyrexia  in  heat-stroke,  1233 

in  hysteria,  1171 

in  rheumatic  fever,  207 

in  scarlet  fever,  238 

in  tetanus,  360 
Hypertrophy  of  the  heart,  638 
Hypnotism  in  hysteria,  1173 
Hypochondria  in  neurasthenia,  1175 
Hypoglossal  nerve,  1060 
paralysis  of,  1061 
spasm  of,  1061 


Hypostatic  congestion  in  typhoid  fever,  38 

of  lung,  501 
Hysteria,  1164 

anesthesia  in,  1169 

ataxia  in,  1169 

cataleptic  form  of,  1168 

contractures  in,  1168,  1169 

convulsions  in,  1167 

dyspnea  in,  1170 

fever  in,  1171 

gymnastic  form  of,  1167 

latent  or  interconvulsant  stage  of,  1169 

nervous  system  in,  1169 

paralysis  in,  1168 

prodromal  stage  of,  1166 

pseudo-angina  in,  1171 

psychic  symptoms,  1170 

stage  of  delirium,  1168 

tachycardia  in,  1171 

traumatic,  1165 

urinary  symptoms,  1171 
Hystero-epilepsy,  1167 

Icterus,  848.     (See  Jaundice.) 

neonatorum,  865 
Idioglossia,  1121 

Idiopathic  anemia,  426.    (See  Progressive  Per- 
nicious Anemia.) 
Ileo-colitis,  803. 

Ileus,  828.     (See  Intestinal  Obstruction.) 
Imbecility  in  cerebral  palsies  of  childhood, 

1134 
Imitation  in  chorea,  1153 
Incontinence  of  urine  in  locomotor  ataxia, 

1083 
Indicanuria,  945 
Infantile  convulsions,  1159 
Infarction,  intestinal,  808 
Infectious  diseases,  17 
Influenza,  158 

antagonism  of,  160 

bacillus  of,  159 

broncho-pueumonia  in,  162 

causes,  159 

clinical  types,  161 

complications,  161 

diagnosis,  163 

from  cerebro-spinal  meningitis,  163 
from  pneumonia,  163 
from  typhoid  fever,  163 

duration,  164 

h-eart-failure  in,  162 

history,  158 

immunity  in,  160 

lobar  pneumonia  in,  161 

manner  of  invasion,  159 

modes  of  conveyance,  159 

mortality,  164 

nervous  system  in,  162 

pathology,  159 

pleurisy  in,  162 

prognosis,  164 

prophylaxis,  in,  164 

sequelae,  164 

symptoms,  160 

treatment,  165 
Injection  of  salines  in  cholera,  117 
Inoculation,  preventive,  in  hydrophobia,  358 
in  small-pox,  229 

protective,  in  yellow  fever,  123 

tuberculosis  produced  by,  267 
Inoculations,  prophylactic,  in  tvphoid  fever, 
53 


1276 


INDEX. 


Insular  sclerosis,  1091 
Intercurrent  relapse,  51 
Intermittent  fever,  84 
Intestinal  catarrh,  793 

hemorrhage  in  typhoid  fever,  34 

iufaiction,  808 

obstruction,  828 

perforation  in  typhoid  fever,  34,  35 

tumors,  830 

ulcers,  809 
Intestine,  carcinoma  of,  835 

diminished  sensibility  of,  844 

neuralgia  of,  843 

neuroses  of,  842 

spasm  of,  845 
Intestines,  diseases  of,  788 
Intoxications,  1208 
Intracranial  growths,  1124 
Intussusception,  828 
Invagination,  828 
Iridoplegia,  1044 
Iritis  in  syphilis,  332 
Irregular  lieart-  and  pulse-beat,  669 
Ixodes,  1263 

Jacksonian  epilepsy,  1137 
Jail-fever,  67.     (See  Typhus  Fever.) 
Japan,  bronchial  fluke  in,  1238 

endemic  neuritis  in,  1032 
Jaundice,  848 

acute  febrile,  367 

catarrhal,  849 

emotional,  853 

forms  of,  852 

hepatogenous,  848 

in  acute  yellow  atrophy,  883 

in  atrophic  cirrhosis  of  liver,  890 

in  biliary  calculi,  855 

in  carcinoma  of  liver,  896 

in  epidemic  form,  849 

in  hypertrophic  cirrhosis  of  liver,  891 

in  impacted  calculi,  882 

in  pneumonia,  147 

in  the  new-born,  848 

in  typhoid  fever,  33 

in  Weil's  disease,  367 

in  yellow  fever,  122 

malignant,  883 

toxic,  849 

xanthelasma  in,  850 
Joints  in  gout.  392-396 

in  rheumatism,  203 

in  small-pox,  221 

in  syphilis,  339 
Jumpers,  1154 

Keratitis  in  inherited  syphilis,  332 

in  small-pox,  222 
Keratosis  foUieularis,  123() 
Kernig's  sign  in  diagnosis  of  cerebro-spinal 

meningitis,  130 
Kidney,  amyloid,  966 

carcinoma  and  sarcoma  of,  1004 

circulatory  disorders  of,  9.37 

cirrhosis  of,  935 

contracted,  985 

cyanotic  induration  of,  937 

cystic,  1002 

dis.ascs  (.f,  9.33 

dislocated,  933 

echinococcns  of,  1255 

floating,  933,  934 

gouty,  985 

granular,  985 


Kidney,    ardaceous,  966 

large  white,  981 

movable,  936 

new  growths  of,  1003 

removal  of,  in  carcinoma,  1005 

rhabdomyoma,  1003 

senile,  991 

syphilis  of,  339 

tuberculosis  of,  312 

wandering,  933 

waxy,  966 
Kidneys,  active  hyperemia  of,  937 

embolic  infarctions  of,  938 

in  diphtheria,  181 

mobility  of,  933 

passive  hyperemia  of,  937 

stone  in,  968 
Kindhusten,  251.     (See  Whooping-cough.) 
Knee-jerk,  loss  of,  in  ataxia,  1081 
in  diphtheria.  186 
in  diseases  of  lumbar  plexus,  1064 
Koplik's  sign  in  measles,  247 

Lactic  acid,  test  for,  738 

Lagophthalmos,  1043 

La  grippe,  158.     (See  Influenza.) 

Landry's  paralysis,  1065 

Lardaceous  degeneration  of  kidney,  966 

infiltration  of  liver,  871 
Larvw  of  flies,  1263 
Laryngeal  crises,  1055,  1083 

nerves,  1055 
Laryngismus  stridulus,  477.     (See  Spasmodic 

LnryngHia.) 
Laryngitis,  acute  catarrhal,  473 

chronic,  475 

edematous,  480 

membranous,  475-478 

spasmodic,  477 
Larynx,  adductor  paralysis  of,  1056 

anesthesia  of,  1057 

diseases  of,  473,  1055 

edema  of,  474-4s0 

hyperesthesia  of,  10.57 

nerves  of,  1054,  1055 

paralysis  of,  1055 
complete,  1056 
of  abductors,  1056 

spasm  of,  1055 

tumors  of,  479 

unilateral  abductor  paralysis  of,  1056 
Latah, 1154 
Lateral  sclerosis,  amyotrophic,  1095 

])riniary,  1087,  1U88 
Lateritous  sediment,  954 
Lathy  rism  us,  1225 
Lathyrus  ciceia,  1225 

clymenum,  1225 

sativus,  1225 
Lavage  in  chronic  gastric  catarrh,  762 

in  dilatation  of  stomach,  748 

in  gastric  ulcer,  770 
Lead  arthralgia,  1218 

colic,  1218 

encephalopathy,  1218 

in  urine,  test  for,  1218 

palsy  or  paralysis,  1218 
Lead -poisoning,  1216 

blue-line  on  gums.  1217 

cerebral  symi)toms,  1218 

cramjis  of,  1218 
Lead-workers,  gout  in,  394 
Lepra  alba,  346 

cells,  345 


INDEX. 


1277 


Leprosy,  345 

anesthetic  form,  346 

bacillus  of,  346 

diagnosis,  347 

etiology,  346 

history,  345 

modes  of  infection,  346 

pathology,  345 

prognosis,  347 

serum-diagnosis  of,  347 

treatment,  347 

trophic  alterations  in,  347 

tubercular  form,  346 
Leptomeningitis,  1068,  1105 

acute,  1068 

as  a  sequel  to  acute  febrile  diseases,  1105 

chronic,  1069 

non-tubercular  form,  1105 

tache  cerebrale  in,  1106 

tubercular  form,  1068,  1105 
Leptus  autumnalis,  1261 
Lesions  of  cauda  equina  and  conus  termi- 

nalis,  1103 
Leucin,  956 

in  leukemia,  437 

in  urine,  test  for,  956 
Leucinuria,  956 
Leukemia,  437.     (See  Leulcocythemia.) 

blood  in,  441 

bone-marrow  in,  438 

complications  of,  443 

etiology,  439 

liver  in,  438 

lymphatic,  437-442 
glands  in  441 

microbic  origin  of,  439 

pathology  of,  437 

pseudo-,  444 

spleen  in,  441 

splenic-myelogenous,  437 

symptoms,  440 
Leukemic  blood,  abnormal  substances  in,  437 

peritonitis,  440 
Leukocythemia,  437 

pseudo-,  444 

pseudo-anemia  Infantum,  449 
Leukocytosis,  436 

pathological,  436 

physiological,  436 
Leukoplakia  oris,  708 
Leyden's  crystals,  493.     (See  Asthma.) 
Lichen  in  jaundice,  850 
Lienteric  diarrhea,  797 
Lingual  psoriasis,  708 
Lips,  tuberculosis  of,  304 
Lipuria,  958 
Lithemia,  400 
Lithic-acid  diathesis,  953 
Lithuria,  953 
Liver,  abscess  of,  878 

active  congestion  of,  866 

acute  yellow  atrophy  of,  883 

affections  of  blood-vessels  of,  870 

altered  shape  of,  847 

amyloid  infiltration  of,  871 

anemia  of,  866 

anomalies  in  shape  and  position  of,  847 

atrophy  of,  871 

carcinoma  of,  895 

circulatory  affections  of,  866 

cirrhosis  of,  887 
atrophic,  864 
hypertrophic,  864 


Liver,  diagram  of,  in  cirrhosis,  893 
diseases  of,  847 

dulness  of,  in  acute  peritonitis,  917 
fatty  degeneration  of,  874 

infiltration  of,  873 
gummata  of,  335 
hydatids  of,  1252 
hyperemia  of,  866 
hypertrophy  of,  871 
in  phosphorus-poisoning,  885 
new  growths  of,  900 
perihepatitis,  875 
psorospermiasis  in,  1236 
syphilis  of,  334 
toxic  symptoms  in  acute  yellow  atrophy 

of,  884 
tuberculosis  of,  311 
waxy,  871 
Lobar  pneumonia,  132.     (See  Pneumonia.) 
Localization,  cerebral,  1026 

spinal,  1023 
Lockjaw,  358.     (See  Tetanus.) 
Locomotor  ataxia,  1081 

Argyll-Eobertson  pupil  in,  1082 
course,  1084 

diagnosis    from    ataxic    paraplegia, 
1084 
from  cerebellar  disease,  1085 
from  peripheral  neuritis,  1084 
etiology,  1082 
gait  in,  1083 
gastric  crisis  in,  1083 
pathology,  1081 
polyesthesia  in,  1083 
prognosis,  1085 
symptoms,  1082 
treatment,  1085 
trophic  changes  in, 1083 
Long  thoracic  nerve,  1062 
Ludwig's  angina,  709 

Lumbago,  363.      (See  Muscular  Rheumatism.) 
Lumbar  puncture,  1069,  1106 

in  cerebro-spinal  meningitis,  130 
Lumpy -jaw,  350.     (See  Actinomycosis.) 
Lung,  actinomycosis  of,  351 
carcinoma  of,  538 
echinococcus  of,  1254 
gangrene  of,  circumscribed,  532 
diflfuse,  531 
embolic,  531 
hemorrhagic  infarction  of,  505 
hydatid  cyst  of.  540 
neoplasms  of  cobalt-miners,  540 
sarcoma  of.  539 
spleuization  of,  502 
Lung-fever,  132 
Lungs,  abscess  of,  534 
embolic,  534 
symptoms  of,  535 
active  hyperemia  of,  500 
apoplexy  of,  510 
brown  induration  of,  501 
cirrhosis  of,  512 
congestion  of,  500 
edema  of,  502 
embolism  of,  510 
emphysema  of,  524 
fibroid  induration  of,  512 
gangrene  of,  531 
etiology,  532 
pathology,  531 
symptoms,  533 
hemorrhage  of,  504 


1278 


INDEX. 


Lungs,  hemorrhagic  infarct  of,  510 

new  growths  of,  538 

passive  hyperemia  of,  501 

syphilis  of,  337 

tuberculosis  of,  277 
Lymphadenitis,  571 

tuberculous,  571 
Lymphadenoma,  general,  444 
Lymphatics,  distended,  1249 
Lymph-glands,  suppuration  of,  571 

tuberculosis  of,  271 
Lymphoma,  multiple  malignant,  444 
Lympho-sarcoma,  malignant,  444 
Lymph-scrotum,  1249 
Lymph-vaccine,  230 
Lymph-vulva,  1249 
Lyssophobia,  357 

Macrocytes,  424 
Macrocytosis,  419 
Ma'idismus,  1224 

"Main  en  grifi'e  "  in  diseases  of  muscles,  1198 
Malacia,  788 
Malarial  cachexia,  91 
fever,  79 

ameba      causing      estivo-autumnal 
fever.  83 
causing  quartan  fever,  83 
causing     tertian     intermittent 
fever,  83 
chart  in,  81 
cilia;  or  flagella  in,  84 
complications,  92 
cutaneous  symptoms,  87 
diagnosis,  93 
etiology,  80 
examination   of  blood   for  parasite 

of,  94 
hematozoa  of,  82 

hematuria  and  hemoglobinuria  in,  92 
hot  stage  of  intermittent,  85 
immunity  in,  84 
incubation  in,  84 
intermittent,  83 

temperature-chart  in.  85 
life-cycle  of  parasite.  83,  84 
localities  of,  79 
masked  intermittent,  91 
mild  form,  87 
mode  of  infection  in,  84 
mosquitoes  and,  84 
occurring  with  typhoid  fever,  44 
parasite  of,  82 

paroxysms  in  intermittent,  84 
pathology  of,  79 

pernicious,  intermittent  form,  87 
algid  form,  88 
comatose  form,  89 
congestive  chills  in,  88 
hematuric  form,  89 
Plasmodium  of,  82 
prognosis,  94 

prophylaxis  in  pernicious  intermit- 
tent, 96 
quartan,  86 
quotidian,  86 
remittent  form,  89 
seasons  favoring,  81 
spleen  in,  80,  87 
splenic  enlargement  in,  87 
sub-varieties,  79 

sweating  stage  of  intermittent,  86 
telluric  conditions,  80 


Malarial  fever,  tertian,  86 

treatment  of  intermittent  form,  95 
urine  in,  87 
Malignant  edema,  353 

lympho-sarcoma,    444.      (See  Pseudo-leu- 
kemia.) 

pustule,  352.     (See  Anthrax.) 
Malta  fever,  368 
Mammary  glands  in  hysteria,  1170 

tuberculosis  of,  315 
Mania-a-potu,  1210 
Mania,  acute  delirious,  1135 

Bell's,  1135 

melancholic  stage  of,'  in  general  paresis. 
1132 

typho-,  1135 
Marriage  in  hemophilia,  417 

in  syphilis,  342 
Marrow  in  bones  in  leukocythemia,  437 
in  pernicious  anemia,  427 
in  small-pox,  216 
Masticatory  spasm,  1047 
Mastodynia,  1036 
McBurney's  point,  817 
Measles,  245 

catarrlial  stages,  246 

causes,  245 

complications,  246 

contagiousness  of,  245 

dequamation  in,  246 

diagnosis,  247 

from  German,  250 

epidemics  of,  245 

eruption  of,  246 

German,  249 

immunity  in,  245 

incubation  of,  246 

mortality,  247 

pathology,  245 

symptoms,  246 

temperature  in,  246 

treatment,  248 

of  German,  290 
Meat  in  animal  parasitic  disease,  1258 

tuberculous  infection  by,  267 
Meat-poisoning,  1223,  1246 
Meckel's  diverticulum,  828 
Median  nerve,  diseases  of.  1063 
Mediastinal  hemorrhage,  574 
Mediastinum,  abscess  of,  572 

carcinoma  of,  .572 

diseases  of,  571 

dysphagia  in  diseases  of,  573 

inflammation  of,  571 

sarcoma  of,  .572 

tumors  of,  .572 
Mediterranean  fever,  368 
Medulla,  tumors  of,  1127 
Megalocytosis,  419.     (See  Anemia.) 
Megalogastria,  747 
Jlclano-sarcoma  of  liver,  900 
Melanotic  carcinoma,  diagnosis  in  Addison's 

disease,  454 
Melanuria,  958 
Melasma  suprarenale,  4.54 
Melena  in  typhoid  fever.  31 
Meniere's  disease,  1053 
Meningeal  apoplexy,  1069 
Meninges,  diseases  of,  1065 
Meningitis,  acute  spinal,  1068 

cerebro-spinal,  129 

in  encephalitis,  1113 

in  erysipelas,  175 


INDEX. 


1279 


Meningitis  in  gout,  397 
in  hydrocephalus,  1129 
tuberculous,  278,  1106 
Meningococcus  intracellularis,  126 
Meningo-encephalitis,  tuberculous,  315 
Meralgia  paresthetica,  1193 
Mercurial  tremor,  1221 
Mercurialism,  1220,  1221 

stomatitis  and  salivation  in,  1221 
Merycism,  784 

Mesenteric  artery,  occlusion  of,  808 
glands  in  typhoid  fever,  19 
tuberculosis  of,  273 
Mesenterica,  tabes,  273,  310 
Mesentery,  hemorrhage  into,  905 
Mesocolon,  hemorrhage  into,  905 
Metallic  rales,  567 

tinkling,  297,  567 
Metastatic  abscesses,  199 
Meteorism  in  typhoid  fever,  64 
Micrococci  in  measles,  245 
Micrococcus  in  dengue,  167 
lanceolatus,  135 
melitensis  in  Malta  fever,  369 
ilicrocytes,  424 
Microcytosis,  419 
Micro-organisms  in  chorea,  1144 

in  rheumatic  fever,  203 
Middle  cerebral  arterv,  embolism  and  throm- 
bosis of,  illO 
ear,  disease  of,  in  measles,  247 
in  scarlet  fever,  239 
Migraine,  1142 

ophthalmique,  1044 
Miliary  abscesses  in  typhoid  fever,  20 
fever,  371 
tubercles.  288 

in  typhoid  fever,  38 
tuberculosis,  general,  275 
Milk  in  scarlet  fever,  235 
in  tuberculosis,  266 
in  typhoid  fever,  26 
poisoning  by,  1222 
Milk-curds,  702 
Milk-sickness,  370 
Mimic  spasm,  1043 
Mind-blindness,  1042 
Mind-deafness,  1122 
Miners'  cachexia,  1242 
lung,  535 

neoplasms  of  lung,  540 
nystagmus.  1043 
Mitchell,  Weir,  rest-cure  in  hysteria,  1173 
Mitral  incompetency,  607 

regurgitation  or  insufficiency,  607 

diagnosis      from     functional     mur- 
murs, 612 
mechanism  of,  608 
murmur  in,  610 
stenosis,  613 

chlorosis  and,  613 
chorea  and,  613 
murmur  in,  616 
pathology  and  etiology,  613 
physical  signs  in,  615 
presystolic  murmur  in,  616 
rheumatism  in,  613 
sphygmogram  of,  615 
symptoms  of,  614 
Moist  rales,  297 
Monoplegia  facialis,  1050 

hysteric,  1168 
Morbus  Addisonii,  454 


Morbus  cosse  senilis,  390.     (See  Arthritis  De- 
formans.) 
maculosus  neonatorum,  418 
Morphea,  1190 
Morphinism,  1215 

Mortality  in  cerebro-spiual  meningitis,  131 
in  pneumonia,  152 
in  small-pox,  225 
in  typhus  fever,  72 
in  whooping-cough,  255 
in  yellow  fever,  122 
Morvau's  disease,  1098 
Mosquitoes,  1263 

and  malarial  fever,  84 
relation  of,  to  tilaria  disease,  1247 
Motor  centers,  1021,  1022 
impulses,  course  of,  1026 
nerves  of  eyeball,  diseases  of,  1043 
oculi,  lesions  of,  1043 
paralysis  of,  1044 
spasm  of,  1043 
phenomena  in  neurasthenia,  1175 
system,  lesions  of,  1027 
Mountain  anemia,  1242 
fever,  67 
sickness.  67 
Mouth,  diseases  of,  694 
Month-breathing,  717 
Movable  kidney,  933 
diagnosis,  935 

dilatation  of  stomach  in,  934 
symptoms,  934 
treatment,  936 
Movement,  limitation  of,  in  eye-muscles,  1045 
Muco-pus,  occlusion  of  bronchioles,  483 
Mucous  membranes,  lesions   of,  in   svphilis, 

337 
Mulberry  calculi,  969 

Multiple  malignant   lymphoma,  444.      (See 
Pseudo-leulceinia.) 
neuritis,  1029 
sclerosis,  1091 
Mumps,  258.     (See  Parotitis.) 
Murmur,  Flint's,  605 
in  aneurysm,  687 
in  congenital  heart  disease,  676 
in  endocarditis,  590 
in  rachitis,  405 

in  subclavian  artery  in  phthisis,  295 
in  valvular  disease,  604,  607,  610,  616, 
619,  621,  622 
Murmurs,  hemic,  423-429 

myocardial,  651 
Musca  domestica,  1263 
Muscaria  amauita,  1225 
Muscidse,  1263 
Muscle,  diseases  of,  1196 
Muscle-trichinse,  1245 
Muscles,  electric  reaction  of,  Erb's  sign,  1157 

of  eye,  paralysis  of,  1045 
Muscular  atrophy,  1204 
arthritic,  1203 
progressive  neural,  1197 
progressive,  1202 

facio-scapulo-humeral  type,  1202 
infantile  type,  1202 
spinal,  1196 
pseudo-hypertrophic.  1199 
contractures,  hysteric,  1163,  1169 
cramp  in  dilatation  of  stomach,  746 
hypertrophy.  1204 
paralysis,  hereditary,  1203 
rheumatism,  362 


12«0 


INDEX. 


Muscular   sense   in    Brown-Sequard's   spinal 
paralysis.  lOSO 

wasting,  hysteric.  1169 

weariness  in  trichiuiasis,  1243 
Muscularis  progressiva,  dystrophia,  1202 
Musculo-spiral  nerve,  paralysis  of,  1063 
Mushroom-poisoning,  1225 
Music-faculty,  loss  of,  in  aphasia,  1224 
Musical  murmur,  611 
Mussel-poisoning,  1223 
Myalgia,  362.     (See  Muscular  Rheumatism.) 

cervical  is.  363 

lumbalis,  .363 
Mycosa  stomatitis,  701 
Mycosis,  intestinal,  3.54 
Mycotic  diarrhea,  800 
Mydriasis,  1044 

Myelin-droplets  of  Virchow,  480 
Myelitis,  acute.  1072 

chronic,  1074 

diagnosis.  1074 

diaphragmatic  breathing  in,  1073 

ditfuse,  1072 

disseminated,  1073 

girdle-feeling  in,  1073 

reflexes  in,  1073,  1075 

transverse,  1072 
Myelocytes,  442 
Myelogenic  leukemia,  437 
Myiases,  internal.  1263 

vulnerum.  1263 
Myocarditis.  650 

acute,  6-50 

circumscribed,  650 
diflfuse  interstitial,  650 
parenchymatous,  650 

angina  pectoris  in.  6.53 

cardiac  arrhythmia  in,  653 

chronic  or  fibrous,  651 

in  rheumatism.  203.  206 

in  syphilis,  339 

segmentaire,  21 
Myocardium,  diseases  of,  650 

lesion  of,  due  to  di-seases  of  the  coronary 
arterv,  655 
Myosis,  1043 

spinal,  1045 
Myositis,  infectious,  1195 

progressive  ossifying,  1196 
Myotonia  congenita.  1204 
Myotonic  contraction.  1205 
Mytilotoxin,  1223 
Myxedema.  4<i2 

associated  with  cretinism,  465 

operative.  465 

pathogenesis,  462 

treatment  of,  by  thvroid-feeding,  464 

true.  462 

varieties,  462 
Myxoma  in  intracranial  growths,  1125 

N.\ILS  in  typhoid  fever,  :J3 
Nasal  catarrh,  acute,  467 
chronic,  468 

diphtheria.  185 
Necrosis,  anemic,  6.55 

in  tubercle,  262 
Necrotic  tonsillitis,  714 
Nematodes,  1239 

uncommon,  12.50 
Neoplasms  of  bladder.  1011 
Nephrectomy,  936 
Nephritides,  the,  959 


Nephritis,  acute  parenchymatous,  974 

cardiac  hypertrophy   in   chronic   inter- 
stitial, 989 
chronic  interstitial,  985 

parenchymatous,  981 
complicating  the  infectious  fevers,  978 
complications,  990 
definition,  974 
diagnosis,  978 
diet  in  treatment,  980 
dropsy  in,  961 
edema  in,  977 
etiology,  976 
glomeruli  in,  975 
hemorrhagic,  975 
hygiene  and  diet  in  treatment  of  acute, 

979 
interstitial  changes  in  acute,  975 
large  white  kidney  in  chronic,  981 
lymphomatous,  of  Wagner,  43 
of  pregnancy.  978 

pale,  granular  kidney  of  chronic,  982 
pathology.  974 
prognosis,  979 
suppurative,  993 
symptoms,  976 
treatment,  979 
tube-casts  in.  9.59,  977 
tabular  changes  in  acute,  974 

in  chronic  interstitial,  986 
uremia  in,  962.  978 
urine  in,  977,  9»3,  988 
Nephrolithiasis,  968 
Nephroptosis,  933 
Nephrorrhaphy,  936 
Nephro-typhoid,  43 
Nerves,  auditory,  1051 
brachial  plexus,  1062 
cervical  plexus,  1062 
fifth,  1047 
fourth,  1045 
glosso-pharygneal,  1054 
hypoglossal,  1060 
lumbar  and  sacral  plexuses.  1064 
of  eyeball  i  motor  i,  diseases  of,  1043 
peripheral,  diseases  of,  1028 
pneumogastric,  1054 
seventh,  1048 
sixth,  1045 
spinal  accessory,  1058 

diseases  of,  1062 
third,  1043 
Nervous  dyspepsia,  779 

system,  diseases  of,  1017 

function  of  cerebrum,  1025 

general    and  toi)ical,    diagnosis    of, 

1026 
histology  of.  1017 
lesions  of,  1026 
localizjition  of  functions  of  segments 

of  spinal  cord,  1023 
tumors  of.  1032 
Nettlcrash.     (.See  Urticaria.} 
Neural  progressive  muscular  atrophy,  1197 
Neuralgia.  10.33 

cervico-brachial.  10.36 
cervico-occipital,  1035 
femoral  or  crural,  1036 
intercostal,  1036 
lumbo-abdominal,  103'"i 
mastodynia.  l(i.T) 
obturator,  1036 


INDEX. 


1281 


Neuralgia  of  extremities,  1035 

of  genitalia  and  rectum,  1037 

of  neck  and  trunk,  1035 

phrenic,  1035 

treatment,  1036 

trigeminal,  1034 

visceral,  1037 
Neurasthenia,  1174 

diagnosis  from  hysteria,  1176 

etiology,  1174 

lithemic,  1176 

motor  phenomena,  1175 

psychic  symptoms  in,  1175 

rest-cure  in,  1178 

sensory  disturbances  in,  1175 

symptomatic,  1174 
Neuritis,  1028 

alcoholic,  1029 

arsenical,  1030 

diffuse,  1028 

focal,  1028 

in  diphtheria,  186 

interstitial,  1028 

lipomatous,  1028 

malarial,  1030 

multiple,  1028 

reflexes  in   1030 

optic,  1040 

recurring  multiple,  1030 

rheumatic,  1028 

spontaneous  or  idiopathic,  1030 
Neurogliar  hyperplasia,  1130 

tissue,  1124 
Neuromata,  1032 
Neurons,  1013 
Neuroses,  occupation-,  1161 

of  bladder,  1012 

of  intestine,  842 

disturbances  of  motility,  845 
secretory  disturbances,  842 
sensory  disturbances,  843 

of  micturition,  1014 

of  stomach,  779.     (See  Stomach.) 

of  the  heart,  663 
Neutrophiles,  442 
Night-blindness,  1039 

in  scurvy,  409 
Night-sweats  in  phthisis,  299 
Nipple,  Paget's  disease  of,  1236 
Nits,  1261 

Nodosities,  Heberden's,  390 
Noma,  703.     (See  Gangrenous  Stomatitis.) 

pudendffi,  714 
Normoblasts,  430 
Nose,  diseases  of,  476 
Nose-bleed,  472.     (See  Epistaxis.) 

in  typhoid  fever,  27,  38 
Nutmeg-liver,  887   (See  Cirrhosis  of  Liver. 
Nyctalopia,  1040 
Nystagmus,  bilateral,  1087 

in  insular  sclerosis,  1092 

paralytic,  1045 

Obesity,  1226 

treatment,  1228 
Oertel's,  1229 

Obstruction,  intestinal,  828 

acute,  and  varieties,  828 
chronic,  and  varieties,  829 

Occupation-neuroses,  1161 

Oculo-motor  palsy,  1043 

Oligemia,  419.     (See  Anemia.) 

Oligochromemia,  419.     (See  Anemia.) 

Oligocythemia,  419.     (See  Anemia.) 

81 


Oliver's  sign,  689 

Omentum,  new  growths  in,  930,  931 

tuberculosis  of,  309 
Omodynia,  364.     (See  Muscular  Rheumatism.) 
Onomatomania,  1153 
Onychia  in  arthritis  deformans,  .3H0 

syphilitic,  331 
Ophthalmic  migraine  of  Charcot,  1044 
Ophthalmoplegia,  1046 
Opium-inebriety,  1214.     (See  Morphinism.) 
Opiumism,  1214 
Opium-poisoning,  differential  diagnosis  from 

uremia,  966 
Oppolzer's  sign,  578 
Optic  atrophy,  1042 

nerve  and  tract,  diseases  of,  1039 

neuritis,  1040 

in  abscess  of  brain,  1114 
in  Bright's  disease,  984 
in  tuberculous  meningitis,  281 
in  tumor,  1125 
Optic-nerve  atrophy    in    locomotor    ataxia, 

1083 
Orchitis  in  parotitis,  259 

interstitial,  in  syphilis,  340 

in  tuberculosis,  313 

in  typhoid  fever,  43 
Oriental  plague,  169 
Osteitis  deformans,  1181 
Osteo-arthropathy,  hypertrophic  pulmonary, 

of  Marie,  il81 
Osteo-myelitis,  acute,  diagnosis  from  rheu- 
matism, 209 
Otitis  media  in  scarlatina,  239 
Ovaries,  tuberculosis  of,  314 
Oxaluria,  954  • 

Oxyuris  vermicularis,  1243 
Oysters,  poisoning  by,  1223 

typhoid  bacilli  conveyed  by,  26 
Ozena,  bacillus  mucosis  as  a  cause  of,  469 

Pachymeningitis,  1067 

externa  and  interna,  1104 

hsemorrhagica,  extra-dural,  1104 

internal  hemorrhagic,  1104 
Palate,  paralysis  of,  in  diphtheria,  186 

tuberculosis  of,  305 
Palpitation  of  heart,  663 
Palsies,  cerebral,  of  childhood,  1133 
Palsy,  lead,  1030 
Paludism.     (See  Malarial  Fever.) 
Pancreas,  calculi  of,  913 

carcinoma  of,  910 

cyst  of,  912 

diseases  of,  905 

hemorrhage  of,  909 

lesions  of,  in  diabetes,  375 

tumors  of,  912 
Pancreatic  cyst,  912 
Pancreatitis,  acute,  905 

chronic,  908 

fat-necrosis  in,  905 

gangrenous,  908 

hemorrhagic,  905 

suppurative,  907 
Paralysis,  acute  ascending  (Landry's  palsy), 
1065 

after  diphtheria,  186 

agitans,  1155 

alcoholic,  1029 

Bell's,  1050 

bulbar,  acute,  1094 
chronic,  1094 

crossed,  1117 


1282 


INDEX. 


Paralysis,  crutch-,  1063 

divers',  1182 

general,  of  insane,  1131 

hysteric,  1168 

in  cerebro-spinal  meningitis,  1128 

infantile,  1133 

in  lateral  sclerosis,  1088 

in  locomotor  ataxia,  1083 

in  progressive  muscular  atrophy,  1198 

of  brachial  plexus,  1062 

of  circumflex  nerve,  1063 

of  diaphragm,  1062 

of  facial  nerve,  1050 

of  fifth  nerve,  1047 

of  fourth  nerve,  1045 

of  hypoglossal  nerve,  1060 

of  larynx,  1055 

of  median  nerve,  1063 

of  musculo-spiral  nerve,  1063 

of  oculo-motor  nerve,  1043 

of  olfactory  nerve,  1037 

of  recurrent  laryngeal  nerve,  1055 

of  sixth  nerve.  1045 

of  tliird  nerve,  1043 

of  ulnar  nerve,  1064 

of  vocal  cords,  1055 

of  paroxysmal  family,  1163 

periodic,  1163 

pseudo-hypertrophic  muscular,  1199 

radial,  1064 

sleep-,  1063 
Paralytic  thorax,  293 
Paramyoclonus  multiplex,  1148 
Paraphasia,  1226 
Paraplegia,  ataxic,  1089 

congenital,  1089 

from  ergotism,  1224 

from  tumors  of  the  cord,  1101 

hysteric,  1168 

in  tabes,  1083 

intermittent,  1691 

pellagra,  1225 

reflex,  1091 

spastic,  1089 

sj'philitic.  334 
Parasites,  animal,  diseases  due  to,  1236 

of  heart,  662 
Parasitic  arachnida,  1260 

gastritis,  750 
Parkinson's  disease,  1257 
Parosmia,  1038 

Paroxysmal  family  paralysis,  1 163 
Parotitis,  259 

chronic,  711 

complications  and  sequela\  259 

contagiousness  of,  258 

duration,  259 

epidemic,  258 

facial  paralysis  in,  260 

immunity  in,  259 

in  lobar  pneumonia,  147 

in  typhoid  fever,  37 

pathology,  258 

symptomatic.  710 

treatment,  2()0 
Paroxysmal  hemoglobinuria,  941 
Parrot's  ulcers,  701 
Pediculosis,  1261 
Pediculus  capitis,  1261 

corporis,  1261 

pubis,  1262 
Peliomata  typhosa  (taches  bleuatres),  33 
Poliosis  rheumatica,  413.    (See  Arthritic  Pur- 
pura.) 


Pemphigus  neonatorum,  331 
Pentastoma  tsenioides.  1260 
Peptones  in  the  urine,  tests  for,  945 
Perforation  of  bowel  in  dysentery,  102 

in  typhoid  fever,  35 
Peri-arteritis  nodosa,  694 
Pericarditis,  575 

acute  plastic  or  fibrinous,  575 

adhesive,  584 

callosa,  585 

chronic,  584 

diagnosis  from  acute  pleurisy,  582 
from  cardiac  dilatation,  582 

hemorrhagic,  584 

hyperpyrexia  in,  581 

in  rheumatism,  206 

pulsus  jiaradoxus  in  sero-fibrinous,  .579 

purulent,  583 

sero-fibrinous,  578 

tuberculo-mediastinal,  577 

varieties  of,  575 
Pericardium,  diseases  of,  575 

dropsy  of,  565 

tuberculosis  of,  308 
Perichondritis,  larvugeal,  in  tvphoid  fever, 

38 
Perihepatitis,  acute,  875 

chronic,  877 
Periuephritic  abscess,  899 
Peripancreatitis.  905 
Perisplenitis,  902 
Peristaltic  unrest,  784,  1170 
Peritoneum,  carcinoma  of,  930 

diseases  of,  914 

new  growths  in,  930 

tuberculosis  of,  309 

tumors  of.  932 
Peritonitis,  acute.  914 

adhesive,  924 

cancerous,  924 

chronic,  923 

hemorrhagic,  923 
tuberculous,  923 

circumscribed.  918 

hysteric.  720 

in  children,  918 

in  typhoid  fever,  35 

leukemic,  440 

localized  or  partial,  918 

proliferative,  923 

saline  treatment  of,  922 

svmptoms  of  general,  916 
PeritVphlitis,  813 
Perlicher,  703 
Pernicious  ansemia,  426 

malaria,  87 
Pertussis,  251.     (See  Whooping-cough.) 
Pettis  major,  170 

minor,  170 

siderans.  170 
Petit  mal.  1139 

Peyer's  patches  in  typhoid  fever,  17 
Pfeifier  serum-reaction,  113 
Phagocytosis  in  erysipelas,  172 

in  tuberculosis,  262 
Pharyngitis,  acute,  720 

chronic,  722 

herpetic,  720 

membranous,  721 
Pharyngocele,  731.     (See  Esophageal  Divertic- 
ulum.) 
Pharynx,  acute  infectious  phlegmon  of,  723 

diseases  of,  720 

inflammatory  edema  of,  724 


INDEX. 


1283 


Pharynx,  tuberculosis  of,  305 
Phosphaturia,  955 
Phosphorus-poisouiug,  liver  in,  885 
Phrenic  nerve,  diseases  of,  1062 
Phthiriasis,  1261 

Phthisis,  acute  broncho-pneumonic,  in  chil- 
dren, 285 

acute  pneumonic,  282 

chronic  ulcerative,  285 

course  of  acute  pneumonic,  284 

diagnosis  of  acute  pneumonic,  284 

fibroid,  302 

pathology  of  acute  pneumonic,  282 

stone-cutters'.  536 

subacute  cases,  284 

symptoms  of  acute  pneumonic,  283 
Pia  mater,  diseases  of,  1105 
Pica,  422 

Pigeon-breast  in  rickets,  405 
Pigmentation   of  skin,   454.     (See  Addison's 

Disease.) 
Pin-vrorms,  1240 

Pituitary  body  in  acromegalia,  1179 
Pityriasis  versicolor,  301 
Plague,  bacillus  of,  169 

bubonic,  169 

clinical  history  of,  170 

diagnosis,  171 

etiology,  169 

prognosis,  171 

treatment,  171 
Plague-pneumonia,  170 
Plasmodium  malarise.     (See  Malaria.) 
Pleura,  diseases  of,  541 

new  growths  in,  570 
Pleurisy,  541 

acute  plastic,  541 

aspiration  in,  557 

Baccelli's  sign  in,  559 

bacteriology  of.  541 

chronic,  562 

diagnosis  from  lobar  pneumonia,  553 

diaphragmatic,  551 

diet  in.  556 

egophouy  in,  549 

encysted,  551 

hemorrhagic,  552 

in  scarlet  fever,  239 

interlobar,  551 

pulsating,  660 

diagnosis  from  aneurysm,  689 

purulent,  558.     (See  Empyema.) 

sero-fibrinous,  544 

Skoda's  resonance  in,  549 

tuberculous,  550 

varieties  of  acute  sero-fibrinous,  550 

■with   effusion,   544.       (See    Sero-fibrinoiis 
Pleurisy.) 
Pleurodynia,  363.  (See  3fuscular  Rheumatism.) 
Plica  polonica,  1261 
Plumbism,  1217 

prevention  of,  1219 
Pneumatinuria,  958 
Pueumogastric  nerve,  branches  of,  1055-1057 

diseases  of,  1054 
Pneumonia,  abortive  treatment  of,  155 

abscess  of  the  lung  in,  134 

auti-pneumococcic  serum  in,  156 

bacteriology  in,  1.35 

blood  in.  142 

catarrhal,  514 

causes,  135 

cerebral  symptoms,  143 


Pneumonia,  chronic  interstitial,  150,  510 

circulatory  symptoms,  142 

complications  of,  145 

crisis  in,  142 

cutaneous  symptoms  of,  143    • 

delayed  resolution  in,  149 

diagnosis,  150 

from  acute  pneumonic  phthisis,  150 

from  meningitis,  152 

from  typhoid  pneumonia,  152  ' 

diet  in,  154 

diflferential  diagnosis,  150 

duration,  149 

endocarditis  in,  146 

epidemic.  14S 

epidemic  influence  in,  136 

ether-,  149 

gangrene  of  the  lung  in,  134 

gray  hepatization  in,  134 

heart-clots  in,  147 

hydrotherapy  in,  155 

hypostatic,  502 

immunity  from,  138 

in  children,  148 

in  diabetes,  381 

inhalation-,  516 

in  influenza,  163 

in  the  aged,  148 

jaundice  in,  147 

latent,  148 

lobar,  1.32 

local  measures  in,  157 

meningitis  in,  147 

micro-organism  of,  135 

migratory,  148 

mode  of  infection,  135 

modes  of  death  in,  153 

mortality  of.  152 

neuritis  in,  148 

pathology,  133 

pericarditis  in.  146 

physical  signs,  144 

pleurisy  in,  145 

preventive  inoculations  in,  138 

prodromal  symptoms,  138 

prognosis,  152 

purulent  infiltration  of  the  lung  in,  134 

red  hepatization  in,  133 

relapses  in.  149 

resolution  in,  134 

secondary,  1.57 

special  symptoms,  139 

sputum  in,  140 

stage  of  engorgement  in,  133 

symptoms,  133 

syphilitic,  337 

temperature-chart  of  lobar,  141 

terminations,  142 

treatment,  1.54 

typhoid,  148 

urine  in,  144 

venesection  in.  1.55 
Pneumonokoniosis,  535 
Pneumopericardium,  587 
Pneumorrhagia,  510 
Pneumothorax,  564 

bell-tympany  in.  567 

diagnosis  from  large  pleural  cavity,  569 
from  large  pulmonary  cavity,  568 

dyspnea  in  565 

etiology.  564 

Hippocratic  succussion  in,  567 

metallic  tinkling  in,  567 


1284 


INDEX. 


Pneumotoxin,  138 
Piieumotyphoid,  38 
Podagra,  392.     (See  Gout.) 
Poikilocytosis,  419.     (Seo  Anemia.) 
Poisoning  by  milk  and  meat,  1222,  1223 
Polioencephalitis,  acute,  1114 

of  Striimpell,  1133 
Poliomyelitis,  acute,  1078 

anterior,  1076 

chronic,  1078 

subacute,  1078 
Polyphagia,  788 

Polysarcia  adiposa,  1225.     (See  Obesity.) 
Polyuria,  38.5.     (See  Diabetes  Insipidus.) 
Pons,  tumors  of,  1127 
Porencephalia  of  Hesche,  1125 
Portal  vein,  stenosis  of,  870 

suppurative  pylephlebitis,  868 
thrombosis  and  embolism  of,  867 
Post-epileptic  phenomena,  1140 
Post-hemiplegic  chorea,  1151 
Post-typhoid  elevations  of  temperature,  32 
Pott's  disease  in  compression  of  cord,  1099 
Presystolic  murmur,  605,  616 
Priapism  in  leukemia,  440 
Proctitis,  797 
Profeta's  law,  328 
Progressive  hemiatrophy  of  the  face,  1187 

ossifying  myositis,  1196 

pernicious  anemia,  426 

arsenic    and     bone-marrow    in 

treatment  of,  432 
blood  in,  430 
diagnosis,  430 
lesions  of,  427 

spinal  muscular  atrophy,  1196 
Prostate,  tuberculosis  of,  313 
Protozoa,  1236.     (See  Psorospermiasis.) 
Pseudo-angina  pectoris,  673 
Pseudo-apoplectic  attacks  in  fatty  heart,  657 
Pseudo-bulbar  paralysis,  1095 
Pseudo-cyesis,  1168 
P.seudo-diphtheria,  179 
Pseudo-hydrophobia,  357 
Pseudo-hypertrophic      muscular     paralysis, 

1200 
Pseudo-leukemia,  444 
Pseudo-sclerosis,  1094 
Psilosis,  H()6 
Psorospermiasis,  1237 
Ptosis,  1044 
Ptyalism,  709 
Pulex  irritans,  1262 

penetrans,  1262 
Pulmonary  apoplexj',  510 

atelectasis,  581 

diagnosis  from  pleuritic  effusion,  523 
physical  signs,  522 

edema,  .503 

embolism,  510 

hemorrhage,  504 
etiology,  505 
treatment,  508 
varieties  not  due  to  phthisis,  507 

incompetency,  621 

regurgitation,  621 

stenosis,  622 
Pulse,  capillary,  Quincke's,  603 

Corrigan's,  603 
Pulse-tracings,  604,  606,  615 
Pulsus  alterans,  669 

paradoxus.  579 
PuTsns  fjuadrigeminus,  670 

trigeminus,  670 


Puncture,  lumbar,  1069,  1105 
Pupil,  Argyll-Robertson,  1083 
Purpura,  412 

arthritic,  413 

factitious,  414 

fulminans,  414 

hsemorrhagica,  414 

Henoch's,  414 

idiopathic,  412 

pemphigoid,  413 

prognosis,  415 

secondary,  412 

simplex,  412 

treatment,  415 
Pustule,  malignant,  352.     (See  Anthrax.) 
Pyelitis,  993 

calculous,  994 

infectious,  994 

obstructive,  994 

patbolog}',  993 

pyuria  in,  995 
Pyelonephritis,  993.     (See  Pyelitis.) 
Pyemia,  199 

abscesses  in,  199 

bacteriology,  199 

diagnosis  from  septicemia,  202 

pathology,  199 

paths  of  infection  of  the  body  in,  200 

spontaneous,  200 

temperature  in,  201 

treatment,  202 

ulcerative  endocarditis  in,  201 
Pylephlebitis  in  appendicitis,  815 

in  dysentery,  102 
Pylorospasm.  784 

Pylorus,  hypertrophic  stenosis  of,  778 
Pyonephrosis,  993 
Pyo-pneumotiiorax,  564.    {Sue  Pneumothorax.) 

subphrenicus,  875.     (See  Acute  Perihepa- 
titis.) 
Pyuria,  946,  995 

in  cystitis,  1008 

Quartan  parasites,  83 

Quinine  as  a  specific  in  malaria,  94 

hydrobromate    Jiypodermically   in   ma- 
laria, 95 
Quinsy,  713.     (See  Tonsillitis.) 
Quotidian  intermittent  fever,  83 

Rabies,  355.     (See  Hydrophobia.) 

preventive  inoculation  in,  357 
Rachitic  rosary,  405 
Rachitis,  402 
Radial   paralysis,    1063.     (See  Musculo-spiral 

Paralysis.) 
Rag-pickers'  disease,  354 
Railroad  spine,  1166 
Rainey's  tube,  1236 
Ray-fungus,  350.     (See  Actinomyces.) 
Raynaud's  disease,  1185 

clinical  grades,  1186 

diagnosis  of,  1186 

hysteric,  1185 

paroxysmal  hemoglobinuria  in,  1186 
Reaction  of  degeneration  in  anterior  polio- 
myelitis, 1078 

in  (rhronic  myelitis,  1076 

in  neuritis,  1029 

in    progressive     muscular    atrophy, 
1096.     (See  Myelopathic.) 
Recrudescence  of  fever  in  typhoid  fever,  32 
Rectum,  syphilis  of,  337 


INDEX. 


1285 


Eectum,  tuberculosis  of,  306 

Eecurrent    laryngeal    nerve,    paralysis    of, 

1056 
Eecurring  multiple  neuritis,  1030 
Eed  softening  of  brain,  1109 
Eeduplicatiou  of  heart-sounds,  670 
Eeichniann's  disease,  783 
Eelapse  in  typhoid  fever,  51 
Eelapsing  fever,  73 
causes,  74 

clinical  varieties,  76 
history,  73 
pathology,  73 
spirillum  of,  74 
Eemittent  fever,  89 
Een  mobilis,  933 
Eenal  colic,  968 

tuberculosis,  312 
Eespiratory  system,  diseases  of,  467 
Eest-cure  in  hysteria,  1178 
Eetina,  diseases  of,  1039 
Eetinitis,  albuminuric,  1038 

leukemic,  440 

pigmentarv,  1039 

syphilitic, 'l039 
Eetroperitoneal  sarcomata,  932 
Eetropharyngeal  abscess,  724 
Ehabdomyoma  of  kidney,  1004 
Ehagades,  331 
Eheumatic  fever,  202 

gout,  387.     (See  Arthritis  Beformaiis.) 

myositis,  364 

nodules,  subcutaneous,  207 

peliosis,  411 
Eheumatism,  acute  articular,  202 

bacteriology,  203 

blood  in,  203 

chronic  articular,  366 

complications,  206 

diagnosis,  209 

differential,  209 

duration,  205 

endocarditis  and  pericarditis  in,  206 

gonorrheal,  209 

immunity  in,  204 

in  children,  209 

joints  in,  205 

local  measures  in,  213 

monarticular,  205 

muscular,  363 

treatment,  365 

pathology,  203 

subacute,  213 

symptoms,  204 

temperature  in,  207 

treatment,  211 
Eheumatoid   arthritis,   387.      (See    Arthritis 

Deformans.) 
Ehinitis,  acute,  467 

atrophica,  468 

chronic,  468 

hypertrophica,  468 

simplex,  467 

syphilitica,  331 
Eibs,  resection  of,  in  empyema,  561 
Eice-water  stools,  113 
Eickets,  402.     (See  Eachitis.) 

etiologv,  403 

"  fat-rickets,"  406 

Harrison's  groove  in,  405 

prophvlaxis,  406 
Eock-fever,  368.     (See  Malta  Fever.) 
Eomberg's  sign,  1083 


Eoot-nerve  symptoms   in  compression-para- 
plegia, 1099 
"Eose-cold,"'  471 
Eose-spots,  32 

Eotheln,  248.     (See  PMhella.) 
Eound  worms,  1234 
Eubella,  248 

Eubeola  notha,  246.     (See  Rubella.) 
Eumination,  784 
Eupture  of  heart,  661 
of  spleen,  905 

Sacchaeomyces  albicans,  701 
Sacral  plexus,  diseases  of,  1064 
Salaam  convulsions  in  hysteria,  1168 
Salad,  chicken,  poisoning  by,  122.3 
Saline  infusion  in  typhoid  fever,  65 

injections,  intravenous,  in  diabetic  coma, 
385 

subcutaneous,  in  cholera,  118 
in  lobar  pneumonia,  155 
Salivary  glands,  diseases  of,  709 
Salivation,  705 

in  bulbar  paralysis,  1095 
Saltatoric  spasm,  1154.     (See  Spasm.) 
Sanatorium  treatment  of  tuberculosis,  322 
Sand-flea,  1262 
Sanitaria,  home,  322 
Sapremia,  195.     ( See  Septicemia.) 
Saranac  sanitarium,  322 
Sarcina  ventriculi,  745 
Sarcoma,  mediastinal,  572 
melanotic,  900 
of  bladder,  1011 
of  brain.  1124 
of  kidney,  1004 
of  liver,  900 
of  lung,  539 
of  pleura,  570 
Sarcoptes  scabiei  hominis,  1261 
Sardonic  grin,  360 
Saturnine  encephalopathy,  1219 

neuritis,  1030 
Saturnism,  1216 
Sausage-poisoning,  1223 
Scarlatina,  234.     (See  Scarlet  Fever.) 
Scarlatinal  svnovitis,  239 
Scarlet  fever,  234 

angiuose  form,  238 

atactic  form,  238 

causes,  235 

complications,  239 

desquamation  in,  239 

diagnosis,  241 

eruption  in,  236 

"goose-skin  "  in,  236 

hemorrhagic,  238 

immunity  in,  236 

incubation-period,  236 

infection  in,  235 

invasion  of,  236 

joint-affections  in,  239 

lesions  in,  234 

malignant,  238 

micro-organisms  in,  234 

mild  form,  238 

modes  of  conveyance  in,  235 

nephritis  in,  239 

otitis  in,  239 

prognosis,  242 

prophylaxis  against  nephritis,  244 

pulse  in,  237 

pyemia  in,  239 


1286 


INDEX. 


Scarlet  fever  sine  eruptione,  238 
synovitis  in,  239 
temperature  in,  237 
tongue  in,  237 
tonsils  in,  236 
treatment,  242 
urine  in,  237 
Schlammfieber,  367 
Schoulein's    disease.     (See    Rheumatic    Peli- 

osis.) 
"Schweinfurth's"  green,  1219 
Sciatic  nerve,  1064 
Sciatica,  1036 

Scleroderma  diffusam,  1189 
Sclerosis,  amyotrophic  lateral,  1095 

arterial,  678 

caused     bv    ergotism — "  ergot     tabes," 
1224 

caused  by  syphilis,  333.     (See  also  Loco- 
motor Ataxia.) 

combined  system,  1090 

lateral,  1087 

multiple  or  disseminated,  1091 

of  brain,  1130 

of  pulmonary  artery,  679 

of  veins,  679 

posterior,  1081 
Sclerotic  changes  in  chronic  gastritis,  755 
Scolices  of  echinococcus,  1251 
Scorbutus,  407 

diagnosis,  410 

dietetic  treatment,  410 

infantile,  411 
Scriveners'  palsy,  1161.  (See  Writers'  Cramp.) 
Scrofula,  271.      (See   Tuberculosis  of  Lymph- 
glands.) 
Scrotal  appendicitis,  815 
Scurvy,  407.     (See  Scorbutus.) 
Seasonal  relations  of  erysipelas,  172 
of  "malaria,  81 
of  pneumonia,  137 
of  rheumatism,  204 
Secondary  fever-curve  in  small-pox,  220 

spastic  paralysis,  1089 

emphysema,  531 

kidney,  991 
"Sepsis  intcstinalis,"  196 
Septicemia,  195 

bacteriology,  195 

coagulation-necrosis  in,  195 

diagnosis  from  saj)remia.  198 

modes  of  infectioia  and  introduction  of 
the  poison  into  the  system,  196 

pathology,  195 

ptomains  in,  195 

symptoms,  197 

treatment,  198 

true,  198 

typhoid,  27 
Septicopyemia,  202 

Serous  membranes,  tuberculosis  of,  .307 
Serum,  antipncumococcic,  156 

antistreptococcic,  177 
Serum-diagnosis  of  typhoid  fever,  46 

of  yellow  fever,  122 
Serum-reaction,  Pfcitfer's,  113 
Sewer-gas,  relation  of,  to  typhoid  fever,  26 
Shaking  palsy,  1154.     (See  Paralysis  Agitars.) 
Shell-fish,  poisoning  by,  1223. 
Ship  fever.     (See  Ti/phus  Fever.) 
Sick  headache,  1142.     (See  3Ii(iraiiK.) 
Siderosis,  537.     (See  Pneumonokoniosis.) 
Simple  continued  fever,  369.    (See  Febricula.) 


Sinus-thrombosis,  1110 
in  chlorosis,  423,  1110 
secondary  to  ear-disease,  1110 
Sixth  nerve,  paralysis  of,  1045 
Skoda's  resonance  in  lobar  pneumonia,  145 

in  sero-fibrinous  eftusion,  549 
Skull  in  external  hydrocephalus,  1128 
in  internal  hydrocephalus,  1128,  1129 
in  rickets,  403 

natiform,  in  congenital  syphilis,  331 
Small-pox,  215 

abortive  form,  223 
bacteriology,  217 
causes,  217 
complications,  219 
confluent  form,  222 
contagion  of,  217 
diagnosis,  223 
eruption  of,  219 
hemorrhagic  form,  222 
immunity  in,  217 
incubation  of,  218 
initial  rashes  in,  218 
mortality  and  prognosis,  225 
prophylaxis  in,  225 
secondary  lesions  in,  216 
special  modes  of  treatment,  228 
symptoms,  219 
treatment,  225 
Snake-virus,  purpura  caused  by,  412 
Snuffles,  331 

Soil,  influence  of.  in  cholera,  111 
in  malaria,  79 
in  tuberculosis,  270 
in  typhoid  fever,  24 
Southern  California  in  tuberculosis,  321 
Southern  Georgia,  .321,  322 
Southern  Italy  and  France,  322 
Spasm,  habit-,  1152 
in  ergotism,  1224 
in  hvdrophobia,  356 
in  hysteria,  1167,  1168,  1169 
mimic,  1048 
of  the  intestine,  845 
retro-colic,  10.59 
saltatoric,  1154 
tonic,  in  tetanus,  360 
Spasmodic  laryngitis,  477 
Spastic  paraplegia,  1087 
congenital,  1089 
family  tendency  in,  1088 
Speech,  1120.     (See  Apha.tia.) 

in  general  i)aralysis  of  insane,  1131 
in  hereditary  ataxia,  1086 
loss  of,  in  bulbar  paralysis,  1094 
scanning,  in  multiple  sclerosis,  1092 
Spina  bifida  in  lesions  of  cauda  equina,  1103 
Spinal  accessory  nerve,  paralysis  of,  1060 
compression,  1098 
cord,  abscess  of,  1078 

compression  of,  1098 
diseases  of,  1065 

disturbance  of  circulation  in,  1070 
hemorrhage  into,  1071 
localization  of  functions  of,  1023 
syphilis  of,  3.34 
tuberculosis  of,  315 
tumors  of,  1100 
unilateral  lesion  of,  1079 
membranes,  hemorrhage  into,  1069 
meningitis,  acute,  1068 
nerves,  diseases  of,  1062 
neurasthenia,  1176 


INDEX. 


1287 


Spirals,  Curscliinann's,  495 
Spirillum  of  relapsing  fever,  74 
Splanchnoptosis,  792 
Spleen,  amyloid  degeneration  of,  904 

diseases  of,  901 

dislocation  of,  901 

ecliinococcus  of,  1255 

floating,  901 

hyperemia  of,  901 

in  anthrax,  353 

in  cirrhosis  of  liver,  891  . 

in  malaria,  80,  91 

in  pseudo-leukemia,  447 

in  rickets,  406 

in  typhoid  fever,  20,  28 

in  typhus  fever,  70 

morbid  growths  of,  904 

rupture  of,  905 

sago,  904 
Splenic  anemia,  450 

fever,  352.     (See  Anthrax.) 

pseudo-leukemia,  443 
Splenitis,  901 

Spondylitis  deformans,  390 
Sporadic  cretinism,  462.     (See  Ilyxedema.) 
Spotted  fever,  124.     (See  Cerehro-spinal  Men- 
ingitis.) 
Sprue,  806 

Spurious  relapse  in  typhoid  fever,  51 
Sputa,  amceba  coli,  103,  881 

in  abscess  of  lung,  535 

in  acute  bronchitis,  482 

in  asthma,  495 

in  bronchiectasis,  490 

in  cancer  of  lung,  538 

in  chronic  bronchitis,  486 

in  chronic  pulmonary  tuberculosis,  290 

in  edema  of  lung,  503 

in  fetid  bronchitis,  486 

in  gangrene  of  lung,  533 

in  lobar  pneumonia,  140 
St.  Anthony's  fire.     (See  Erysipelas.) 
St.  Vitus's  dance,  1144.     (See  Chorea.) 
Status  eclampticus,  1160 

epilepticus,  1140 
Stellwag's  sign,  459 

Stenocardia,  671.     (See  Angina  Pectoris.) 
Stenosis,  bronchial,  493 

of  aortic  orifice,  605 

of  mitral  orifice,  613 

of  pylorus,  hypertrophic,  778 

pulmonary,  622 

tricuspid,  620 
Stomach,  auscultation  of,  742 

carcinoma  of,  771 

chemical  examination  of  contents,  736 

dilatation  of,  744 

diminished  peristalsis  of,  784 

diseases  of,  735 

hemorrhage  of,  778 

hyperacidity  of,  782 

hyperesthesia  of,  787 

increased  peristalsis  of,  784 

inflammatory  diseases  of,  749 

malposition  of,  743 

neuroses  of,  779 

of  motility  of,  784 
of  secretion  of,  782 
of  sensation  of,  786 

palpation  of,  741 

percussion  of,  742 

physical  or  external  examination  of,  740 

test  for  absorptive  power  of,  740 


Stomach,  test-meals  used  in  diagnosis,  736 

tests  for  motor  function  of,  739 

ulcer  of,  763 
Stomatitis,  695 

aphthous,  696 

gangrenous,  703 

La  Perleche,  703 

membranous,  698 

mercurial,  705 

neurotica  chronica,  700 

parasitic,  701 

ulcerative,  699 
Strabismus,  1045 
Strangulation  of  bowel,  828 
"  Strawberry  tongue  "  in  scarlet  fever,  237 
Stricture  of  esophagus,  732 
Strictures  and  tumors  of  bowel,  830 
Strongyloides  intestinalis,  1250 
Strumitis,  455.     (See  Thyroiditis.) 
Styrians,  arsenical  habit  in,  1220 
Subphrenic  abscess,    568.     (See   Acute  Peri- 
hepatitis.) 
Succussion,  Hippocratic,  567,  568 
Sudoral  form  of  typhoid  fever,  33 
Sugar  in  the  urine,  374.     (See  Diabetes  3Iel- 

litus.) 
Suu-sti-oke,  1230.     (See  Heat-stroke.) 
Suppurative  pneumonitis,  534.     (See  Abscess 
of  Lungs.) 
pylephlebitis,  868 
Surgical  kidney,  994 
Swamp-fever.     (See  Malaria.) 
Sweating  sickness,  371.     (See  Miliary  Fever.) 
Sydenham's  chorea,  1144.    (See  Acute  Chorea.) 
Symptom-complex  of  Brown-Sequard,  1101 
Syncope,  local,  in  Eaynaud's  disease,  1186 
Synovitis,  gonorrheal,  213 
Syphilis,  326 

amyloid  degeneration  in,  330 

bacteriology  of,  327 

brain  tumor  in.  334 

Colles'  law  in,  328 

contagion  of,  328 

diflTerential  diagnosis  of,  341 

eruption  of,  329 

general  diagnosis,  340 

gummata  in,  330 

bsemorrhagica  neonatorum,  418 

hereditary,  328 

Hutchinson  teeth  in,  332 

hypodermic  treatment,  343 

incubation  of,  329 

inunctions  in,  343 

Justus's  blood-test  for,  341 

late  symptoms  of  hereditary,  333 

malignant,  330 

modes  of  infection,  328 

morbid  anatomy,  327 

of  alimentary  tract,  336 

of  arteries,  339 

of  brain  and  cord,  333 

of  circulatory  system,  338 

of  joints,  339 

of  kidnevs,  339 

of  liver,  334 

of  lungs,  337 

of  spleen,  338 

of  testicles,  340 

primary  sore  of,  329 
stage,  329 

secondary  stage,  329 

tertiary  stage,  330 

treatment  of  acquired,  343 


1288 


INDEX. 


Syphilis,  treatment  of  hereditary,  342 

visceral,  333 
Syphilitic  cachexia,  329 

fever,  329 

paralysis,  334.    (See  Dementia  Paralytica.) 
Syringomyelia,  1097 

hydromyelia  iu,  1097 

Tabes,  diabetic,  380 

dorsalis,  1081.     (See  Locomotor  Ataxia.) 

mesenterica,  310 
Tache  bleuatres,  33 
Tachycardia,  665 

neurotic,  666 

symptomatic,  666 
Tactile  fremitus  in  emphysema,  529 

in  passive  hyperemia,  501 

in  pleural  effusion,  548 

in  pneumothorax,  566 

in  pulmonary  tuberculosis,  294 
Taenia  cucumerina,  1260 

echinococcus,  1251 

flavopunctata,  1260 

mediocanellata,  1257 

nana,  1260 

solium,  1256 
Taeniae  or  tape-worm,  1256 
Teeth,  Hutchinson's,  332 
Temperature-sense,  loss  of,  in  syringomyelia, 

1097 
Tertian  intermittent  fever,  ameba  causing,  82 
Testes,  syphilis  of,  340 

tuberculosis  of,  313 
Tetanus,  358 

acute,  359 

antitoxin  of,  362 

bacillus  of,  359 

cephalic,  360 

chronic,  360 

diagnosis,  360 

duration,  361 

idiopathic,  359 

immunity  in,  359 

incubation,  359 

modes  of  infection,  359 

morbid  anatomy,  359 

mortality,  361 

traumatic,  359 

treatment,  361 
Tetany,  1156 
Thermic  fever,  1231 
Third  nerve,  diseases  of,  1043 
paralysis  of,  1043 

relapsing  and  recurring  paralysis  of, 
1044 
Thiroloix  Achalmii,  203 
Thomson's  disease,  1205 
Thoracic  aorta,  aneursym  of,  683 

dropsy,  5^9.     (See  Hydrothorax.) 

duct,  rupture  of  tuberculous  focus  into, 
275 
Thorax  in  emphy.sema,  528 

in  pulmonary  tuberculosis,  283 

in  rachitis,  405 
Thread-worm,  1240 

Throat,  acute  infectious  phlegmon  of,  723 
Thrombi  in  veins  in  typhoid  fever,  39 
Thrombosis,  cardiac,  636 
Thrush,  701.     (See  Parasitic  Stomatitis.) 
Thymus  gland,  diseases  of,  574 
Thyroid  extract,  use  of,  461,  464,  465 

gland,  diseases  of,  455 
in  cretinism,  465 


Thyroid  gland  in  exophthalmic  goiter,  458 
in  goiter,  456 
in  myxedema,  462 
Thryoidin,  462 
Thryoiditis,  455 
Thyro-proteid,  462 
Tic  convulsif,  1049 

douloureux,  1034 

general,  1152 
Tobacco  as  a  cause  of  arrhythmia,  670 

of  tremor,  1155 
Tongue,  acute  inflammation  of,  706 

atrophy  of,  1061 

chronic  inflammation  of,  707 

diseases  of,  706 

fissure  of,  708 

in  bulbar  paralysis,  1095 

paralysis  of,  1061 

spasm  of,  1061 

ulcers  of,  in  syphilis,  329 
Tonsillitis,  acute  catarrhal,  712 

acute  parenchymatous,  713 

chronic,  717 

follicular,  712 

necrotic,  714 
Tonsils,  disease  of,  711 
Toothache  in  actinomycosis,  351 
Topfer's  tests  in   examination   of  stomach- 
contents,  737,  738 
Tophi  in  gout,  393 

Torticollis,  363.     (See  Muscular  Rheumatism.) 
Tracheo-bronchitis,  480 
Traube's  semilunar  space,  549 
Tremor,  hereditary,  1156 

hysteric,  1156 

in  exophthalmic  goiter,  460 

in  multiple  sclerosis,  1156 

in  paralysis  agitans,  1155 

senile,  1156 

simple,  11.56 

smokers',  1156 

toxic,  11.56 
Trichina  spiralis,  1243 
Trichinosis,  1243 

diagnosis,  1246 

symptoms,  1245 

treatment,  1246 
Trichocephalus  dispar,  1242 
Tricuspid    incompetency    or    regurgitation, 
617 

regurgitation,  murmur  in,  619 
venous  congestion  in,  619 

stenosis,  620 
Trigeminus,  1047.     (See  Fifth  Nerve.) 
Trismus,  358.     (See  Tetanus.) 
Trousseau'vS  sign  in  tetany,  1157 
Tuberculosis,  260 

acute,  274 

cerebral  or  meningeal  form,  278 
general  miliary  form,  275 
pulmonary  form,  277 
typhoid  form,  275 

amyloid  degeneration  in,  289 

antiseptic  treatment  of,  319 

associated  diseases  and  complications,  316 
inflammatory  processes  in,  263 

bacillus  of,  263 

biology  of  bacillus,  264 

cavities  in  chronic,  287 

changes  occurring  in  a  tubercle,  262 

chemical  products  elaborated  by  bacillus, 
264 

chronic,  285 

climatic  treatment  of,  321 


INDEX. 


128S> 


Tuberculosis,   clinical  types  of  tuberculous 
meningitis,  281 
contagious  theory  of,  266 
diagnosis,  281 

of  acute,  276 

of  chronic,  301 
diet  in,  323 

differential  diagnosis,  302 
direct  hereditary  transmission,  268 
disseminated,  288 
distribution  of  the  bacilli  in,  264 

of  tubercular  lesions  in,  261 
dyspnea  in, 293 
elastic  fibers  in,  292 
elementary  tubercle,  261 
etiology,  263 

of  chronic,  285 
Flick's  studies  in,  266 
general  pathology  of  tubercular  lesions, 
261 

prognosis,  316 

symptoms,  297 

tuberculous  adenitis,  274 
geographical  distribution  of,  260 
hemoptysis  in  chronic,  293 
histology  of  tuberculous  meningitis,  280 
historic  note  of,  261 
infection  by  inoculation,  267       • 

by  swallowing,  266 
inhalation  of  the  bacilli,  265 
inoculations  in,  264 
interstitial  pneumonia  in,  288 
intestinal,  305 
isolation  in,  318 
local  causes,  270 

symptoms  of  chronic,  290 
mensuration  in,  294 
method  of  staining  bacilli,  291 
modes  of  infection,  265 
morbid  anatomy  of  chronic,  285 
night-sweats  in,  299 
of  alimentary  tract,  305 
of  arteries  and  veins,  316 
of  brain,  315 
of  bronchial  glands,  273 
of  endocardium,  289 
of  Fallopian  tabes,  ovaries,  and  uterus, 

314 
of  genito-urinary  system,  312 
of  heart,  315 
of  intestinal  tract,  289 
of  kidneys,  312 
of  larynx,  289 
of  lip,  304 
of  liver,  311 
of  lymph-glands,  271 
of  mammary  glands,  315 
of  mesenteric  glands,  273 
of  pericardium,  308 
of  peritoneum,  309 
of  pleura,  288 
of  serous  membranes,  307 
of  spinal  cord,  315 
onset  of  chronic,  289 
pathology  of  tuberculous  meningitis,  278 
physical  signs  in  stage  of  consolidation, 
293 
of  cavity,  296 
predisposing  causes,  268 
prognosis  of  tuberculous  meningitis,  282 
prophylaxis,  317 
sanatorium  treatment  of,  322 
serum-diagnosis  in,  302 


Tuberculosis,  serum -therapy  of,  324 
sources  of  the  bacilli,  264 
special  remedies  in,  324 
special  symptoms  of  chronic,  299 
sputum  in,  290 

stages  in  development  of  tubercle,  261 
temperature  in  chronic,  298 
treatment,  319 

of  leading  symptoms,  324 

tuberculin  in,  320 
Tumors,  intracranial,  1124 
of  larynx,  479 

of  nerves,  1032.     (See  Neuromata.) 
of  pancreas,  912 
of  peritoneum,  932 
of  spinal  cord,  1100 
Tunnel-anemia,  1242 

Tussis  convulsiva,  251.    (See  Whooping-cough.) 
Twists  and  knots  in  the  bowels,  829 
Tylosis  linguse,  708.     (See  Lingual  Psoriasis.) 
Tympanites  in  acute  peritonitis  917 
in  appendicitis,  820 
in  intestinal  obstruction,  831,  832 
in  typhoid  fever,  34 
Typhoid  fever,  17 

abnormal  course  of  fever,  31 

bacteriology  of,  22 

bed-sores  in,  33 

blood-changes  in,  40 

chart  showing  effect  of  cold  baths 
in,  opposite  p.  55 

clinical  history,  27 
varieties,  44 

complicated  by  infectious  diseases, 
44 

constipation  in,  34 

contraindications  to  cold  baths  in,  00 

delirium  in,  41 

diabetes  in,  43 

diagnosis,  46 

diarrhea  in,  34 

diazo-reactiou  in,  43 

diet  in,  54 

differential  diagnosis,  47 

disinfection  in,  52 

Ehrlich's  reaction  in,  43 

epistaxis  in,  38 

etiology,  22 

experimental,  23 

fastigium  or  second  stage,  28 

gastric  symptoms  in,  36 

guaiacol  in  treatment  of,  61 

headache  in,  62 

history,  17 

hydrotherapy  of,  55 

hypostatic  congestion  of  lungs  in,  38 

immunity  to,  25 

in  children,  46 

incubation  of,  27 

insanity  in,  42 

insomina  in,  63 

internal  antipyretics  in,  61 

intestinal  antiseptics  in,  61 
hemorrhages  in,  35 

in  the  aged,  46 

isolation  of  patients,  53 

jaundice  in,  33 

leukocytosis  in,  36 

liver  in,  20 

lobar  pneumonia  in,  38 

lobular  pneumonia  in,  37 

lungs  in,  21 

management  of  convalescence  in,  66 


1290 


INDEX. 


Typhoid  fever,  methods  of  conveyance  of  the 
poison  into  the  human  body,  25 

modes  of  infection,  25 

mouth  and  tonsils  in,  37 

muscular  system  in,  22,  44 

nephritis  in,  43 

nervous  symptoms  in,  41 

neuralgia  in,  42 

ocular  complications  in,  42 

osseous  system  in,  44 

oysters  and,  26 

pathology,  18 

perforation  in,  35 

pericarditis  in,  39 

perichondritis  in,  38 

period  of  Wunderlich,  29 

peritonitis  in,  35 

Peyer's  patches  in,  18 

pleuro-typhoid,  45 

post-typhoid  elevations  of  tempera- 
ture in,  32 

predisposing  causes,  24 

prognosis,  49 

prophylactic  inoculations  in,  53 

prophylaxis  in,  52 

pseudo-membranous      inflammation 
in,  44 

pulse  in,  39 

pyelitis  in,  43 

recurrence  of,  52 

relapses  in,  51 

rose-colored  spots  in,  32 

saline  infusion  in,  65 

serum-diagnosis  of,  46 

serum-therapy  in,  46,  62 

skin-rashes  in,  33 

spleen  in,  36 

stage  of  decline,  28 

of  develoi)inent,  27 

stimulants  in,  55 

stools  in,  34 

substitutes  for  the  cold  bath  in,  60 

subsultus  tcndinum  in,  42 

sweating  in,  33 

temperature-charts  in,  30 

thrombosis  in,  39,  40 

tonsillo-typhoid,  37 

treatment,  52 

of  bed-sores,  66 
of  hemorrhages.  65 
of  individual  symptoms,  62 
of  lobar  pneumonia.     (See  Sec- 
ondary Pneumonia.) 
of  tympanites,  64 

tympanites  in,  34 

typho-toxin  of,  23 

urine  in,  42 

walking-form,  45 

Widal's  reaction  in,  47,  48 
septicemia,  27 
Typho-toxin,  23 
Typhus  fever,  67 

causes,  68 

contagiousness  of,  69 

course  and  duration,  71 

diagnosis,  72 

eruption  in,  70 

history,  67 

pathology,  68 

symptoms,  69,  71 

temperature  in,  70 

treatment,  72 
Isevissimus,  44.     (See  Typhoid  Fever.) 


Ulcer,  duodenal,  809 

follicular.  811 

gastric,  763 

intestinal,  809 

in  typhoid  fever,  18 

of  bowel  in  dysentery,  99,  101,  104,  107 

of  esophagus,  726 

solitary,  812 

stercoral,  811 
Ulcerative  endocarditis.     (See  Endocarditis.) 

stomatitis,  699 
Ulcero-membranous  tonsillitis,  711 
Ulcers,  aphthous,  697 
Ulnar  nerve,  diseases  of,  21,  1064 
Uremia,  962 

acute,  963 

chronic.  963 

diagnosis    from    cerebellar  hemorrhage 
and  alcoholic  narcosis,  965 

in  chronic  nephritis,  988 

pathology  and  etiology,  962 

symptoms,  963 
Ureter,  blocking  of,  969 

tuberculosis  of,  313 
Urethritis  in  lithemia,  401 
Uric-acid  calculi,  969 

diathesis,  400.     (See  Lithemia.) 
Urinary  syst^em,  diseases  of,  933 
Urine,    acetone,    diacetic     and     oxybutyric 
acids  in,  952 

albumin  in,  942 

alkaptone  in, 959 

bacteria  in,  959 

bile-pigment  in,  948 

blood  in,  938 

chlorides  in,  958 

chyle  in,  947 

cystin  in,  9.56 

fat  in,  958 

fibrinous  cast  in,  955 

gas-formation  in,  958 

glucose  in,  949 

hematoporphyrin  in,  958 

hemoglobin  in,  940 

in  acute  cvstitis.  1007 

in  Bright's  disease,  977,  983,  988 

in  chronic  parenchymatous  nephritis,  983 

in  dial)etes  insipidus,  ;i86 

in  diabetes  mellitus,  378 

in  diphtheria,  186 

in  jaundice,  849 

in  pneumonia,  144 

in  scarlet  fever,  240 

in  typhoid  fever.  42 

incontinence  of,  1014 

indican  in,  945 

inosite  in,  9.59 

lactose  in,  9.59 

leucin  and  tyrosin  in,  956 

oxalates  in  excess  in,  954 

peptone  and  albumose  in,  945 

phosphates  in  excess  in,  955 

pus  in,  946 

retention  of,  1016 

special  pathologic  states  of,  936 

suppression   of,   in  acute  intestinal  ob- 
struction, 831 
in  acute  nephritis,  977 

urea  in,  957 

uric  acid  in  excess  in,  953 

urobilin  in,  949 
Urobilinuria.  949 
Urticaria  epidemica,  1263 


WDEX. 


1291 


Urticaria,  giant,  1184 

in  acute  articular  rheumatism,  207 

in  chronic  gastritis,  758 

in  pneumonia,  143 

in  typhoid  fever,  33 
Uterus,  tuberculosis  of,  314 
Uvula,  edema  of,  in  diphtheria,  184 

Vaccination,  229 
complications,  231 

danger  of  conveying  syphilis  when  hu- 
manized virus  is  used,  230 
history,  229 
lymph  used  in,  230 
operation,  230 
period  of  life  for,  231 
site,  230 
symptoms,  231 
time  for  revacciuation,  231 
Vaccine  virus,  230 
Vaccinia,  229 
"  Vagabonds'  disease,"  454 
Valvular  (cardiac)  diseases,  complications  of, 
623 
duration,  624 
prophylaxis  in,  626 
treatment,  627 
venesection  in,  631 
disease  of  the  heart,  chronic,  596 
tuberculosis,  316 
Varicella,  231 
cause,  231 
diagnosis,  233 

from  variola,  224 
eruption  in,  232 
gaugrseuosa,  232 
immunity  in,  232 
incubation,  232 
treatment,  233 

with  sero-purulent  vesicles,  232. 
Variola,  215.     (See  Small-pox.) 
Varioloid,  223 

Vasomotor  and  trophic  disorders,  1184 
disturbance  in  chronic  pleurisy,  563 
in  exophthalmic  goiter,  458 
in  migraine,  1142 
in  myelitis,  1074 
in  neuralgia,  1034 
in  tumors  of  the  spinal  cord,  1101 
Veal  pie,  poisoning  by,  1223 
Veins,  arterio-venous  aneurysm,  694 
cerebral,  thrombosis  in,  1111 
diastolic  collapse  of,  585 
Vena  cava  inferior,  compression   of,   by  an- 
eurysm, 684 
Venesection  in  chronic  valvular  disease,  631 
in  emphysema,  531 
in  pneumonia,  155 
Venous  cerebral  hemorrhage,  1116 
pulse  in  aortic  incompetency,  603 
in  neurasthenia,  1176 
in  tuberculosis,  299 
Ventricles  of  brain,  enlargement  of,  1129 

tapping  of,  1130 
Ventricular  hemorrhage,  1115 
Vertebrge,  injuries  and  caries  of,  1099 
Vertigo,  auditory,  1053.     (See  Meniere's  Dis- 
ease.) 
gastric,  758 

in  arterio-sclerosis,  681 
in  cerebellar  disease,  1125 
Vesical  catarrh  in  typhoid  fever,  43 
hemorrhage,  1011 


Vesical  irrigation,  1010 

medication,  1010 
Vesiculse  seminales,  tuberculosis  of,  313 
Voice,   change  of,  in   mouth-breathers,  718. 

(See  Speech.) 
Volitional  tremor,  1092 
Volvulus,  829 

Vomica,  287.     (See  Cavities  in  Chronic  Tuber- 
culosis.) 
Vomit,  black,  122 

coffee-ground,  773 

stercoraceous,  831 

Wall-papee   a   source  of  arsenical  poison- 
ing, 1219 
War  of  the  Eebellion,  statistics  of   dysen- 
tery in,  98 
Washing  out  the  stomach,  method  of,  736 
Water,  infection  by,  in  cholera,  112 
in  dysentery,  101 
in  typhoid  fever,  25 
Water-hammer  pulse,  603 
Weber,  syndrome  of,  281 
Weil's  disease,  367 
Weir  Mitchell's  disease,  1191 
WerlhofF's  disease,  414 
Wernicke's  "aphasia  of  conduction,"  1121 
Westphal's  symptom,  1045 
Wet  pack,  60 

"White  flux  "  of  India,  804 
White  softening,  cerebral,  1109 
Whooping-cough,  251 

bacteriology,  253 

catarrhal  stage,  254 

complications  and  sequelae,  255 

contagiousness,  251 

diagnosis,  256 

etiology,  251 

incubation,  254 

mortality,  255 

nature  and  bacteriology,  203 

paroxysmal  stage,  254 

pathology,  251 

prognosis,  255 

symptoms,  254 

treatment,  257 
Widal  reaction  in  typhoid  fever,  47 

in  yellow  fever,  122 
Winckel's  disease,  418.     (See  Epidemic  Hemo- 
globinuria.) 
Winged  scapulae,  294,  528 
Wiutrich's  sign,  297 
Wood-tick,  1263 

Wool-sorters'  disease,  352.     (See  Anthrax.) 
Word-blindness,  1123 
Word-deafness,  1122 
Wormian  bones,  1129 
Worms,  1238.     (See  Nematoda.) 
Wound-diphtheria,  185 
Wrist-drop,  1063 

in  plumbism,  1218 
Writers'  cramp,  1161 
Wry-neck,  1058.     (See  Torticollis.) 
Wunderlich,  "ambiguous  period"  of,  2i 

Xanthelasma,  850 
Xanthin,  965 
Xanthopsia,  850,  1240 
Xerostoma,  710 

Yellow  Fevek,  119 

bacteriologv,  120 
blood  in,  120 


1292 


INDEX. 


Yellow  fever,  causes,  120 
duration,  122 
epidemics  of,  119 
;?rave  symptoms  in,  122 
hemorrhages  in,  121 
history,  119 
incubation.  120 
invasiou-stagre,  121 
mortality.  122 
pathology.  119 
prophylaxis  in,  123 
protective  inoculation  in,  123 


;  Yellow  fever,  remission  stage,  121 

j  secondary  fever  or  collapse  in,  121 

j  serum-diaguosis  of,  122 

serum-therapeutics  of,  124 

temperature  in,  120 

treatment,  12.3 

varieties,  122 

vomit  in,  121 
softening,  cerebral,  110£ 
vision,  1240 
j  Yeo's  diet-list,  1229 


CATALOGUE 

OF   THE 

MEDICAL  PUBLICATIONS 

OF 

W.  B.  SAUNDERS  &  CO., 

No.   925   WALNUT   STREET,   PHILADELPHIA^ 
Arranged  Alphabetically  and  Classified  under  Subjects, 


THE  books  advertised  in  this  Catalogue  as  being  sold  by  sitbscriptiott  are  usually  to  be 
obtained  from  travelling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States;  but 
books  will  be  sent  to  any  address,  carriage  prepaid,  on  receipt  of  the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways  •.  A  post- 
office  money  order,  an  express  money  order,  a  liank  check,  and  in  a  registered  letter.  Money 
sent  in  any  other  way  is  at  the  risk  of  the  sender. 


See  pages  32,  33  for  a  L"st  of  Contents  classified  according  to  subjects. 


LATEST  PUBLICATIONS. 

American  Students^  Medical  Dictionary,     See  page  34. 

American  Text-Book  of  Physiolog-y — Second  (Revised)  Ed.     Page  7, 

Friedrich  and  Curtis  on  Nose,  Throat,  and  Ear,     See  page  34. 

Le  Roy^s  Histology.    See  page  34. 

Ogden  on  the  Urine.     See  page  34. 

Pyle^s  Personal  Hygiene.     See  page  34. 

Salinger  and  Kalteyer's  Modern  Medicine.     See  page  34. 

Stoney^s  Surgical  Technic  for  Nurses.     See  page  34. 

Hyde   and  Montgomery's   Syphilis   and  Venereal  Diseases — Revised 

and   Enlarged  Edition.     See  page  15. 
International  Text-Book  of  Surgery,     See  page  15. 
Garrigues*  Diseases  of  Women — Third  (Revised)  Edition.     Page  13. 
American  Text-Book  of  Dis.  of  Eye,  Ear,  Nose,  and  Throat.     Page  5. 
Saunders*  American  Year-Book  for  J  900,     See  page  8. 
Levy  and  Klemperer's  Clinical  Bacteriology.     See  page  i7. 
Scudder's  Treatment  of  Fractures,     See  page  26. 
Sennas  Tumors — Second  Edition,     See  page  27, 
Beck  on  Fractures.     See  page  9. 
"Watson's  Handbook  for  Nurses,     See  page  31. 
Heisler's  Embryology.     See  page  15. 
Nancrede's  Principles  of  Surgery,     See  page  20. 
Jackson's  Diseases  of  the  Eye,     See  page  16. 
Kyle  on  the  Nose  and  Throat.     See  page  17. 

Penrose's  Diseases  of  "Women — Third  (Revised)  Edition.     Page  20. 
"Warren's  Surgical  Pathology— Second  (Revised)  Edition.     Page  31. 
Saunder's  Medical  Hand- Atlases.     See  pages  2,  3,  4. 
American  Pocket  Medical  Dictionary — Third  (Revised)  Ed.     Page  J2, 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized 
translations  into  English  of  the  world-famous  Lehmann  Medicinische 
Handatlanten,  which  for  scientific  accuracy,  pictorial  beauty,  cona- 
pactness,  and  cheapness  surpass  any  similar  volumes  ever  published. 
Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the 
text.  There  is  a  full  and  appropriate  description  of  each  plate,  and 
each  book  contains  a  condensed  but  adequate  outline  of  the  subject  to 
which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  *atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  To  those 
unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable. 

In  planning  this  series  of  books  arrangements  were  made  with  the  rep- 
resentative publishers  in  the  chief  medical  centers  of  the  world  for  the 
publication  of  translations  of  the  atlases  into  different  languages,  the  litho- 
graphic plates  for  all  these  editions  being  made  in  Oermany,  where  work  of 
this  kind  has  been  brought  to  the  greatest  perfection.  The  expense  of 
making  the  plates  being  shared  by  the  various  publishers,  the  cost  to  each 
one  was  materially  reduced.  Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  the  publishers  have  been  enabled  to  secure  for  these 
atlases  the  best  artistic  and  professional  talent,  to  produce  them  in  the 
most  elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unap- 
proached  in  cheapness.  The  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  the  volumes  have  already  appeared  in  thirteen  different 
languages — German,  English,  French,  Italian,  Russian,  .Spanish,  Japanese, 
Dutcli,  Danish,  Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  striking  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hun- 
dred thousand  copies  of  the  atlases.  In  consideration  of  this  enormous 
undertaking,  the  publisher  has  been  enabled  to  prepare  and  furnish  special 
additional  colored  plates,  making  the  series  even  handsomer  and  more 
complete  than  was  originally  intended. 

As  an  indication  of  the  practical  value  of  the  atlases  and  of  the  favor 
with  which  they  have  been  received,  it  should  be  noted  that  the  Medical 
Department  of  the  U.S.  Army  has  adopted  the  "Atlas  of  Operative 
Surgery"  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been 
secured  in  the  English  edition  as  in  the  originals,  the  translations  being 
edited  by  the  leading  American  specialists  in  the  different  subjects. 


SAUNDERS^  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  REx\DY. 
Atlas  and  Epitome  of    Internal  Medicine  and    Clinical    Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner,  M.  D.  , 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  ^3.00  net. 

"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyti  Aledical  Journal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmanx,  of  A'ienna.  Edited 
by  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Dept.,  College 
of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates,  and  193  beautiful  half-tone  illustrations.      Cloth,  §3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine  '  is  a  unique  work.  This  immense  field  finds  in  this 
book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 
Vioxk.'''' — Philadelphia  Medical  Jon7-nal. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  ^NI.D.,  Physician-in- Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text-illustrations,  and  103  pages 
of  text.     Cloth,  $2.50  net. 

"  Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 
the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists." — St. 
Louis  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.     By  Dr.  O.  Zuckerkandl, 

of  Vienna.     Edited  by  J.   Chalmers  DaCosta,  M.  D.,   Proiessor  of 
,  Practice  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.      With   24  colored  plates,  217  text-illustrations,  and  395 
pages  of  text.     Cloth,  $3.00  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." — Micncheiier  tjiediciiiische  Wochenschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.  By  Prof. 
Dr.  Franz  Mracek,  of  A^ienna.  Edited  by  L.  Bolton  Bangs,  M.D., 
Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hospital 
Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.  Cloth,  $3.50  net. 
"  A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 

Journal  of  the  American  Medical  Association. 

Atlas    and    Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  ]M.D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76 
colored  illustrations  on  40  plates,  and  228  pages  of  text.    Cloth,  $3.00  net. 

"  It  is  always  difficult  to  represent  pathological  appearances  in  colored  plates,  but  this 
work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  exceptions, 
are  absolutely  satisfactory." — Bostoti  Aledical  and  Sicrgical  Journal. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.  Edited  by  Henry  W.  Stelwagon,  M.D.,  Clinical  Professor 
of  Dermatologv,  Jefferson  Medical  College,  Philadelphia.  With  6^^  colored 
plates,  39  half-tone  illustrations,  and  200  pages  of  text.    Cloth,  $3.50  net. 

"  The  importance  of  personal  inspection  of  cases  in  the  study  of  cutaneous  diseases  is 
readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  .the  appear- 
ance of  the  disease  under  consideration.  Altogether  the  work  will  be  found  of  veiy  great 
value  to  the  general  practitioner." — Journal  of  the  American  Aledical  Association. 

3 


SAUNDERS^  MEDICAL  HAND-ATLASES. 

VOLUMES  JUST  ISSUED. 
Atlas  and  Epitome  of   Special  Pathological  Histology.     By  Dr.   H. 

DuRCK,  of  Munich.  Edited  by  Ludvig  Hektoex,  M.  D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts.  Part  I. 
Just  Ready,  including  the  Circulatory,  Respiratory,  and  Gastro- 
intestinal Tract,  with  120  colored  figures  on  62  plates  and  158  pages 
of  text.     Price,  S3. 00  net.     Parts  sold  separately. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.  By  Dr.  Ed. 
GoLEBiEWSKi,  of  Berlin.  Translated  and  edited  with  additions  by 
Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Cor- 
rections and  to  the  Almshouse  and  Incurable  Hospitals,  New  York. 
With  40  colored  plates,  143  text-illustrations,  and  600  pages  of  text. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecologist  to 
the  Methodist  Episcopal  and  the  Philadelphia  Hospitals;  Surgeon-in- 
Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored  plates,  65 
text-illustrations,  and  308  pages  of  text. 

IN  PRESS  FOR  EARLY  PUBLICATION. 
Atlas  and  Epitome  of  Obstetrical   Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  Edited  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstretics  and  Clinical  Midwifery,  Cornell  Univer- 
sity Medical  School.  72  colored  plates,  numerous  text-illustrations, 
and  copious  text. 

Atlas  and  Epitome  of  the  Nervous  System  and  its  Diseases.  By 
Prof.  Dr.  A.  vox  Strumpell,  of  Erlangen.  Edited  by  Edward  D. 
Fisher,  M.  D.,  Profes.sor  of  Diseases  of  the  Nervous  System,  Univer- 
sity and  Belle\"ue  Hospital  Medical  College,  New  York,  'ii^  plates  and 
a  copious  text. 

Atlas  and  Epitome  of  General  Pathological  Histology.  With  an 
Appendix  on  Pathohistological  'Fechnic.  By  Dr.  H.  Durck,  of 
Munich.  Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of  Path- 
ology, Rush  Medical  College,  Chicago.  With  80  colored  plates, 
numerous  text-illustrations,  and  copious  text. 

IN  PREPARATION. 
Atlas  and  Epitome  of  Orthopedic  Surgery. 
Atlas  and  Epitome  of  Operative  Gynecology. 
Atlas  and  Epitome  of  Diseases  of   the  Ear. 
Atlas  and  Epitome  of  General  Surgery. 
Atlas  and  Epitome  of  Psychiatry. 
Atlas  and  Epitome  of  Normal  Histology. 
Atlas  and  Epitome  of  Topographical  Anatomy. 


THE  AMERICAN  TEXT-BOOK  SERIES. 
AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
I7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

•'  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  o\ 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  we'l  covered.  The  work  is  thoroughly  prac- 
rical,  and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful,'' — The  Indian  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 
Second  Edition^  Revised. 

By  65  Eminent  Contributors.  Edited  by  Louis  Starr,  M.  D.,  Con- 
sulting Pediatrist  to  the  ISIaternity  Hospital,  etc.  ;  assisted  by  Thomp- 
son S.  Westcott,  M.  D.,  Attending  Physician  to  the  Dispensary 
for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  1244  pages, 
profusely  illustrated.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
^8.00  net.     Sold  by  Subscription. 

"  This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
English  language,  and  is  certainlj'  the  one  which  is  best  adapted  to  American  readers. 
We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the 
attention  of  every  student  and  practitioner. " — American  journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz,  M.Dc, 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia ;  and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
01^  the  Ear  in  the  University  of  Pennsylv^ania.  Imperial  octavo,  1251 
pages  ;  766  illustrations,  59  of  them  in  colors.  Cloth,  37.00  net ;  Sheep 
or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

Illustrated  Catalogue  of  the  ** American  Text-Books^  sent  free  upon  application. 


6        Medical  Publications  of  W.  B.  Saunders  &  Co. 


AN  AMERICAN   TEXT=BOOK    OF   GENITO=URINARY  AND  SKIN 
DISEASES. 

By   47    Eminent   Specialists   and   Teachers.     Edited   by  L.   Boltom 
Bangs,  M.  D.,  Professor  of  Genito- Urinary  Surgery,  University  and 
Bellevue  Hospital    Medical  College,  New  York  ;    and  W.  A.   Hard- 
AWAV,  M.  D.,   Professor  of   Diseases    of  the    Skin,  Missouri    Medical 
College.     Imperial  octavo  volume  of  1229  pages,  with  300  engravings 
and  20  full-page  colored  plates.     Cloth,  $7.00  net;    Sheep  or  Half 
Morocco,  $8.00  net.      Sold  by  Subscription. 
"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of '  American  Text- 
Books.'     The  list  of  contributors  represents  an    extraordinary  array  of  talent  and  extended 
experience.     The  book  will  easily  take  the  place    in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  heretofore  been  necessary  to 
a  well-equipped  librarv." — A^ew   York  Polvclinic. 

AN  AMERICAN  TEXT=B00K:  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL.     Second  Edition,  Revised. 

By  10  of  the  Leading  Gynecologists  of  America.     Edited  by  J.   M. 
Baldv,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  718  pages,  with  341   illus- 
trations in  the  text,  and  38  colored  and  half-tone  plates.     Cloth,  $6.00 
net;   Sheep  or  Half  Morocco,  $7.00  net.     Sold  by  Subscription. 
"  It  is  practical  from  beginning  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations  for   treatment,  and   above  all  the   necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.     .     .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place  in  gynecological   literature  which  will  be  peculiarly  its  own." — 
Medical  Record ,  New  York. 

AN  AMERICAN  TEXT-BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  INLD.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  To.xicology  in  Rush  Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
Ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  1014  pages,  with  nearly  900  beautiful  colored 
and  half-tone  illustrations.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
^8.00  net.     Sold  by  Subscription. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufiicient  to  place  you  first  in  the  ranks  of  medical  publishers." — ALEXANDER 
J.  C.  Skene,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  V. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  Ir 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upxMi  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
librar)'  should  omit  to  purchase." — British  Medical  Journal. 

"  A*  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 
titioner, W2  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  tht 
Medical  Sciences. 

lUttBtrated  Catalogue  of  the  "American  Text-Books  "  sent  free  upon  application* 


Medical  Publications  of  W.  B.  SRiinders  &  Co.        7 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  Ludvig  Hektoen,  M.  D..  Professor  of  General  Pathology 
and  of  Morbid  Anatomy  in  the  University  of  Pennsylvania ;  and 
David  Riesman,  M.  D.,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.     In  preparation. 

AN  AMERICAN  TEXT=BOOK  OF  PHYSIOLOGY. 

By  I o  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  Second  edition,  revised  and  enlarged, 
in  two  volumes. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — Londott  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journal  of  the  Medical  Sciences. 

AN   AMERICAN  TEXT=BOOK   OF   SURGERY.     Third  Edition. 

By  II  Eminent  Professors  of  Surgery.  Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  and  J.  William  White,  M.D.,  Ph.D.  Handsome  im- 
perial octavo  volume  of  1230  pages,  with  496  wood-cuts  in  the  text, 
and  37  colored  and  half-tone  plates.  Thoroughlv  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  S7.00  net;  Sheep  or  Half  Morocco,  $8. 00  net. 

•'  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book),  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examiners  of  the  Royal  College  of  Surgeons,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
Lottdon  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  SHeep  or  Half  Morocco, 
$6.00  net.     Sold  by  Subscription. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Practice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
Is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see." — New  York  Medical 
Journal. 

Illustrated  Catalogtie  of  the  ** American  Text-Books^'  sent  free  upon  application. 


8        Medical  Publications  of  W.  B.  Saunders  &  Co. 

AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Arranged  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  general  editorial  charge  of  George  M. 
Gould,  M.D.  Volumes  for  1896,  '97,  '98,  and  '99.  One  imperial 
octavo  volume  of  about  1200  pages.  Cloth,  $6.50  net;  Half  Morocco, 
$7.50  net.  Year-Book  of  1900  in  two  volumes — Vol.  I.,  including 
General  Medieine ;  Vol.  II.,  General  Surgery.  Prices  per  volume: 
Cloth,  S3. 00  net;   Half  Morocco,  §3.75  net.     Sold  by  Subscription. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Vear-Book,  oi-  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advant- 
age of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  nseful  than  the  famous  '  Jahrbiicher ' 
of  Germany."' — London  Lancet. 

ABBOTT  ON  TRANSMISSIBLE  DISEASES. 

The  Hygiene  of  Transmissible  Diseases  ;  their  Causation, 
Modes   of    Dissemination,  and  Methods  of  Prevention.     Bv  A. 

C.  Abbott,  M.D.,  Professor  of  Hygiene  and  Bacteriology,  University 
of  Pennsylvania ;  Director  of  the  Laboratory  of  Hygiene.  Octavo 
volume  of  311  pages,  containing  a  number  of  charts  and  maps,  and 

numerous  illustrations.      Cloth,  52.00  net. 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY. 

[See  Dorland' s  Pocket  Dictionary,  page  12.] 

ANDERS'  PRACTICE  OF  MEDICINE.  Third  Revised  Edition. 
A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1292  pages,  fully  illustrated.  Cloth, 
$5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilso.n,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson 
Medical  College,  Philadelphia. 

ASHTON'S  OBSTETRICS.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor  of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages;  75  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  23.] 

"  Embodies  the  whole  subject  in  a  nut-shell.  We  cordially  recommend  it  to  our  read 
2rs." — Chicago  Medical  limes. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  ^i.oo; 
interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compeiids,  page   23.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  Bv  Edson  S.  Bastin,  M.A., 
late  Prof,  of  Materia  Medica  and  Botany,  Philadelphia  College  of  Phar- 
macy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  $2.00  net. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alumni  Report  to  the  Philadelphia  College  of  Pharmacy. 

BECK  ON  FRACTURES. 

Fractures.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital 
and  the  New  York  German  Poliklinik,  etc.  225  pages,  170  illustration's. 
Cloth,  $3.50  net. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"  An  excellent  exposition  of  the  '  verj'  latest '  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Biriningham  (Eng.)  Medical  Review. 

"  This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

BoiSLiNiERE,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.     381  pages,  handsomely  illustrated.    Cloth,  ^2.00  net. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Aledical Jotirnal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  ]M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages;   155  fine  illustrations. 
Cloth,  ^i.oo  net ;  interleaved  for  notes,  ^1.25  net. 

[See  Saunders''  Question- Compends,  page   2 3. J 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — Neiv  York  Medical  Journal. 


10      Medical  Publications  of  W.  B.  Saunders  *Sr  Co. 

BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. Third  Edition,  Revised. 
A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago ;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  S74 
pages,  illustrated.     Cloth,  $4.00  net;    Sheep,  $5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market." — Journal  of  the  American 
I  Medical  Association. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecture-r  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania;  Dei:ponstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  $1.00  net. 

"The  appearance  of  this  new  edition  of  Dr.  Cerna's  veiy  valuable  work  shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  por.session  of  every  practising  physi- 
cian."— New   York  Medical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.     By  John  B.  Chapin,  M.D.,  LL.D., 

Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium,  lamo,  234  pages, 
illustrated.     Cloth,  $1.25  net. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially  to  call- attention  to  the  fact  that  on  the  subject  of  therapeutics  of  insanity 
the  work  is  exceedingly  valuable.  It  is  not  a  made  book,  but  a  genuine  condensed  thesis, 
which  has  all  the  value  of  ripe  opinion  and  all  the  chaim  of  a  vigorous  and  natural  style." — ■ 
Philadelphia  Medical  Journal. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  gi.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — N'rzv  ior.i 
Madical  Tivies. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 
Second  Edition. 
Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical  Juris- 
prudence in  the  Northwestern  University  Medical  School,  Chicago  ; 
and  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Dis- 
eases, Woman's  Medical  College,  N.  Y.  ;  Chief  of  Clinic,  Nervous 
Dept.,  College  of  Physicians  and  Surgeons,  N.  Y.  Handsome  octavo 
volume  of  843  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half 
Morocco,  $6.00  net. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      11 

CLARKSON'S  HISTOLOGY. 

A   Text=Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  CM.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $4.00  net. 

"The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text- books, 
and  is  to  be  highly  recommended." — Neiv  Yoi'k  Medical  Journal. 

"This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1 89 1.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)      Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS.  Second  Edition,  Revised. 
Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
,  fessor  of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D.  ,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  417  pages;  55 
illustrations.     Cloth,  $1.00  net. 

[See  Saunders'   Question- Compends,  page   23.] 

"  We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS.     Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  CoRWiN,  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    219  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis. '  ''—Journal  of  Nervous  and  Mental  Diseases. 

CRAGIN'S  GYNECOLOGY.     Fourth  Edition,  Revised. 

Essentials  of  Gynaecology.  By  Edwin  B.  Cragin,  M.  D.,  Lecturer 
in  Obstetrics,  College  of  Physicians  and  Surgeons,  New  York.  Crown 
octavo,  200  pages;  62  illustrations.  Cloth,  $1.00  net;  interleaved  for 
notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  23.] 
«  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.     No 
author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student  s  needs 
so  thoroughly  as  Dr.  Cragin  has  Aox^^:'— Medical  Record,  New  York. 


12      Medical  Publications  of  W.  B.  Saunders  &  Co. 

CROOKSHANK'S  BACTERIOLOGY.     Fourth   Edition,  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  I\I.  Crookshank,  M.B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  $6.50  net;   Half  Morocco,  $7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  restaue  of  what  has  been  done  in  bacteri- 
ology, or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — London  Lancet. 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery.  General  and  Operative.  By  Johx  Chalmers 
DaCosta,  M.  D.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia  :  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  911  pages,  profusely  illus- 
trated.    Cloth,  $4.00  net;   Half  Morocco,  $5.00  net. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modern  student.'" — MediiO-Chirm gical Journal,  Bristol,  Englaiui. 

DE  SCHVVEINITZ  ON  DISEASES  OF  THE  EYE.      Third  Edition, 
Revised. 
Diseases  of    the  Ej'e,     A  Handbook   of   Ophthalmic    Practice. 

By  G.  E.  DE  ScHWEiNiTZ,  j\LD.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  696  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  jMedical  Journal. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper.  M.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania. 

DORLAND'S  DICTIONARY.     Third  Edition,  Revised. 

The  American  Pocket  Medical  Dictionary.  Containing  the  Pro- 
nunciation and  Definition  of  all  the  principal  words  and  phrases,  and  a 
large  number  of  useful  tables.  Edited  by  W.  A.  Newman  Borland, 
ISL  D. ,  Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania ; 
Fellow  of  the  American  Academy  of  Medicine.  518  pages  ;  handsomely 
bound  in  full  leather,  limp,  with  gilt  edges  and  patent  inde.x.  Price, 
$f.oo  net;  with  thumb  index,  $1.25  net. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  AV.  A.  Newman  Borland,  M.D., 
Assistant  Demonstrator  of  Obstetrics,  L'niversity  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.     Cloth,  $2.50  net. 

"  By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medical  Revie-iv. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
perusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts." — American  Aledico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      13 


FROTHINQHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
INGHAM,  M.D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages,  "—^w^r/- 
caji  Medico- Surgical  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Third  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro- 
fessor of  Gynecology  in  the  New  York  School  of  Clinical  Medicine ; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary, 
New  York  City,  etc.  Handsome  octavo  volume  of  783  pages,  illus- 
trated by  367  engravings  and  colored  plates.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.00  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  SB., 
M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with  114 
illustrations.     Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders''  Question- Compends,  page   23.] 

"It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. ' ' — Liverpool  Medico-  Chirujgical  Journal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates. 

POPULAR  EDITION:  Cloth,  $3.00  net;  Half  Morocco,  $4.00  net. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  K  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value:  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its  readers." — Af/iericait  Medico- Surgical  Bulletin. 


14      Medical  Publications  of  W.  B.  Saunders  &  Co. 

GRAFSTROM'S    MECHANO=THERAPY. 

A  Text=Book  of  Mechano=Therapy  i  Massage  and  Medical  Gym= 
nasties.).  By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  Lieutenant  in 
the  Royal  Swedish  Army ;  late  House  Physician  City  Hospital,  Black- 
well's  Island,  New  York.    i2mo,  139  pages,  illustrated.    Cloth,  31.00  net. 

GRIFFITH  ON  THE  BABY.     Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal Protessor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404 
pages,  with  67  illustrations  in  the  text,  and  5  plates.     Cloth,  Si-Sonet. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage. ' ' — Archives  of  Pediatrics. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  obser\'ing  children." — Ameri- 
can Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.D., 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.     Per  pad,  50  cents  net. 

GROSS,   SAMUEL  D.,   AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  ALD.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  bv  his  Sons, 
S.\MUEL  VV.  Gross,  M.D.,  LL.D.,  and  A.  Haller  Gro.ss,  A.M.  Pre- 
ceded by  a  Memoir  of  Dr.  Gross,  by  the  late  Austin  Plixt,  ^LD. 
Two  handsome  volumes,  over  400  pages  each,  demy  octavo,  gilt  tops, 
with  Fronti-spiece  on  steel.      Price  per  volume,  32.50  net. 

HAMPTON'S  NURSING.  Second  Edition,  Revised  and  Enlarged. 
Nursing:  Its  Principles  and  Practice.  By  Isabel  Adams  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  late  Superintendent  of  Nurses  and  Principal  of 
the  Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore, 
Md.     12  mo,  512  pages,  illustrated.     Cloth,  §2.00  net. 

"  Seldom  have  we  perused  a  lx)ok  upon  the  subject  that  has  given  us  so  much  pleasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self"— Ovta  rio  Medical  Journal. 

HARE'S  PHYSIOLOGY.  Fourth  Edition,  Revised. 

Essentials  of  Physiology.  By  H.  A.  Hare,  ]\LD.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia.  Crown  octavo,  239  pages.  Cloth,  31.00  net;  inter- 
leaved for  notes,  31.25  net. 

[See  Sau7iders'  Question- Commends,  page  23.] 

"  The  best  condensation  of  physiological  knowledge  we  have  yet  seen." — Medical 
Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      15 


HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  IMrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.     220  pages.      Cloth,  $1.50  net. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — A^ew  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  ^2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.      The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico- Chirurgical  College,  Philadelphia.  Oc- 
tavo volume  of  405  pages,  handsomely  illustrated.    Cloth,  $2.50  net.  ■ 

HIRST'S  OBSTETRICS.  Second  Edition. 

A   Text=Book   of   Obstetrics.     By  Barton    Cooke   Hirst,  M.  D., 

Professor  of  Obstetrics  in  the  L'niversity  of  Pennsylvania.  Handsome 
octavo  volume  of  848  pages,  with  618  illustrations,  and  7  colored 
plates.     Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  |6.oo  net. 

"The  illustrations  ai'e  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  As  a  true  model  of  what  a  modern  text-book  on  obstetrics  should  be,  we  feel 
justified  in  affirming  that  Dr.  Hirst's  book  is  without  a  rival." — N'e-w  York  Medical  Reco7-d. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.  Second  Edition,  Revised  and  Enlarged. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.  D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.  Octavo,  nearly  600  pages,  with 
14  beautiful  lithographic  plates  and  numerous  illustrations. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  bis  study  of  venere?.! 
diseases. ' ' — Livej-pool  Medico- Chi7-iirgical  Jow-nal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Lmiis  Medicai 
and  Surgical  Journal. 

INTERNATIONAL  TEXT=BOOK  OF  SURGERY.  In  two  volumes. 
Bv  American  and  British  authors.  Edited  by  J.  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Harvard  Medical  School,  Boston; 
and  A.  Pearcf.  Gould,  M.S.,  F.R.C.S.,  Lecturer  on  Practical  Sur- 
gery and  Teacher  of  Operative  Surgerv,  Middlesex  Hospital  jNIedical 
School,  London,  Eng.  Vol.  T.  General  Suri^ery. — Handsome  octavo, 
947  pages,  with  '-S  beautiful  illustrations  and  g  lithographic  plates. 
A^ol.  II.  S^ecia  '  or  Reo;ional  Surgery. — Handsome  octavo,  1072  pages, 
with  471  beautiful  illustrations  and  8  lithographic  plates.  Prices  per 
volume:    Cloth,  $5.00  net;   Half  Morocco,  $6.00  net. 


16      Medical  Publications  of  W.  B.  Saunders  &  Co. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.M., 
M.D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia 
Polyclinic  and  College  for  Graduates  in  Medicine.  i2mo  volume  of 
535  P^ges,  with  178  beautiful  illustrations,  mostly  from  drawings  by  the 
author.     Cloth,  S2.50  net. 

JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye,  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine  ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win- Gleasox.  M.D..  Surgeon-in-Cliarge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
§1.00  net ;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  22.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men^ 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATINQ'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia, and  Henry  Hamilton  ;  with  the  collaboration  of  J.  Chal- 
mers DaCosta,  M.D.,  and  Fkederick  A.  Packard,  M.D.  With  an 
Appendix  containi  g  Tables  of  Bacilli,  Micrococci,  Leucoma'ines, 
Ptomaines,  etc.  One  volume  of  over  800  pages.  Prices,  with  Ready- 
Reference  Index:  Clrth,  S5-oo  net:  .Sheep  or  Half  Morocco,  $6.00 
net.  Without  Patent  Index:  Cloth,  S4-oo  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lym.'^.v,  M.  D.,  Professor  of  (he  Principles  and  Practice 
■f  Medicine,  Rusk  Medical  College,  Chicago,  III. 

KEATINQ'S    LIFE    INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating 
M.  D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Pccdiatric  Society;  Ex- President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages  ;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  bv 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  $2.00  net. 

KEEN'S  OPERATION  BLANK.     Second   Edition,  Revised  Form. 
An  Operation  BI   .ik,  with   Lists  of  Instruments,  etc.,  Required 
in  Various  Operations.     Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.     Price  per  pad,  blanks  for  lifty  operations,  50  cents  net. 


Medical  Publications  of  W.  B.  Saunders  dt  Co.      17 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The   Surgical  Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Soci^te  de  Chirurgie,  Paris;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
SS6  pages,  illustrated.      Cloth,  $3.00  net. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader 
a  clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human 
organism.  This  book  should  be  in  the  possession  of  every  medical  man  in  America." — 
American  Medico-Surgical  Bulletin. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  :M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Handsome  octavo  volume  of  about 
630  pages,  with  over  150  illustrations  and  6  lithographic  plates.  Price, 
Cloth,  ^4.00  net;   Half  Morocco,  $5. 00  net. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8x131^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid." — India?z  Lancet,  Calcutta. 

LEVY  AND   KLEMPERER'S   CLINICAL  BACTERIOLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Profes- 
sor in  the  University  of  Strassburg,  and  Felix  Klemperer,  Privat  docent 
in  the  University  of  Strassburg.  Translated  and  edited  by  Augustus 
A.  EsHNER,  M.D.,  Professor  of  Clinical  ^ledicine  in  the  Philadelphia 
Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
WOOD,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.      Cloth,  $2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONQ'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  '« An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  M.D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of* 
Virginia,  etc.      Cloth,  interleaved,  |i.oo  net. 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  kaow,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well.'"' — Brookfyn  Medical  Journal. 
2 


18      Medical  Publications  of  W.  B.  Saunders  &  Co. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  F.R.  C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
$6.00  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — The 
Medical  News,  New  York. 

"The  work  is  brimful  of  just  the  kind  of  -jractical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  ijommend  the  bock  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  wich  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallorv,  A.m.,  M.D.,  Asriistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.IvL, 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
%2.'-^o  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  v/ell  up  to  date." — William  H.  Welch,  Frofesso/-  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Md. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  RL\rtin,  A.JNL,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  L'niversity  of  Pennsylvania,  etc.  Cniwn 
octavo,  166  ])ages,  with  78  illustrations.  Cloth,  ^i.oo  net;  interleaved 
for  notes,  51.25  net. 

[See  Saitndcrs'  Question- Compends,  page   23.] 

"A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Seventh  Edition,  Revised. 

Essentials  of  Surgery.  Containing  ako  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  M.\rtix,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  o(  Pennsylvania,  etc.  Crown  octavo,  342 
pages,  illustrated,  With  an  Appendix  on  the  preparation  of  the  materials 
used  in  Antiseptic  Surgery,  etc.,  and  a  chapter  on  Appendicitis.  Cloth, 
$1.00  net :   interleaved  for  notes,  $1.25  net 

[See  Saunders'  Question-  Compcnds,  page  23.] 

"  Contains  all  necessary  essentials  of  modern  surgen,'  in  a  comparatively  small  space. 
Its  style  is  interesting,  and  its  illustrations  are  admirable." — Medical  and  Surgical  Reporter. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      19 

McFARLAND'S  PATHOGENIC  BACTERIA.  Second  Edition,  Re- 
vised and  Greatly  Enlarged. 
Text=Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFar- 
LAND,  M.  D. ,  Professor  of  Pathology  and  Bacteriology  in  the  Medico- 
Chirurgical  College  of  Philadelphia,  etc.  Octavo  volume  of  497  pages, 
finely  illustrated.     Cloth,  ^2.50  net. 

*'  Dr.  McFarland  has  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto- 
gether, the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College." — H.  B.  Anderson,  M.  D.  ,  P}-ofessor  of  Pathology  and  Bac- 
teriology,  Trinity  Aledical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"  This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 

Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.      Cloth,  $2.50  net. 

"A  most  attractive  work.  The  illustrations  and  the  care  with  which  the  book  is  adapted 
to  the  wants  of  the  general  practitioner  and  the  student  are  worthy  of  great  praise." — Chicago 
Aledical  Recorder. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  Jouj-nal. 

MORRIS'S  MATERIA  MEDICA  ANR  THERAPEUTICS.  Fifth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription' 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia;  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  2 88  pages.  Cloth, 
^i.oo  net;  interleaved  for  notes,  ^1.25  net. 

[See  Saunders^  Question- Compends,  page  22.] 

"  This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi- 
sion. ' ' — American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.D,, 
late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulse  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.      Cloth,  $1.50  net. 

[See  Saunders^   Question- Compends,  page    22.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  anri 
Style  attractive." — American  Practitioner  and  News. 


20      Medical  Publications  of  W.  B.  Saunders  &  Co. 

MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered, 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
"  How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.    Cloth,  $1.00  net. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  alL 
of  which  is  ar'-anged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference^ 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Review, 

NANCREDE'S  ANATOMY.  Sixth  Edition,  Thoroughly  Revised. 
Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and 
of  Clinical  Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown 
octavo,  420  pages;  151  illustrations.  Based  upon  Grafs  Anatomy. 
Cloth,  $1.00  net  ;   interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Co7npe7ids,  page  23.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — Amei-ican  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of   Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and  o| 
Clinical  Surgery,  L^niversity  of  Michigan,  Ann  Arbor.  Post-octavo  \ 
500  pages,  with  full-page  lithographic  plates  in  colors,  and  nearly  20Q 
illustrations.     Extra  Cloth  (or  Oilcloth  for  dissection-room),  §2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinvy  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  American  Medical  Association. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede, 
ALD  ,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  L^niver- 
sity  of  Michigan,  Ann  Arbor.  Octavo  volume  of  398  pages,  illustrated. 
Cloth,  $2.50  net. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised, 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  L'niversity  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  $2.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.     Third  Edition,  Revised. 
A  Text=Book  of  Diseases  of  Women.     By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  Formerly  Professor  of  Gynecology  in  the  University 
of  Pennsylvania ;    Surgeon   to   the   Gynecean   Hospital,    Philadelphia. 
Octavo  volume  of  531  pages,  handsomely  illustrated.    Cloth,  S3. 75  net. 

«•  I  shall  value  very  highly  the  copy  of  Penrose's  *  Diseases  of  Women '  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book."— Howard  A.  Kelly. 
Professcr  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      21 

POWELL'S  DISEASES  OF  CHILDREN,     Second  Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Physician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.     Cloth,  ^i.oonet;  interleaved  for  notes,  $1.25  net. 

[See  Saunders^  Question- Compends,  page  21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates." — 
American  Practitio7ier  and  News. 

PRINQLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
J.  J.  Pringle,  ]\I.B.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12'  Parts.  Price  per  Part,  $3.00.  Complete  in 
one  volume,  Half  Morocco  binding,  $40. 00  net. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
will  be  of  great  value  to  all  studying  dermatology." — STEPHEN  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal. 

PRYOR— PELVIC  INFLAMMATIONS. 

The  Treatment  of    Pelvic  Inflammations  through  the  Vagina. 

By  W.  R.  Pryor,  M.D.,  Professor  of  Gynecology  in  New  York  Poly- 
clinic.     i2mo,  24S  pages,  handsomely  illustrated.      Cloth,  $2.00  net. 

"This  subject,  which  has  recently  been  so  thoroughly  canvassed  in  high  gynecological 
circles,  is  made  available  in  this  volume  to  the  general  practitioner  and  student.  Nothing  is 
too  minute  for  mention  and  nothing  is  taken  for  granted  ;  consequently  the  book  is  of  the  utmost 
value.    The  illustrations  and  the  technique  are  beyond  criticism." — Chicago  Medical  Recorder. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 

"  The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 
"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical Jour7ial. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full -page  colored  plates.     Cloth,  $1.25  net. 

"  Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical Joicrnal. 


►AUNDERS' 

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^    OVER  J  75,000  COPIES  SOLD.    ^ 
THE  REASON  WHY. 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches) ,  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  tlie 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  cf  these  Compends  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders^  Question-Compend  Series^ 

Price,  Clotli,  $t.00  net  per  copy,  except  when  otherwise  ordered. 

"Where  the  work   of  preparing  students'  manuals   is   to  end  we   cannot   say,  but  the 
Saunders  Series,  in  our  opinion,  bears  off  the  palm  at  present."— AVzc/  York  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.   Hare,  M.D.    Fourth  edition, 

revised  and  enlarged. 

2.  ESSENTIALS  OF  SURGERY.     By  Edward  Martin,  M.  D.     Seventh  edition, 

revised,  with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  ESSENTIALS   OF   ANATOMY.      By  Chart.es  B.   Nancrede,  M.D.      Sixth 

edition,  thoroughily  revised  and  enlarged. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.D.     Fifth  edidon,  revised. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Armand  Semple,  M.D. 

7.  ESSENTIALS  OF  MATERIA  MEDIC  A,  THERAPEUTICS,  AND  PRE- 

SCR1PTI0N=WRITINQ.    By  Henry  Morris,  M.D.       Fifth  edition,  revised. 

8.  9.    ESSENTIALS   OF   PRACTICE    OF   MEDICINE.      By  Henry  Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulse,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.      (Double  number,  ^1.50  net.) 

10.  ESSENTIALS  OF  GYN/ECOLOQY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Fourth  edition,  revised  and  enlarged. 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D. ,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.D.     Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By  Lawrence  Wolff, 

M.D.     Colored  "  VoGEL  Scale."      (75  cents  net.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

M.D.      Second  edition,  thoroughly  revised. 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By  Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw%  M.D.      Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By  Fred  J.    Brockway,    M.D. 

Second  edition,  revised. 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


Saunders' 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners. 


'TTHAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press.  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  w^ritten  by  w^ell-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  written  and  exhaustive  in  detail,  without 
being  encumbered  w^ith  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  pa^e  after  page  of  elaborate  treatises  for  what  he 
wants  to  fcnow^,  they  w^ill  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now^  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  work  worthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders^  New  Series  of  Manuals* 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.    Cloth,  ^1.25  net. 

SURGERY,  General  and  Operative. — By  John  Chalmers  DaCosta,  M.  D.,  Pro- 
fessor of  Practice  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia; Surgeon  to  the  Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised 
and  greatly  enlarged.  Octavo,  911  pages,  profusely  illustrated.  Cloth,  ^4.00  net; 
Half  Morocco,  ^5.00  net. 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTI0N=WRIT1NG.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.     Cloth,  ^1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Pohklinik,  etc.     Illustrated.      Cloth,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.      Cloth,  ;^ 1. 50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Di-ieasps,  and  Frank  H.  Montgomery,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.     Second   edition,  thoroughly  revised  and  greatly  enlarged. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
Cloth,  $2.50  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  Ne"v  Yc-i 
University,  etc.      Beautifully  illustrated.      Cloth,  ^2.50  net. 

MANUAL  'OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Chief  of  Gynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.     Profusely  illustrated.     Cloth,  ^2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London ;  and  Arthur  E. 
Giles,  M.  D.,  B.  Sc.  Lond.,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     Cloth,  ^2.50  net. 


VOLUMES  IN  PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia ;  Pathologist  to  the  Orthopsedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  work* 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containiag  specimen  pages,  etc.  sent  free  upon  application. 


26      Medical  Publications  of  W.  B.  Saunders  &  Co. 


SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  S2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical Jomnal. 

5AUNDER5'  MEDICAL  HAND=ATLA5ES. 

For  full  description  of  this  series,  with  list  of  volumes  and  prices,  see 
page  2. 

"  Lehmann  Medicinische  Handatlanten  belong  to  that  class  of  books  that  are  too  good 
to  be  appropriated  by  any  one  nation." — yournal  of  Eye,  Ear,  and  Throat  Diseases. 

"The  appearance  of  these  works  marks  a  new  era  in  illustrated  English  medical 
works." — T/ii  Catuidian  Practinover. 

SAUNDERS'    POCKET  MEDICAL    FORMULARY.      Sixtii   Edition, 
Revised. 

By  William  >L  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1800 
formulcC  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulje  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Fcetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remem.brancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap, 
^1.75  net. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  ver}'  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Savre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  si.oo  net;  interleavec  for 
notes,  31.25  net. 

[See  Saunders'  Question- Coynpends,  page  21.] 

"The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  fonns  a  verj-  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 

SCUDDERS  FR.ACTURES. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  ^LD.,  .\s. 
sistant  in  Clinical  and  Operative  Surgery,  Harvard  Medical  School. 
Octavo,  433  pages,  with  nearly  600  original  illustrations.  Cloth  ^4  eo 
net.  "^ 


Medical  Publications  of  W.  B,  Saunders  &  Co.      27 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 
Essentials  of    Legal   Medicine,  Toxicology,  and  Hygiene.     By 

C.  E.  Armand  Semple,  B.  A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lend., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  212  pages;  130  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  ^1.25  net. 

[See  Saundei's    Question- Compends,  page   21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By   C.   E. 

Armand  Semple,  B.A.,  M.B.  Cantab.,  M.R.C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.  Crown  octavo,  1 74 
pages;  illustrated.     Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  n^t. 

[See  Sau7iders'  Question- Coftipends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  GENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.      Cloth,  ^3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Seen,  M.  D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  ^1.50  net. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it. " — Nezv  York  Medical  Times. 

SENN'S  TUMORS.     Second   Edition,   Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  N.  Senn, 
M.D,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital  ;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Second  Edition,  Thoroughly  Revised.  Oc- 
tavo volume  of  718  pages,  with  478  illustrations,  including  12  full-page 
plates  in  colors.      Prices:    Cloth,  $5.00  net;  Half  Morocco,  $6.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  Ergnsh  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
'^or  some  years.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical  Association. 


28      Medical  Publications  of  W.  B.  Saunders  &  Co. 

SHAW'S  NERVOUS  DISEASES  AND  INSANITY.     Third  Edition, 

Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  i86  pages;  48  original  illustrations.  Cloth, 
;^i.oo  net;  interleaved  for  notes,  Si. 25  net. 

[See  Saunders'  Question- Compends,  page   21.] 
"Clearly  and  intelligently  written." — Boston  Medical  and  Surgical  Journal. 

"There  is  a  mass  of  valuable  material  crowded  into  this  small  compaso." — American 
Medico- Surgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D. ,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.     $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life  ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.      Formulae  for  the  preparation  of  diluents  and  foods  are  appended. 

STELWAQON'S  DISEASES  OF  THE  SKIN.  Fourth  Ed.,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  276  pages;  88  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  gi.25  net. 

[See  Saunders'  Question- Compends,  page   21.] 
"The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register, 

STENGEL'S  PATHOLOGY.      Second  Edition. 

A  Text=Book  of  Pathology.  By  Alfred  Stengel,  M.D.,  Professor 
of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Physician  to 
the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hospital,  etc. 
Handsome  octavo  volume  of  848  pages,  with  nearly  400  illustrations, 
many  of  them  in  colors.  Cloth,  $4.00  net;  Half  Morocco,  $5.00 
net. 

STEVENS'   MATERIA    MEDICA    AND   THERAPEUTICS.      Second 
Edition,  Revised. 
A  Manual  of   Materia    Medica   and   Therapeutics.       By  A.   A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Physical  Diagnosis  in  the  LTniversity  of  Pennsylvania ;  Professor  of 
Pathology  in  the  Woman's  Medical  College  of  Pennsylvania.  Post- 
octavo,  445  pages.     Flexible  leather,  $2.00  net. 

"The  author  has  faithfully  jiresented  modern  therapeutics  in  a  comprehensive  work, 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice." — University  Medical  Magazine. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      29 


5TEVENS'  PRACTICE  OF  MEDICINE.  Fifth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  ori  Terminology  and  Instructor  in  Physical  Diagnosis 
in  the  University  of  Pennsylvania;  Professor  of  Pathology  in  the 
Woman's  Medical  College  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  519  pages;   illustrated.     Flexible  leather,  ^2.00  net. 

"  The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  maybe  found  also  an  excellent  reminder  for  the  busy  physician." — Buffalo 
Medical  Journal. 

STEWART'S  PHYSIOLOGY.      Third  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
D.Sc,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  848  pages ;  300  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.75  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  teict-books  on  the  subject." — London  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical  Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
^i.oo  net;  interleaved  for  notes,  ^1.25  net. 

[See  Saunders'  Question- Co?7tpends,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 
knowledge  of  their  subject." — Medical  News. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice, 

By  Emily  A.  M,  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass.;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 

"  There  are  few  books  intended  for  non-professional  readers  which  can  be  so  -cordially 
endorsed  by  a  medical  journal  as  can  this  one." — Therapeutic  Gazette. 

"  This  is  a  well-written,  eminently  practical  volume,  which  "covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  ever>'thing  ordi^iarily 
needed  in  the  illness  of  her  patient." — American  Jotirnal  of  Obstetrics  and  Diseases  of 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the 
assurance  of  benefit." — Ohio  Medical  Journal. 


30      Medical  Publications  of  W.  B.  Saunders  &  Co. 

STONEY'S   MATERIA   MEDICA   FOR   NURSE& 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Graduate  of 
the  Training-School  for  Nurses,  Lawrence,  Mass.  ;  late  Superintendent 
of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston,  Mass. 
Handsome  octavo  volume  of  306  pages.     Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of  which  are 
intended  to  render  it  more  practical  and  genera!!}'  useful.  The  general  plan  of  the  contents 
follows  the  lines  laid  down  in  training-schools  for  nurses,  but  the  book  contains  much  use- 
ful m.atter  not  usually  included  in  works  of  this  character,  such  as  Poison-emergencies, 
Ready  Dose-list,  Weights  and  Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms 
used  in  Materia  Medica,  and  describing  all  the  latest  drugs  and  remedies,  which  have  been 
generally  neglected  by  other  books  of  the  kind. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Blaxd  Suttox,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond.,  F.R.C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.     Cloth,  $2.50  net. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
American  Aledical  Association. 

THOMAS'S  DIET  LISTS.     Second   Edition,  Revised. 

Diet  Lists  and  Sick=Room  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to 
the  Kings  County  Hospital.     Cloth,  Si. 25  net.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of    Prescription= Writing.       By   E.    Q. 

Thornton,  I\LD.,  Demonstrator  of  'I'herapeutics,  Jefferson  Medical 
College,  Philadelphia.     334  pages,  illustrated.     Cloth,  $1.25  net. 

"Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  Willia.m  W.  Van  Valzah,  M.D., 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  Vork  Polyclinic;  and  J.  Dougl.as  Niseet,  ]\LD., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.      Cloth,  $3.50  net. 

"  Its  chief  claim  lies  in  its  clearness  and  general  adaptability  to  the  practical  needs  of 
the  general  practitioner  or  student.  In  these  rtrlations  it  is  probably  the  best  of  the  recent 
special  works  on  diseases  of  the  stomach." — Chicago  Clinical  Review. 

VECKI'S   SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecri,  MT).  From  the  second  German  edition,  revised  and  en- 
larged.     Demi-octavo,  291  pages,      ("loth,  S2.00  net. 

The  subject  of  impotence  has  seldom  been  treated  in  this  country  in  the  truly  scientific 
spirit  that  it  deserves.  Dr.  Vecki's  work  has  long  been  favorably  known,  and  the  German 
book  has  received  the  higliest  consideration.  This  edition  is  more  than  a  mere  translation, 
Jcr,  although  based  on  the  German  edition,  it  has  been  entirely  rewritten  in  English. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      31 

V^IERORDT'S  MEDICAL  DIAGNOSIS.  Fourth  Edition,  Revised. 
Medical  Diagnosis.  .By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  iifth  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Handsome  royal  octavo  volume 
of  603  pages;  194  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is. mentioned ;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatoiy  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands."' — University  Medical 
Magazine. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.D.,  Edin.  Ameri- 
can Edition,  under  supervision  of  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.      Cloth,  $1.50  net. 

WARREN'S  SURGICAL  PATHOLOGY.     Second  Edition. 

Surgical  Pathology  and  Therapeutics.  Bv  John  Collins  Warren, 
ALD.,  LL.D.,  Professor  of  Surgery,  Harvard  iSIedical  School.  Hand- 
some octavo,  832  pages  ;  136  relief  and  lithographic  illustrations,  33  in 
colors ;  with  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and 
a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net;  Half 
Morocco,  ^6.00  net. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  ;NLD., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents  net. 

[See  Saunders''  Question- Compends,  page   21.] 
"  A  very^ood  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fifth  Edition,  Revised. 

Essentials    of    Medical    Chemistry,    Organic    and    Inorganic. 

Containing  also  Questions  on  INIedical   Physics,  Chemical  Physiology, 
Analytical    Processes,    L'rinalysis,    and    Toxicology.      By   Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College,  ' 
Philadelphia,  etc.      Crown  octavo,  222  pages.    Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saundeis''  Question- Cojtipends,  page   21.] 

"The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistry." — Pharmaceutical  Era. 


CLASSIFIED    LIST 

OF    THE 

Medical  Publications 


W»  B.  SAUNDERS  &  COMPANY, 

925  "Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  1 1 

Haynes — A  Manual  of  Anatomy,  .    .    .  15 

Heisler — A  Text- Book  of  Embryology,  15 

Nancrede — Essentials  of  Anatomy,  .    .  20 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ...  20 

Semple — Essentials  of  Pathology,     .    .  27 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...  S 
Crookshank — A  Text-Book  of  Bacteri- 
ology,    12 

Frothingham  — Laboratory  Guide,    .    .  13 
Levy  and  Klemperer's  Clinical  Bacte- 
riology,    17 

Mallory   and    Wright  —  Pathological 

Technique, iS 

McFarland — Pathogenic  Bacteria,    .    .  19 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,         .    .  14 

Hart — Diet  in  Sickness  and  in  Health,  .  15 

Keen — Operation  Blank, 17 

Laine — Temperature  Chart 17 

Meigs — Feeding  in  Early  Infancy,     .    .  19 

Starr — Diets  for  Infants  and  Children,  .  28 

Thomas — Diet-Lists 30 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Phys- 
ics,    9 

Wolff — Essentials  of  Medical  Chemistry,  3 1 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children,    .    .             5 

Griffith — Care  of  the  Baby 14 

Griffith — Infant's  Weight'Chart,   ...  14 

Meigs — Feeding  in  Early  Infancy,    .    .  19 

Powell — Essentials  of  Dis.  of  Children,  21 

Starr — Diets  for  Infants  and  Children,  .  26 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Di- 
agnosis,     II 

Corwin — Physical  Diagnosis,      ....  11 

Macdonald — Surgical    Diagnosis    and 

Treatment,      iS 

Vierordt — Medical  Diagnosis 31 

DICTIONARIES. 

Borland — Pocket  Dictionary 12 

Keating — Pronouncing  Dictionary,    .    .  16 

Morten — Nurse's  Dictionary,     ....  20 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .  5 
De  Schweinitz — Diseases  of  the  Eye, .  12 
Gleason — Essentials  of  Dis.  of  the  Ear,  13 
Jackson — Manual  of  Diseases  of  Eye,  .  16 
Jackson   and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  16 
Kyle — Diseases  of  the  Nose  and  Throat,   17 

GEN1T0=URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 6 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 15 

Martin — Essentials   of   Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .  iS 
Saundby — Renal  and  Urinary  Diseases,  26 
Senn — Cenito-Urinary  Tuberculosis,  .  27 
Vecki — Sexual  Impotence, 30 

GYNECOLOGY. 

American  Text- Book  of  Gynecology,  6 

Cragin — Essentials  of  Gynecology,    .    .  II 

Garrigues — Diseases  of  Women,  .    .    ;  13 

Long — Syllabus  of  Gynecology,     .    .    .  17 

Penrose — Diseases  of  Women,  .    .    .  '.  20 

Pryor — Pelvic  Inflammations,     .    .    .  i.  34 

Sutton  and  Giles  —  Diseases  of  Women,  30 

MATERIA  MEDICA,  PHARMACOL- 
0(iY,  AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics 5 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology,  ...  10 
Cerna — Notes  on  the  Newer  Remedies,  10 
Griffin — Materia  Med.  and  Therapeutics,  14 
Morris — Essentials  of  Materia  Medica 

and  Therapeutics, 19 

Saunders'  Pocket  Medical  Formular}',  26 
Sayre— Essentials  of  Pharmacy,  ...  2b 
Stevens — Essentials  of  Materia  Medica 

and  Therapeutics, 28 

Stoney — Materia  Medica  for  Nurses,  .  .  30 
Thornton — Dose- Book  and   Manual  of 

Prescription-Writing 30 

MEDICAL   JURISPRUDENCE    AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology, 10 

Semple — Essentials  of  Legal  Medicine, 
Toxicology,  and  Hygiene, 27 


Medical  Publications  of  W,  B,  Saunders  &  Co, 


33 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 9 

Chapin — Compendium  of  Insanity,  .  .  10 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 10 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 28 

NURSING. 

Griffith— The  Care  of  the  Baby,    .    .    .  I4 

Hampton — Nursing,    . 14 

Hart — Diet  in  Sickness  and  in  Health,  15 

Meigs — Feeding  in  Early  Infancy,    .    .  19 

Morten — Nurse's  Dictionary,     ....  20 

Stoney — Materia  Medica  for  Nurses,  .    .  30 

Stoney — Practical  Points  in  Nursing,    .  29 

Watson — Handbook  for  Nurses,    ...  31 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  6 
Ashton — Essentials  of  Obstetrics, 
Boisliniere — Obstetric  Accidents, 
Borland — Manual  of  Obstetrics, 
Hirst — Text-Book  of  Obstetrics,  ...  15 
Norris — Syllabus  of  Obstetrics,  ....    20 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,  7 
Mallory    and    Wright  —  Pathological 

Technique, 18 

Semple — Essentials   of    Pathology  and 

Morbid  Anatomy, 27 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 27 

Steiigel — Text-Book  of  Pathology,   .    .    28 
"Wa  Ten — Surgical  Pathology  and  Thera- 
peutics,    31 

PHYSIOLOGY. 

An  American  Text-Book  of  Physi- 
ology,    7 

Hare — Essentials  of  Physiology,    ...  14 

Raymond — Manual  of  Physiology,  .    .  21 

Stewart — Manual  of  Physiology,  ...  29 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine,  ....       7 

An  American  Year-Book  of  Medicine 
and  Surgery,       8 

Anders — Text-Book  of  the  Practice  of 
Medicine, 8 

Lockwood — Manual  of  the  Practice  of 
Medicine, 

Morris — Essentials  of  the  Practice  of 
Medicine, 

Stevens — Manual  of  the  Practice  of 
Medicine, 29 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 5 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 15 


17 


19 


Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    18 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    21 

Stelwagon — Essentials  of  Diseases  of 
the  Skin, 28 

SURGERY. 

An  American  Text-Book  of  Surgery,  7 
An  American  Year-Book  of  Medicine 

and  Surgery, 8 

Beck — Fractures, 9 

Beck — Manual  of  Surgical  Asepsis,  .    .  9 

DaCosta — Manual  of  Surgery,  ....  12 

International  Text-Book  of  Surgery,  .  15 

Keen — Operation  Blank, 17 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 17 

Macdonald — Surgical    Diagnosis    and 

Treatment, 18 

Martin — Essentials  of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,     .  18 

Martin — Essentials  of  Surgery, ....  18 

Moore — Orthopedic  Surgery, 19 

Nancrede — Principles  of  Surgery,    .    .  20 

Pye — Bandaging  and  Surgical  Dressing,  21 

Scudder — Treatment  of  Fractures,   .    .  26 

Senn — Genito-Urinary  Tuberculosis,     .  27 

Senn — Syllabus  of  Surgery, 27 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 27 

Warren — Surgical  Pathology  and  Ther- 
apeutics,        31 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  26 
Wolff — Essentials    of    Examination    of 
Urine, 31 


MISCELLANEOUS. 

Abbott — Hygiene  of  Transmissible  Dis- 
eases,        o 

Bastin — Laboratory    Exercises    in    Bot- 
any,           9 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 1 3 

Grafstrom — Massage 14 

Keating — How   to    Examine    for  Life 

Insurance, ,    -    .    «      16 

Rowland    and    Hedley — Archives   of 

the  Roentgen  Ray, 21 

Saunders'  Medical  Hand- Atlases,  .  2,  3,  4 
Saunders'  New  Series  of  Manuals,  24,  25 
Saunders'  Pocket  Medical  Formulary,  26 
Saunders'  Question-Compends,  .  .  22,  23 
Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 27 

Stewart  and  Lawrance — Essentials  of 

Medical  Electricity, 29 

Thornton — Dose-Book  and  Manual  of 

Prescription-Writing, 3° 

Van  Valzah  and  Nisbet— Diseases  of 
the  Stomach, 3° 


BOOKS  JUST  ISSUED. 

THE   AMERICAN    ILLUSTRATED   MEDICAL   DICTIONARY. 

For  Students  and  Practitioners,  A  Complete  Dictionary  of  the  Terms  used  in  Medi- 
cine and  the  Allied  Sciences,  with  a  large  number  of  Valuable  Tables  and  Numerous 
Handsome  Illustrations.  Edited  by  W.  A.  Newman  Borland,  M.  D.,  Editor  of  the 
American  Pocket  Medical  Dictionary.  Handsome  large  octavo,  800  pages,  bound  in 
full  limp  leather,  and  printed  on  thin  paper  of  the  finest  quality,  forming  a  handy 
volume,  only  1)^  inches  thick. 

This  is  an  entirely  new  and  unique  work,  intended  to  meet  the  need  of  practitioners  and  students  for  a 
complete,  up-to-date  dictionary  of  moderate  price.  The  boolc  is  designed  to  furnish  a  maximum  amount  of 
matter  in  a  minimum  space  and  at  the  lowest  possible  cost.  It  contains  double  the  material  in  the  ordinary 
students'  dictionary,  and  yet,  by  the  use  of  a  clear,  condensed  type  and  thin  paper  of  the  finest  quality,  is  only 
1 5^  inches  in  thickness.  It  is  bound  in  full  flexible  leather,  and  is  just  the  kind  of  a  book  that  a  man  will  want 
to  keep  on  his  desk  for  constant  reference.  The  book  makes  a  special  feature  of  the  newer  words,  and 
defines  hundreds  of  important  terms  not  to  be  found  in  any  other  dictionary.  It  is  especially  full  in  the 
matter  of  tables,  containing-  more  than  a  hundred  of  great  practical  value.  A  new  feature  is  the  inclusion 
of  numerous  handsome  illustrations,  many  of  them  in  colors,  drawn  and  engraved  specially  for  this  book. 
These  have  been  chosen  with  great  care  and  add  infinitely  to  the  value  of  the  work.  The  book  will  appeal 
to  both  practitioners  and  students,  since,  besides  a  complete  vocabulary,  it  gives  to  the  more  important 
subjects  extended  consideration  of  an  encyclopedic  character. 

BOHM,  DAVIDOFF,  AND    HUBER'S   HISTOLOGY. 

A  Text=Book  of  Human  Histology.  Including  Microscopic  Technic.  By  Dr. 
A.  A.  BiJHM  and  Dr.  M.  von  Davidoff,  of  Munich,  and  G.  C.  Huber,  M.  D., 
Junior  Professor  of  Anatomy  and  Histology,  University  of  Michigan. 

FRIEDRICH  AND  CURTIS  ON  THE  NOSE,  THROAT,  AND  EAR. 

Rhinology,  Laryngology,  and  Otology  in  their  Relations  to  General 
Medicine.  By  Dr.  E.-  P.  Friedrich,  of  the  University  of  Leipsig.  Edited  by 
H.  H01.BROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat 
Hospital. 

LEROY'S    HISTOLOGY. 

The  Essentials  of  Histology.  By  I.ouis  Leroy,  M.D.,  Professor  of  Histology 
and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 

OGDEN   ON   THE   URINE. 

Clinical  Examination  of  the  Urine.  By  J.  Bergen  Ogden,  M.  D.,  Assistant 
in  Chemistry,  Harvard  Medical  School.  Handsome  octavo  volume  of  over  408  pages, 
with  54  illustrations  and  1 1  full-page  plates,  many  in  colors. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assist- 
ant Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages, 
fully  illustrated. 

SALINGER   AND    KALTEYER'S   MODERN  MEDICINE. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of  Clinical 
Medicine,  Jefferson  Medical  College,  and  F.  J.  Kalteyer,  M.  D.,  Assistant  Demon- 
strator of  Clinical  Medicine,  Jefferson  Medical  College.  Handsome  octavo  volume  of 
over  800  pages,  fully  illustrated. 

STONEY'S  SURGICAL  TECHNIC   FOR   NURSES. 

Surgical  Technic  for  Nurses.  By  Emily  A.  M,  Stoney.  late  Superintendent 
of  the  Training-School   for  Nurses,  Carney   Hospital,  South  Boston,  Massachusetts. 


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